Prevalence of <i>Helicobacter pylori</i> infection in dyspeptic patients presenting to a tertiary care center of a developing country: a cross-sectional study

Ram Chandra Subedi; Binit Upadhaya Regmi; Bishnu Deep Pathak; Bishal Dhakal; Deekshanta Sitaula; Ujjawal Paudel; Prabal KC; Srijana Maharjan; Anurag Karki; Sunil Baniya; Sushil Joshi; Chiranjibi Pant; Kumar Roka

doi:10.12688/f1000research.137429.1

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Research Article

Prevalence of Helicobacter pylori infection in dyspeptic patients presenting to a tertiary care center of a developing country: a cross-sectional study

[version 1; peer review: 1 approved, 1 not approved]

Ram Chandra Subedi¹, Binit Upadhaya Regmi², Bishnu Deep Pathak ², [...] Bishal Dhakal³, Deekshanta Sitaula⁴, Ujjawal Paudel², Prabal KC⁴, Srijana Maharjan⁵, Anurag Karki⁶, Sunil Baniya⁷, Sushil Joshi⁸, Chiranjibi Pant³, Kumar Roka³

Ram Chandra Subedi¹, Binit Upadhaya Regmi², [...] Bishnu Deep Pathak ², Bishal Dhakal³, Deekshanta Sitaula⁴, Ujjawal Paudel², Prabal KC⁴, Srijana Maharjan⁵, Anurag Karki⁶, Sunil Baniya⁷, Sushil Joshi⁸, Chiranjibi Pant³, Kumar Roka³

PUBLISHED 25 Sep 2023

Author details Author details

¹ Department of Neurology, Grande International Hospital, Kathmandu, Bagmati province, 44600, Nepal
² Department of Medicine, Jibjibe Primary Health Care Center, Rasuwa, Bagmati province, 45007, Nepal
³ Department of Internal Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Bagmati province, 10160, Nepal
⁴ Department of Medicine, Rasuwa Hospital, Rasuwa, Bagmati province, 45007, Nepal
⁵ Department of Medicine, Nepal Medical College, Kathmandu, Bagmati province, 44600, Nepal
⁶ Department of Medicine, Panchkhal Primary Health Care Center, Kavrepalanchok, Bagmati province, 45200, Nepal
⁷ Department of Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Bagmati province, 44700, Nepal
⁸ Department of Medicine, Dodhara Primary Health Care Center, Kanchanpur, Sudurpashchim province, 10400, Nepal

Ram Chandra Subedi
Roles: Conceptualization, Data Curation, Funding Acquisition, Investigation, Project Administration, Resources, Supervision, Validation, Visualization, Writing – Review & Editing

Binit Upadhaya Regmi
Roles: Data Curation, Funding Acquisition, Investigation, Methodology, Software, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Bishnu Deep Pathak
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Software, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Bishal Dhakal
Roles: Data Curation, Formal Analysis, Funding Acquisition, Investigation, Software, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Deekshanta Sitaula
Roles: Data Curation, Formal Analysis, Funding Acquisition, Methodology, Resources, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing

Ujjawal Paudel
Roles: Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Software, Supervision, Visualization, Writing – Review & Editing

Prabal KC
Roles: Data Curation, Formal Analysis, Funding Acquisition, Investigation, Resources, Software, Writing – Original Draft Preparation, Writing – Review & Editing

Srijana Maharjan
Roles: Conceptualization, Data Curation, Funding Acquisition, Investigation, Project Administration, Resources, Supervision, Writing – Original Draft Preparation

Anurag Karki
Roles: Data Curation, Funding Acquisition, Investigation, Project Administration, Resources, Supervision, Validation, Writing – Review & Editing

Sunil Baniya
Roles: Conceptualization, Data Curation, Funding Acquisition, Methodology, Project Administration, Software, Validation, Writing – Review & Editing

Sushil Joshi
Roles: Formal Analysis, Funding Acquisition, Methodology, Software, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Chiranjibi Pant
Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Supervision, Validation, Visualization, Writing – Review & Editing

Kumar Roka
Roles: Conceptualization, Formal Analysis, Funding Acquisition, Methodology, Project Administration, Resources, Supervision, Validation, Writing – Review & Editing

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Abstract

Background: Among the various causes for dyspepsia in patients presenting to the gastroenterology department, Helicobacter pylori is the most common etiological agents. Here, we explore the prevalence of Helicobacter pylori infection, particularly, in dyspeptic patients and different endoscopic findings in such patients.
Methods: We conducted a simple observational study in the gastroenterology department of a tertiary care center of Nepal. The Helicobacter pylori was detected using rapid urease test and endoscopic findings were collected from gastroduodenoscopy unit. The obtained data was analyzed using Statistical Package for Social Sciences (IBM-SPSS), version 22.
Results: The overall prevalence of Helicobacter pylori infection in dyspeptic patients in our center was found to be 0.329 (0.259 – 0.406) at 95% Confidence Interval (CI). There was significant association of Helicobacter pylori infection with alcohol history (12 [52.17] vs 44 [29.93], p = 0.035) and endoscopic findings of duodenal ulcer (3, 100%) followed by gastritis (29, 50.88%).
Conclusions: Amidst various etiology for dyspepsia, Helicobacter pylori was still prevalent at our center. However, considering the variability of its prevalence due to factors like alcohol history, more comprehensive studies are needed to estimate actual proportion in patients presenting with dyspeptic symptoms.

Keywords

Helicobacter, dyspepsia, peptic ulcer, gastritis

Corresponding author: Bishnu Deep Pathak

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2023 Subedi RC et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Subedi RC, Regmi BU, Pathak BD et al. Prevalence of Helicobacter pylori infection in dyspeptic patients presenting to a tertiary care center of a developing country: a cross-sectional study [version 1; peer review: 1 approved, 1 not approved]. F1000Research 2023, 12:1195 (https://doi.org/10.12688/f1000research.137429.1) First published: 25 Sep 2023, 12:1195 (https://doi.org/10.12688/f1000research.137429.1) Latest published: 25 Sep 2023, 12:1195 (https://doi.org/10.12688/f1000research.137429.1)

Introduction

Dyspepsia is defined as having a combination of one or more symptoms among epigastric pain, epigastric burning sensation, postprandial fullness or early satiation. These symptoms are thought to originate from gastrointestinal region in the absence of organic or systemic disorders.¹ Although symptoms such as nausea and bloating may co-occur in dyspeptic patients and may point towards the disorder, newer definitions do not include these as cardinal or localizing symptoms of dyspepsia.² Of all patients with dyspeptic symptoms, 20-25 percent have an underlying organic cause on diagnostic evaluation such as peptic ulcer disease, Helicobacter pylori gastritis, gastroesophageal reflux, biliary pain, malignancy, gastroparesis, pancreatitis, medication, etc.³ while the rest are attributed as functional dyspepsia which is defined as at least three months of symptoms without definite structural or biochemical explanation.⁴

Helicobacter pylori is a spiral-shaped, microaerophilic, Gram negative, urease positive bacterium that is adapted to survive the harsh, acidic environment of the stomach.⁵ H. pylori infection is often an underlying cause of dyspepsia and reports verify that eradication of H. pylori improves the symptoms in dyspeptic patients.⁶^,⁷ The principal mechanism mostly involves altered gastric acid secretion and persistent active inflammation of gastric mucosa, in addition to delayed gastric emptying and antral gastric secretion.⁸^,⁹ Among different invasive and non-invasive tests available for detection of H. pylori, the rapid urease test is a simple, cheap and quick test to detect urease activity in the gastric mucosa, which requires sampling of the mucosa with an endoscopic approach. The upper GI endoscopy with biopsies has an increasing diagnostic yield with increasing age in patients with dyspepsia, particularly in patients above the age of 60 or those with warning signs. The common endoscopic findings in a background of dyspepsia include erosive esophagitis, gastritis, duodenitis and peptic ulcer disease.¹⁰

Limited studies have estimated the prevalence of H. pylori in the Nepalese population with specific targeting of patients suffering from dyspepsia, with varying results depicted in available studies. The purpose of this study was to estimate the prevalence of H. pylori infection among dyspeptic patients presenting at the gastroenterology department of a tertiary care centre in Nepal and to stratify the different endoscopic findings seen among such patients.

Methods

Study setting

This study was conducted at Shree Birendra Hospital, Kathmandu Nepal. It is a tertiary care hospital dedicated to serving the Nepalese army and their dependent families.

Study design and participants

This study is a cross-sectional, analytical study done on the patients who presented to the Gastroduodenoscopy unit of Shree Birendra Hospital from May 2019 to March 2020. Patients with dyspepsia aged 18 years and above were included in the study. Patients not tolerating endoscopy, previously diagnosed with active peptic ulcer, or stomach cancer, and those who had received H. pylori eradication therapy in the last three months were excluded from the study. Patients with a history of partial or complete gastrectomy, and patients with active UGI bleeding were also excluded.

Sampling and sample size

Non-probability consecutive sampling method was used. Dyspeptic patients presenting for gastroduodenoscopy during the study period were included consecutively. The sample size was calculated by using Cochran’s formula¹ where:

Sample (n) = Z^{2} pq / e^{2}

Studies done in similar populations in Nepal had shown a prevalence of 70 to 90%.²^,³ Thus, p was taken as 70%, q = 100 – p = 30%, Z = 1.96 for 95% confidence, and e = margin of error = 10%. Sample size was calculated to be 164. The final sample size was 170 considering a few non-responses.

Data collection and study variables

A pre-designated proforma was used to record the data. Socio-demographic data and a brief history were collected. The patient’s age, sex, address, occupation, alcohol and smoking history, any history of dyspepsia, or any significant medical history were recorded. They were also asked about dyspeptic symptoms such as epigastric pain, epigastric burning, postprandial fullness, early satiety, bloating, and nausea/vomiting.

Endoscopic findings were categorized as gastritis, duodenitis, gastric ulcer, duodenal ulcer, malignancies; normal, and others. UGI endoscopy was performed using the PENTAX and FUJINON scope by a trained and experienced specialist. A flexible endoscopy tube was introduced after applying a local anesthetic agent and a biopsy sample was taken. Rapid Urease Test (RUT) was done using Helikochek and Pylochek. Biopsy samples, approximately 2–3 mm each were taken from the antrum and placed on the yellow-colored well-containing urea and a pH indicator. The urease enzyme produced by H. pylori breaks down urea into bicarbonate and ammonia, which causes the pH to rise and the color of the dot to change from yellow to red or pink.⁴ The positive results were read within 24hrs. No color change after 24 hours was considered negative.

Ethical consideration

The ethical clearance for this study was obtained from Institutional Review Committee, Nepalese Army Institute of Health Sciences (IRC-NAIHS) with the reference number of 245 (Ref. No. 245). Written informed consent was obtained from each respondent. Data were de-identified and kept on password protected computer.

Data analysis

All data were entered and analyzed using Statistical Package for Social Sciences (IBM-SPSS), version 22. Both descriptive and inferential statistics were used for analysis. Frequencies, mean/standard deviation and median/interquartile range (IQR) were calculated for descriptive analysis. The Chi-square test was used to check the association between independent and dependent variables of categorical data and a p-value of <0.05 was considered to be statistically significant.

Results

A total of 170 patients with dyspeptic symptoms presenting to the Gastroduodenoscopy unit were taken for the study. The median age was 49 (36 – 60) years with majority of patients below sixty years age group (125, 73.53%). The females (87, 51.18%) constituted majority among the total participants. Out of the total, fewer patients had smoking (49, 28.82%) and alcoholic (23, 13.53%) history. The mean years of smoking and alcohol units per day were 6.54 ± 12.349 years and 1.29 ± 5.034 respectively. Similarly, the endoscopic findings revealed gastritis (57, 33.53%) as a major pathology depicted in patients presenting with dyspeptic symptoms. Pantoprazole (131, 77.06%) was the drug taken by most of the patients for their dyspepsia (Table 1).

Table 1. Baseline and clinical characteristics of dyspeptic patients.³⁰

S. N	Variables	Total	H. pylori		p value
S. N	Variables	Total	Positive	Negative	p value
	N	170 (100.00)	56 (32.94)	114 (67.06)
1	Age group				0.663
	<60 years	125 (100.00)	40 (32.00)	85 (68.00)
	≥60 years	45 (100.00)	16 (35.56)	29 (64.44)
2	Gender				0.232
	Male	83 (100.00)	31 (37.35)	52 (62.65)
	Female	87 (100.00)	25 (28.74)	62 (71.26)
3	Smoking history				0.303
	Yes	49 (100.00)	19 (38.78)	30 (61.22)
	No	121 (100.00)	37 (30.58)	84 (69.42)
4	Alcohol history				0.035
	Yes	23 (100.00)	12 (52.17)	11 (47.83)
	No	147 (100.00)	44 (29.93)	103 (70.07)
5	Endoscopy findings				<0.001
	Gastritis	57 (100.00)	29 (50.88)	28 (49.12)
	Duodenitis	5 (100.00)	2 (40.00)	3 (60.00)
	Gastric ulcer	4 (100.00)	2 (50.00)	2 (50.00)
	Duodenal ulcer	3 (100.00)	3 (100.00)	0
	Normal	93 (100.00)	19 (20.43)	74 (79.57)

The overall prevalence of H. pylori was found to be 0.329 (0.259 – 0.406) at 95% Confidence Interval (CI). The males were found to have H. pylori infection more as compared to females (31 [37.35] vs 25 [28.74], p = 0.232). Individuals equal to or above sixty years of age tend to be infected more with H. pylori (16 [35.56] vs 40 [32.00], p = 0.663). And the smoker group was associated more with the infection (19 [38.78] vs 37 [30.58], p = 0.303). However, none of them were statistically significant.

The patients with alcoholic history were significantly associated with H. pylori infection (12 [52.17] vs 44 [29.93], p = 0.035). Likewise, based on endoscopic findings, patients with duodenitis (3, 100%) followed by gastritis (29, 50.88%) were associated more with H. pylori infection. But, this was statistically significant (p < 0.001).

Discussion

The present study reported an overall prevalence rate of 32.9% of H. pylori infection among the studied dyspeptic patients. Previous studies from Nepal have reported wide variation in the prevalence of H. pylori infection among patients with dyspepsia (20.0%-68.1%).¹¹^–¹⁴ In the studies conducted in North India and Bangladesh, the prevalence of H. pylori infection was 85% and 78% respectively.¹⁵^,¹⁶ As compared to the present study, the prevalence of H. pylori infection was relatively lower in developed countries like the United Kingdom 27.4%, Sweden 26.2% and New Zealand 24%.¹⁷^,¹⁸ In contrast, higher prevalence rates than our study have been reported from other developing countries like Kenya 40.86%, Cameroon 64.39%, Mongolia 80.0%, Nigeria 64.0%.¹⁹^–²² The variations in H. pylori prevalence rates throughout studies around the world may be caused by a variety of influencing factors, such as socioeconomic status, standard of living, ethnicity, and geographic location, different diagnostic methods and prior antibiotic use.¹⁹^,²³ In our study, RUT was used as a diagnostic method for H. pylori infection. Among the previous studies conducted in Nepal, some used histological examination as the diagnostic method.¹²^,¹⁴ Chaudhary et al. used H. pylori stool antigen test for diagnosing H. pylori¹¹ while Shrestha et al. diagnosed H. pylori using rapid urease test in his study.¹³ Khalifehgholi et al. conducted a study comparing various diagnostic methods of H. pylori in which the sensitivity of histology, RUT and stool antigen test was reported to be 95.6%, 95.6% and 73.9% respectively. In that study, RUT showed the highest specificity (100%), followed by stool antigen test (86.7%) and histology (77.8%).²⁴

In the present study, the most common endoscopic findings among the H. pylori positive patients were Duodenal ulcer (100.0%), Gastritis (50.88%) and Gastric Ulcer (50.00%). In a study by KC et al., the most common endoscopic findings were Gastric Ulcer (87.3%), Duodenal Ulcer (85%) and Gastritis (63.9%).¹⁴ In another study reported from Saudi Arabia, Duodenal ulcer (47.1%), Gastric Ulcer (45.2%) and Gastritis (44.0%) were the most common endoscopic findings.²³ These kinds of disparities may be attributed to other factors like ethnicity, socio-economic status and geographical location. In the present study, no significant association was found between the H. pylori infection and smoking habit. 38.78% smokers were found to be H. pylori infected while 30.58% non-smokers were H. pylori positive. This finding is in agreement with Akeel et al. and Khalifa et al. who also reported no significant difference in H. pylori infection between smokers and non-smokers.²³^,²⁵ There have been conflicting reports from studies regarding the H. pylori infection and smoking. Ogihara et. al. reported significant negative association between smoking and H. pylori infection, whose study showed 1.5-fold greater risk of H. pylori infection among non-smokers than smokers. This study suggested the hypothesis that smoking causes an increase in acid and pepsin production that shields the stomach mucosa from H. pylori infection.²⁶ In contrast, another study reported a strongly positive correlation between H. pylori infection and current smoking.²⁷ There was a significant association between history of alcohol consumption and H. pylori infection in our study. Similar finding was reported by Chaudhary et al.¹¹ However, few studies have reported that moderate alcohol intake is associated with decreased prevalence of H. pylori infection and may facilitate elimination of H. pylori.²⁸^,²⁹

There has been a wide variation in the prevalence of H. pylori infection from different hospital-based studies conducted in different parts of Nepal. There seems to be a need for another more comprehensive study in this region to examine the relationship between various socio-economic factors, presenting complaints, the effectiveness of various diagnostic methods, premorbid conditions and H. pylori infection.

Limitation of the study

The present study was a hospital-based study. The findings of the study may not be generalizable to the entire population. As the present study was a cross-sectional study, it could not assess the risk factor for H. pylori infection.

Conclusions

H. pylori infection was still prevalent among a sizable majority of dyspeptic patients in our setting. It was significantly associated with alcohol consumption. More comprehensive studies are necessary in this region to study the relationship between socio-economic factors, diagnostic methods, premorbid conditions and H. pylori infection.

Data availability

Underlying data

Figshare: Prevalence of Helicobacter pylori infection in dyspeptic patients presenting to a tertiary care center of a developing country (spss), https://doi.org/10.6084/m9.figshare.22815713.v1.³⁰

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

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