Iraqi J Pharm Sci, Vol.22(1) 2013 ABO blood group and ulcer 97 The Relationship between ABO Blood Group Distribution and the incidence of Upper Gastric and Duodenal Ulcer in Iraqi Patients Manal K. Abdulridha *, 1 * Department of Clinical Pharmacy, College of Pharmacy, AL-Mustansiriyah University, Baghdad, Iraq. Abstract The relationship between blood group antigens and peptic ulcer disease has been widely evaluated in the past, but only one study relating H pylori seroprevalence to ABO blood groups among Iraqi patients with peptic ulcer disease is available. We aimed to evaluate the frequency of peptic ulcer disease among different ABO blood groups in Iraqi patients, and we thought it was worthwhile to try to determine whether these components take some part in disease etiology. One hundred and six patients with peptic ulcer disease (PUD) (43 male and 63 female; mean age: 48 ± 18 years) who attended Baghdad teaching hospital and Al- Yarmouk teaching hospital endoscopy centers were enrolled , and 238 control Subjects. Finger blood samples were used for ABO/Rhesus (Rh) blood group antigen typing. The ABO blood group phenotype frequency in peptic ulcer patients was as follows: 18.9% for blood group A, 15.1% for blood group B, 57.5 % for blood group O and 8.5% for blood group AB. Rh positivity was found in 100% of patients. Significant higher percentage of patients with both gastric and duodenal ulcer disease are those holding blood group O + compared to other blood group phenotypes (57.5%)( p= 0.003) .The present study show higher incidence of doudenal ulcer( DU) in patients with blood group O + compared to gastric ulcer( GU) patients (65.6%vs 54.1%) , although no statistical difference between both diseases was found,( p ˃ 0.05) in respect to other blood group phenotypes. Peptic ulcer disease is predominant in patients aged between 50-59 years represents with higher percentage (26.4%) compared to other age groups. Patients with blood group O + phenotype presented with a highly significant percentage of Peptic ulcer disease, since those individuals may express a higher inflammatory responses to H. pylori with higher levels of lymphocyte infiltration in the gastrointestinal mucosa , and a higher frequency of secretor status . In addition, they do not produce the substance on the surface of blood group O + cells that may protect the lining of the duodenum .According to these results, probably ABO/Rh blood group (mainly blood group O+) has an important role in patients with peptic ulcer disease as additional risk . The functional significance of ABO blood group distribution might be associated with biological behavior of Peptic ulcer disease. The impact of blood group on Peptic ulcer disease may be a focus for further studies. Keywords: ABO/ Rh Blood group system - Upper gastrointestinal disorders –Age & Gender distribution تقٍٍن العالقت بٍن فصٍلت الدم هع تقرحاث الوعدة واالثنً عشري عند الورضى العراقٍٍن هنال خالد عبد الرضا *،1 * .العشاق بغذاد،، الجبهعت الوسخٌظشَت ،ولُت الظُذلت ، فشع الظُذلت السشَشَت الخالصة حن فٍ السببك حمُُن العاللت بُي فظُلت الذم الىساثُت واهشاع حمشدبث الوعذة واالثٌٍ عششٌ لىي هٌبن دساست وادذة فمؾ حشبؾ العاللت لهزا َهذف البذث الً حمُُن الخشابؾ والزٌ دسب اعخمبدًب َسخذك .بُي الوسبب البىخُشٌ للخمشدبث وفظُلت الذم عٌذ الوشػً فٍ العشاق 63روش و 43)هشَغ 106حشخول الذساست علً .الوذبولت لوعشفت فُوب ارا وبًج فظُلت الذم عٌذ االًسبى حلعب دوس وعبهل هسبب للوشع وسفٍ هسخشفً بغذاد الخعلُوٍ و هسخشفً الُشهىن هي الوظببُي بمشدت الوعذة واالثٌٍ عششٌ الزَي حن حذىَلهن الً ودذة الٌبظ( اًثً وبًج ًخبئج حىصَع فظُلت الذم . و حن حذذَذ فظُلت الذم هي لطشة دم االبهبم .هي االشخبص الطبُعُُي 238الخعلُوٍ للخشخُض ووزله : الىساثٍ عٌذ هشػً حمشدبث الوعذة واالثٌٍ عششٌ وبالحٍ ووبى جوُع الوشػً َذولىى . .ABلفظُلت الذم %8,5و Oلفظُلت الذم %57,5و Bلذم لفظُلت ا %15,1و Aلفظُلت الذم 18,9% دلج الٌخبئج علً ًسبت عبلُت راث هغضي ادظبئٍ لوشع حمشدبث الوعذة واالثٌٍ عششٌ عٌذ الوشػً. الوىجب ( Rh)ًىع العبهل الشَسٍ Oالذبهلُي لفظُلت الذم + . ( p= 0.003( )%57,5)لببلٍ اًىاع فظبئل الذم همبسًت ببلوشػً االخشَي الذبهلُي Corresponding author E-mail: mkar_3564 @yahoo.com Received:20/10/2012 Accepted:25/3/2013 Iraqi J Pharm Sci, Vol.22(1) 2013 ABO blood group and ulcer 98 O الذمدة عٌذ هشػً فظُلت ـسح الوعـهشع حك ًسبت عبلُت هي واوذث الذساست الذبلُت علً + عششٌ االثٌٍ اث ـهع حمشح اسًت ـببلوك ( دلج الذساست اَؼب علً اى ًسبت حمشدبث . لىي الٌسبت لن حىي رو هغضي ادظبئٍ ببلومبسًت هع ببلٍ فظبئل الذم ( % 54,1همببل 65,6% دلج الذساست . همبسًت بببلٍ الفئبث العوشَت ( %26,4)سٌت 59-50الوعذة واالثٌٍ عششٌ اوبش عٌذ الوشػً الزَي حخشاوح اعوبسهن بُي O الذبهلُي لفظُلت الذم الوشػً علً اى + َوثلىى ًسبت عبلُت راث هغضي ادظبئٍ َعىد الً لذعشش وهي هشع حمشدبث الوعذة واالثٌٍ داخل جذاس الوعذة واالهعبء ( سبَجاللوفى)واسحفبع ًسبت حجوع الشاص الذم البُؼبء H. pyloriصَبدة الخذسس االلخهببٍ ػذ بىخشَب ببالػبفت الً عذم وجىد هبدة ولبئُت علً سطخ وشَبث الذم الذوشاء عٌذ . ووزله صَبدة افشاصاث الوعذة واالثٌٍ عشش عٌذ هؤالء الوشػً O فظُلت الذم + لهب حبثُش واػخ ( +Oالذم وخبطت فظُلت)هي هزٍ الذساست ببى ًىع فظُلت الذم ًسخٌخج.َوىٌهب دوبَت غالف االثٌٍ عشش وهزا . عٌذ الوشػً الوظببُي بخمشدبث الوعذة واالثٌٍ عششَىجضء هي ؽبُعت حىىى الوشع هوب َوىي اعخوبدهب وعبهل هسبب اخش للوشع .الخبثُش َخطلب دساست اعوك لخىػُخ الفىشة . تىزٌع العور -اهراض الجهاز الهضوً العلٍا -ABO/ Rh فصٍلت الدم : الوفتاحٍت الكلواث Introduction The relationship between blood group and the incidence of peptic ulcer disease had been evaluated by several references whom provided a new clue to the etiology of the disease (1, 2, 3) . It is well known that Helicobacter pylori (H. pylori) infection and aspirin/(non steroidal anti- inflammatory drugs (NSAIDs)) are the most important factors predisposing peptic ulcer disease in the community (3) . In addition, the possible relationship between genetic factors and the natural history of peptic ulcer has been Studied (4) . A number of evidence is in favor of both hereditary (ABO blood group) and environmental factors playing a part in the development of bleeding duodenal ulcer (5,6,7) .Some reports postulated that overt bleeding from the gastric mucosa, whether aspirin- induced or not, may be related to ABO blood group and secretor status (8, 9) . The association of blood group O with bleeding from duodenal ulcer was also confirmed (10) . Recently it was considered that the life expectancy of persons holding blood group O is less than that of other blood groups , and generally , blood group O holders are more prone to various diseases mainly duodenal ulcer ( 11) . Similarly, gastric carcinoma was found to be associated with blood group A, but no explanation for this condition was found (12) . In addition, type O people may be more vulnerable to the bacteria that can cause peptic ulcers, Helicobacter pylori (13,14) . Many epidemiologic studies had found that non secretors of ABO blood group antigens and individuals of blood group O were overrepresented among patients with peptic ulcers (15, 16) . These studies encouraged many researchers to investigate the relation between ABO blood groups and their secretor status with peptic ulcer (9, 11) . Data concerning the association of ABO blood groups among Iraqi patients with gastric compared to duodenal ulcer was presented in one study only. We aimed to evaluate this association and we thought it was worthwhile to try to determine whether these components take some part in disease etiology. Patients and Methods This study include 106 patients with peptic ulcer disease (PUD) either gastric ulcer (GU) or duodenal ulcer (DU) admitted to Baghdad teaching hospital and Al- Yarmouk teaching hospital for gastrointestinal endoscopy, and 238 control subjects. The database was collected from Octobor 2011 till March 2012. The demographic and clinical characteristics including age, gender, and ABO/ Rh phenotype blood group were recorded. The patients were clinically evaluated and the gastrointestinal signs and symptoms were recorded. Upper gastrointestinal endoscopy was done according to standard medical procedure. Since blood group is not routinely checked in endoscopy clinics, finger blood samples were taken from each patient after endoscopy. ABO blood groups and Rh phenotype evaluations were carried out by standard rapid slide agglutination method ( using anti ABO monoclonal kit) ( 17) . .The control subjects were clinically disease free. Statistical analysis Data were analyzed using Statistical Package for Social Sciences (SPSS) (student version 13, McGraw Hill Company 2006). Chi square test was used to detect statistically significant differences among variables. P-values <0.05 were considered significant. http://www.springerlink.com.tiger.sempertool.dk/content/k46j33r4u8130716/fulltext.html#CR2 http://www.springerlink.com.tiger.sempertool.dk/content/k46j33r4u8130716/fulltext.html#CR2 http://www.scialert.net/asci/result.php?searchin=Keywords&cat=&ascicat=ALL&Submit=Search&keyword=environmental+factors Iraqi J Pharm Sci, Vol.22(1) 2013 ABO blood group and ulcer 99 Results This study includes a total of 344 subjects 106 (30.8%) patients and 238 (69.2%) controls. The demographics and clinical characteristics is shown in table (1). Table 1: Demographics and clinical characteristics Table (2) (Figure 1) show that the ABO blood group phenotype distribution in patient and control groups was as follows : 61 (57.5 %) versus 86 (36.1 %) for group O , 20 (18.9 %) versus 71 (29.8 %) for group A, 16 (15.1 %) versus 49 (20.6 %) for group B, and 9 (8.5 %) versus 32 (13.4 %) for group AB respectively. Blood group O was found to have highly significant PUD frequency in patient group than in the other blood group phenotypes (p= 0.003). The Rh positive was in 329 (95.60 %) subjects , and negative was in 15 (4.40%) subjects in all study groups table (1). The Rh positivity was 100% in patient group, and 93.6% in the controls. Table 2: Blood group distribution between patients and controls *Pearson Chi-Square Figure 1 : Blood group distribution between patients and controls Table (3) (Figure 2) show that the distribution of endoscopic findings in patient group were 32 (30.2%) for DU, and 74 (69.8 %) for GU. The frequencies of ABO blood group among endoscopic findings (DU vs GU): 21 (65.6 %) versus 40 (54.1%) for group O, 6 (18.8%) versus 14 (18.9%) for group A, 2 (6.20 %) versus 14 (18.9%) for group B, and 3 (9.30%) versus 6 (8.10%) for group AB respectively. The higher incidence of DU was in patients with blood group O + compared to GU patients (65.6%vs 54.1%) , although no statistical significance was found between both diseases (p ˃ 0.05) in respect to other blood group phenotypes .Table (1) also show that the mean age of control subjects was (39 ±20) years , and in peptic ulcer patients was (48 ±18) . The mean age distribution in patients was as follows : (13.2%) for group 20-29 years , (17.9%) for 30-39 years, (20.8%) for 40=49 years, (26.4%) for 50-59 years , and (21.7%) for 60-69 years. The higher frequency of PUD was found in the fifth decade of age. Variable Total N (%) Patients N (%) Controls N (%) Subjects 344 (100) 106 (30.80) 238 (69.20) Gender Male Female 146(42.40) 198(57.60) 43.(40.6) 63(59.4) 103(43.3) 135(56.7) Age (Year) 20 – 29 113(32.8) 14(13.2) 99(41.6) 30 – 39 85(24.70) 19(17.9) 66(27.7) 40 – 49 61(17.7) 22(20.8) 39(16.4) 50 – 59 56(16.3) 28(26.4) 28(11.7) 60 – 69 29(8.4) 23(21.7) 6(2.6) Blood group Subjects N (%) P* P * Patients Controls A 20 (18.90) 71 (29.80) 0.003 B 16 (15.10) 49 (20.60) AB 9 (8.50) 32 (13.40) O 61 (57.50)* 86 (36.10)* Total 106 (100) 238 (100) Iraqi J Pharm Sci, Vol.22(1) 2013 ABO blood group and ulcer 100 Table 3: Association between blood group and endoscopic findings *Pearson Chi-Square. Figure 2: Association between blood group and endoscopic findings Discussion The association between the ABO blood group and both gastric cancer and peptic ulcers has been studied previously (18-19 ) . This study provide an estimation of the extent of such associations in Iraqi patients. In general adult population 22% of all of peptic ulcer (GU&DU) disease were idiopathic and almost 40% of duodenal were H.pylori infection. Obesity is a risk factor for gastric ulcer as for use of low- dose of aspirin (20,21) . Previous studies demonstrated that blood group O is associated with duodenal ulcer disease, while gastric ulcer and gastric carcinoma are associated with blood group A (21,22 , 23) . Also it was concluded that gastric ulcer near the pylorus and those occurring with duodenal ulcer were associated with acid hypersecrtion, these cases were marked in patients with blood group O, while gastric ulcer in body of the stomach occurring in patients in which their duodenum was normal, were characterized by acid hyposecretion and this marked in patients with blood group A, the cause that blood type A is most likely to have gastric cancer (24) .Romshoo et al. (1997) reported that, the majority of peptic ulcer patients (56%) had blood group O and it though a risk factor for peptic ulcer (25) . In another study, Bayan et al. (2009) finding contributes to the positive correlation between group O and upper gastrointestinal bleeding caused by gastroduodenal ulcers and erosive gastropathy and the blood group O which was found to have higher frequency in patient group than in controls ( p = 0.004) (26) . In prospective well-defined cohort study of Swedish and Danish blooddonors have confirmed that individuals with blood group O have a higher risk of peptic ulcers than those with other blood groups (27) . Those findings have been confirmed by many other reports (28,29) . Despite epidemiological evidence of increased peptic ulcer disease in ABO blood group O subjects, and the evidence that H. pylori adhesion to gastric epithelial cells is mediated by blood group epitopes, no significant association between blood groups and H. pylori serological status was detected ( p˃ 0.05) (30) . Jaff MS. (2011) showed a significant association between the O blood group and infection caused by H. pylori (P = 0.01) , the prevalence of seropositivity to H. pylori infection was (64.8%) in symptomatic patients in the Kurdistan region of Iraq (31) . In the present study, patients with blood group O phenotype presented with a highly significant percentage of PUD compared to controls ( 57.5%) vs( 36.1% ) respectively p = 0.003. Blood group O individuals express a higher inflammatory responses to H. pylori with higher levels of lymphocyte infiltration in the gastrointestinal mucosa (32) , a lower level of Von Willebrand’s factor (33,34) , and a higher frequency of secretor status (35) , in addition , they do not produce the substance on the surface of blood cells that may protect the lining of the duodenum (36,37) all these together explain the possible cause of these individuals’ increased susceptibility to peptic ulceration. Jaff MS. study support this epidemiological view of gastric susceptibility of O blood group to H. pylori infection which is most probably due to high secretor status (31) . This correlation was supported in many reports (38-40) . Bayan et al (2009) showed higher frequency of DU among patients with blood group O with significantly higher H. pylori positivity ( p=0.031) compared to other ABO phenotype . Although no statistical difference was noticed in O blood group distribution between DU and GU endoscopic findings (26) .The present study show higher incidence of DU in patients with blood group O compared to GU (65.6%vs 54.1%) , although no Blood group Endoscopic findings N (%) P * GU DU A 14 (18.90) 6 (18.80) 0.401 B 14 (18.90) 2 (6.20) AB 6 (8.10) 3 (9.40) O 40 (54.10) 21 (65.60) Total 74 (100) 32 (100) http://en.wikipedia.org/wiki/Blood_type#cite_note-0 http://en.wikipedia.org/wiki/Blood_type#cite_note-0 http://en.wikipedia.org/wiki/Blood_type#cite_note-0 http://en.wikipedia.org/wiki/Blood_type#cite_note-0 http://en.wikipedia.org/wiki/Blood_type#cite_note-0 http://en.wikipedia.org/wiki/Blood_type#cite_note-0 http://scialert.net/fulltext/?doi=pjbs.2009.991.993#165541_ja http://scialert.net/fulltext/?doi=pjbs.2009.991.993#165541_ja http://scialert.net/fulltext/?doi=pjbs.2009.991.993#165525_ja http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=PubMed&term=%20Jaff%2BMS%5bauth%5d Iraqi J Pharm Sci, Vol.22(1) 2013 ABO blood group and ulcer 101 statistical difference between both diseases in blood group O in respect to other blood groups , p ˃ 0.05. This is probably due to small number of patients enrolled in this study . Most studies stated that stomach ulcers are more likely to develop in older people. This is may be because arthritis be prevented by daily use of aspirin / (NSAIDs) , in addition to age related relaxation of pylorus valve allowing backflow of bile to erode the stomach lining (41) . H. pylori Seropositivity increased with age, and was not related to gender (30) . This age – related ulcer development was correlated to ABO blood group phenotype in many studies (42,43) , including our study . Further studies screening the effect of age on incidence of peptic ulcer disease are warranted to exclude other confounders. According to results, probably ABO/Rh blood group (mainly blood group O+) has an important role in patients with peptic ulcer disease as additional risk . We can conclude that the functional significance of ABO blood group distribution might be associated with biological behavior of PUD. 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