Abstract
This study aimed to determine the association between Helicobacter pylori infection and variceal bleeding as well as rebleeding in cases of cirrhosis with portal hypertension. This prospective cohort study included patients with bleeding oesophageal varices and was conducted at the Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India, from August 2016 to July 2018. A total of 190 patients were assessed for eligibility, of which 159 patients were included in this study. Among the 159 patients, 124 (78.0%) had alcohol-related liver disease and eight had hepatitis B virus-related liver disease. Seven patients with varices had bled neither at presentation nor during the follow-up period. A total of 78 (49.1%) patients were H. pylori infected. The primary outcome, which was correlation between prevalence of H. pylori and the incidence of bleeding/rebleeding from varices as well as encephalopathy found that patients with oesophageal varices (adjusted risk [AR] = 0.714) and H. pylori infection (AR = 0.682) had a lower risk of variceal rebleeding. Among H. pylori-negative patients, pepsinogen I was higher in patients with rebleeding (30.7 versus 14.4 ng/mL; P <0.001). The secondary outcome, which was correlation of the site of bleeding with H. pylori infection and the association of the ratio of pepsinogen I/II with bleeding showed that among H. pylori-positive patients, the ratio of pepsinogen I/II was higher in patients with rebleeding (2.9 versus 1.3 ng/mL; P = 0.023). H. pylori infection was associated with a lower risk of rebleeding in cases of cirrhosis with portal hypertension. Irrespective of the status of the H. pylori infection, rebleeding was associated with increased levels of gastric acid output, as demonstrated by the level of pepsinogen.
Highlights
Helicobacter pylori infection is an universal bacterial infection of mankind and remains a common cause of morbidity and mortality.[1,2,3] It is known that H. pylori infection is associated with chronic gastritis and peptic ulcer disease and mucosa-associated lymphoid tissue (MALToma) lymphoma and gastric adenocarcinoma.[2]
Patients with H. pylori infection were found to have lesser rebleeding episodes than those patients without it [Adjusted Risk (AR) =0.682; p=0.046; CI =0.47 - 0.99](Table 2). 7 out of patients who had encephalopathy were H. pylori infected [Relative risk (RR) =1.83], this difference was not statistically significant (p=0.363).The site of variceal bleeding in patients were independent of H. pylori status (Table 3)
It was found that the prevalence of H. pylori infection among cirrhotic was lower than the general population
Summary
Helicobacter pylori infection is an universal bacterial infection of mankind and remains a common cause of morbidity and mortality.[1,2,3] It is known that H. pylori infection is associated with chronic gastritis and peptic ulcer disease and mucosa-associated lymphoid tissue (MALToma) lymphoma and gastric adenocarcinoma.[2] Bleeding from varices is one of the most common cause of upper gastrointestinal (UGI) bleeding and at times fatal in patients of liver cirrhosis.[4] Esophageal varices by making the esophagogastric junction patulous increase acid reflux into the oesophagus and may lead to high risks for bleeding.[5]. Prevalence of H. pylori infection in patients with Gastro-Esophageal Reflux Disease (GERD). Is significantly lesser than those who do not have GERD indicating possible low acid output with H. pylori. Sakamoto et al in their prospective analysis, proposed the possible negative correlation between variceal bleeding and rebleeding with H. pylori infection due to a possible reduction in the gastric acid output.[4] the proposed negative association has not been clearly established
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