Research ArticleResearch

Helicobacter pylori status among patients undergoing gastroscopy in rural northern Alberta

Isabelle N. Colmers-Gray, Ben Vandermeer, Robert I. Greidanus and Michael R. Kolber
Canadian Family Physician September 2016; 62 (9) e547-e554;

Abstract

Objective To determine the Helicobacter pylori status of patients who underwent gastroscopy.

Design Retrospective chart review.

Setting Peace River Community Health Centre in rural northwestern Alberta.

Participants Data were collected from patients who had a gastroscopy performed by either of 2 family physicians between January 1, 2011, and December 31, 2012.

Main outcome measures The proportion of patients who had positive test results for H pylori overall and among first-time gastroscopy patients. For first-time gastroscopy patients, the associations between H pylori infection and patient age, sex, residence, and procedural indications and findings were explored.

Results A total of 251 gastroscopies were conducted in 229 unique patients during the study period. Overall, 12.4% (95% CI 8.3% to 16.4%) of patients had positive results for H pylori and among the 159 first-time gastroscopy patients, 17.6% (95% CI 11.7% to 23.5%) had positive test results for H pylori. Helicobacter pylori status did not differ significantly by geography, sex, or age. The prevalence of H pylori was higher among patients with H pylori–related indications for gastroscopy (such as dyspepsia and upper gastrointestinal tract bleeding) than among patients with other indications; however, H pylori infection was not statistically significantly greater in patients diagnosed with peptic ulcer disease.

Conclusion The prevalence of H pylori infection among patients undergoing gastroscopy in rural northern Alberta appears lower than other Canadian estimates. In regions with low H pylori rates, patients with dyspepsia might be better served by acid suppression and nonsteroidal anti-inflammatory drug cessation before investigating for H pylori infection. Population-based research is required to further describe regional differences in H pylori rates.

Helicobacter pylori is a Gram-negative gut bacterium associated with dyspepsia, peptic ulcer disease (PUD), and gastric cancer.1 Transmitted by the fecal-oral route in childhood, around 50% of the world’s population is infected with H pylori,2 with rates being higher in developing countries with lower socioeconomic status.3,4 It is estimated that about 25% of the general Canadian population is infected with H pylori,5,6 with higher infection rates among the Inuit, some First Nations communities, and immigrants from H pylori–endemic countries.7 Population-based research suggests H pylori infection rates in some regions are declining over time8,9; however, the current prevalence of H pylori in rural northern Alberta is unknown. Dyspepsia is a common reason for patients to visit health care providers10 and for having gastroscopy performed in rural northern Alberta.11 Having knowledge about regional H pylori rates would help determine appropriate treatment strategies for dyspeptic patients. The primary objective of the study was to determine the prevalence of biopsy-proven H pylori in patients who underwent gastroscopy in Peace River, a rural northern Albertan community. Secondary objectives were to explore whether patient age, sex, geographic residence, and gastroscopic indications or findings were associated with H pylori infection.

METHODS

We performed a 2-year retrospective chart review (January 1, 2011, to December 31, 2012) of all patients who underwent gastroscopy at the Peace River Community Health Centre.

Peace River is a rural northern Albertan town, with 6774 residents and a surrounding population of 7252.12 Two family physicians perform gastroscopies; one received additional training in gastrointestinal (GI) medicine (M.R.K.) and the other in surgery (R.I.G.). Both physicians receive referrals from throughout the Peace River region, and the closest general surgeons and gastroenterologists are 170 km and 500 km away, respectively.

Gastroscopy reports were retrospectively reviewed for patient demographic characteristics, gastroscopic indications and findings, and the use of nonsteroidal anti-inflammatory drugs (NSAIDs), including acetylsalicylic acid, as well as proton pump inhibitors (PPIs) at the time of gastroscopy. Indications for gastroscopy were adapted from the American Society of Gastrointestinal Endoscopy guidelines,13 while findings were modified from previous clinical primary care endoscopy research.11 Findings were determined from the text of the endoscopic report and classified at the time of data collection. Peptic ulcer disease included both gastric and duodenal erosions and healing ulcers. Procedures could have more than 1 endoscopic indication or finding and formal ranking of the clinical relevance of the indications and findings was not performed. Pathology reports of gastric biopsies were reviewed to determine H pylori infection status and other pathology including celiac disease, eosinophilic esophagitis, Barrett syndrome, and cancers. As PPI therapy might decrease the ability to detect H pylori on antral biopsies,2 it was routine practice to perform additional biopsies of the proximal stomach (cardia or body) for patients taking PPIs.

The overall proportion of H pylori infection was calculated by examining the H pylori results from all gastroscopies performed in the study period, while the proportion of H pylori infection among first-time gastroscopy patients was calculated by examining the H pylori results only in patients undergoing their first gastroscopy. Patient charts were reviewed to determine whether gastroscopy had been performed before the study. The associations between age, sex, patient residence, and endoscopic indications and findings and H pylori status were evaluated in first-time gastroscopy patients. Patient residence was determined by the 6-digit postal code on file and patient age was categorized into 39 years and younger, 40 to 64 years, and 65 years and older to approximate clinically relevant tertiles.

Data analysis was performed using Cytel StatXact, version 10.0.0. The Cochran-Armitage trend test was used to compare results across the 3 age categories; otherwise, Fisher exact tests were used to determine statistical significance, with an α level of .05.

The study was approved by the Health Research Ethics Board of the University of Alberta in Edmonton.

RESULTS

During the study period, 251 gastroscopies were performed in 229 unique patients (Figure 1). The mean (SD) patient age was 52.4 (16.1) years and 52.8% were women. Patients from across northwestern Alberta were served, with 52.0% of the patients residing in Peace River (Table 1). Overall, 159 gastroscopies (63.3%) were the patient’s first gastroscopy. Among all patients, NSAID use was recorded in 134 cases and 70 of 134 patients (52.2%) were taking NSAIDs at the time of gastroscopy. Similarly, 157 endoscopy reports mentioned PPI status and 116 of 157 (73.9%) were taking PPIs at the time of endoscopy. Forty-one patients were taking both NSAIDs and PPIs. For the remaining patients, NSAID or PPI use was not mentioned in the endoscopic report and was therefore unknown.

Figure 1.
Figure 1.

Patient selection flow chart

View this table:
Table 1.

Patient demographic characteristics

Gastroscopy indications

There were 371 indications for the 251 gastroscopies, giving a mean of 1.5 indications per gastroscopy. The most common indications for gastroscopy were persistent upper abdominal symptoms (predominantly dyspepsia) or symptoms suggestive of serious organic disease (38.2%); gastroesophageal reflux disease symptoms (including dysphagia or odynophagia [32.7%]); and follow-up from a previously documented endoscopic lesion (21.9%) (Figure 2). Compared with the other age categories, patients 39 years of age and younger were more likely to have a gastroscopy performed for upper abdominal symptoms (P = .03), while patients 65 years of age and older were more likely to have a gastroscopy performed for anemia (P = .0005).

Figure 2.
Figure 2.

Individuals with indications for gastroscopy out of all gastroscopies performed: N = 251. Multiple indications per individual were possible.

GERD—gastroesophageal reflux disease, GI—gastrointestinal.

*Other indications included diagnosis of radiologically demonstrated lesions, and confirmation or investigation for celiac markers. Only 4 of 229 individuals had “other” as their sole indication.

Gastroscopy findings

There were 294 clinically relevant endoscopic findings in the 251 gastroscopies, for a mean of 1.2 findings per gastroscopy. Overall, the most common findings were gastritis or duodenitis (68.1%), no findings (normal) (20.3%), or PUD (17.5%) (Figure 3). Hiatus hernia and fundic gland polyps (found in 9.1% and 4.0% of procedures, respectively) were recorded but were not considered clinically relevant findings for our analyses.

Figure 3.
Figure 3.

Individuals who had endoscopic findings out of all gastroscopies performed: N = 251. Multiple findings per individual were possible.

*Peptic ulcer disease included gastric and duodenal erosions or healing ulcers.

†Other findings included fundic gland polyps, hiatus hernia, lax lower esophageal sphincter, gastric outlet obstruction, and Schatzki ring. Only 5 of 229 individuals had “other” as their sole finding.

Among all gastroscopies, there were 6 pathologically confirmed cases of Barrett syndrome (without dysplasia), 3 cases of eosinophilic esophagitis, and 4 cases of celiac disease. There were no cases of gastric or esophageal cancer or foreign bodies.

The likelihood of being diagnosed with PUD increased with age and the likelihood of having no findings on gastroscopy decreased with age, although these differences were not statistically significant (P = .1 and P = .16, respectively). All cases of eosinophilic esophagitis were in individuals 39 years of age and younger. Age was otherwise not associated with any gastroscopic findings.

First-time gastroscopy patients and NSAID use

Among first-time gastroscopy patients, NSAID use was noted in 99 endoscopic reports. Fifty-one patients (51.5%) were documented as taking NSAIDs at the time of gastroscopy. In patients having their first gastroscopy, and in whom NSAID status was known, 14 of 18 (77.8%) patients diagnosed with PUD were taking NSAIDs. The odds of finding PUD on gastroscopy were 4.2 (95% CI 1.3 to 13.0) times higher among NSAID users than nonusers.

Prevalence and incidence of H pylori

Of all the gastroscopies performed (N = 251), biopsies for H pylori were performed in 237 (94.4%) cases. All 14 procedures without H pylori biopsy were for patients who had been previously documented as having negative results for H pylori. Three study patients had positive test results for H pylori and had a previously documented gastroscopy. Two patients had a gastroscopy without biopsies performed before the study period, while 1 patient had a persistent H pylori infection at a repeat gastroscopy within the study period. Overall, 31 of 251 gastroscopies had positive results for H pylori (12.4%; 95% CI 8.3% to 16.4%).

All first-time gastroscopies (n = 159) included a biopsy for H pylori, and 28 had positive results for H pylori (17.6%; 95% CI 11.7% to 23.5%).

Predictive factors for H pylori on first-time gastroscopy

To determine possible predictive factors of H pylori infection, we calculated the association between H pylori status and various patient factors among patients undergoing first-time gastroscopy (n = 159).

Patient demographic characteristics and H pylori incidence.

Positive results for H pylori were not significantly different among women (13.8%; 95% CI 6.2% to 21.3%) and men (21.5%; 95% CI 12.5% to 30.6%; P = .2). Although positive results for H pylori increased with age (≤ 39 years, 12.4%; 40 to 64 years, 18.0%, ≥ 65 years, 24.1%), this trend was not statistically significant (P = .21). Positive results for H pylori did not differ between residents of Peace River and those living outside of Peace River (19.8% vs 15.4%; P = .54).

Endoscopic indications and findings, and H pylori rates

The relative risk of H pylori infection was 2.9 times higher (22.4% vs 7.7%; P = .03) among individuals with H pylori–associated endoscopic indications (upper abdominal symptoms, upper GI bleeding, anemia, or family history of gastric cancer) compared with endoscopic indications not associated with H pylori infection (such as gastroesophageal reflux disease or other esophageal symptoms).

Helicobacter pylori infection was more common in patients with PUD than in those who did not have PUD; however, this difference was not statistically significant (29.2% vs 15.6%; P = .14).

DISCUSSION

Among patients receiving gastroscopy in rural northern Alberta’s Peace River region, H pylori was found in 12.4% of all cases and 17.6% of first-time gastroscopies. These results are lower than rates previously reported in Canada.

While the overall prevalence of H pylori in Canada has been estimated to be around 25%,5,6 substantial differences are seen in certain populations and jurisdictions. The most noteworthy of these differences are the elevated H pylori rates in the Inuit population, in some First Nations communities, and in immigrants to Canada from H pylori–endemic countries.7

A population-based study of 333 predominately Inuit and aboriginal peoples from Aklavik, NWT, reported a 58% H pylori prevalence using urea breath tests.14 Two earlier studies using immunoglobulin G serology to determine past or current H pylori infection in Arctic and Manitoba First Nations communities found 50.8% and 95% of individuals, respectively, had positive test results.15,16

Our study differs from these studies as we determined H pylori status only among patients who underwent gastroscopy, and therefore it is not a population-based study. By design, our population included only individuals requiring invasive investigation of their symptoms. As such, one would postulate that the proportion of patients who had positive test results for H pylori would be higher in our study relative to the rest of the population in the region.

A study more similar to ours, from Sioux Lookout, Ont, reported that 37.9% of 203 patients who underwent gastroscopy and gastric biopsies had positive results for H pylori.17 In this study, endoscopists selectively performed biopsies for H pylori depending on the clinical indication, and therefore might have overestimated the true proportion of patients with H pylori infection.

Finally, in the CADET-PE (Canadian Adult Dyspepsia Empiric Treatment—Prompt Endoscopy) study, Canadian patients with dyspepsia (predominantly from eastern Canada) who underwent prompt endoscopy had positive results for H pylori 30% of the time.6 Whether this difference in H pylori rates reflects a temporal decline (the CADET-PE study was done about 15 years ago) or geographic differences between populations studied is not known.

In our study, gastric biopsies were performed on all patients undergoing their first gastroscopy, regardless of clinical indication. Patients known to have previous negative results for H pylori or who had previously confirmed H pylori eradication were not biopsied owing to the low rate of H pylori recurrence in adults in developed countries.18 We also found that patients with an H pylori–related indication for gastroscopy (upper abdominal symptoms, upper GI bleeding, anemia, or family history of gastric cancer) were nearly 3 times more likely to have an H pylori infection compared with those who did not have such an indication.

Consensus guidelines suggest the “test and treat” approach for uninvestigated young individuals with dyspepsia (without alarm features) is appropriate if baseline H pylori prevalence is 20% or greater.2 Our enhanced understanding of gastroscopy indications associated with H pylori infection, combined with our knowledge of the low overall proportion of patients who have positive results for H pylori in the Peace River region, can have a meaningful influence on clinical practice. First, for patients with dyspepsia, discontinuation of NSAIDs and empiric trial of PPIs have been demonstrated to provide equivalent patient outcomes19 with cost savings20 compared with the test and treat approach. Given the relatively low proportion of patients infected with H pylori and moderate NSAID use, NSAID cessation and empiric PPI prescription might be a reasonable first step before testing for H pylori in patients with dyspepsia in the Peace River region.

In regions where H pylori prevalence is low, endoscopists could use clinical indications and endoscopic findings to determine which patients might be at a higher risk of H pylori infection (ie, require gastroscopic biopsy) and which might not. Using a more selective threshold to perform biopsies could reduce endoscopy-associated system costs while still capturing most cases of H pylori infection.

It is possible that the low H pylori findings reflect a temporal decline in H pylori prevalence. Such a trend has been demonstrated in other jurisdictions8,9; however, as we do not have previously documented H pylori rates from the Peace River region, we are unable to confirm this. Alternatively, our findings might reflect earlier testing and treatment of H pylori by noninvasive methods (such as the urea breath test). To more precisely determine the regional H pylori prevalence, a population-based study including all methods of determining H pylori status is needed.

This study demonstrated that the odds of having a peptic ulcer were more than 4 times higher among NSAID users than nonusers. While the association between PUD and NSAIDs is well known,21 these findings should be tempered by the fact that NSAID status was unknown in many patients. However, even if we assume that none of the patients in whom NSAID use was not known were using NSAIDs, a minimum of 51 of 229 patients (22.3%) would have been taking NSAIDs. This supports the need for judicious medication reviews (including over-the-counter medications such as acetylsalicylic acid) among individuals with GI complaints.

Limitations

Our study has several limitations. Owing to the limited study duration, our sample size was relatively small. This likely contributed to many of our results not reaching statistical significance. In addition, many of the patients with previous gastroscopy had undergone the procedure before the initiation of our electronic medical records. This fact combined with the limited resources of our study team rendered it not feasible to formally analyze the results of all preceding gastroscopies performed before the commencement of our study.

Consistent with a previous Canadian study that reported no rural-urban difference in H pylori rates,22 our study did not find differences in H pylori infection status between patients living within or outside of Peace River. However, in our study, it became apparent that the mailing addresses were not always consistent with a patient’s actual place of residence, thus limiting the accuracy of our geographic analyses. This limitation affected our ability to determine whether, as has been found in other Canadian studies,14–17 H pylori infection is more common among patients living in First Nations communities. In addition, other studies have correlated H pylori infection with households that have a greater number of children and lower socioeconomic status.5,7 These variables are not routinely included in endoscopy reports and, therefore, were not captured by our study. Finally, as with all retrospective studies, our data were limited by the amount and quality of information captured by the original endoscopy reports.23 For example, the inconsistent reporting of NSAID use limits the ability to draw definitive conclusions about the influence of NSAIDs on endoscopic findings and requires prospective studies to fully ascertain.

Conclusion

We found that 12.4% of patients who underwent gastroscopy in the rural Peace River region of northern Alberta had positive results for H pylori, approximately half of the reported national average. Positive results for H pylori were higher among individuals with a first-time gastroscopy (17.6%) and among individuals with H pylori–associated indications for gastroscopy, notably dyspepsia.

Given the moderate use of NSAIDs in our population undergoing gastroscopy, patients in the Peace River region are likely to benefit from cessation of NSAIDs and initiation of empiric PPI therapy as a first step, before further H pylori testing is done. Our findings also suggest that selectively performing H pylori biopsies in patients with H pylori–associated endoscopic indications or findings could be considered with minimal adverse implications for patients and potential cost savings.

Population-based research is required to better ascertain temporal and regional differences in H pylori prevalence.

Acknowledgments

We thank Stephanie Couperthwaite for assistance with data organization; and we thank Robyn Matlock, Carole Lavoie, and the rest of the wonderful staff at the Peace River Community Health Centre and the Associate Medical Clinic. This project was funded by a Northern Alberta Academic Family Physicians grant from the Department of Family Medicine at the University of Alberta.

Notes

EDITOR’S KEY POINTS

  • It was found that 12.4% of patients who underwent gastroscopy in the rural Peace River region of northern Alberta had positive results for Helicobacter pylori, approximately half of the reported national average. Positive results for H pylori were higher among individuals with a first-time gastroscopy (17.6%) and among individuals with H pylori–associated indications for gastroscopy, notably dyspepsia.

  • Given the moderate use of nonsteroidal anti-inflammatory drugs in this population undergoing gastroscopy, patients in the Peace River region are likely to benefit from cessation of nonsteroidal anti-inflammatory drugs and initiation of empiric proton pump inhibitor therapy as a first step, before further H pylori testing is done. Selectively performing H pylori biopsies in patients with H pylori–associated endoscopic indications or findings could be considered with minimal adverse implications for patients and potential cost savings.

  • Population-based research is required to better ascertain temporal and regional differences in H pylori prevalence.

POINTS DE REPÈRE DU RÉDACTEUR

  • On a observé que 12,4 % des patients de la région rurale de Peace River du nord de l’Alberta avaient des résultats positifs pour l’Helicobacter pylori, soit environ la moitié du taux moyen rapporté pour l’ensemble du Canada. Le nombre de résultats positifs était plus élevé chez ceux qui en étaient à leur première gastroscopie (17,6 %) et chez ceux où il était indiqué d’en faire une, notamment en raison d’une dyspepsie.

  • Étant donné que les patients de la région de Peace River qui subissent une gastroscopie font un usage modéré d’anti-inflammatoires non stéroïdiens, ils auraient vraisemblablement avantage à cesser cette médication pour commencer une thérapie empirique à base d’inhibiteurs de la pompe à protons comme première étape avant toute nouvelle recherche d’H pylori. On devrait envisager d’être plus sélectif lors de la recherche d’Helicobacter pylori chez les patients pour lesquels il y a indication d’endoscopie, et ce, avec un minimum de conséquences fâcheuses pour les patients et possiblement à un meilleur coût.

  • Il faudra d’autres études de population pour mieux évaluer les différences régionales dans la prévalence d’H pylori.

Footnotes

  • This article has been peer reviewed.

  • Cet article a fait l’objet d’une révision par des pairs.

  • Contributors

    Drs Kolber and Colmers-Gray contributed to the concept and design of the study, and data gathering, analysis, and interpretation. Dr Greidanus contributed to the data gathering and interpretation. Mr Vandermeer performed statistical analysis. All authors contributed to preparing the manuscript for publication.

  • Competing interests

    None declared

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Helicobacter pylori status among patients undergoing gastroscopy in rural northern Alberta
Isabelle N. Colmers-Gray, Ben Vandermeer, Robert I. Greidanus, Michael R. Kolber
Canadian Family Physician Sep 2016, 62 (9) e547-e554;
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