Saudi Journal of Gastroenterology
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Year : 2007  |  Volume : 13  |  Issue : 2  |  Page : 95-97
Does Helicobacter pylori affect portal hypertensive gastropathy?

Division of Gastroenterology, Department of Medicine, King Saud University, Saudi Arabia

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Helicobacter pylori (H. pylori) is a major etiological factor of peptic ulcer disease (PUD). It is supposed to be a risk factor for the more frequently encountered PUD in patients with liver cirrhosis. Several investigators have evaluated the effect of H. pylori on liver cirrhosis, portal hypertensive gastropathy (PHG) and encephalopathy with controversial results. Some reports have shown a higher seroprevalence and suggested a synergistic effect of H. pylori on liver cirrhosis and PHG. However, this increased prevalence is associated with a negative histology and is not influenced by the cause of cirrhosis, PHG, Child class or gender. Most studies have not found any correlation between H. pylori and PHG. In contrast, other studies have reported a markedly lower prevalence of H. pylori in cirrhotics with duodenal ulcer compared to controls. The aim of this article is to review the relationship between H. pylori infection and portal hypertensive gastropathy and the role of H. pylori eradication in cirrhotic patients.

Keywords: H. pylori , peptic ulcer disease, liver cirrhosis, portal hypertensive gastropathy

How to cite this article:
Al Mofleh IA. Does Helicobacter pylori affect portal hypertensive gastropathy?. Saudi J Gastroenterol 2007;13:95-7

How to cite this URL:
Al Mofleh IA. Does Helicobacter pylori affect portal hypertensive gastropathy?. Saudi J Gastroenterol [serial online] 2007 [cited 2022 Jun 26];13:95-7. Available from:

   Helicobacter pylori and Liver Cirrhosis Top

It is well known that peptic ulcer disease (PUD) is encountered more frequently in patients with liver cirrhosis compared to non-cirrhotic patients. [1] Whether this increased prevalence is due to H. pylori infection which is usually associated with PUD, is a subject of much debate. The seroprevalence of H. pylori has been significantly higher in 254 patients with HCV-induced liver cirrhosis than in controls (89% vs 59%). [2] This may explain the frequent occurrence of PUD in patients with liver cirrhosis. Other authors have also reported an increased anti- H. pylori IgG in cirrhosis. [3] In another study of 153 cirrhotic patients, anti- H. pylori IgG levels have been significantly higher than seen in blood donors (76.5% vs 41.8%) and is not influenced by etiology of cirrhosis, Child class, portal hypertensive gastropathy (PHG) or gender. [4] However, the increased anti- H. pylori antibody levels detected by enzyme-linked immunosorbent assay (ELISA) have been associated with a negative histology. [5]

In a meta-analysis of seven studies including 976 patients with cirrhosis (275 with PUD and 701 controls), the prevalence of H. pylori has been higher in patients with PUD. Hence, H. pylori was considered as a risk factor for the increased prevalence of PUD in cirrhosis. [6] Furthermore, diffuse gastric colonization with H. pylori has partly contributed to hyperammonemia in cirrhotic patients. [7] In experimental studies, portal vein and systemic ammonia levels have increased after inoculating cirrhotic gerbils with H. pylori. [8] However, to say that H. pylori plays a role in cirrhosis and encephalopathy based on evidence requires a leap of logic since, 1) Although increasing ammonia levels (due to H. pylori ) may contribute to hepatic encephalopathy, cirrhosis itself may lead to hepatic encephalopathy. 2) As the gerbils were already cirrhotic, how can it be said that H. pylori had a role in cirrhosis and hepatic encephalopathy? In contrast, the majority of reviewed articles have not proven any correlation between H. pylori and PHG. In an epidemiological and clinical questionnaire surveying 209 patients of whom 50% were positive for anti- H. pylori IgG, the pattern of H. pylori infection in cirrhotic patients did not differ from that seen in the general population. [9] In another study of 130 patients with liver cirrhosis, no correlation was found in the ages, Child class of cirrhosis or in the incidence of congestive gastropathy in H. pylori -positive and -negative patients. [10]

In contrast, other studies have reported a markedly lower prevalence of H. pylori in cirrhotics with duodenal ulcer compared to controls (cirrhotics with duodenal ulcer but H. pylori -negative) (40% vs 95%). There has been no significant difference in the presence of H. pylori in cirrhotic patients with or without duodenal ulcer (40% vs 37%). [11] Other authors have also reported a lower incidence of H. pylori in cirrhotics in comparison to the normal non-cirrhotic population. [12] Furthermore, the trend of H. pylori infection decreases in proportion with PHG severity. [13] It has been suggested that PHG does not provide an adequate environment for H. pylori colonization and that H. pylori does not add significantly to PHG. [13],[14] Therefore, H. pylori infection is unlikely to contribute to PHG pathogenesis. [15]

   H. pylori effect on PHG Severity Top

Several studies have not found a correlation between severity of PHG and H. pylori infection. [12,16] Both PHG and H. pylori without PHG significantly increase inducible nitric oxide synthase (iNOS) production. [17] In fact, there is a positive correlation between the expression of iNOS and the severity of PHG. However there has been no evidence of synergistic action between H. pylori and PHG on iNOS expression. [17]

   H. pylori and Ammonia concentration Top

Involvement of H. pylori in hepatic encephalopathy has been suggested although the results of investigating the influence of H. pylori infection on serum ammonia levels are variable. Experimental studies have shown increases in portal vein and systemic ammonia levels in cirrhotic animals infected with H. pylori . [8] Diffuse H. pylori gastritis contributes partly to hyperammonemia in liver cirrhosis. [7] In contrast, other investigators have not found a significant difference in the fasting ammonia levels in H. pylori -positive and -negative, non-advanced cirrhosis patients. Thus, there was no significant effect of H. pylori infection on the fasting ammonia level or on other parameters used for the assessment of subclinical hepatic encephalopathy. [18] [It has already been mentioned in this article that H. pylori infection increases serum ammonia levels. Obviously, gastric ammonia levels would also rise due to the proximity of the bacteria and their ureases. Mentioning a correlation or lack thereof between gastric and serum ammonia (both of which would increase in H. pylori infection) only increases confusion]. A fall in ammonia levels has been reported after H. pylori eradication but is thought to be due to the non-specific effect of antibiotics rather than a result of H. pylori eradication. [20]

   H. pylori Eradication in PHG Top

Due to the lack of correlation between H. pylori infection and PHG, some authors have not advocated eradication of H. pylori in the treatment of PHG. [20],[21] However, H. pylori eradication has been suggested in patients with diffuse H. pylori gastritis. [7] Furthermore, for patients with hepatitis B who do not clear the virus in the presence of H. pylori , the prognosis of chronic liver disease may benefit from early eradication. [22]

   Conclusions Top

  • The data on seroprevalence of H. pylori in cirrhosis and PHG are controversial.
  • There is no correlation between H. pylori and etiology, stage of cirrhosis, presence and severity of PHG.
  • Large scale studies are required for further exploration of the effect of H. pylori on PHG.
  • Until further information is obtained, it would be advisable to follow the same H. pylori eradication strategies in cirrhotic patients as in non-cirrhotic patients.

   References Top

1.Wu CS, Lin CY, Liaw YF. Helicobacter pylori in cirrhotic patients with peptic ulcer disease: A prospective, case controlled study. Gastrointest Endosc 1995;42:424-7.   Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Pellicano R, Leone N, Berrutti M, Cutufia MA, Fiorentino M, Rizzetto M, et al . Helicobacter pylori seroprevalence in hepatitis C virus positive patients with cirrhosis. J Hepatol 2000;33:648-50.   Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Flisiak R, Prokopowicz D, Tynecka E. Macroscopic changes in endoscopy of upper digestive tract and Helicobacter pylori infections in patients with liver cirrhosis. Przegl Epidemiol 1994;48:455-9.   Back to cited text no. 3  [PUBMED]  
4.Siringo S, Vaira D, Menegatti M, Piscaglia F, Sofia S, Gaetani M, et al . High prevalence of Helicobacter pylori in liver cirrhosis: Relationship with clinical and endoscopic features and the risk of peptic ulcer. Dig Dis Sci 1997;42:2024-30.   Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Altman C, Ladouch A, Briantais MJ, Rason T, Martin E, Jacques L, et al . Antral gastritis in chronic alcoholism. Role of cirrhosis and Helicobacter pylori . Presse Med 1995;24:708-10.   Back to cited text no. 5    
6.Vergara M, Calvet X, Roque M. Helicobacter pylori is a risk factor for peptic ulcer disease in cirrhotic patients. A meta-analysis. Eur J Gastroenterol Hepatol 2002;14:717-22.   Back to cited text no. 6    
7.Miyaji H, Ito S, Azuma T, Ito Y, Yamazaki Y, Ohtaki Y, et al . Effect of Helicobacter pylori eradication therapy on hyperammonaemia in patients with liver cirrhosis. Gut 1997;40:726-30.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Suto H, Azuma T, Ito S, Ohtani M, Dojo M, Ito Y, et al . Helicobacter pylori infection induces hyperammonaemia in Mongolian gerbils with liver cirrhosis. Gut 2001;48:605-8.   Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Calvet X, Mavarro M, Gil M, Mas P, Rivero E, Sanfeliu I, et al . Seroprevalence and epidemiology of Helicobacter pylori infection in patients with cirrhosis. J Hepatol 1997;26:1249-54.  Back to cited text no. 9    
10.Tsai CJ. Helicobacter pylori infection and peptic ulcer disease in cirrhosis. Dig Dis Sci 1998;43:1219-25.   Back to cited text no. 10  [PUBMED]  [FULLTEXT]
11.Wang CH, Ma LR, Lin RC, Kou TY, Chang KK. Helicobacter pylori infection and risk of peptic ulcer among cirrhotic patients. J Formosa Med Ass 1997;96:55-8.  Back to cited text no. 11    
12.Pan WD, Xun RY, Chen YN. Correlation of portal hypertensive gastropathy of hepatitis B cirrhosis with other mfactors. Hepatobiliary Pancreat Dis Int 2002;1:527-31.   Back to cited text no. 12    
13.Batmanabane V, Kate V, Ananthakrishnan N. Prevalence of Helicobacter pylori in patients with portal hypertensive gastropathy-a study from South India. Med Sci Monit 2004;10:CR133-6.   Back to cited text no. 13  [PUBMED]  [FULLTEXT]
14.Bhargava N, Venkateswaran S, Ramakrishna BS, Mathan M. Colonization by Helicobacter pylori and its relationship to histological changes in the gastric mucosa in portal hypertension. J Gatroenterol Hepatol 1994;9:507-11.   Back to cited text no. 14  [PUBMED]  
15.Balan KK, Jones AT, Roberts NB, Pearson JP, Critchley M, Jenkins SA. The effects of Helicobacter pylori colonization on gastric function and incidence of portal hypertensive gastropathy in patients with cirrhosis of the liver. Am J Gastroenterol 1996;91:1400-6.   Back to cited text no. 15  [PUBMED]  
16.Parikh SS, Desai SB, Prabhu SR, Trivedi MH, Shankaran K, Bhukhanwala FA, et al . Congestive gastropathy: Factors influencing development, endoscopic features, Helicobacter pylori infection and microvessel changes. Am J Gastroenterol 1994;89:1036-42.   Back to cited text no. 16  [PUBMED]  
17.Arafa UA, Fujiwara Y, Higuchi K, Shiba M, Uchida T, Watanabe T, et al . No additive effect between Helicobacter pylori infection and portal hypertensive gastropathy on inducible nitric oxide synthase expression in gastric mucosa of cirrhotic patients. Dig Dis Sci 2003;48:162-8.   Back to cited text no. 17  [PUBMED]  [FULLTEXT]
18.Vasconez C, Elizalde JI, Llach J, Gines A, de la Rosa C, Fernandez RM, et al . Helicobacter pylori , hyperammonemia and subclinical portosystemic encephalopathy: Effects of eradication. J Hepatol 1999;30:260-4.   Back to cited text no. 18  [PUBMED]  [FULLTEXT]
19.Nam YJ, Kim SJ, Shin WC, Lee JH, Choi WC, Kim KY, et al . Gastric Ph and Helicobacter pylori infection in patients with liver cirrhosis. Korean J Hepatol 2004;10:216-22.   Back to cited text no. 19  [PUBMED]  [FULLTEXT]
20.Quero JC, Hartmann IJ, de Rooij F, Wilson JH, Schalm SW. Hyperammonaemia and Helicobacter pylori . Lancet 1995;346:713-4.  Back to cited text no. 20  [PUBMED]  
21.Bahancy A, Kupsculik P, Eles Z, Jaray B, Flautner L. Helicobacter pylori infection in congestive gastropathy. Helicobacter 1996;1:168-71.   Back to cited text no. 21    
22.Chen NL, Bai L, Deng T, Zhang C, Kong QY, Chen H. Expression of hepatitis B virus antigen and Helicobacter pylori infection in gastric mucosa of patients with chronic liver disease. Hepatobiliary Pancreat Dis Int 2004;3:223-5.  Back to cited text no. 22  [PUBMED]  [FULLTEXT]

Correspondence Address:
Ibrahim A Al Mofleh
P.O. Box 2425, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-3767.32186

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