Helicobacter pylori Helicobacter pylori infection and its infection and its consequencesconsequences

We pathologists We pathologists knew squat knew squat

about gastritis about gastritis before before H pyloriH pylori

was discovered.was discovered.

H pylori infects the H pylori infects the whole stomach, but whole stomach, but it induces a chronic it induces a chronic gastritis that is most gastritis that is most intense in the antal intense in the antal mucosamucosa

Classic H pylori gastritis: Classic H pylori gastritis: the great blue biopsythe great blue biopsy

Plasmacytosis Plasmacytosis (superficial) in(superficial) in

the lamina propriathe lamina propria

Induced lymphoid follicles Induced lymphoid follicles at the base of the mucosaat the base of the mucosa

Activity withActivity withPMNs in the necksPMNs in the necks

In most cases, the bacteria In most cases, the bacteria can be found in the H and E can be found in the H and E stained section, on the surface stained section, on the surface epithelium, often over the epithelium, often over the intecellular junctions and intecellular junctions and beneath the surface mucus beneath the surface mucus coat. They appear as tiny thin coat. They appear as tiny thin rods often with a bend in the rods often with a bend in the center, like a set of wings.center, like a set of wings.

Bugs on the surface of the epitheliumBugs on the surface of the epitheliumBugs on the surface of the epitheliumBugs on the surface of the epithelium

Often they hide in the detached mucusOften they hide in the detached mucus

Not allNot all H pylori H pylori gastritis is the same gastritis is the same..

There may beThere may be population differencespopulation differences individual differencesindividual differences minimal disease with tons of bugsminimal disease with tons of bugs intense disease with few bugsintense disease with few bugs variable eosinophils variable eosinophils variable activityvariable activity

H pyloriH pylori identification when they identification when they are difficult to find on H&E; are difficult to find on H&E; other stains have been used.other stains have been used.

Silver Silver

Diff-quickDiff-quick

H pyloriH pylori identification when identification when they are difficult to find on H&Ethey are difficult to find on H&E

Immunostain, our current methodImmunostain, our current method

Active Active H pyloriH pylori antral gastritisantral gastritis

H pylori H pylori GastritisGastritis

Untreated Plasmacytosis Activity Bugs Lymphoid hyperplasia

Treated Bugs disappear Activity stops Plasmacytosis recedes Lymphoid follicles atrophy

H pyloriH pylori

killerkiller

H pyloriH pylori

killerkiller

Biopsies that Biopsies that look like look like treated treated H pyloriH pylori gastritis are gastritis are commoncommon

Superficial Superficial PlasmacytosisPlasmacytosis

No activity. No activity. No bugs on No bugs on the surface.the surface.

Usually, this inactive Usually, this inactive chronic gastritis has chronic gastritis has

no no H pyloriH pylori

These days, a few biopsies of inactive chronic These days, a few biopsies of inactive chronic gastritis have bugs gastritis have bugs on immunostainon immunostain,, often deep in often deep in the the pitspits and even in the and even in the glandsglands and and not on the not on the surface.surface. Thid may result from chronic Thid may result from chronic PPI usePPI use

In the pitsIn the pitsIn the glandsIn the glands

Otherwise, this common inactive Otherwise, this common inactive chronic gastritis without chronic gastritis without H pylori H pylori has no name and no literature.has no name and no literature. But we keep seeing it.But we keep seeing it.

Chronic Chronic inactiveinactive gastritis, gastritis,with no bugs: WHY?with no bugs: WHY?

Biopsy missed bugsBiopsy missed bugs different causedifferent cause proton pump inhibitorsproton pump inhibitors antibioticsantibiotics

Approach to patients with Approach to patients with heartburn and dyspepsiaheartburn and dyspepsia

First, acid suppression, First, acid suppression, commonly commonly Proton Proton Pump Inhibitors (PPIs)Pump Inhibitors (PPIs)If no response, then upper If no response, then upper endoscopy and potential endoscopy and potential biopsiesbiopsies

Protein pump inhibitor effectsProtein pump inhibitor effectsParietal cell acid secretionParietal cell acid secretion

HypergastrinemiaHypergastrinemia Parietal cell hypertrophy: Parietal cell hypertrophy: snoutssnouts ?Parietal cell hyperplasia?Parietal cell hyperplasia ?Polyps containing fundic glands?Polyps containing fundic glands ECL cell stimulation in humans ECL cell stimulation in humans unclearunclear

antral pHantral pH

Protein pump inhibitor effectsProtein pump inhibitor effectsParietal cell acid secretionParietal cell acid secretion antral pHantral pH

Treats antral Treats antral H pylori:H pylori:Bugs migrate proximally Bugs migrate proximally or deeply or deeply activity disappearsactivity disappears Plasmacytosis recedesPlasmacytosis recedes lymphoid follicles atrophylymphoid follicles atrophy

H pyloriH pyloriCauses:Causes:

peptic ulcers ( mechanism peptic ulcers ( mechanism unknown), unknown), a clinical diseasea clinical disease chronic active gastritis, chronic active gastritis, mostly antralmostly antral, , not a clinical not a clinical diseasedisease

Complications of H pylori infectionPeptic ulcers, mainly in the duodenumAdenocarcinoma, secondary to dysplasias that develop in atrophic gastritis (see atrophic gastritis module for definitions and diagnostic criteria)B cell lymphomas, both low and high grade, probably developing in the induced lymphoid follicles at the base of the mucosa

There is a second There is a second bacterium that causes an bacterium that causes an active chronic gastritis, active chronic gastritis, similar to, but less similar to, but less intense than, intense than, H pylori H pylori gastritis.gastritis.

Helicobacter heilmanniiHelicobacter heilmannii

Helicobacter heilmannii is Helicobacter heilmannii is really rare around here.really rare around here.The bugs:The bugs: 7-10 microns7-10 microns Urease +Urease + Dog and cat transmittedDog and cat transmitted

The disease:The disease: 39 cases in 15,180 antral bxs 39 cases in 15,180 antral bxs (Heilmann & Borchard, Gut 32:137, 1991(Heilmann & Borchard, Gut 32:137, 1991 Antrum 100%; body 20%Antrum 100%; body 20% Chronic active -it is, less than H pyloriChronic active -it is, less than H pylori

H heilmanniiH heilmannii comes from household comes from household pets, so don’t share eating utensiles with pets, so don’t share eating utensiles with your cats and dogs unless you eat first.your cats and dogs unless you eat first.