Helicobacter pylori (H. pylori) is one of the most common chronic bacterial infections in the world, and it is currently estimated that approximately half of the world’s population is infected with the bacterium. The correct diagnosis and effective treatment of H. pylori gastric infection are essential in controlling this condition. The available diagnostic methods have advantages and limitations related to factors such as age of patients, technical difficulty level, costs and extensive accessibility in hospitals. The eradication therapy of H. pylori infection is still a challenge for gastroenterologists. One of the main causes of failure in H. pylori eradication is antibiotic resistance. Biopsy cultures are the most widely used methods among the antimicrobial susceptibility tests. In case of a negative culture, H. pylori can be clearly recognised in histological sections. The sensitivity and specificity of histology for the diagnosis depend on clinical settings, density of colonisation and the experience of the histopathologist. A prospective study was performed in order to analyse patients with H. pylori gastric infection with positive histology and positive culture versus positive histology and negative culture.
- Helicobacter pylori culture
Numerous diagnostic tests are available for detecting
Two tests are recommended to define
The aims of our study were to assess the histological findings and to compare them with the results of bacterial cultures, obtained through gastric biopsy, in children with
2. Materials and methods
This was a prospective, single-centre study (in Maria Sklodowska Curie Children’s Emergency Hospital Bucharest, Romania) that evaluated consecutive children referred by their physicians for an upper endoscopy because of dyspepsia. They were all screened for
Excluding criteria were the use of proton pump inhibitors or H2-receptor antagonists and antibiotics as well as non-steroidal anti-inflammatory drugs or steroidal treatment 2 weeks before the beginning of the study, previous intestinal surgery (except for polypectomy and appendectomy), concomitant severe disease (heart, lungs, kidney and endocrine diseases) and smoking or alcohol consumption among adolescents.
The study was approved by the ethics committee.
All patients underwent endoscopy with biopsy specimens for histology (one for the antrum, one for the corpus). One sample from the antrum was used for rapid urease test. Two additional biopsies were taken from the antrum for bacterial culture. The samples were placed into separate vials, previously identified, containing the appropriate medium for each test. The first sample was used for bacterial culture.
This procedure was performed in patients with a minimum of 10 hours of fasting, under general anaesthesia or conscious sedation. Vital signs were continuously monitored for the entire procedure.
Written informed consent was obtained from the parent or guardian of each child included in the study.
2.3. Bacterial culture
The biopsy specimens collected for bacterial culture were transported in commercial selective transport
A biopsy of the gastric body and antrum was fixed in a solution of formaldehyde 10%. Subsequently, the gastric mucosa samples were processed, following the usual steps of dehydration and paraffin embedding.
Two stains were used for histological study: haematoxylin-eosin and Giemsa. Haematoxylin-eosin stain was used to evaluate inflammatory cells and
Gastritis was graded according to the Sydney system  that assesses the severity of inflammation, the level of activity (the degree of polymorph neutrophil inflammation) and the presence of atrophy and of intestinal metaplasia on a scale from 0 to 3.
In accordance with the Sydney system, the density of
2.5. Statistical analysis
The data was collected and analysed with Microsoft Excel 2013 and PSPP version 1.0.1. Continuous variables with a normal distribution were expressed as a mean with standard deviation (SD). Differences and relationships between variables were analysed using Fisher’s exact for low expected frequencies. A p < 0.05 was considered statistically significant for all the analysed parameters.
We calculated the sensitivity and specificity for
In the study, the culture findings and histological examination findings were accepted as “gold standard”. The detection of
Of the 38 patients who underwent upper endoscopy with biopsies by protocol (Figure 3), nine were excluded because of negative results in both culture and histology.
Twenty-nine cases (76.31%) were included in the final analysis, nineteen females (65.51%) and ten males (34.49%). The ages were between 3 years and 7 months and 17 years and 8 months (mean age 13, 5 ± 4.53 years).
The results for the diagnosis of
Indeed, the histological examination of samples was able to identify the presence of
We did not analyse separately the presence of the
The histology also showed that 14/28 (50%) patients had mild
In one case, the culture was positive, but the bacterium was not identified through the histological exam. Among the other five cases with positive culture, two were associated with a mild score of
|Patients (n)||Patients (n)|
We analysed the correlation between densities of
We used haematoxylin-eosin as the main staining method, while Giemsa stain was reserved for a few cases, not identified through haematoxylin-eosin staining, in which the suspect of infection was high.
We also tried to find out if there existed a relationship between the activity of gastritis and the density of
|Mild ||3 (21.43%)||7(50%)||4(28.57%)||0|
|Moderate ||0||4 (36.36%)||6 (54.54%)||1 (9.0%)|
|Marked ||1 (33.33%)||1 (33.33%)||1 (33.33%)||0|
The relationship between the degree of inflammation and
|Mild ||6 (42.80%)||7 (50.0%)||1 (7.20%)|
|Moderate ||4 (36.36%)||7 (63.64%)||0|
|Marked ||2 (66.67%)||1 (33.3%)||0|
The specificity for
The enthusiasm beginning with the isolation of
The correct diagnosis and effective treatment of
76.31% of patients enrolled in the study were positive for
The specificity for
A recent Israeli study, conducted in the paediatric population, reported 57.8% of positive
Although the culture method is accepted as a “gold standard” for the diagnosis, it is difficult to use alone as a routine diagnostic method. As the sensitivity of culture method is low,
Despite its long use, culture remains a challenge because of the fastidious nature of the bacterium, with particular growth requirements regarding environment and atmosphere . Altering pH, the proton pump inhibitors (PPIs) indirectly interfere with
In our study, exclusion criteria were of inhibitory proton pump or H2-receptor antagonists and antibiotics 2 weeks before the beginning of the study, similarly with another study and recommendations .
The recent Maastricht V/Florence Consensus Report recommends discontinuation of antibiotics 4 weeks before the study to allow an increase of detectable bacterial load .
The number of biopsies necessary to diagnose
We took two biopsies from the antrum for
The usual recommendation derived from the Sydney system is to obtain two biopsy specimens from the antrum and two specimens from the corpus. Bacteria are usually present at both sites even if the lesions occur essentially in the antrum. When topographic studies of
We took the biopsy specimens for culture before specimens for histology, and we used an appropriate commercially transport medium, according to the recommendations.
We analysed the correlation between densities of
We analysed the correlation between gastritis activity and density of
The results of this study are in agreement with published work, suggesting that a strain of the organism may be a more important factor than the density of infection in determining the gastric inflammatory response to
In our study, we had four children with bleeding, and all of them had negative
Peptic ulcer bleeding and atrophic gastritis decreased the accuracy of
When atrophic changes occur in the gastric mucosa, a high percentage of endoscopic biopsy samples become negative at bacterial histology [20, 21]. During atrophy progression the density of
In childhood, advanced gastric atrophy is rare. We found only one case with atrophy, but the
The sensitivity of histology in our study was 96.55%, while the specificity was 90.90%.
The sensibility and specificity of haematoxylin and eosin stain have been reported as 69–93% and 87–90%, respectively. The specificity can be improved to 90–100% by using special stains such as Giemsa stain, Warthin-Starry silver stain, Genta stain and immunohistochemical stain [15, 20, 21]. Immunohistochemical stain has a particular advantage in patients partially treated for
In our study, we analysed the sensibility and specificity of histology in
Histology is an excellent method for detecting
The authors thank Dr. Violeta Cristea and Dr. Augustina Enculescu for their laboratorial and histological support, respectively.
Conflict of interest
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