Prevalence of Helicobacter pylori infection among β-thalassemia major children with recurrent abdominal pain at Suez Canal University Hospital

GK Yousab Feiby; M Handoka Nesrin; AM Mesbah Badr

doi:10.4103/1110-1067.161292

ORIGINAL ARTICLE

Year : 2015 | Volume : 40 | Issue : 2 | Page : 74-79

Prevalence of Helicobacter pylori infection among β-thalassemia major children with recurrent abdominal pain at Suez Canal University Hospital

GK Yousab Feiby, M Handoka Nesrin, AM Mesbah Badr
Department of Pediatrics, Faculty of Medicine, Suez Canal University, Ismaelia, Egypt

Date of Submission	09-Mar-2015
Date of Acceptance	16-Apr-2015
Date of Web Publication	22-Jul-2015

Correspondence Address:
G K Yousab Feiby
MBBCh, Madenat Alsalam 17 Awadalla Street, Mansoura
Egypt

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1110-1067.161292

Abstract

Background Recurrent abdominal pain (RAP) is a common pediatric problem and it is also one the several gastrointestinal tract disturbances frequently seen in β-thalassemia major (β-TM) patients. Helicobacter pylori is known to be an etiological agent of chronic gastritis and peptic ulcer diseases, but its correlation with RAP is still under debate.
Aim The aim of the study was to determine the prevalence of H. pylori infection among β-TM children with RAP.
Patients and methods This study was cross-sectional in design. We recruited 48 β-TM cases (24 β-TM children who presented with RAP and 24 β-TM children who did not present with RAP), aged 5-18 years, and 48 age-matched and sex-matched controls (24 children who presented with RAP without any other apparent manifestations of disease and 24 healthy children who did not present with RAP). Children who presented with RAP fulfilled Apley's criteria for the diagnosis of RAP. All patients and controls had undergone serum H. pylori IgG evaluation by ELISA.
Results The seroprevalence of H. pylori in β-TM patients who presented with RAP was more common than in controls who presented with RAP [14/24 (58.3%) vs. 7/24 (29.2%); P = 0.04]. Also, there was a statistically significantly higher seroprevalence of H. pylori among the total number of β-TM children than among the total number of control children [24/48 (50%) vs. 12/48 (25%)]. The mean duration of splenectomy was statistically significantly higher in total β-TM children who were H. pylori IgG positive than among total β-TM children who were H. pylori IgG negative. There was no significant difference between total H. pylori IgG-positive β-TM children and age, sex, duration of blood transfusion, duration of iron chelating agent, criteria of abdominal pain, and serum ferritin level.
Conclusion There was a higher prevalence of H. pylori IgG in β-TM children with RAP than among control children with RAP, as well as among total β-TM children than among total control children. H. pylori IgG was detected more frequently in thalassemic patients with a longer duration of splenectomy.

Keywords: Helicobacter pylori , recurrent abdominal pain, thalassemia major

How to cite this article:
Yousab Feiby G K, Nesrin M H, Mesbah Badr A M. Prevalence of Helicobacter pylori infection among β-thalassemia major children with recurrent abdominal pain at Suez Canal University Hospital. Egypt J Haematol 2015;40:74-9

How to cite this URL:
Yousab Feiby G K, Nesrin M H, Mesbah Badr A M. Prevalence of Helicobacter pylori infection among β-thalassemia major children with recurrent abdominal pain at Suez Canal University Hospital. Egypt J Haematol [serial online] 2015 [cited 2021 Jul 31];40:74-9. Available from: http://www.ehj.eg.net/text.asp?2015/40/2/74/161292

Introduction

β-Thalassemia is the result of deficient or absent synthesis of β globin chains leading to excess α chains ^[1] , which form unstable aggregates that precipitate and affect erythrocyte membrane plasticity. This leads to erythrocyte destruction, resulting in ineffective erythropoiesis and anemia ^[2] . Patients with β-thalassemia major (β-TM) are at greater risk for infectious diseases. Infections constitute the second most common cause of mortality and is a main cause of morbidity in thalassemia ^[3] .

Helicobacter pylori is a Gram-negative, microaerophilic, spiral, bacterial organism. It is highly prevalent, with prevalence rates varying from 80 to 90% in developing countries and from 35 to 40% in developed countries ^[4] .

Recurrent abdominal pain (RAP) is a common pediatric disorder, affecting up to 10-20% of normal children ^[5] . The role of H. pylori was disputable in the etiology of RAP in children ^[6],[7] . However, in some studies H. pylori in children with RAP was stated to be 40-54% ^[8],[9] .

Because of the role of H. pylori in causing abdominal pain and peptic ulcer, it is important in β-TM patients presenting with RAP ^[10] .

Aim

The present study aims to determine the prevalence of H. pylori infection among β-TM children with RAP for minimizing the disease burden of such children and improving their quality of life.

Patients and methods

Study population

The study was conducted on children aged 5-18 years who were followed up at Suez Canal University Hospital. A consecutive sample method was used. A total of 96 cases and controls were included, who were divided into four groups - two patients and two control groups - each group comprising 24 children.

Group 1: This group comprised β-TM children who presented with RAP.

Group 2: This group comprised β-TM children who did not present with RAP.

Both sets of patients were recruited from the hematology outpatient clinic at Suez Canal University Hospital from among those who came for routine follow-up. All of them had proven β-TM on the basis of usual hematological confirmation (peripheral blood evaluation, complete blood cell count, hemoglobin electrophoresis) from the first years of life and were on regular blood transfusion and chelating therapy program.

Group 3: This group included age-matched and sex-matched control children who presented with RAP without any other apparent manifestations of disease. They were recruited from the pediatric gastroenterology outpatient clinic at Suez Canal University Hospital.

Group 4: This group included age-matched and sex-matched healthy children who did not present with RAP.

Patients and controls who presented with RAP were selected from among those who fulfilled Apley's criteria for the diagnosis of RAP: at least three discrete episodes of abdominal pain over a period of three or more consecutive months and of sufficient severity to impair the normal activity of the child (at least one of the following: staying home from school, terminating or avoiding play, taking medication) ^[11] .

A detailed medical history and physical examination were carried out in all children.

Clinical history taking, with special emphasis on age, sex, age at blood transfusion initiation, age at iron chelating agent initiation, age at splenectomy, and all information about abdominal pain (site, onset, course, duration, severity, nature of abdominal pain, pain radiation, aggravating/alleviating agents), was also carried out.

Physical examination

This included abdominal examination for detection of site, intensity, and radiation of abdominal pain.

Laboratory investigations

Complete blood count and evaluation of serum ferritin level were carried out in all cases as a part of routine evaluation. Hemoglobin level was evaluated in all control groups. Serum samples from all groups were examined for anti-H. pylori antibody using H. pylori IgG ELISA.

Serology test for Helicobacter pylori

Approximately 2 ml of venous blood was collected from both cases and controls. The sample was centrifuged at 2000g (the relative centrifugal force) for 2 min to isolate serum, which was frozen until assayed. Determination of IgG to H. pylori was done by means of enzyme-linked immunosorbent assay (VIR-ELISA Anti-Helicobacter-IgG; VIRO-IMMUN Labor-Diagnostika GmbH, Oberursel, Germany), according to the manufacturer's instructions. ELISA values less than 0.9 were considered negative, those greater than 1.1 were considered positive, and those between 0.9 and 1.1 were considered equivocal. Samples giving equivocal results were retested, and those remaining equivocal were excluded from additional analyses. The specificity of the test was 92.8% and sensitivity was 100%.

Ethical approval

The study was approved by the institutional ethical committee review board of Suez Canal University. Informed consent was obtained from all participants and their parents.

Statistical analysis

Data entry and statistical analyses were performed using statistical package for the social sciences (SPSS, version 16.0; SPSS Inc., Chicago, Illinois, USA). Parametric data were expressed as mean ± SD. Nonparametric data were expressed as median, minimum, and maximum values. Normality of data was first tested by means of the one-sample K-S test. In addition, the independent t-test was used to compare the mean values of continuous parametric variables between two groups. The Mann-Whitney U-test (Z) was used to compare nonparametric continuous variables between two groups. The Pearson χ² -test was used to compare the categorical variables between cases and control. P values less than 0.05 were considered statistically significant.

Results

There were no statistically significant differences in the mean age and sex distribution between cases and controls (P = 0.6 and 1.0, respectively) ([Table 1]).

Table 1 Distribution of age and sex in the studied groups

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The highest prevalence of H. pylori IgG was among β-TM children with RAP (14, 58.3%), followed by β-TM children without RAP (10, 41.7%) and healthy children with RAP (seven, 29.2%); the least prevalence was among healthy children without RAP (five, 20.8%). There was a statistically significant difference in the prevalence of H. pylori IgG among the studied groups (P = 0.04). There was a statistically significantly higher prevalence of H. pylori IgG among β-TM children with RAP (14, 58.3%) than among healthy control children with RAP (seven, 29.2%) (P = 0.04) ([Table 2]).

Table 2 Prevalence of Helicobacter pylori IgG in the studied groups

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There was also a significantly higher prevalence of H. pylori IgG among the total β-TM children (24, 50%) than among the total healthy control children (12, 25%) (P = 0.01) ([Figure 1]).

Figure 1 Helicobacter pylori IgG among total β-thalassemia major cases and total control children

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The mean duration of splenectomy was statistically significant higher in total H. pylori IgG-positive β-TM children than among total H. pylori IgG-negative β-TM children (P = 0.03) ([Figure 2]). However, there was no significant difference between the two groups regarding other patient characteristics ([Table 3]).

Figure 2 Comparison of mean duration of splenectomy between total Helicobacter pylori IgG-positive β-thalassemia major children and total H. pylori IgG-negative β-thalassemia major children

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Table 3 Comparison of clinical and laboratory characteristics between total H. pylori IgG-positive β -thalassemia major children and total H. pylori IgG-negative β -thalassemia major children

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Discussion

RAP is a common pediatric disorder, affecting up to 10-20% of normal children because of various causes ^[5] ; it is also one of the most common presenting symptoms in β-TM children ^[12] . The role of H. pylori was disputable in the etiology of RAP in children ^[6],[7] . However, in some previous studies, H. pylori frequency in children with RAP was stated to be 40-54% ^[8],[9] , and 70% in Egyptian children with RAP ^[13] . Because of the role of H. pylori in causing abdominal pain and peptic ulcer, it can be considered an important factor in β-TM patients presenting with RAP ^[10] .

The present study shows a statistically significantly higher prevalence of H. pylori IgG among β-TM children with RAP (58.3%) than among healthy control children with RAP (29.2%). There was also a significantly higher prevalence of H. pylori IgG among total β-TM children (50%) than among total healthy control children (25%).

Mofidi and Kouhsar ^[10] compared the prevalence of H. pylori infection in 132 β-TM patients and 135 age-matched and sex-matched controls in Iran. By using anti-H. pylori IgG ELISA, a significantly higher prevalence of H. pylori IgG was seen in β-TM patients (81.8%) compared with controls (54.8%) ^[10] .

Another study conducted in Jeddah, Saudi Arabia, using anti-H. pylori IgG ELISA found that the prevalence of H. pylori IgG was higher among chronic hemolytic anemia patients than among controls (31.7 vs. 23.6%) ^[14] .

In contrast, in a study conducted in Turkey by Balci et al. ^[15] , anti-H. pylori antibody IgG ELISA was performed on 62 β-TM children aged between 4 and 21 years and on 41 age-matched and sex-matched controls, both of whom presented with RAP. There was no statistically significant difference in the prevalence of H. pylori IgG in β-TM children with RAP (58.1%) compared with controls (48.8%) ^[15] .

Christoforidis et al. ^[16] also compared the prevalence of H. pylori infection among 40 asymptomatic patients with β-thalassemia in Greece of a mean age of 27.2 ± 9.7 years and among 30 age-matched and sex-matched controls by using anti-H. pylori IgG. No significant difference was observed in the prevalence of H. pylori IgG in β-thalassemia patients (15%) compared with controls (20%) ^[16] .

In a study conducted in Iran by Karimi et al. ^[17] , upper gastrointestinal endoscopy with biopsy was performed on 50 patients with β-TM who were aged between 6 and 25 years and on 50 age-matched and sex-matched controls, both of whom presented with RAP. There was no statistically significant difference in the prevalence of H. pylori infection in β-TM patients with RAP (68%) compared with healthy children with RAP (60%) ^[17] .

Host iron is known to be essential for pathogen growth. However, there have been inconsistent reports on the roles of iron in the acquisition of H. pylori infection ^[14],[18] . Perhaps, the iron overload in thalassemia patients might have contributed to the high prevalence of H. pylori infection observed in this study.

Moreover, the mean duration of splenectomy was statistically significantly higher in total β-TM children positive for H. pylori IgG than among total β-TM children negative for H. pylori IgG. This means that splenectomy weakens the immunity against H. pylori, establishing the role of the immune system in protection against H. pylori infection.

In harmony with our result, Christoforidis et al. ^[16] and Karimi et al. ^[17] found a clear relationship between the prevalence of H. pylori infection and splenectomy. However, Christoforidis et al. ^[16] , Karimi et al. ^[17] , and Balci et al. ^[15] did not find any relationship between H. pylori infection and splenectomy.

There have been conflicting results on the association between H. pylori and RAP in children. Whereas some studies report an association between RAP and H. pylori ^{[5],[13],[19]} , others found no association ^[20],[21] .

In the present study, there was no significant difference between RAP and H. pylori seroprevalence in β-TM children and healthy control children. This may, however, not exclude H. pylori as a cause of RAP ^[22] .

The present study shows that the prevalence of H. pylori IgG significantly increased with age in total healthy control children, which is compatible with the literature ^[23] . Surprisingly we found that in thalassemia children there was no significant difference in age between H. pylori IgG-positive and H. pylori IgG-negative children, and the only identified significant variable was the long duration of splenectomy.

Moreover, Balci et al. ^[15] stated a significant relationship between H. pylori-positive β-TM children and epigastric pain and pain duration and no significant relationship with sex, periumbilical pain, and serum ferritin level.

Christoforidis et al. ^[16] stated a significantly lower mean serum ferritin level in H. pylori-positive patients compared with negative ones.

Karimi et al. ^[17] found a significant relationship between H. pylori-positive β-TM children and pain duration, duration of blood transfusion, and duration of iron chelating agent and did not find a significant relationship with abdominal pain characteristics or serum ferritin.

The present study showed that there was no significant difference between total H. pylori IgG-positive β-TM and sex, duration of blood transfusion, duration of iron chelating agent, criteria of abdominal pain, and serum ferritin level. However, the mean hemoglobin level in total H. pylori IgG-positive healthy children was significantly lower than that of total H. pylori IgG-negative ones.

Conclusion

We conclude that there is a higher prevalence of H. pylori IgG in β-TM children with RAP (58.3%) than among healthy control children with RAP (29.2%).

There is also a higher prevalence of H. pylori IgG in total β-TM children (50%) than among total healthy control children (25%).

H. pylori IgG was detected more frequently in thalassemic patients with longer duration of splenectomy.

H. pylori may be one of the causes of RAP in β-TM patients as well as in healthy children in our developing country, especially in splenectomized patients.

We recommend that H. pylori be included in the differential diagnosis of RAP in β-TM children in our developing country. More studies are needed with a greater sample size for an extended evaluation of the effect of H. pylori on the occurrence of RAP.

Acknowledgements

Conflicts of interest

There are no conflicts of interest.

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