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Helicobacter pylori antigen in stool specimens: A new enzyme immunoassay
Esophageal, Gastric, and Duodenal Disorders A87
April 1998 G0353 CHARACTERIZATION OF CANINE GASTROSPIRILLA. G. Cattol~l; J.G. Kusters2; R.G. Zanoni3; V. Sanguinetti3; M. Gualtieri'~; L.J. van DooruS; C.MJ.E. Vandenbroucke-Granls2; W. GaastraL1 Dept. of Bacteriology, Faculty of Veterinary Medicine, Utrecht, The Netherlands. 2 Dept. of Medical Microbiology. Free University, Amsterdam, The Netherlands. 3 Dept. of Veterinary Public Health and Animal Pathology, Faculty of Veterinary Medicine, Bologna, Italy. 4 Inst. of Clinical Surgery, Faculty of Veterinary Medicine, Milano, Italy. 5 Diagnostic Center SSDZ, Delft, The Netherlands. Introduction. Non-pylori helicobacters are frequently observed in gastric biopsies from dogs and cats and their potential zoonotic role as well as their importance in gastric diseases in animals have been the subject of several studies. In this study we investigated the prevalence of these organisms in dogs, their morphological and biochemical characteristics and the presence of specific virulence factors. Methods. Biopsies from the gastric regions of antrum, body and fundus were obtained from two groups of dogs: A) by autopsy of 15 dogs from a single kennel and B) by endoscopy of 10 pet dogs from different owners. All samples were screened for the presence of helicobacter-like organisms (HLO's) by Gram stain and samples from 13 animals were examined histologically by hematoxyline-eosine stain. Electron microscopy (EM) was performed on 11 tissue samples. Biopsies from all stomachs were cultured on both Brucella agar and Brain Heart Infusion agar supplemented with 10% defibrinated sheep blood. Biochemical characterization and 16S rDNA sequencing of the isolates were performed. Presence of the virulence factors vacA, cagA and iceA genes was analyzed by PCR and reverse hybridization. Results. Cytological and histological examinations revealed the presence of large, Gram negative, tightly coiled bacteria in all 15 dogs of group A and 8 out 10 dogs of group B. Of the 11 samples submitted to EM 4 were negative, 5 revealed Helicobacter heilmannii-like organisms (with no periplasmic fibrils), one revealed H4'~lis-like organisms (with periplasmic fibrils) and one sample was positive for both morphological types. We sucessfully cultured HLO's from 5/25 dogs. Gram stain and EM on positive cultures revealed organisms morphologically similar to the bacteria seen in sire. All 5 isolates were catalase, oxidase and urease positive. Preliminary data of 16S rDNA sequence indicate that these strains are closely related to the H.]~lis/H.heilmannii group. H:felis-like organisms were all positive for vacA/cagA while H.heilmannii-like organisms were negative. All strains were positive for iceA. Conclusion. HLO's are very common in the stomachs of dogs and H.heilmannii-like organisms are prevalent. VacA and cagA do occur in H.felis-like organisms but not in H.heilmannii-like strains; in contrast iceA is present in both morphological types. • G0354
HELICOBACTER PYLORI ANTIGEN IN STOOL SPECIMENS: A NEW ENZYME IMMUNOASSAY. Cavallero A., Mezzi G.*, Fanti L.*, Gesu G., Bonato C., and Masci E.* Clinical Microbiology and Gastroenterology* Units. San Raffaele Hospital ~ Milan, Italy Several diagnostic tests are today available to determine H. pylori infection. Aims: To evaluate sensitivity and specificity of a new enzyme immunoassay, HpSA (Meridian Diagnostics Inc.), for detecting H. pylori antigen in stool specimens, compared with histology and culture. Patients and methods: 45 subjects (21 males, 24 females, mean age 51.06 years) with dyspeptic complaints, who were referred for upper gastrointestinal endoscopy, were enrolled. Exclusion criteria: previous eradication treatment, use of H2-antagonists, proton pump inhibitors, or antibiotics in the last month. Four biopsies (2 antrum and 2 corpus) were taken for histology (H). A further 2 antral biopsies were taken for culture (C). Hp infection was diagnosed if the bacterium was detected by both histology and culture. Stool specimens were collected and submitted to the laboratory to be stored at -20°C until the HpSA test was performed. HpSA is a sandwich EIA procedure that can be performed in about 75 minutes. Results: 34 patients showed normal mucosa (NUD) and 11 patients showed an active or scarred gastric or duodenal ulcer (PU). Histology and culture results were in accordance in all patients except one (H+/C-/HpSA-). Results obtained are shown in the following table:
HpSA-Positive HpSA-Negative
Histology + Culture Positive Negative 25 2 2 15
The test showed a sensitivity, specificity, positive predictive value and negative predictive value of 92.6%, 88.2%, 92.6% and 88.2%, respectively. Concluslon: These preliminary results show that HpSA, a novel, simple, noninvasive test is a promising new tool in the diagnosis of Hp infection.
• G0355 THE FIRST YEAR OF THE U.K. NATIONAL BARRETT'S ESOPHAGUS REGISTRY. C.PJ. Caygill, Slough UK; P.I. Reed, Slough UK; A. Watson, London UK; A. McIntyre, High Wycombe UK; MJ. Hill, Slough UK. Lady Sobell Gastrointestinal Unit, Wexham Park Hospital, Slough SL2 4HL, UK. A U.K. National Registry of Barrett's Esophagus (BE) patients was established in late 1996 as a joint initiative between the Esophageal Section of the British Society of Gastroenterology and the European Cancer Prevention Organization, as the first of its kind in the world. Since then, over 2,000 patients have been registered from 12 centres and baseline demographic and pathological data have been entered onto the database. Preliminary findings include variation among the centres in the diagnostic criteria used to identify B.E. and variation in the perceived requirement for histological confirmation ranging between 20 and 100%. In a more detailed pilot study between two adjacent Health Districts serving a collective catchment population of almost 0.6 million, 268 new patients with B.E. > 3 cm in length were identified in a one year period. The prevalence of B.E. of 46 per 100,000, the male/female preponderance of 1.7, the mean age at diagnosis of 62 in males and 70 in females and the incidence of adenocarcinoma of 1.2% were comparable between the two districts. This study has confirmed the feasibility of establishing a National Registry of B.E. patients, subject to encouraging uniformity of diagnostic criteria, in order to establish regional and temporal variations in prevalence. It will enable monitoring in a large cohort of patients the natural history of the columnarised segment and in particular the incidence on these parameters of medical, endoscopic and surgical therapies. The Registry is also providing a central resource for histopathological confirmation of high grade dysplasia, for molecular genetic studies and a co-ordinating infrastructure for prospective studies in B.E. The U.K. model is already stimulating the establishment of National Registries in other countries, which is to be encouraged in improving our knowledge in this important area. This research was supported by the Childwick Trust, St. Albans, UK. • G0356 ERADICATION OF H. PYLORI VERSUS MAINTENANCE ACID SUPPRESSION TO PREVENT RECURRENT ULCER HEMORRHAGE IN HIGH RISK NSAID USERS: A PROSPECTIVE RANDOMIZED STUDY. FKL Chan l, JY Sung 1, R Suen 2, YT Lee 1, WK Leung l, VKS Leung 1, JCY Wu 1, SCS Chung2. Departments of Medicine I and Surgery 2, Chinese University of Hong Kong. BACKGROUND We have shown that eradication of 1t. pylori before NSAID therapy reduces the risk of ulcer development. AIM To study if eradication of H. pylori reduces recurrent ulcer hemorrhage in NSAID users with past history of ulcer bleeding. METHOD Chronic users of NSAIDs and aspirin presenting with ulcer bleeding were recruited in this study if confirmed to have H. pylori infection. An 8-week course of omeprazole (Omp) 20 mg o.d. was given. After ulcer healing was confirmed by endoscopy, patients receiving aspirin or NSAIDs were separately randomized to receive either maintenance treatment with omeprazole or a 1-week course of triple therapy (BMT: bismuth, tetracycline, and metronidazole) followed by placebo. Patients with arthritis were resumed on naproxen (500 mg b.d.) and patients with ischemic heart disease or TIA were prescribed aspirin (80 mg o.d.). They were followed up regularly for up to 6 months. The study endpoint was recurrent hematemesis -+melena, or drop in Hb > 2 g/dl. RESULTS NAPROXEN (n=100) Omp BMT 53 47 1 : 1.2 1 : 1.2 67 (28-90) 67 (36-85) 23 (43) 29 (62) 29 / 24 19 / 28
Number Sex (M : F) Age(range) Comorbidity (%) GU / DU Endoscopic hemostasis (%) 12 (23) Default (%) 7 (13) Rebleeding (%) 1/46 (2)* Death (%) 1 (2) * p < 0.01 Fisher's Exact test
13 (28) 6 (13) 8/41 (20) 0 (0)
ASPIRIN (n=63) Omp BMT 34 29 1.8:1 2.6:1 72 (47-87) 68 (42-84) 34 (100) 29 (100) 23/11 15/14 7 (21) 3 (9) 1/31 (3) 2 (6)
12 (41) 2 (7) 1/27 (3) 1 (3)
CONCLUSION 1. Eradication of 1-1.pylori protects against recurrent ulcer hemorrhage induced by aspirin but not by non-aspirin NSAID; 2. Omeprazole is effective in preventing recurrence of ulcer hemorrhage both in aspirin and NSAID users with history of ulcer bleeding. This research was not funded by any organization
April 1998 G0353 CHARACTERIZATION OF CANINE GASTROSPIRILLA. G. Cattol~l; J.G. Kusters2; R.G. Zanoni3; V. Sanguinetti3; M. Gualtieri'~; L.J. van DooruS; C.MJ.E. Vandenbroucke-Granls2; W. GaastraL1 Dept. of Bacteriology, Faculty of Veterinary Medicine, Utrecht, The Netherlands. 2 Dept. of Medical Microbiology. Free University, Amsterdam, The Netherlands. 3 Dept. of Veterinary Public Health and Animal Pathology, Faculty of Veterinary Medicine, Bologna, Italy. 4 Inst. of Clinical Surgery, Faculty of Veterinary Medicine, Milano, Italy. 5 Diagnostic Center SSDZ, Delft, The Netherlands. Introduction. Non-pylori helicobacters are frequently observed in gastric biopsies from dogs and cats and their potential zoonotic role as well as their importance in gastric diseases in animals have been the subject of several studies. In this study we investigated the prevalence of these organisms in dogs, their morphological and biochemical characteristics and the presence of specific virulence factors. Methods. Biopsies from the gastric regions of antrum, body and fundus were obtained from two groups of dogs: A) by autopsy of 15 dogs from a single kennel and B) by endoscopy of 10 pet dogs from different owners. All samples were screened for the presence of helicobacter-like organisms (HLO's) by Gram stain and samples from 13 animals were examined histologically by hematoxyline-eosine stain. Electron microscopy (EM) was performed on 11 tissue samples. Biopsies from all stomachs were cultured on both Brucella agar and Brain Heart Infusion agar supplemented with 10% defibrinated sheep blood. Biochemical characterization and 16S rDNA sequencing of the isolates were performed. Presence of the virulence factors vacA, cagA and iceA genes was analyzed by PCR and reverse hybridization. Results. Cytological and histological examinations revealed the presence of large, Gram negative, tightly coiled bacteria in all 15 dogs of group A and 8 out 10 dogs of group B. Of the 11 samples submitted to EM 4 were negative, 5 revealed Helicobacter heilmannii-like organisms (with no periplasmic fibrils), one revealed H4'~lis-like organisms (with periplasmic fibrils) and one sample was positive for both morphological types. We sucessfully cultured HLO's from 5/25 dogs. Gram stain and EM on positive cultures revealed organisms morphologically similar to the bacteria seen in sire. All 5 isolates were catalase, oxidase and urease positive. Preliminary data of 16S rDNA sequence indicate that these strains are closely related to the H.]~lis/H.heilmannii group. H:felis-like organisms were all positive for vacA/cagA while H.heilmannii-like organisms were negative. All strains were positive for iceA. Conclusion. HLO's are very common in the stomachs of dogs and H.heilmannii-like organisms are prevalent. VacA and cagA do occur in H.felis-like organisms but not in H.heilmannii-like strains; in contrast iceA is present in both morphological types. • G0354
HELICOBACTER PYLORI ANTIGEN IN STOOL SPECIMENS: A NEW ENZYME IMMUNOASSAY. Cavallero A., Mezzi G.*, Fanti L.*, Gesu G., Bonato C., and Masci E.* Clinical Microbiology and Gastroenterology* Units. San Raffaele Hospital ~ Milan, Italy Several diagnostic tests are today available to determine H. pylori infection. Aims: To evaluate sensitivity and specificity of a new enzyme immunoassay, HpSA (Meridian Diagnostics Inc.), for detecting H. pylori antigen in stool specimens, compared with histology and culture. Patients and methods: 45 subjects (21 males, 24 females, mean age 51.06 years) with dyspeptic complaints, who were referred for upper gastrointestinal endoscopy, were enrolled. Exclusion criteria: previous eradication treatment, use of H2-antagonists, proton pump inhibitors, or antibiotics in the last month. Four biopsies (2 antrum and 2 corpus) were taken for histology (H). A further 2 antral biopsies were taken for culture (C). Hp infection was diagnosed if the bacterium was detected by both histology and culture. Stool specimens were collected and submitted to the laboratory to be stored at -20°C until the HpSA test was performed. HpSA is a sandwich EIA procedure that can be performed in about 75 minutes. Results: 34 patients showed normal mucosa (NUD) and 11 patients showed an active or scarred gastric or duodenal ulcer (PU). Histology and culture results were in accordance in all patients except one (H+/C-/HpSA-). Results obtained are shown in the following table:
HpSA-Positive HpSA-Negative
Histology + Culture Positive Negative 25 2 2 15
The test showed a sensitivity, specificity, positive predictive value and negative predictive value of 92.6%, 88.2%, 92.6% and 88.2%, respectively. Concluslon: These preliminary results show that HpSA, a novel, simple, noninvasive test is a promising new tool in the diagnosis of Hp infection.
• G0355 THE FIRST YEAR OF THE U.K. NATIONAL BARRETT'S ESOPHAGUS REGISTRY. C.PJ. Caygill, Slough UK; P.I. Reed, Slough UK; A. Watson, London UK; A. McIntyre, High Wycombe UK; MJ. Hill, Slough UK. Lady Sobell Gastrointestinal Unit, Wexham Park Hospital, Slough SL2 4HL, UK. A U.K. National Registry of Barrett's Esophagus (BE) patients was established in late 1996 as a joint initiative between the Esophageal Section of the British Society of Gastroenterology and the European Cancer Prevention Organization, as the first of its kind in the world. Since then, over 2,000 patients have been registered from 12 centres and baseline demographic and pathological data have been entered onto the database. Preliminary findings include variation among the centres in the diagnostic criteria used to identify B.E. and variation in the perceived requirement for histological confirmation ranging between 20 and 100%. In a more detailed pilot study between two adjacent Health Districts serving a collective catchment population of almost 0.6 million, 268 new patients with B.E. > 3 cm in length were identified in a one year period. The prevalence of B.E. of 46 per 100,000, the male/female preponderance of 1.7, the mean age at diagnosis of 62 in males and 70 in females and the incidence of adenocarcinoma of 1.2% were comparable between the two districts. This study has confirmed the feasibility of establishing a National Registry of B.E. patients, subject to encouraging uniformity of diagnostic criteria, in order to establish regional and temporal variations in prevalence. It will enable monitoring in a large cohort of patients the natural history of the columnarised segment and in particular the incidence on these parameters of medical, endoscopic and surgical therapies. The Registry is also providing a central resource for histopathological confirmation of high grade dysplasia, for molecular genetic studies and a co-ordinating infrastructure for prospective studies in B.E. The U.K. model is already stimulating the establishment of National Registries in other countries, which is to be encouraged in improving our knowledge in this important area. This research was supported by the Childwick Trust, St. Albans, UK. • G0356 ERADICATION OF H. PYLORI VERSUS MAINTENANCE ACID SUPPRESSION TO PREVENT RECURRENT ULCER HEMORRHAGE IN HIGH RISK NSAID USERS: A PROSPECTIVE RANDOMIZED STUDY. FKL Chan l, JY Sung 1, R Suen 2, YT Lee 1, WK Leung l, VKS Leung 1, JCY Wu 1, SCS Chung2. Departments of Medicine I and Surgery 2, Chinese University of Hong Kong. BACKGROUND We have shown that eradication of 1t. pylori before NSAID therapy reduces the risk of ulcer development. AIM To study if eradication of H. pylori reduces recurrent ulcer hemorrhage in NSAID users with past history of ulcer bleeding. METHOD Chronic users of NSAIDs and aspirin presenting with ulcer bleeding were recruited in this study if confirmed to have H. pylori infection. An 8-week course of omeprazole (Omp) 20 mg o.d. was given. After ulcer healing was confirmed by endoscopy, patients receiving aspirin or NSAIDs were separately randomized to receive either maintenance treatment with omeprazole or a 1-week course of triple therapy (BMT: bismuth, tetracycline, and metronidazole) followed by placebo. Patients with arthritis were resumed on naproxen (500 mg b.d.) and patients with ischemic heart disease or TIA were prescribed aspirin (80 mg o.d.). They were followed up regularly for up to 6 months. The study endpoint was recurrent hematemesis -+melena, or drop in Hb > 2 g/dl. RESULTS NAPROXEN (n=100) Omp BMT 53 47 1 : 1.2 1 : 1.2 67 (28-90) 67 (36-85) 23 (43) 29 (62) 29 / 24 19 / 28
Number Sex (M : F) Age(range) Comorbidity (%) GU / DU Endoscopic hemostasis (%) 12 (23) Default (%) 7 (13) Rebleeding (%) 1/46 (2)* Death (%) 1 (2) * p < 0.01 Fisher's Exact test
13 (28) 6 (13) 8/41 (20) 0 (0)
ASPIRIN (n=63) Omp BMT 34 29 1.8:1 2.6:1 72 (47-87) 68 (42-84) 34 (100) 29 (100) 23/11 15/14 7 (21) 3 (9) 1/31 (3) 2 (6)
12 (41) 2 (7) 1/27 (3) 1 (3)
CONCLUSION 1. Eradication of 1-1.pylori protects against recurrent ulcer hemorrhage induced by aspirin but not by non-aspirin NSAID; 2. Omeprazole is effective in preventing recurrence of ulcer hemorrhage both in aspirin and NSAID users with history of ulcer bleeding. This research was not funded by any organization