Effect of Helicobacter pylori infection
on Non-steroidal Anti-inflammatory
Drug (including Acetylsalicylic acid)
induced Gastric Damage: A Protector or
Disaster?
JayaKrishna Chintanaboina MBBS
Stanley J Pietrak MD
NSAID-induced Gastric damage
Most commonly used medications
 30 billion OTC pills/year
 70 million prescriptions/year
 Bleeding / Perforation- 3-4% users/year
 Mortality - 20,000 patients/year

Gastroduodenal mucosal defense
Components involved in providing gastroduodenal mucosal defense and repair.
NSAID-induced gastric damage
Mechanisms by which NSAIDs may induce mucosal injury
Helicobacter pylori

Barry Marshall and Robin Warren in 2005



Prevalence in USA – 30%
< 30yrs of age – 10%
< 50yrs of age - 50%

Rate of infection is USA : Declined

Route of transmission

Frank peptic ulceration -10-15%
Risk Factors for H.pylori infection
1.
2.
3.
4.
5.
6.
Birth or residence in a developing
country
Low socioeconomic status
Domestic crowding
Unsanitary living conditions
Unclean food or water
Exposure to gastric contents of infected
individual
Helicobacter pylori
Potential mechanisms by which H. pylori may lead to gastric secretory abnormalities
Diagnostic tests
Radiographic Barium studies
 Endoscopy
 Tests for detection of H.pylori
1. Invasive:
a) Rapid Urease
- 80-95% / 95-100%
b) Histology
- 80-90% / > 95%
c) Culture
2. Non-invasive:
a) Serology
- >80/>90 %
b) Urea breath test
- >90/>90 %

Research question

What is the prevalence and effect of
Helicobacter pylori infection in/on NSAID
(including ASA) induced gastroduodenal
damage?
Previous Research Studies?

Kamada T et al; Endoscopic characteristics and Helicobacter pylori
infection in NSAID-associated gastric ulcer. J Gastroenterol
Hepatol. 2006 Jan;21(1 Pt 1):98-102

Zapata-Colindres JC et al; The association of Helicobacter pylori
infection and non-steroidal anti-inflammatory drugs in peptic ulcer
disease; Can J Gastroenterol. 2006 Apr;20(4):277-80

Ootani H et al; Role of Helicobacter pylori infection and
nonsteroidal anti-inflammatory drug use in bleeding peptic ulcers
in Japan; J Gastroenterol. 2006 Jan;41(1):41-6

Okan A et al; Relationship between non-steroidal antiinflammatory drug use and Helicobacter pylori infection in
bleeding or uncomplicated peptic ulcers: A case-control study; J
Gastroenterol Hepatol. 2003 Jan;18(1):18-25
METHODS
Retrospective study
 Total of 965 charts reviewed
 345 subjects selected for the study
 Variables: Age, Gender, Medical illnesses,
Status- NSAID/ H.Pylori / both, severity of
gastric damage, PPI status, Endoscopyindication and results.
 SPSS version 17.0

METHODS

1.
2.
3.
4.
Inclusion criteria:

1.
2.
3.
4.
Exclusion criteria:
Age : 21- 90yrs
On NSAIDs at the time of endoscopy
H. pylori test positivity
Both
On Steroids
Gastrointestinal malignancy
Gastric Bypass surgery
Inflammatory bowel disease
METHODS

Grades of GI damage:
Grade 1 Mild inflammatory changes in esophagus, stomach and/or
duodenum
Grade 2 Moderate inflammatory changes, erosions, small single non
bleeding ulcer
Grade 3 Severe inflammation, deep ulcers, bleeding ulcers, multiple
ulcers ( 2 or more), non-malignant strictures
METHODS

Rapid Urease Detection

Immunohistochemistry

Biopsy
DATA ANALYSIS
DATA ANALYSIS
DATA ANALYSIS
Males
DATA ANALYSIS
Females
DATA ANALYSIS
Age and NSAIDs
DATA ANALYSIS
Age and Helicobacter pylori
DATA ANALYSIS
Medical Illnesses
DATA ANALYSIS
Most common complaint
NSAIDs
H. pylori
Both
NSAID Users- Not on PPI
NSAID users- On PPI
RESULTS
1.
2.
3.
4.
5.
6.
7.
8.
2/3rd of subjects : 51-80yrs
60% of subjects: Females
Males: 77% NSAID users
Females: 87% NSIAD users
Prevalence of H.pylori is highest between 7180yrs
Most common co-morbid condition- HTN
Back pain and OA- about 8% of subjects
MC indication for upper GI endoscopyAbdominal pain ( 20%)
RESULTS (contd..)
Grade III GI damage among
NSAID users
(H.pylori –ve)
: 25.8%
10. Grade III GI damage among Non NSAID users
with H.pylori +ve
: 29.1%
11. Grade III GI damage among NSAID users with
H.pylori +ve
: 29.8%
12. Grade III GI damage :
NSAID users (on PPi)
- 20.8%;
NSAID users (not on PPi) - 31.8%
9.
CONCLUSIONS
1.
2.
3.
4.
5.
H.Pylori: Increases with Age
H.pylori infection: Males> Females
NSAIDs: Increased use among elderly
females
Gastric damage: Highest grade 3 among
NSAID users with H.pylori infection
PPIs are beneficial with NSAIDs
LIMITATIONS
1.
2.
3.
4.
5.
Retrospective study
Single community hospital
Duration of NSAID intake
Lead time bias
Confounding factors
THANK YOU !!!!!