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Distribution of Helicobacter pylori organisms in the stomachs of children with H. pylori infection
Distribution of Helicobacter Pylori Organisms in the Stomachs of Children With H. Pylori Infection YORAM ELITSUR, MD, ZANDRA LAWRENCE, MT, AND WILLIAM E. TRIEST, MD Histology has been recognized as the gold standard for the diagnosis of Helicobacter pylori (Hp) infection in children. For ethical reasons, the number of mucosal biopsies obtained during endoscopic procedures is limited in the pediatric population. The aim of this study was to identify the optimal location where Hp organisms are colonized. Children who were scheduled for upper endoscopic procedures were prospectively recruited for the study. At least 2 mucosal biopsy samples were obtained from the following anatomic locations: greater curvature (mid-fundus [B3], mid-body [B1], and mid-antrum [A1] and lesser curvature mid-body [B2], incisura angularis [A3], and mid-antrum [A2]). In addition, a biopsy sample for a rapid urease test was obtained. The biopsy samples were stained with hematoxylin and eosin and Giemsa for the detection of inflammation and Hp colonization. The degree of mucosal inflammation and Hp colonization was
assessed. The study group comprised 206 children, of whom 16 (8%) were positive for Hp infection. Hp colonization was significantly greater in the antral locations (A1, A2, and A3) than the body locations (B1, B2, and B3) (P <.001). The degree of mucosal inflammation correlated with the presence of Hp organisms, Hp density, and antral location. The mid-antrum location (A2) was superior for the detection of Hp organisms. The antrum, especially mid-antrum, at the lesser curvature is the best location in which to detect Hp organisms in children who have not recently used antibiotics or proton pump inhibitor medications. HUM PATHOL 33:1133-1135. Copyright 2002, Elsevier Science (USA). All rights reserved. Key words: Helicobacter pylori bacteria, pediatric, gastric location. Abbreviations: CLOtest, Camphobacter-like organism test; Hp, Helicobacter pylori.
Helicobacter pylori (Hp) infection occurs mainly in early childhood and has been recognized as a major etiology for gastritis and peptic ulcer disease in children.1 Chronic infection may lead to the development of gastrointestinal malignancy in older persons; thus, proper diagnosis and treatment are important.2 Of all the diagnostic modalities available for diagnosing Hp infection in children, histology has been found to be the most accurate. Consequently, several expert panels on Hp infection in children have established endoscopy with gastric biopsy as the “gold standard” for the diagnosis of this disease in children.3,4 Nonetheless, endoscopy is an invasive procedure that, especially in children, is associated with significant anxiety (in both parents and patients) and is not without risks of anesthesia- or procedural (surgical)-related complications. Thus, for ethical considerations, endoscopic procedures in children should be done rapidly with the intent of retrieving maximum data at 1 setting. Reducing the number of gastric biopsies obtained during endoscopic procedure in children is crucial in achieving this goal. Identifying the anatomic location in the stomach where Hp organisms are most likely to be present is an important step in this direction. Previous studies in
adults have documented the optimal anatomic sites in which to detect Hp organisms in the gastric mucosa.5,6 To our knowledge, no published reports have systematically evaluated the anatomic distribution of Hp organisms in the gastric mucosa of infected children. In this study, we examined the gastric distribution of Hp organisms in children undergoing endoscopy for various medical indications.
From the Department of Pediatrics, Gastroenterology Division, and Department of Pathology, Joan C. Edwards School of Medicine at Marshall University, Huntington, WV. Accepted for publication August 5, 2002. Address correspondence and reprint requests to Yoram Elitsur, MD, Professor and Director, Division of Gastroenterology, Department of Pediatrics, Joan C. Edwards School of Medicine at Marshall University, 1600 Medical Center Drive, Huntington, WV 25701-3655. Copyright 2002, Elsevier Science (USA). All rights reserved. 0046-8177/02/3311-0012$35.00/0 doi:10.1053/hupa.2002.129201
MATERIALS AND METHODS Patient Populations Children who underwent upper endoscopic procedures for various medical reasons were prospectively recruited to the study. The exclusion criteria included children under age 2 years, children with a previous diagnosis of Hp infection, and children who had received antibiotics, proton pump inhibitors, or bismuth salt compounds 1 month before endoscopy. The study was approved by the Marshall University Institutional Review Board (IRB).
Endoscopy Procedures All endoscopic procedures were performed by an experienced endoscopist (Y. E.). All procedures were executed under general anesthesia or deep sedation with propofol. During endoscopy, 2 biopsy samples were taken from each of the following anatomic locations: greater curvature (midfundus [B3], mid-body [B1], and mid-antrum [A1] and lesser curvature mid-body [B2], incisura angularis [A3], and midantrum [A2]), as shown in Figure 1. In addition, 2 biopsy samples from the antrum were obtained for a rapid urease test (Camphobacter-like organism test [CLOtest]; Ballard Medical Products, Draper, UT). The presence of gastric nodularity or ulcer was recorded in each procedure.
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HUMAN PATHOLOGY
Volume 33, No. 11 (November 2002)
firmed by morphologic evaluation under oil immersion (⫻1000).
Statistical Analysis The 2 (Epi Info 2000, Version 1.12; Epi Info, Center for Disease Control, Atlanta, GA) or Mann-Whitney ranked sum (Sigmastat; Jandel Scientific Software, San Rafael, CA) test was used to calculate P values and odds ratios.
RESULTS
FIGURE 1. Schematic representation of the gastric sites from which mucosal biopsies were obtained (A-antrum, B-body)
Histologic Assessment The degree of inflammation and presence of Hp organisms were assessed by hematoxylin and eosin and Giemsa staining, respectively. A single experienced pathologist (W. E. T.) read all specimens. At the time of the histologic evaluation, the pathologist was blinded to the macroscopic appearance of the stomach during endoscopy and to the CLOtest results. Mucosal inflammation was graded according to the revised Sydney system.7 Inflammation was graded as mild, moderate, or marked/severe, and Hp organism density was graded on a scale of 0 to 4: 0, negative; .5, scant or rare; 1⫹, mild; 2⫹, moderate; 3 to 4⫹, marked or severe. A biopsy sample was considered positive when Hp organisms were found histologically. Giesma-stained slides were examined at ⫻400 magnification. Identification of Hp organisms was con-
A total of 206 children were recruited into the study (Table 1). The male to female ratio was .8:1.0, and the mean age was 10.6 ⫾ 3.8 years (range, 2 to 20 years; median, 10 years). A total of 16 (8%) children were positive for Hp infection; of these, 12 (75%) were also positive for the CLOtest. Overall, in Hp-infected children, the bacterium was more often detected in the antrum (A1, A2, and A3) than in the body sites (B1, B2, and B3), (mean detection rate, 94% versus 73%, respectively; Table 1). In addition, the density grade of Hp colonization was also greater in the antrum than in the body (Table 2). Gastric nodularity was observed in 14 patients in the Hp-positive group and in 2 patients in the Hp-negative group. Three duodenal ulcers were reported in the Hp-positive group and 5 in the Hpnegative group. Mucosal inflammation (gastritis) was significantly associated with the presence of Hp organisms (93% in Hp-positive children versus 34% in Hp-negative children; P ⬍.0001, odds ratio 24.5 [10.8 to 58.2]) (Table 1). Moreover, the inflammatory score (gastritis grading) was increased in children with Hp infection. The total number of all biopsies with moderate/severe gastritis (antrum and body) was 55 of 96 (57%) in Hp-
TABLE 1. Anatomic Distribution of H. pylori Organisms in the Gastric Mucosa No. of Patients H. pylori-positive Gastritis-positive Grade: Mild Moderate Severe Moderate/severe H. pylori-negative Gastritis-positive Grade: Mild Moderate Severe Moderate/severe
16 16
190 126
A-1
A-2
A-3
Total A
B-1
B-2
B-3
Total B
15 14 87%
16 16 100%
14 15 93%
45 (94%)* 45 94%
11 15 93%
12 15 93%
12 14 87%
35 (73%) 44 92%
3 7 4
3 6 7
2 4 9
8 (17%) 17 (38%) 20 (44%)§
9 6 0
6 8 1
11 3 0
26 (59%) 17 (38.6%) 1 (2.3%)
190 82 43%
190 86 45%
190 84 44%
570 252 44%
190 44 23%
190 49 25%
190 45 24%
570 138 24%
70 11 1
66 19 1
69 14 1
205 (81.3%) 44 (17.5%)¶ 3 (1.2%)
42 2 0
44 4 1
42 3 0
128 (92.8%) 9 (6.5%) 1 (0.7%)
*P value .01; Hp detection rate in Hp-positive children; antrum compared with body. †P value ⬍ .0001; gastritis rate in Hp-positive children compared with Hp-negative children. §P value ⬍ .0001; moderate/severe gastritis in Hp-positive children compared with Hp-negative children. 㛳 P value .0001; severe gastritis in Hp-positive children; antrum compared with body. ¶P value ⬍ .004; moderate gastritis in Hp-negative children; antrum compared with body.
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Total A⫹B 96 89 93%† 34 34 21 55㛳 1140 390 34% 333 53 4 57
CLO-Positive 12
0
ANATOMIC DISTRIBUTION OF H. PYLORI IN CHILDREN (Elitsur et al)
TABLE 2. Colonization of H. pylori Organisms in the Gastric Mucosa Colonization Density (Grade)
A1 #
A2 #
A3 #
Total-A #
B1 #
B2 #
B3 #
Total-B #
0 0.5 to 2⫹ 3 to 4⫹ Total positive
0 9 7 16
0 7 9 16
2 4 10 14
2 20 26* 46†
5 9 2 11
4 7 5 12
4 11 1 12
13 27 8 35
*P value .002, colonization density (grade 3 to 4⫹); antrum (all As) compared to body (all Bs). †P value .002, colonization rate; antrum (all As) compared to body (all Bs).
positive children and 57 of 1140 (5%) in Hp-negative children (P ⬍.0001, odds ratio 25.5 [15.3 to 42.6] (Table 1). In addition, significantly greater inflammation was noted in the antrum locations (A1, A2, and A3) than in the body locations (B1, B2, and B3) in both Hp-positive (severe gastritis, 44% versus 2.3%, respectively; P ⬍.0001, odds ratio 34.4 [4.4 to 729.5]) and Hp-negative children (moderate gastritis, 17.5% versus 6.5%, respectively; P ⬍.004, odds ratio 3.0 [1.4 to 6.9]) (Table 1).
pecially the A2 location, is the preferred location for obtaining biopsy samples. We conclude that when a limited number of gastric biopsy samples is considered, the antrum is the best anatomic location in which to detect Hp organisms in children. Acknowledgment: We acknowledge the help of the pathology technicians, especially Mrs Virginia L. Maynard, HT (ASCP), and the staff from the histology laboraotry at Cabell Huntington Hospital for their technical assistance.
DISCUSSION REFERENCES Hp infection is most commonly contracted in early childhood. Because Hp infection is associated with childhood morbidity and future cancer development, treatment protocols to eradicate the bacteria have been suggested by several expert committees.3,4 Unfortunately, the resistance of Hp organisms to commonly used antibiotics is increasing in the United States8,9 and worldwide.10 This trend clearly demonstrates the importance of making an accurate diagnosis and determining which patient to treat. Gastric histology is the most accurate diagnostic method for detecting Hp infection in children; thus identifying the best anatomic location from which to obtain the biopsy is crucial to increase sensitivity and reduce morbidity and cost. Unfortunately, to the best of our knowledge, the anatomic distribution of Hp colonization in the stomach of children has not been previously reported. In the present study, we have demonstrated the anatomic distribution of Hp organisms in children with Hp infection. Similar to the data published for the adult population,5,6 the antrum demonstrated the highest sensitivity rate (mean detection, 94% in the antrum versus 73% in the body) for the detection of Hp organisms. Among the antrum locations, detection was best in the A2 location (sensitivity 100%; Table 1). Among the body sites, B1 had the lowest sensitivity (68.75%). In concordance with previous reports,11 we also found that gastritis was significantly associated with the presence of Hp organisms, and that its severity was directly correlated with the degree of bacterial colonization. In conclusion, we have demonstrated for the first time the gastric distribution of Hp organisms in children undergoing endoscopic procedure for various medical reasons. We have shown that the antrum, es-
1. Drumm B. Helicobacter pylori in the pediatric patient. Gastroenterol Clin North Am 22:169-182, 1993 2. Huang JQ, Sridhars CY, Hunt RH. Meta-analysis of the relationship between Helicobacter pylori seropositivity and gastric cancer. Gastroenterology 114:1169-1179, 1998 3. Sherman P, Hassall E, Hunt RH, et al: Canadian Helicobacter study group consensus conference on the approach to Helicobacter pylori infection in children and adolescents. Can J Gastroenterol 13:553-559, 1999 4. Gold BD, Colletti RB, Abbott M, et al: Helicobacter pylori infection in children: Recommendations for diagnosis and treatment. A medical position statement of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr 31:490-497, 2000 5. Genta RM, Graham DY: Comparison of biopsy sites for the histopathologic diagnosis of Helicobacter pylori: A topographic study of H. pylori density and distribution. Gastrointest Endosc 40:342-345, 1994 6. Satoh K, Kimura K, Taniguchi Y, et al: Biopsy sites suitable for the diagnosis of Helicobacter pylori infection and the assessment of the extent of atrophic gastritis. Am J Gastroenterol 93:569-573, 1998 7. Dixon MF, Genta RM, Yardley J, et al and the participants in the International Workshop on the Histopathology of Gastritis, Houston 1994: Classification and grading of gastritis. The updated Sydney System. Am J Surg Pathol 20:1161-1181, 1996 8. Vasundhara T, Brown W, El-Baba M, et al: Helicobacter pylori culture and antimicrobial susceptibility from pediatric patients in Michigan. Pediatr Infect Dis J 19:1167-1171, 2000 9. Laine L, Malone T, Bocheneck W, et al: Current U.S. rates of H. pylori antibiotic resistance and factors predicting resistance: Results for ongoing trials at 77 sites [abstract]. Gastroenterology 116: A228, 1999 10. European Study Group on Antibiotic Susceptibility of Helicobacter pylori: Results of a multicenter survey in 1991 of metronidazole resistance in Helicobacter pylori. Eur J Clin Microbiol 11:777781, 1992 11. Alam K, Schubert TT, Bologna SD, et al: Increased density of Helicobacter pylori on antral biopsy is associated with severity of acute and chronic inflammation and likelihood of duodenal ulceration. Am J Gastroenterol 87:424-428, 1992
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assessed. The study group comprised 206 children, of whom 16 (8%) were positive for Hp infection. Hp colonization was significantly greater in the antral locations (A1, A2, and A3) than the body locations (B1, B2, and B3) (P <.001). The degree of mucosal inflammation correlated with the presence of Hp organisms, Hp density, and antral location. The mid-antrum location (A2) was superior for the detection of Hp organisms. The antrum, especially mid-antrum, at the lesser curvature is the best location in which to detect Hp organisms in children who have not recently used antibiotics or proton pump inhibitor medications. HUM PATHOL 33:1133-1135. Copyright 2002, Elsevier Science (USA). All rights reserved. Key words: Helicobacter pylori bacteria, pediatric, gastric location. Abbreviations: CLOtest, Camphobacter-like organism test; Hp, Helicobacter pylori.
Helicobacter pylori (Hp) infection occurs mainly in early childhood and has been recognized as a major etiology for gastritis and peptic ulcer disease in children.1 Chronic infection may lead to the development of gastrointestinal malignancy in older persons; thus, proper diagnosis and treatment are important.2 Of all the diagnostic modalities available for diagnosing Hp infection in children, histology has been found to be the most accurate. Consequently, several expert panels on Hp infection in children have established endoscopy with gastric biopsy as the “gold standard” for the diagnosis of this disease in children.3,4 Nonetheless, endoscopy is an invasive procedure that, especially in children, is associated with significant anxiety (in both parents and patients) and is not without risks of anesthesia- or procedural (surgical)-related complications. Thus, for ethical considerations, endoscopic procedures in children should be done rapidly with the intent of retrieving maximum data at 1 setting. Reducing the number of gastric biopsies obtained during endoscopic procedure in children is crucial in achieving this goal. Identifying the anatomic location in the stomach where Hp organisms are most likely to be present is an important step in this direction. Previous studies in
adults have documented the optimal anatomic sites in which to detect Hp organisms in the gastric mucosa.5,6 To our knowledge, no published reports have systematically evaluated the anatomic distribution of Hp organisms in the gastric mucosa of infected children. In this study, we examined the gastric distribution of Hp organisms in children undergoing endoscopy for various medical indications.
From the Department of Pediatrics, Gastroenterology Division, and Department of Pathology, Joan C. Edwards School of Medicine at Marshall University, Huntington, WV. Accepted for publication August 5, 2002. Address correspondence and reprint requests to Yoram Elitsur, MD, Professor and Director, Division of Gastroenterology, Department of Pediatrics, Joan C. Edwards School of Medicine at Marshall University, 1600 Medical Center Drive, Huntington, WV 25701-3655. Copyright 2002, Elsevier Science (USA). All rights reserved. 0046-8177/02/3311-0012$35.00/0 doi:10.1053/hupa.2002.129201
MATERIALS AND METHODS Patient Populations Children who underwent upper endoscopic procedures for various medical reasons were prospectively recruited to the study. The exclusion criteria included children under age 2 years, children with a previous diagnosis of Hp infection, and children who had received antibiotics, proton pump inhibitors, or bismuth salt compounds 1 month before endoscopy. The study was approved by the Marshall University Institutional Review Board (IRB).
Endoscopy Procedures All endoscopic procedures were performed by an experienced endoscopist (Y. E.). All procedures were executed under general anesthesia or deep sedation with propofol. During endoscopy, 2 biopsy samples were taken from each of the following anatomic locations: greater curvature (midfundus [B3], mid-body [B1], and mid-antrum [A1] and lesser curvature mid-body [B2], incisura angularis [A3], and midantrum [A2]), as shown in Figure 1. In addition, 2 biopsy samples from the antrum were obtained for a rapid urease test (Camphobacter-like organism test [CLOtest]; Ballard Medical Products, Draper, UT). The presence of gastric nodularity or ulcer was recorded in each procedure.
1133
HUMAN PATHOLOGY
Volume 33, No. 11 (November 2002)
firmed by morphologic evaluation under oil immersion (⫻1000).
Statistical Analysis The 2 (Epi Info 2000, Version 1.12; Epi Info, Center for Disease Control, Atlanta, GA) or Mann-Whitney ranked sum (Sigmastat; Jandel Scientific Software, San Rafael, CA) test was used to calculate P values and odds ratios.
RESULTS
FIGURE 1. Schematic representation of the gastric sites from which mucosal biopsies were obtained (A-antrum, B-body)
Histologic Assessment The degree of inflammation and presence of Hp organisms were assessed by hematoxylin and eosin and Giemsa staining, respectively. A single experienced pathologist (W. E. T.) read all specimens. At the time of the histologic evaluation, the pathologist was blinded to the macroscopic appearance of the stomach during endoscopy and to the CLOtest results. Mucosal inflammation was graded according to the revised Sydney system.7 Inflammation was graded as mild, moderate, or marked/severe, and Hp organism density was graded on a scale of 0 to 4: 0, negative; .5, scant or rare; 1⫹, mild; 2⫹, moderate; 3 to 4⫹, marked or severe. A biopsy sample was considered positive when Hp organisms were found histologically. Giesma-stained slides were examined at ⫻400 magnification. Identification of Hp organisms was con-
A total of 206 children were recruited into the study (Table 1). The male to female ratio was .8:1.0, and the mean age was 10.6 ⫾ 3.8 years (range, 2 to 20 years; median, 10 years). A total of 16 (8%) children were positive for Hp infection; of these, 12 (75%) were also positive for the CLOtest. Overall, in Hp-infected children, the bacterium was more often detected in the antrum (A1, A2, and A3) than in the body sites (B1, B2, and B3), (mean detection rate, 94% versus 73%, respectively; Table 1). In addition, the density grade of Hp colonization was also greater in the antrum than in the body (Table 2). Gastric nodularity was observed in 14 patients in the Hp-positive group and in 2 patients in the Hp-negative group. Three duodenal ulcers were reported in the Hp-positive group and 5 in the Hpnegative group. Mucosal inflammation (gastritis) was significantly associated with the presence of Hp organisms (93% in Hp-positive children versus 34% in Hp-negative children; P ⬍.0001, odds ratio 24.5 [10.8 to 58.2]) (Table 1). Moreover, the inflammatory score (gastritis grading) was increased in children with Hp infection. The total number of all biopsies with moderate/severe gastritis (antrum and body) was 55 of 96 (57%) in Hp-
TABLE 1. Anatomic Distribution of H. pylori Organisms in the Gastric Mucosa No. of Patients H. pylori-positive Gastritis-positive Grade: Mild Moderate Severe Moderate/severe H. pylori-negative Gastritis-positive Grade: Mild Moderate Severe Moderate/severe
16 16
190 126
A-1
A-2
A-3
Total A
B-1
B-2
B-3
Total B
15 14 87%
16 16 100%
14 15 93%
45 (94%)* 45 94%
11 15 93%
12 15 93%
12 14 87%
35 (73%) 44 92%
3 7 4
3 6 7
2 4 9
8 (17%) 17 (38%) 20 (44%)§
9 6 0
6 8 1
11 3 0
26 (59%) 17 (38.6%) 1 (2.3%)
190 82 43%
190 86 45%
190 84 44%
570 252 44%
190 44 23%
190 49 25%
190 45 24%
570 138 24%
70 11 1
66 19 1
69 14 1
205 (81.3%) 44 (17.5%)¶ 3 (1.2%)
42 2 0
44 4 1
42 3 0
128 (92.8%) 9 (6.5%) 1 (0.7%)
*P value .01; Hp detection rate in Hp-positive children; antrum compared with body. †P value ⬍ .0001; gastritis rate in Hp-positive children compared with Hp-negative children. §P value ⬍ .0001; moderate/severe gastritis in Hp-positive children compared with Hp-negative children. 㛳 P value .0001; severe gastritis in Hp-positive children; antrum compared with body. ¶P value ⬍ .004; moderate gastritis in Hp-negative children; antrum compared with body.
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Total A⫹B 96 89 93%† 34 34 21 55㛳 1140 390 34% 333 53 4 57
CLO-Positive 12
0
ANATOMIC DISTRIBUTION OF H. PYLORI IN CHILDREN (Elitsur et al)
TABLE 2. Colonization of H. pylori Organisms in the Gastric Mucosa Colonization Density (Grade)
A1 #
A2 #
A3 #
Total-A #
B1 #
B2 #
B3 #
Total-B #
0 0.5 to 2⫹ 3 to 4⫹ Total positive
0 9 7 16
0 7 9 16
2 4 10 14
2 20 26* 46†
5 9 2 11
4 7 5 12
4 11 1 12
13 27 8 35
*P value .002, colonization density (grade 3 to 4⫹); antrum (all As) compared to body (all Bs). †P value .002, colonization rate; antrum (all As) compared to body (all Bs).
positive children and 57 of 1140 (5%) in Hp-negative children (P ⬍.0001, odds ratio 25.5 [15.3 to 42.6] (Table 1). In addition, significantly greater inflammation was noted in the antrum locations (A1, A2, and A3) than in the body locations (B1, B2, and B3) in both Hp-positive (severe gastritis, 44% versus 2.3%, respectively; P ⬍.0001, odds ratio 34.4 [4.4 to 729.5]) and Hp-negative children (moderate gastritis, 17.5% versus 6.5%, respectively; P ⬍.004, odds ratio 3.0 [1.4 to 6.9]) (Table 1).
pecially the A2 location, is the preferred location for obtaining biopsy samples. We conclude that when a limited number of gastric biopsy samples is considered, the antrum is the best anatomic location in which to detect Hp organisms in children. Acknowledgment: We acknowledge the help of the pathology technicians, especially Mrs Virginia L. Maynard, HT (ASCP), and the staff from the histology laboraotry at Cabell Huntington Hospital for their technical assistance.
DISCUSSION REFERENCES Hp infection is most commonly contracted in early childhood. Because Hp infection is associated with childhood morbidity and future cancer development, treatment protocols to eradicate the bacteria have been suggested by several expert committees.3,4 Unfortunately, the resistance of Hp organisms to commonly used antibiotics is increasing in the United States8,9 and worldwide.10 This trend clearly demonstrates the importance of making an accurate diagnosis and determining which patient to treat. Gastric histology is the most accurate diagnostic method for detecting Hp infection in children; thus identifying the best anatomic location from which to obtain the biopsy is crucial to increase sensitivity and reduce morbidity and cost. Unfortunately, to the best of our knowledge, the anatomic distribution of Hp colonization in the stomach of children has not been previously reported. In the present study, we have demonstrated the anatomic distribution of Hp organisms in children with Hp infection. Similar to the data published for the adult population,5,6 the antrum demonstrated the highest sensitivity rate (mean detection, 94% in the antrum versus 73% in the body) for the detection of Hp organisms. Among the antrum locations, detection was best in the A2 location (sensitivity 100%; Table 1). Among the body sites, B1 had the lowest sensitivity (68.75%). In concordance with previous reports,11 we also found that gastritis was significantly associated with the presence of Hp organisms, and that its severity was directly correlated with the degree of bacterial colonization. In conclusion, we have demonstrated for the first time the gastric distribution of Hp organisms in children undergoing endoscopic procedure for various medical reasons. We have shown that the antrum, es-
1. Drumm B. Helicobacter pylori in the pediatric patient. Gastroenterol Clin North Am 22:169-182, 1993 2. Huang JQ, Sridhars CY, Hunt RH. Meta-analysis of the relationship between Helicobacter pylori seropositivity and gastric cancer. Gastroenterology 114:1169-1179, 1998 3. Sherman P, Hassall E, Hunt RH, et al: Canadian Helicobacter study group consensus conference on the approach to Helicobacter pylori infection in children and adolescents. Can J Gastroenterol 13:553-559, 1999 4. Gold BD, Colletti RB, Abbott M, et al: Helicobacter pylori infection in children: Recommendations for diagnosis and treatment. A medical position statement of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr 31:490-497, 2000 5. Genta RM, Graham DY: Comparison of biopsy sites for the histopathologic diagnosis of Helicobacter pylori: A topographic study of H. pylori density and distribution. Gastrointest Endosc 40:342-345, 1994 6. Satoh K, Kimura K, Taniguchi Y, et al: Biopsy sites suitable for the diagnosis of Helicobacter pylori infection and the assessment of the extent of atrophic gastritis. Am J Gastroenterol 93:569-573, 1998 7. Dixon MF, Genta RM, Yardley J, et al and the participants in the International Workshop on the Histopathology of Gastritis, Houston 1994: Classification and grading of gastritis. The updated Sydney System. Am J Surg Pathol 20:1161-1181, 1996 8. Vasundhara T, Brown W, El-Baba M, et al: Helicobacter pylori culture and antimicrobial susceptibility from pediatric patients in Michigan. Pediatr Infect Dis J 19:1167-1171, 2000 9. Laine L, Malone T, Bocheneck W, et al: Current U.S. rates of H. pylori antibiotic resistance and factors predicting resistance: Results for ongoing trials at 77 sites [abstract]. Gastroenterology 116: A228, 1999 10. European Study Group on Antibiotic Susceptibility of Helicobacter pylori: Results of a multicenter survey in 1991 of metronidazole resistance in Helicobacter pylori. Eur J Clin Microbiol 11:777781, 1992 11. Alam K, Schubert TT, Bologna SD, et al: Increased density of Helicobacter pylori on antral biopsy is associated with severity of acute and chronic inflammation and likelihood of duodenal ulceration. Am J Gastroenterol 87:424-428, 1992
1135