SP/Vaira 18/3/02 9:55 am Page 13

Science Progress (2002), 85 (1), 13–31

Helicobacter: a paradigm shift in

peptic ulcer disease and more?
CHRISTELLE BASSET, JOHN HOLTON AND DINO VAIRA

There are many diseases where the cause is unknown and this makes a
specific treatment difficult. In many cases all that can be achieved is ame-
lioration of the illness. Peptic ulcer disease was one such condition no
more that 20 years ago. The management was drastic – either an operation
or life-long medication in order to reduce the acid secreted by the stomach.
However, the cause of this condition was discovered in 1983. Although ini-
tially sceptical, the medical fraternity now almost universally endorse
Helicobacter pylori as the cause of the majority of stomach ulcers. Peptic
ulcers can now be cured by antibiotics. This is a major shift in medical
practice. Continued investigations on Helicobacter pylori are bringing to
light other possible associations with disease as well as delineating plaus-
ible biological mechanisms for disease pathogenesis.

Christelle Basset is a lecturer at the Royal Free & University

College London Medical School in the Windeyer Institute of Medical
Sciences. She is a member of the Gastrointestinal Inflammation
Group and an immunologist by training. Her main research interests
are in mucosal immunology, Helicobacter pylori and inflammatory
bowel disease. She is currently funded by the National Association
of Crohns and Colitis and from 2002 will be funded by the European
Union.

John Holton is a Senior Lecturer at the Royal Free & University

College London Medical School in the Windeyer Institute of Medical
Sciences, 46 Cleveland Street, London W1T 4JF, UK. He is a
microbiologist and a member of the Gastrointestinal Inflammation
Group and his main research interests are in Helicobacter pylori
and inflammatory bowel disease.

Dino Vaira is a Professor at the University of Bologna working in the

First Medical Clinic in St Orsola Hospital, Bologna. He is a
Gastroenterologist who’s main research interest is in Helicobacter
pylori.

13
SP/Vaira 18/3/02 9:55 am Page 14

Introduction
It had long been the belief that stomach ulcers were caused by
“stress” or spicy food and somehow related to excess stomach acid.
However, in 1983 an Australian histopathologist1 noted the associ-
ation between the presence of a spiral shaped organism in the human
stomach and inflammation. This was not the first time organisms had
been seen in the stomach but the time was opportune, as cultural
techniques were to hand which allowed the organism to be isolated
for the first time. Dr Warren suggested to a sceptical medical public
that this organism (initially called a Campylobacter-like organism
because of a superficial microscopic resemblance to campylobac-
ters) could be the cause of peptic ulceration. Nearly two decades
later the organism, now named Helicobacter pylori, is recognised to
be the proximate cause of the majority of peptic ulcers. It is also a
Class I carcinogen2 and colonisation by the organism is correlated
with a higher risk of developing gastric cancer and gastric mucosal-
associated lymphoid tissue (MALT) lymphoma. There is also sug-
gestive evidence that colonisation by Helicobacter pylori may be
related to some extra-gastrointestinal diseases (Figure 1).
The isolation of Helicobacter pylori has had a major effect on the
treatment of ulcer disease. In the pre-Helicobacter era the treatment
was aimed at acid-reduction either by vagotomy (an operation to

Fig. 1 Association between clinical conditions and colonisation by

Helicobacter pylori.

14 Christelle Basset, John Holton and Dino Vaira

SP/Vaira 18/3/02 9:55 am Page 15

sever the vagus nerve supplying the stomach, which controls acid
output) or the continual use of H2-receptor antagonists (which
inhibits the secretion of acid in the stomach). If the medication was
stopped, the level of stomach acid increased and the relapse rate for
peptic ulceration was high. Currently, in the Helicobacter era the
therapeutic aim is a permanent cure of peptic ulcer disease, by eradi-
cation of the organism, using a short course of antibiotics3. Once
eradicated, the ulcer relapse rate is less than 1%. A further hope,
opened up by the discovery of Helicobacter, is the possibility of
reducing the global burden of gastric cancer by widespread eradica-
tion programmes. It has to be emphasised however that currently
there is no evidence that eradication of Helicobacter will affect the
prevalence of gastric cancer and clearly there are dangers in the
widespread use of multiple antibiotics given to large numbers of
people, the majority of whom are asymptomatic. This is an issue that
will take many years to resolve.

Why is Helicobacter important?

Despite the fact that everyone who is colonised by Helicobacter
pylori has either acute or chronic gastritis, depending upon the stage
of infection, only relatively few individuals have symptoms of dys-
pepsia (“heartburn”). Gastritis is recognised histologically by the
infiltration of the lamina propria underlying the epithelium with neutro-
phils or monocytes. Infection principally occurs in the antrum of the
stomach, but a pan-gastritis can also occur where inflammation
extends to the fundus of the stomach – which is where the acid pro-
ducing capacity is located (Figure 2). The vast majority of patients
infected by Helicobacter pylori are completely asymptomatic and
unaware they have the organism in their stomach. On the other hand,
dyspepsia is a very common symptom and one of the most common
presenting symptoms to the General Practitioner. In fact the relation-
ship between colonisation by Helicobacter pylori and dyspepsia in
the absence of an ulcer – i.e. non-ulcer dyspepsia (NUD) is contro-
versial. There is no uniquely characteristic clinical profile to hand to
indicate in which patients colonisation by Helicobacter pylori may
be contributing to symptoms and therefore which patients may ben-
efit from treatment. Despite a considerable number of studies on the
relationship between colonisation by Helicobacter and symptoms,
there is still no clear answer4.
On the other hand, Helicobacter pylori is recognised as the prin-
ciple cause of peptic ulcer disease- both gastric and duodenal ulcer-
ation and is a predominant risk factor for the development of gastric

Helicobacter: a paradigm shift in peptic ulcer disease and more? 15

SP/Vaira 18/3/02 9:55 am Page 16

Fig. 2 Location of Helicobacter pylori in the stomach and associated

pathological effects.

cancer, although duodenal ulceration and gastric cancer usually

occur in different subgroups of patients. This raises the question of
how the same organism can have separate and to a large extent,
mutually exclusive clinical outcomes. Recent evidence suggests that
there are different strains of Helicobacter with different virulence
potential which are related to the clinical outcome. Other important
contributing factors to the clinical outcome, associated with coloni-
sation, are the host genetic background and other environmental factors
such as diet.
Evidence from animal studies has shown that in certain types of
immune deficient mice, other Helicobacter species, notably Helico-
bacter hepaticus and Helicobacter bilis are causally related to inflam-
matory bowel disease (IBD)5. This raises the intriguing possibility of
Helicobacter species being involved in the pathogenesis of this dis-
tressing human disease. There is no firm evidence for this currently,
but it is an issue that is being actively investigated. In addition to the
possible role of Helicobacter hepaticus and H. bilis in IBD, there is
also some recent evidence that the presence of these organisms and
possibly Helicobacter pylori, may be causally related to liver cancer
in animals (and humans?), pancreatitis and gall stones6.
Finally, Helicobacter pylori has also been linked with a number of
extra gastrointestinal conditions, such as some skin rashes, vascular

16 Christelle Basset, John Holton and Dino Vaira

SP/Vaira 18/3/02 9:55 am Page 17

disorders such as migraine, stroke and coronary heart disease7,

although the evidence for this is contradictory. There also appears to
be an association between colonisation by Helicobacter pylori and
various autoimmune diseases such as insulin-dependant diabetes
mellitus (IDDM) and thyroiditis.

The Helicobacters and their ecology

Helicobacter pylori is a motile helical gram-negative bacterium that
is a slowly growing micro-aerobic organism and it is one of the
important human pathogens to recently have had its genome
sequenced8. Helicobacter pylori is one of the most genetically
diverse organisms known with virtually each individual colonised by
a unique strain, although closely related strains can be recognised
within family groups, suggesting spread between family members.
Examination of isolates from diverse geographically separate locations
by multi-locus enzyme electrophoresis and random amplified PCR,
indicate that the genome has a panmictic (i.e. genetically diverse)
structure9 in contrast to many other human pathogens which have a
clonal structure. Evidence indicates extensive recombination has
occurred within the Genus Helicobacter and this is supported by the
presence of regions of the Helicobacter genome with divergent GC
ratios such as the pathogenicity island (PAI) and the plasticity
region, indicating horizontal transfer from another genome10. This
genetic diversity is important in relation to the divergent clinical out-
comes associated with infection.
The majority of strains of Helicobacter possess the vacA gene
which produces a vacuolating cytotoxin, but only about 50–60% of
strains secrete the toxin. Within the gene coding for the toxin, there
is a molecular heterogeneity with four signal sequences labelled S1a,
S1b, S1c and S2 and two mid region sequences M1 and M211.
Although most strains possess the vacA gene, some strains possess
another virulence marker called cagA (cytotoxin associated gene)
and are called Type I strains12. Those that are vacA positive but cagA
negative are relatively non-toxigenic (Type II strains). Fifty to sixty
percent of isolates carry the cagA locus which acts as a marker for
the cag pathogenicity island (an assembly of some 40 genes that are
linked to virulence of the organism and codes in large part for a type
IV bacterial secretion system) that is involved in the stimulation
of pro-inflammatory cytokines from the gastric epithelium.
Another important enzyme possessed by Helicobacter pylori is
urease which is both a virulence factor and its detection can be used
diagnostically.

Helicobacter: a paradigm shift in peptic ulcer disease and more? 17

SP/Vaira 18/3/02 9:56 am Page 18

The organism is found in the human stomach beneath the protec-

tive mucus layer adherent to the gastric epithelial cells. This ecologi-
cal niche has until recently been relatively neglected by microbiolo-
gists but an increasing interest in the complex communities resident
in this location have shown that the mucosa of the gastrointestinal
tract of animals is host to a wide variety of bacterial species – many
being Helicobacters. Large numbers of these bacteria reside in the
mucus-filled crypts or on the mucosa (Figure 2). Most of the bacteria
have a spiral morphology, which is likely to give them an advantage
in penetrating the thick mucus layer which covers the mucosa.
Although the first to be isolated, Helicobacter pylori is now just one
of an increasing number of Helicobacter species isolated from a
broad range of animals as diverse as the shrew, cheetah, tern and
dolphin. In the coming years there will certainly be more species iso-
lated. Broadly the Helicobacter species can be found in three prin-
cipal sites: the stomach; the lower intestine or associated with the
hepatobiliary system. Some of the Helicobacters isolated from various
animals including humans is shown in Figure 3.

How do people become infected?

The source and route of infection of Helicobacter pylori is not
known with any certainty, however, there are three potential sources
of infection: (a) animals, (b) the environment and (c) another human
(Figure 4).

Fig. 3 Some Helicobacter species currently identified.

18 Christelle Basset, John Holton and Dino Vaira

SP/Vaira 18/3/02 9:56 am Page 19

Fig. 4 Suggested routes of acquisition of Helicobacter pylori (arrowed).

Only tenuous evidence supports animals as a source of infection

and this derives principally from the isolation of Helicobacter pylori
from a colony of laboratory cats. Subsequent work did not detect
Helicobacter pylori in cats in general and cat owners are no more
frequently serologically positive than non-cat owners. There was
also some serological evidence that Sardinian shepherds may be
more frequently sero-positive for Helicobacter pylori than a control
population and there was a purported isolation of Helicobacter
pylori from milk of sheep but these results need to be confirmed13.
There is more evidence that contaminated water may act as a
source of infection. In South America, some seroprevalence studies
have shown that individuals using the municipal water source are
more likely to be positive than those using an artesian well14. This
suggests that faecally contaminated public water in some countries
may be a risk for colonisation. Circumstantial evidence that faecally
contaminated food could also act as a source of infection is the sur-
vival of Helicobacter pylori in artificially contaminated food for
days, or even months if the food was refrigerated. Additionally,
experiments showed that Helicobacter pylori can survive on the sur-
face and in the gastrointestinal tract of flies that had been artificially
contaminated15. However, there is no convincing evidence that in

Helicobacter: a paradigm shift in peptic ulcer disease and more? 19

SP/Vaira 18/3/02 9:56 am Page 20

developed countries, either faecally contaminated food acts as a

vehicle or flies as a vector for the transmission of Helicobacter
pylori.
The most likely source of infection is from another infected
human. Sero-epidemiological studies have identified socio-economic
and demographic factors that indicate close personal contact is
important in the transmission cycle and that infection is most com-
monly happening in childhood. These demographic factors, such as
social class, reflect the childhood living conditions and overcrowd-
ing in areas of social deprivation16. Two factors that are strongly
correlated with sero-positivity are lack of a fixed hot-water supply
and domestic overcrowding in childhood. Additional evidence that
overcrowding is important in transmission of Helicobacter pylori
derives from sero-epidemiological studies of institutions such as
orphanages, psychiatric institutions, military barracks, submarine
crews and families which all support a role of person-to-person
transmission of Helicobacter pylori facilitated by social overcrowd-
ing and lack of social hygiene17.
In industrialised countries, the prevalence of Helicobacter pylori
increases with age increasing from about 5% in the first decade to
over 60% in the sixth decade, reflecting the improved social condi-
tions and hence lower transmission in current times compared to the
past. In non-industrialised countries, the prevalence of infection in
childhood is high at about 80% in the first decade and there is little
age related increase reflecting the poor Public Health infrastructure
in some areas of the world.
Under natural circumstances, transmission could be by one of two
routes: oro-oral or faeco-oral and Helicobacter pylori has been
detected in oral secretions, gastric juice and faeces. The opportunity
for transmission occurring under conditions of overcrowding would
be high, if this was associated with an absence of basic hygienic
standards, as may happen in childhood or if there was a lack of
adequate sanitary facilities. There is no strong evidence to support
either the oral or faecal route as the primary one and both may be
relevant depending on other factors. Although the oral route (via oral
secretions or vomit) is a more direct one and is consistent with direct
person to person transmission, the faecal route may in addition to the
direct faeco-oral spread occurring within a family unit, also admit
of indirect spread via faecally contaminated food or water from a
contaminated river source.
It is worth pointing out, however, that there may be multiple
routes of transmission which may vary in importance according to
geographic and socio-demographic factors.

20 Christelle Basset, John Holton and Dino Vaira

SP/Vaira 18/3/02 9:56 am Page 21

How does Helicobacter cause disease?

Disease pathogenesis is brought about by five general mechanisms:
by direct action of surface exposed or secreted toxins; indirectly by
modulating the normal gastric homeostasis and thereby affecting
gastrin and pepsinogen levels and acid secretion; affecting the nor-
mal intracellular signalling of the gastric epithelial cell leading to
disordered cell regulation; as part of a bystander effect caused by
Helicobacter-induced activation of inflammatory cells with release
of inflammatory mediators and finally by a Helicobacter-stimulated
auto-immunity (Figure 5).

Local effects
The first steps in the pathogenesis of disease are the ability to pene-
trate the mucus and adhere to the gastric epithelial cells. Motility and
the ability to survive acid conditions for a short period of time, are
thus important virulence characteristic and here the urease activity of
Helicobacter pylori is important for modulation of the bacterial
intracellular pH whilst transiently in an acid environment18. The
organism adheres by a number of different adhesins, the most impor-
tant of which is BabA, whose ligand is the Lewis blood group antigen19.

Fig. 5 Overview of mechanisms of pathogenesis of disease caused by

Helicobacter pylori.

Helicobacter: a paradigm shift in peptic ulcer disease and more? 21

SP/Vaira 18/3/02 9:56 am Page 22

Once adherent, the organism begins to affect the local environment

by the secretion of enzymes and toxins. Helicobacter pylori secretes
phospholipase A2, which may have a direct effect upon the host cell
membrane or mucus; as well as the enzyme urease, which hydrolyses
urea, releasing the directly acting toxin- ammonia. The net effect is
destruction of the mucus in addition to a direct inimical action upon
the gastric epithelial cell. A further locally acting toxin is the vacuo-
lating cytotoxin (coded for in the vacA locus) which interferes with
the normal endosomal cycle within the cell leading to coalescence
and the production of large cytoplasmic vacuoles and eventual
destruction of the cell20. The toxin is activated by the acid of the
stomach and inserts into the lipid membrane of the gastric cell to
form oligomeric anion selective channels. The toxin is internalised and
binds to the membranes of the endosomes affecting the late endo-
somal (pre-lysosomal) compartment. It activates a vacuolar-ATP’ase
inducing an acid environment in the vacuole with the accumulation
of weak bases (NH4 from the NH3 produced as a result of the urease
activity of the organism) and thus an osmotic effect to cause enlarge-
ment of the vacuole (Figure 6). The vacuolating cytotoxin also inter-
feres with antigen presentation by B-cells and thus has an immuno-
modulatory effect.

Alteration of gastric physiology

Individuals colonised by Helicobacter pylori have hypergastrinaemia
which is caused by an inhibition of somatostatin secretion from
D-cells21. Somatostatin has a negative feedback effect on gastrin
secretion and its secretion is stimulated by acid. The lipopolysaccha-
ride of Helicobacter pylori inhibits somatostatin secretion, by a
mechanism not yet understood, but whose net effect is to lead to ele-
vated gastrin levels and thus, as gastrin stimulates acid secretion,
elevated acid levels. Helicobacter pylori also leads to hyperpepsino-
genaemia: pepsin is an enzyme involved in digestion of food by an
unknown mechanism. The high level of pepsin and acid in the stom-
ach combined with a deficient mucus blanket may all contribute to
damage to the gastric epithelium and enhance ulcerogenesis.

Auto-immunity
Antibodies directed against Helicobacter pylori and cross-reacting
with gastric tissue have been demonstrated following infection22.
High levels of these cross-reacting antibodies can lead to patho-
logical changes in the gastric mucosa. The auto-antibodies are
directed against muco-substances in the epithelium. A further target
for an auto-immune reaction is the Lewis antigens, and antibodies

22 Christelle Basset, John Holton and Dino Vaira

SP/Vaira 18/3/02 9:56 am Page 23

Fig. 6 Action of vacuolating cytotoxin of Helicobacter pylori.

raised against the Lewis epitopes expressed upon the lipopoly-

saccharide of Helicobacter may be involved in the development of
gastric atrophy. Once the antibody is bound to the gastric cell it may
induce lysis of the cell by a complement dependent mechanism.

Interference with cell signalling

(a) Inflammation
After adhesion of Helicobacter pylori, the CagA protein is trans-
ported into the gastric cell by a Type IV secretion system coded for
in the pathogenicity island. The CagA protein becomes phosphoryl-
ted on a tyrosine residue by an as yet unknown kinase and in turn
affects tyrosine phosphorylation on other host cell proteins23.
Subsequently, there is upregulation of NF␬B (the chronic inflam-
matory transcription factor) which is mediated by the NF␬B kinase
pathway and which leads to an increase in synthesis and release of
IL-18, IL-8 and monocyte chemoattractant protein (MCP-1)24–26
(Figure 7). Interleukin-18 is a potent cytokine which polarises the
immune system to a Th-1 response thereby upregulating other pro-
inflammatory cytokines such as tumor necrosis factor (TNF␣), IL-1

Helicobacter: a paradigm shift in peptic ulcer disease and more? 23

SP/Vaira 18/3/02 9:56 am Page 24

Fig. 7 Action of CagA protein and stimulation of chemokine production by

gastric epithelium.

and INF␥ . IL-8 is a potent chemo-attractant for neutrophils. MCP-1

is a potent chemoattractant for monocytes. The net result of these
effects is infiltration of the stomach wall by inflammatory cells such
as neutrophils and monocytes. Further, Helicobacter can activate the
neutrophils to degranulate and release cytotoxic proteins and reac-
tive oxygen metabolites, which in turn may damage the gastric cells.
In addition to these effects, the upregulation of NF␬B leads to the
upregulation of intercellular adhesion molecule (ICAM-1) on the
gastric cell to which the inflammatory cell binds27.
The significance of cagA locus is that patients who are colonised
by cagA strains (Type I) have higher levels of IL-8, a more intense
inflammatory response and are more likely to develop ulcer (duode-
nal or gastric) disease and are more likely to develop gastric adeno-
carcinoma28 . Thus on binding of the Helicobacter to the gastric
cells, an acute inflammatory response is mounted by the host in
response to the presence of the organism, but the hosts’ immune sys-
tem is unable to eradicate the organism. Persistence of the organism
leads to the development of a chronic inflammatory response.

24 Christelle Basset, John Holton and Dino Vaira

SP/Vaira 18/3/02 9:56 am Page 25

(b) Cell cycle regulation

Exposure of gastric epithelial cells to Helicobacter pylori leads to an
increase in cell proliferation and an increase in apoptosis29. This is
associated with an induction of caspase 3, 8 and 9 and the expression
of Bad and Bid- both members of the pro-apoptotic protein family 30.
Furthermore, the microenvironment of the stomach may modulate
the pro-apoptotic induction phenotype of Helicobacter pylori.
Chronic infection leads to an apoptosis resistant phenotype with a
reduction in the cyclin dependant kinase p27 kip1 . This reduction is
also noted in patients with gastric cancer who have a poor prognosis
and thus establishes a potential link between infection and clinical
outcome in relation to cancer 31. These effects may in part be medi-
ated by the lipopolysaccharide component of the organism. These
effects may be highly relevant to the association between
Helicobacter pylori and gastric adenocarcinoma by disturbing the
normal proliferative-apoptotic balance in the cells. Additionally
because of the low acid found in the stomach of this group of
patients, there may be bacterial overgrowth of other organisms in the
stomach, which can reduce nitrate to nitrite and thus which could be
involved in the production of nitrosamines – i.e. carcinogens. These
effects could be very relevant to the ultimate progression in some
individuals to developing gastric cancer.

The progression to gastric cancer of duodenal ulcer?

If clinical illness develops following colonisation, binding of
Helicobacter pylori to the antrum of the stomach is often associated
with the development of duodenal ulceration (Figure 2). If, however,
the organism binds in the fundus of the stomach, which is the acid
producing part of the stomach, rather than developing an hyper-
chlorhydria (excess acid) the acid producing cells may be damaged
and the person becomes hypochlorhydric. This is often associated
with the development of gastric cancer. The site of binding of the
organism may be determined in part by differences in adhesins,
although the fundus of the stomach may become affected during
long term colonisation with Helicobacter pylori, as the inflammatory
process spreads from the antrum to the whole stomach to give a pan-
gastritis. Host genetic factors are important in the development of
gastric cancer as certain polymorphisms in the gene for the cytokine
IL-1 (which is a potent acid suppressant) are linked to a higher risk
of developing cancer32. Long-term colonisation may lead to the
development of atrophic gastritis and intestinal metaplasia. Atrophic
gastritis is characterised by infiltration of inflammatory cells

Helicobacter: a paradigm shift in peptic ulcer disease and more? 25

SP/Vaira 18/3/02 9:56 am Page 26

throughout the mucosa with atrophy of the gastric glands and depo-
sition of fibrous materials. In this case there is a reduction in the acid
secreting capacity of the stomach. Atrophic gastritis is often a pre-
cursor to intestinal metaplasia. Both atrophic gastritis and intestinal
metaplasia are considered pre-cancerous lesions. In addition to
colonisation by Helicobacter and host factors, other factors are
strongly implicated in the progression from an inflamed stomach,
through atrophic gastritis, intestinal metaplasia, dysplasia and ulti-
mately cancer. These factors relate to dietary factors such as lack of
green vegetables (and hence low levels of the anti-oxidant, vitamin
C) and excess salt intake. This is an important consideration that is
receiving much attention, as it may be possible to prevent the develop-
ment of gastric cancer either by dietary supplementation or eradication
of Helicobacter. Currently there are a number of studies addressing
this issue and trying to determine if atrophic gastritis and or intesti-
nal metaplasia, the pre-cancerous conditions, can be reversed by
eradication of the organism. To date there is no firm answer upon this
point.

Diagnosis
The tests available for the diagnosis of Helicobacter pylori can be
divided into those which require an endoscopy- an invasive procedure
where an endoscope is passed into the stomach and tissue samples
taken and those which do not require an endoscopy33 (Figure 8). The
latter are the more frequently used and more so by GP’s in primary
care. If a biopsy is taken the presence of the organism in these tissue
samples can be detected by histology and culture. Histology pro-
vides information both about the presence of Helicobacter pylori and
the presence of inflammation, atrophy or metaplasia. Microscopically,
Helicobacter pylori can readily be recognised by its characteristic
curved or S-shaped morphology and its location to the epithelial cell
surface, within the gastric pits or in the mucus overlaying the cell
surface. Culture also has an important role to play in diagnosis and
although cheap is the slowest of the tests available because the
organism takes 4–5 days to grow on primary isolation. One advan-
tage culture has is the ability to obtain data on the antibiotic sensi-
tivity of the organism, although recently specific PCR’s have been
developed to detect antibiotic resistant organisms. In clinical terms,
obtaining antibiotic sensitivity results may be relevant in treating
relapsing disease but also to follow trends in antibiotic resistance,
which is important when suggesting empirical treatment. Another
test that can be used on the tissue sample is the rapid urease test

26 Christelle Basset, John Holton and Dino Vaira

SP/Vaira 18/3/02 9:56 am Page 27

Fig. 8 Methods of diagnosis of Helicobacter pylori colonisation.

(RUT). This involves placing the tissue in a solution of urea with a

pH indicator and detecting a pH change brought about by the pres-
ence of the enzyme urease. This bacterial enzyme acts as a surrogate
marker for the presence of the organism. The rapid urease test can
also be performed per-endoscopically with the use of a pH sensitive
biosensor, giving a high sensitivity and specificity. The final tests
that can be used on the tissue sample are the polymerase chain reac-
tion (PCR) and in-situ hybridisation. The polymerase chain reaction
is a biochemical technique that can greatly amplify lengths of DNA
to such an extent that their presence can then be detected either by
electrophoresis and staining with ethidium bromide, or immunologi-
cally. This is a powerful and very sensitive technique which, as long
as the primary sequence of the DNA of the specific target organism
is known, can be used to detect that organism amongst a complex

Helicobacter: a paradigm shift in peptic ulcer disease and more? 27

SP/Vaira 18/3/02 9:56 am Page 28

mixture of other organisms. In-situ hybridisation also requires the

primary sequence of the DNA to be known and uses a fluorescently
labelled probe as the detection system.
Of the non-invasive tests available, there are the urea-breath test,
serology and antigen detection. The urea-breath test indicates
current infection with Helicobacter pylori and is based up on ingest-
ing labelled urea and detecting the breakdown product, as evidence
of the presence of Helicobacter. Urea is labelled with either 14C or
13C and given as a test meal to patients. Hydrolysis of the labelled

urea by the urease enzyme of Helicobacter releases labelled carbon

dioxide which is exhaled in the breath. The urea breath test can be
used to screen a patient prior to endoscopy and as a follow-up test to
determine effect of treatment in eradicating Helicobacter. Recent
developments of breath analysis are investigating the use of quartz
crystal microbalances to differentiate colonised patients from
patients without the organism by analysis of the volatile products
on the breath of patients without prior ingestion of urea- labelled or
otherwise.
Serology has frequently been used in epidemiological studies on
the population distribution of Helicobacter but serology is also used
diagnostically as a screening test. It is not as accurate as antigen
detection as it only indicates past exposure to the organism and not
current infection. The majority of serological tests are laboratory
based although increasingly rapid near-patient or office tests are
becoming commercially available. Kits are now available for detect-
ing anti-Helicobacter antibodies in saliva (usually IgA), serum (IgG)
(the ones most commonly available) and most recently in the urine.
One of the most recent developments for the detection of
Helicobacter pylori is faecal antigen detection because of its speed,
technical simplicity and ease of collecting specimens. Several kits
are now available based on a polyclonal capture antibody or more
recently a monoclonal antibody.

Management
The current treatment for peptic ulcer disease is a one week course
of an acid inhibitor and a combination of two antibiotics, either
amoxycillin and metronidazole or amoxycillin and clarithromycin.
These regimens eradicate Helicobacter pylori in 80–90 % of cases3.
The main problem with these courses of treatment is the number of
tablets that have to be taken and thus the lack of compliance of the
patient with failure of eradication and often the development by the
organism of resistance to the antibiotics. Globally the prevalence of

28 Christelle Basset, John Holton and Dino Vaira

SP/Vaira 18/3/02 9:56 am Page 29

antibiotic resistance is increasing dramatically, particularly for

metronidazole. This is leading to effective treatment being compro-
mised. Rescue regimens often now comprise a combination of four
anti-bacterial agents which can include bismuth and tetracycline. If
the evidence is such that it would be worth eradicating Helicobacter
pylori in asymtomatic patients (a considerable proportion of the
worlds’ population) then this increasing antibiotic resistance pre-
sents a stumbling block. An alternative strategy that is being actively
persued by pharmaceutical companies is the development of
vaccines and although promising results have been obtained from
animal studies, human studies have not been as successful. Novel
strategies are also being investigated such as new “organic” pharma-
ceuticals e.g. garlic, tea, and millet- all of which have anti-
Helicobacter properties; treatments based on the inhibition of the
first step in the pathological process – adhesion, and methods to
upregulate the immune response by, for example, enhancing phago-
cytosis of the organism, are also under investigation.

References
1. Warren, J.R. & Marshall, B. (1983) Unidentified curved bacilli on gastric
epithelium in active chronic gastritis. Lancet, 1: 1273–1275
2. IARC Working Group on the Evaluation of Carcinogenic Risks to Humans.
(1994) Schistosomes, liver flukes and Helicobacter pylori. IARC-Monogr-Eval-
Carcinog-Risks-Hum. 61, 1–241
3. de Boer, W.A. & Tytgat, G.N.J. (2000) Treatment of Helicobacter pylori
infection BMJ, 320, 31–34
4. Talley, N.J. & Xia, H.H. (1998) Helicobacter pylori infection and non-ulcer
dyspepsia. Br. Med. Bull., 54 63–9.
5. Cahill, R.J., Foltz, C.J., Fox, J.G., Dangler, C.A., Powrie, F. & Schauer, D.B.
Inflammatory bowel disease: an immune mediated condition triggered by
bacterial infection with Helicobacter hepaticus. Infection Immunity 65,
3126–3131
6. Fox, J.G., Dewhirst, F.E., Shen, Z., Feng, Y., Taylor, N.S., Paster, B.J.,
Ericson, R.L., Lau, C.N., Correa, P., Araya, J.C. & Roa, I. (1998) Hepatic
Helicobacter species identified in bile and gallbladder tissue from Chileans with
chronic cholecystitis. Gastroenterology, 114, 755–763
7. Ridker, P.M., Danesh, J., Youngman, L., Collins, R., Stampfer, M.J., Peto, R. &
Hennekens, C.H. (2001) A prospective study of Helicobacter pylori sero-
positivity and the risk for future myocardial infarction among socioeconomi-
cally similar U.S. men. Ann. Intern. Med. 135, 184–188.
8. Tomb, J.F., White, O., Kerlavage, A.R.,Clayton, R.A.,Sutton, G.G.,
Fleischmann, R.D., Ketchum, K.A., Klenk, H.P., Gill, S., Dougherty, B.A.,
Nelson, K., Quackenbush, J., Zhou, L., Kirkness, E.F., Peterson, S., Loftus, B.,
Richardson, D., Dodson, R., Khalak, H.G., Glodek, A., McKenney, K.,
Fitzegerald, L.M., Lee, N., Adams, M.D., Hickey, E.K., Berg, D.E.,

Helicobacter: a paradigm shift in peptic ulcer disease and more? 29

SP/Vaira 18/3/02 9:56 am Page 30

Gocayne, J.D., Utterback, T.R., Peterson, J.D., Kelley, J.M., Cotton, M.D.,
Weidman, J.M., Fujii, C., Bowman, C., Watthey, L., Wallin, E., Hayes, W.S.,
Borodovsky, M., Karp, P.D., Smith, H.O., Fraser, C.M. & Venter, C. (1997)
The complete genome sequence of the gastric pathogen Helicobacter pylori.
Nature, 388: 539–547.
9. Salaun, L., Audibert, C., Le Lay, G., Burucoa, C., Fauchere., J.L., Picard, B.
(1998) Panmictic structure of Helicobacter pylori demonstrated by the
comparative study of six genetic markers. FEMS Microbiol Lett. 161, 31–39.
10. Covacci, A., Falkow, S., Berg, DE. & Rappuoli, R. (1997) Did the inheritance
of a pathogenicity island modify the virulence of Helicobacter pylori? Trends
Microbiology, 5, 205–209
11. Atherton, J.C., Cover, T.L., Twells, R.J., Morales, M.R., Hawkey, C.J. &
Blaser, M.J. (1999) Simple and accurate PCR-based system for typing
vacuolating cytotoxin alleles of Helicobacter pylori J. Clin. Micro., 37,
2979–2982
12. Xiang, Z., Censini, S., Bayeli, P.F., Telford, J.L., Figura, N., Rappuoli, R. &
Covacci, A. (1995) Analysis of expression of CagA and VacA virulence factors
in 43 strains of Helicobacter pylori reveals that clinical isolates can be divided
into two major types and that CagA is not necessary for expression of the
vacuolating cytotoxin. Infect. Immun., 63(1), 94–98.
13. Dore, MP., Bilotta, M., Vaira, D., Manca, A., Massarelli, G.,Leandro, G., Atzei,
A., Pisanu, G., Graham, DY. & Realdi, G. (1999) High prevalence of
Helicobacter pylori infection in shepherds. Dig Dis Sci., 44, 1161–1164.
14. Hulten, K., Han, S.W., Enroth, H., Klein, P.D., Opekun, A.R., Gilman, R.H.,
Evans, D.G., Engstrand, L., Graham, D.Y. & El-Zaatari, F.A.K. (1996)
Helicobacter in the drinking water in Peru. Gastroenterology, 110, 1031–1035
15. Vaira, D. & Holton, J. (1998) Vector potential of houseflies (Musca domestica)
for Helicobacter pylori. Helicobacter, 3, 65–66
16. Webb, P.M., Knight, T., Greaves, S., Wilson, A., Newell, D.G., Elder, J. &
Forman, D. (1994) Relation between infection with Helicobacter pylori and
living conditions in childhood: evidence for person to person transmission in
early life, BMJ, 308, 750–753
17. Lambert, J.R., Lin, S.K., Sievert, W., Nicholson, L., Schembri, M. & Guest, C.
(1995) High prevalence of Helicobacter pylori antibodies in an institutionalized
population: evidence for person-to-person transmission, Am. J. Gastroenterol.,
90, 2167–2171
18. Weeks, D.L. & Sachs, G. (2001) Sites of pH regulation of the urea channel of
Helicobacter pylori., Mol Microbiol., 40, 1249–1259.
19. Prinz, C., Schoniger, M., Rad, R., Becker, I., Keiditsch, E., Wagenpfeil, S.,
Classen, M., Rosch, T., Schepp, W. & Gerhard, M. (2001) Key importance of
the Helicobacter pylori adherence factor blood group antigen binding adhesin
during chronic gastric inflammation. Cancer Res., 61, 1903–1909.
20. Cover, T.L. (1996) The vacuolating cytotoxin of Helicobacter pylori
21. Calam, J. (1999) Helicobacter pylori modulation of gastric acid. Yale J. Biol.
Med., 72, 195–202.
22. Parente, F., Negrini, R., Imbesi, V., Maconi, G., Sainaghi, M., Vago, L. &
Porro, G.B. (2001) Presence of gastric autoantibodies impairs gastric secretory
function in patients with Helicobacter pylori-positive duodenal ulcer. Scand. J.
Gastroenterol., 36, 474–47

30 Christelle Basset, John Holton and Dino Vaira

SP/Vaira 18/3/02 9:56 am Page 31

23. Segal, E.D., Lange, C., Covacci, A., Tompkins, L.S., Falkow, S. (1997)
Induction of host signal transduction pathways by Helicobacter pylori. PNAS,
94, 7595–7599
24. Tomita, T., Jackson, A.M., Hida, N., Hayat, M., Dixon, M.F., Shimoyama, T.,
Axon, ATR., Robinson, PA. & Crabtree, JE. (2001) Expression of Interleukin-
18, a Th1 cytokine in human gastric mucosa is increased in Helicobacter pylori
infection. J. Infect. Dis., 183, 620–627
25. Noach, L.A., Bosma, N.B., Jansen, J., Hoek, F.J., van Deventer, S.J. &
Tytgat, G.N. (1994) Mucosal tumor necrosis factor alpha, interleukin-1 beta and
interleukin 8 production in patients with Helicobacter pylori infection. Scand. J.
Gastroenterol., 29, 425–429
26. Mori, N., Ueda, A., Geleziunas, R., Wada, A., Hirayama, T., Yoshimura, T.,
Yamamoto, N. (2001) Induction of monocyte chemoattractant protein –1 by
Helicobacter pylori involves NF␬B. Infection Immunity, 69, 1280–1286
27. Mori, N., Wada, A., Hirayama, T., Parks, T.P., Stratowa, C., Yamamoto, N.
(2000) Activation of intracellular adhesion molecule-1 expression by
Helicobacter pylori is regulated by NF␬B in gastric epithelial cancer cells.
Infection Immunity, 68, 1806–1814
28. Blaser, M.J., Perez-Perez, G.I., Kleanthous, H., Cover, T.L., Peek, R.M.,
Chyou, P.H., Stemmermann, G.N. & Normura, A. (1995) Infection with
Helicobacter pylori strains possessing cagA is associated with increased risk of
developing adenocarcinoma of the stomach. Cancer Res., 55, 2111–2115
29. Peek, R.M., Wirth, H.P., Moss, S.F., Yang, M., Abdalla, A.M., Tham, K.T.,
Zhang, T., Tang, L.H., Modlin, I.M. & Blaser, M.J. (2000) Helicobacter pylori
alters gastric epithelila cell cycle events and gastrin secretion in Mongolian
Gerbils Gastroenterology, 118, 48–59
30. Shibayama, K., Doi, Y., Shibata, N., Yagi, T., Nada, T., Linuma, Y. &
Arakawa, Y. (2001) Apoptotic signalling pathway activated by Helicobacter
pylori infection and increase of apoptosis-inducing activity under semi-starved
conditions. Infection Immunity, 69, 3181–3189
31. Shirin, H., Sordillo, E.M., Kolevska, T.K., Hibshoosh, H., Kawabata, Y.,
Oh, S.H., Kuebler, J.F., Delohery, T., Weghorst, C.M., Weinstein, I.B. &
Moss, S.F. (2000) Chronic Helicobacter pylori infection induces an apoptosis-
resistant phenotype associated with decreased expression of p27kip1. Infection
Immunity, 68, 5321–5328
32. El-Omar, E.M., Carrington, M., Chow, W.H., McColl, K.E., Bream, J.H.,
Young, H.A., Herrera, J., Lissowska, J., Yuan, C.C., Rothman, N., Lanyon, G.,
Martin, M., Fraumeni, J.F. & Rabkin, C.S. (2000) Interleukin-1 polymorphisms
associated with increased risk of gastric cancer. Nature, 404, 398–402.
33. Vaira, D., Holton, J., Menegatti, M., Ricci, C., Gatta, L., Geminiani, A. &
Miglioli, M. (2000) Review article:invasive and non-invasive tests for
Helicobacter pylori infection. Aliment. Pharmacol. Ther. Suppl 3, 13–22.

Helicobacter: a paradigm shift in peptic ulcer disease and more? 31

SP/Vaira 18/3/02 9:56 am Page 32