|Year : 2017 | Volume
| Issue : 2 | Page : 188-193
Influence of Helicobacter pylori infection on the prevalence and patterns of upper gastrointestinal symptoms in Nigerians with diabetes mellitus
A Oluyemi1, E Anomneze2, S Smith3, O Fasanmade4
1 Gastroenterology Unit, ReMay Consultancy and Medical Services, Ikeja, Lagos, Nigeria
2 Gastroenterology Unit, Health Gates Consultancy and Medical Services, Maryland, Lagos, Nigeria
3 Division of Molecular Biology, Nigerian Institute of Medical Research, Lagos, Nigeria
4 Endocrinology Unit, College of Medicine, University of Lagos, Lagos, Nigeria
|Date of Acceptance||03-May-2016|
|Date of Web Publication||13-Jan-2017|
Dr. A Oluyemi
ReMay Consultancy and Medical Services, Ikeja, Lagos
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Infection with Helicobacter pylori infection is widespread in our environment. However, whether this fact has any bearing on the prevalence and pattern of symptoms referable to the upper gastrointestinal (GI) system in our population of diabetes mellitus (DM) patients has not been much studied.
Aim: We embarked on this study to evaluate if H. pylori infection played any significant role in the prevalence and patterns of upper GI symptoms in type 2 DM patients in Lagos, Nigeria.
Materials and Methods: A case–control design was employed. One hundred consecutive, consenting, and ambulant type 2 DM patients were recruited from the Lagos University Teaching Hospital and 100 age- and sex-matched nondiabetic controls were drawn from medical outpatient clinics of the same hospital. All subjects were investigated for a marker of active infection with H. pylori via stool antigen testing, had anthropometric measurements taken, and completed a structured questionnaire administered to elicit for the presence of various upper GI symptoms over the preceding 3 months prior to the time of the study. The controls were further tested for DM. For analysis, the symptoms were divided into dyspepsia, gastroesophageal reflux (GER), and others.
Results: H. pylori infection status was neither significantly associated with dyspepsia in either cases or controls (χ2  = 2.198, P = 0.138) nor significantly associated with the symptomatic suggestion of GER in either cases or controls (χ2  = 3.742, P = 0.053). Moreover, the same held for the other upper GI symptoms in cases or controls (χ2  = 0.157, P = 0.203). H. pylori infection was detected in 18% of DM patients and 13% of controls, but there was no statistical significance in this difference (χ2  = 0.954, P = 0.329).
Conclusion: Infection with H. pylori does not appear, from the results of this study, to influence the prevalence and patterns of upper GI symptoms in patients with DM in Nigeria.
Keywords: Diabetes mellitus, gastrointestinal symptoms, Helicobacter pylori, Nigeria
|How to cite this article:|
Oluyemi A, Anomneze E, Smith S, Fasanmade O. Influence of Helicobacter pylori infection on the prevalence and patterns of upper gastrointestinal symptoms in Nigerians with diabetes mellitus. Niger J Clin Pract 2017;20:188-93
|How to cite this URL:|
Oluyemi A, Anomneze E, Smith S, Fasanmade O. Influence of Helicobacter pylori infection on the prevalence and patterns of upper gastrointestinal symptoms in Nigerians with diabetes mellitus. Niger J Clin Pract [serial online] 2017 [cited 2020 Jan 19];20:188-93. Available from: http://www.njcponline.com/text.asp?2017/20/2/188/183257
| Introduction|| |
Some researchers consider that gastrointestinal (GI) symptoms are more prevalent in diabetes mellitus (DM) patients than in the general population.,, Furthermore, others have noted that Helicobacter pylori infection might contribute significantly to this relationship. The latter notion has been put to the test by various researchers.
Gasbarrini et al. reported a higher prevalence of several dyspeptic symptoms in type 1 DM patients with H. pylori infection as compared with the H. pylori-negative group. The study, however, did not correct for confounding factors such as age, gender, and socioeconomic factors with multivariate analyses. The same investigators also suggested that the upper GI symptoms observed previously were improved with H. pylori eradication. The second report was also flawed in that there was no placebo control group. Their results were supported by similar earlier findings among type 2 diabetics. In addition, a local study from Lagos showed a higher prevalence of GI symptoms in DM patients than in nondiabetics.
On the other hand, later studies have strengthened arguments against the notion that H. pylori infection influences GI symptoms in DM. Xia et al. found that H. pylori infection was not associated with any upper GI symptom, either before or after adjustments for potential risk factors. Similarly, findings were reported in a population of young people with type 1 DM.
Again, other workers in the Iasi region of Romania reported that the prevalence of H. pylori infection was neither associated with the known duration of diabetes nor any significant difference in the upper GI symptoms score between H. pylori-positive and H. pylori-negative diabetic patients. In fact, the endoscopic findings in patients with DM (whatever their H. pylori infection status) were in the same range with those found in dyspeptic subjects from the same region.
In 2008, a Turkish publication reported that even within a type 2 DM population, there was no significant increase in H. pylori prevalence between those who complained of dyspeptic symptoms and those who did not. Such results were mirrored a study from Abakaliki where it was found that prevalence and patterns of dyspeptic symptoms were not significantly different between H. pylori seropositive diabetics and similarly, infected nondiabetic controls.
The objective of this study was to investigate if H. pylori had any significant role to play in the pattern of upper GI symptoms in Nigerians with DM.
| Materials and Methods|| |
Lagos University Teaching Hospital (LUTH), the location for this study, is situated in Idi-Araba, Surulere Local Government Area of Lagos State, Nigeria. The catchment area of the hospital referral base is statewide (and even beyond) and embraces a diverse array of patients with differing tribal, socioeconomic, and lineage backgrounds.
The study employed a case–control design. Here, measurement of cause and outcome variables among both cases and controls was carried out at the same point in time.
The subjects for this study were drawn from adults with type 2 DM patients of LUTH. They were all ambulant patients attending the DM outpatient clinics.
The age of the patients was from 31 to 82 years, and they agreed to sign the consent forms as an indication of willingness to participate in the study.
Selection criteria for cases
Inclusion criteria for cases
(1) Patients with objective evidence of DM as demonstrated by the World Health Organization (WHO) criteria for diagnosis of diabetes, i.e., fasting plasma glucose is ≥7.1 mmol/l (126 mg/dl) or a 2-h postprandial plasma glucose of ≥11.1 mmol/l (200 mg/dl) or those with classical symptoms and random blood glucose >11 mmol/l. Those who had been previously diagnosed with DM by this criterion but whose blood glucose had now been controlled with diet, drugs ± insulin were included in the study. (2) All recruited subjects agreed to sign the informed consent form for permission to be included in the study.
Exclusion criteria for cases
Presumed type 2 DM patients whose blood glucose estimations at diagnosis do not meet the minimum requirements as dictated by the WHO were excluded from this study along with those that declined the offer to sign the informed consent form.
As diarrheic stools are not appropriate for testing with the immunoassay-based Rapid Strip HpSA™ kit, cases (and controls) whose submitted loose, watery stools were excluded.
Selection criteria for controls
Inclusion criteria for controls
Age- and sex-matched controls were drawn from the other patients attending the other nondiabetic medical outpatient clinics.
All were required to show consent to participate in the study by agreeing to sign the informed consent form in the presence of a witness before being enrolled in the study and before samples are taken for relevant tests.
Exclusion criteria for controls
Controls whose blood glucose estimations met the WHO criteria for diagnosis of DM were excluded from inclusion as controls. Prospective controls with diarrhea and those who declined the offer to sign the informed consent form were also excluded from the study.
The possibility of bias was excluded by ensuring that patients with dyspepsia complaints attending the gastroenterology clinics were excluded from the study. Further, all controls who had had eradication therapy for H. pylori in the past were excluded from the study.
After obtaining informed consent, 100 consecutive consenting patients and 100 consenting controls satisfying the inclusion criteria were recruited from among only ambulant outpatients of LUTH.
A well-structured pretested questionnaire was administered by a medical doctor to each participant. The first page of the questionnaire included biodata, anthropometry, socioeconomic variables such as occupation and level of education, and if the participant had prior knowledge of whether he or she was diabetic.
The already validated diabetes bowel symptom questionnaire was modified and administered to determine GI symptoms. All questionnaires were administered by a medical doctor.
The patients were then required to submit stool samples which were tested for evidence of H. pylori infection with the immunoassay-based Rapid Strip HpSA™ (Meridian Bioscience, Europe- a division of Meridian Bioscience, Incorporated, Cincinnati, U.S.A) (sensitivity 96.1%, specificity 90.6%).
Age- and gender-matched controls were then selected from the pool of nondiabetics attending the other outpatient clinics in LUTH. After signing informed consent forms, they had the questionnaires administered to them.
However, each one of the controls had blood drawn for fasting blood glucose and those who met the minimum WHO requirements were excluded from being controls in this study. They were also required to provide stool samples for H. pylori testing. However, they were encouraged to submit their own stool samples early on a working day morning as they would simultaneously have fasting blood glucose analysis.
The two analyses run in this study were those of determining if all participants were positive or not for H. pylori stool antigen and if the controls had blood glucose ranges that were diabetic or not. A glucometer was used to determine the latter in the fasted state according to the WHO guidelines. The former parameter was determined as stated in the manual of the immunoassay-based Rapid Strip HpSA™.
Ethical approval was obtained from the Ethics Committee of LUTH prior to the commencement of the study.
For analysis, the upper GI symptoms were divided into three groups:
- Dyspepsia (defined as pain or discomfort centered around the upper abdomen)
- Gastroesophageal reflux (GER; indicated in the questionnaire as persistent heartburn and/or regurgitation)
- Overall (defined as any of the above symptoms put together).
The body mass index (BMI) was used to determine obesity by the formula; weight/height 2 - a value of ≥30 kg/m 2 being the threshold for obesity.
The data obtained were analyzed using the IBM SPSS Statistics for Windows, Version 20.0. IBM Corp. Released 2011. Armonk, NY: IBM Corp. Data were expressed as means ± standard deviation and frequencies.
Statistical analysis was done using Student's t-test for continuous variables and Chi-square for categorical data. Multivariate analysis was included in view of possible confounding factors.
| Results|| |
Helicobacter pylori and dyspepsia
Of the 100 recruited type 2 DM patients, 30% (n = 30) had symptoms of pain and/or discomfort in the upper half of the abdomen (dyspepsia) over the preceding 3 months to time of questionnaire administration. A similar high percentage of controls, 40% (n = 40), also had these complaints [Figure 1]. Infection with H. pylori was not significantly associated with the difference in the prevalence of dyspepsia across the two groups (χ2  = 2.198, P = 0.138).
Helicobacter pylori and gastroesophageal reflux-suggestive symptoms
The predominant complaints in GER are typically heartburn and acid regurgitation  – these two symptoms were itemized in the administered questionnaire.
Results show that a high proportion of respondents (20% of diabetics and 32% of controls) had, within a 3-month period, symptoms suggestive of GER. There was no significant relationship between groups (χ2  =3.742, P = 0.053) [Figure 2].
|Figure 2: Prevalence of gastroesophageal reflux symptoms among study participants|
Click here to view
Again, H. pylori infection status was not significantly associated with the symptomatic suggestion of GER in either cases or controls (χ2  = 3.742, P = 0.053). The association between sex and likelihood of having GER symptoms was not statistically significant in either set-controls (χ2  = 2.804 P = 0.094) and diabetics (χ2  = 0.500, P = 0.480).
A noteworthy fact from the data in this study is that it did not reveal significant relationship between BMI and the presence of symptoms suggestive of GER (case: [χ2  = 1.667 P = 0.435]; control: [χ2  = 3.236 P = 0.357]). Further, smoking appeared not to be significantly associated with GER symptoms both in cases (χ2  = 0.336 P = 0.845) and in controls (χ2  = 0.064 P = 0.969).
Helicobacter pylori and other upper gastrointestinal symptoms
[Table 1] summarizes the pattern of upper GI symptoms among respondents.
|Table 1: Prevalence of Helicobacter pylori infection and gastrointestinal symptoms in diabetics and nondiabetic controls|
Click here to view
Among control subjects, a high percentage (56%) had experienced one or more upper GI symptoms within 3 months of symptoms questionnaire administration – the list of symptoms is presented in [Figure 3]. In the nondiabetic controls, the prevalence of individual symptoms ranged from 40% (for abdominal pain or discomfort) to 2% (for dysphagia).
|Figure 3: Prevalence of upper gastrointestinal symptoms in cases (n = 100) and controls (n = 100)|
Click here to view
The overall prevalence of upper GI symptoms was 51% in men and 61% in women which was not significantly different across the sexes for controls (χ2  = 2.029, P = 0.154). Age was similar in those with or without symptoms (means 53.8 ± 10.85 vs. 55.8 ± 9.86 years), t (198) = −1.364, P > 0.05.
Overall, symptoms were not associated with H. pylori status in controls 53.9% in H. pylori-negative subjects and 55.2% in H. pylori-positive subjects, (χ2  = 0.020, P = 0.887) neither BMI (χ2  = 1.376, P = 0.241) nor smoking history (χ2  = 0.064, P = 0.469).
A similar high proportion of type 2 DM cases (47%) had experienced one or more upper GI symptoms. On comparison with controls, upper GI symptoms were not significantly associated with the presence or otherwise of type 2 diabetes among the study population (χ2  = 3.742, P = 0.053).
However, analysis of relationship between DM status and dyspepsia in obese participants revealed that female sex in this subgroup was significantly associated with this particular symptom (χ2  = 5.000, P = 0.025, odds ratio = 0.143, 95% confidence interval = 0.023–0.877). The same did not hold true for male sex in this subgroup (χ2  = 0.117, P = 0.733).
H. pylori infection as detected by the presence of the stool antigen marker was positive in 18% of DM patients and 13% of controls; however, there was no statistical significance in this difference (χ2  = 0.954, P = 0.329) [Figure 4].
|Figure 4: Prevalence of Helicobacter pylori infection among study participants|
Click here to view
| Discussion|| |
The objective of this study was to assess whether H. pylori infection is associated with prevalence and patterns of upper GI symptoms in the study population. From the findings in this study, H. pylori infection does not appear to significantly influence the prevalence in both cases and controls or pattern of GI symptomatology. The results are in keeping with findings in a local study where it was found that H. pylori infection prevalence did not have any relationship with dyspeptic symptoms between diabetics and nondiabetics. Although another study reported a higher prevalence of GI symptoms in Lagos DM patients versus nondiabetics, the difference failed to reach statistical significance.
There are also various reports that support this finding., While the former  was a report from a community-based, seroprevalence study, the latter  is a 2008 Turkish study on histology findings from the gastric mucosa of dyspeptic diabetics and controls.
An Italian study reported a higher prevalence of several upper GI symptoms in H. pylori-positive compared with H. pylori-negative patients with type 1 DM. The need for correction for potential confounding variables such as age and socioeconomic factors by multivariate analysis has been noted above. Unfortunately, it seems that this was not done by the Italian team before reaching conclusions about the differences observed.
Female sex in the subgroup of obese DM patients was shown to be significantly associated with dyspeptic symptoms. This might have not been previous documented in our locality, but it is not a novel concept. Previous studies had identified female gender as an independent risk factor for upper GI symptoms.,,, Xia et al. summarized the proposed underlying mechanisms that are speculated to account for this association:
- Estrogen and progesterone secretion may modulate GI motility ,
- Psychological factors play a significant role in this difference as Talley et al. had reported that emotional and psychological distress was independently associated with upper GI symptoms in diabetes while Wredling et al. have reported that women with DM experienced more anxiety and depression than men.
In addition, obesity has been established to have a significant association with several key GI symptoms. Increasing BMI has long been significantly related to increases in prevalence and differences in pattern of GI symptoms.,,
The sample size was small, and thus, the study is rather underpowered to decisively answer the scientific question of whether H. pylori has any influence at all on the prevalence and pattern of upper GI symptomatology in DM patients. However, it represents an initial step to this. Another possible confounding factor could be control of diabetes in the study subjects. Hence, the interpretation of the results of this study will be limited as this was not accounted for. All in all the study results, however, still merit consideration as a springboard for further discuss inquiries and larger more empowered studies on the subject matter.
| Conclusion|| |
Colonization of the GI tract with H. pylori did not have a significant association with the prevalence and patterns of upper GI symptoms in patients with DM in Lagos, Nigeria. The study shows that female sex in the subgroup of obese DM patients was significantly associated with symptoms of dyspepsia.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ricci JA, Siddique R, Stewart WF, Sandler RS, Sloan S, Farup CE. Upper gastrointestinal symptoms in a U.S. national sample of adults with diabetes. Scand J Gastroenterol 2000;35:152-9.
Ko GT, Chan WB, Chan JC, Tsang LW, Cockram CS. Gastrointestinal symptoms in Chinese patients with Type 2 diabetes mellitus. Diabet Med 1999;16:670-4.
Enck P, Rathmann W, Spiekermann M, Czerner D, Tschöpe D, Ziegler D, et al.
Prevalence of gastrointestinal symptoms in diabetic patients and non-diabetic subjects. Z Gastroenterol 1994;32:637-41.
Gasbarrini A, Ojetti V, Pitocco D, De Luca A, Franceschi F, Candelli M, et al. Helicobacter pylori
infection in patients affected by insulin-dependent diabetes mellitus. Eur J Gastroenterol Hepatol 1998;10:469-72.
Gasbarrini A, Ojetti V, Pitocco D, Armuzzi A, Silveri NG, Pola P, et al.
Efficacy of different Helicobacter pylori
eradication regimens in patients affected by insulin-dependent diabetes mellitus. Scand J Gastroenterol 2000;35:260-3.
Gentile S, Turco S, Oliviero B, Torella R. The role of autonomic neuropathy as a risk factor of Helicobacter pylori
infection in dyspeptic patients with type 2 diabetes mellitus. Diabetes Res Clin Pract 1998;42:41-8.
Onyekwere C, Ogbera A. Prevalence of gastrointestinal symptoms in diabetics in an urban Hospital in Nigeria. Internet J Endocrinol 2006;4:1039-46.
Xia HH, Talley NJ, Kam EP, Young LJ, Hammer J, Horowitz M. Helicobacter pylori
infection is not associated with diabetes mellitus, nor with upper gastrointestinal symptoms in diabetes mellitus. Am J Gastroenterol 2001;96:1039-46.
Candelli M, Rigante D, Marietti G, Nista EC, Crea F, Bartolozzi F, et al. Helicobacter pylori
, gastrointestinal symptoms, and metabolic control in young type 1 diabetes mellitus patients. Pediatrics 2003;111(4 Pt 1):800-3.
Stanciu OG, Trifan A, Sfarti C, Cojocariu C, Stanciu C. Helicobacter pylori
infection in patients with diabetes mellitus. Rev Med Chir Soc Med Nat Iasi 2003;107:59-65.
Demir M, Gokturk HS, Ozturk NA, Kulaksizoglu M, Serin E, Yilmaz U. Helicobacter pylori
prevalence in diabetes mellitus patients with dyspeptic symptoms and its relationship to glycemic control and late complications. Dig Dis Sci 2008;53:2646-9.
Ugwu N, Ugwuja E, Ejikeme B, Obeka N. Helicobacter pylori Seropositivity in Nigerians with Type 2 Diabetes Mellitus. Internet J Trop Med 2007;4(2).
Definition and Diagnosis of Diabetes Mellitus and Intermediate Hyperglycemia. Report of a WHO/IDF Consultation; 2006.
Rapid Strip HpSA™ Information Pamphlet from Meridian Bioscience, Europe- a division of Meridian Bioscience, Incorporated, Cincinnati, USA.
World Health Organization. Obesity: Preventing and Managing the Global Epidemic. Report of a WHO Consultation. WHO Technical Report Series 894. Geneva: World Health Organization; 2000.
Quan C, Talley NJ, Cross S, Jones M, Hammer J, Giles N, et al.
Development and validation of the diabetes bowel symptom questionnaire. Aliment Pharmacol Ther 2003;17:1179-87.
Talley NJ, Axon A, Bytzer P, Holtmann G, Lam SK, Van Zanten S. Management of uninvestigated and functional dyspepsia: A working party report for the World Congresses of gastroenterology 1998. Aliment Pharmacol Ther 1999;13:1135-48.
Schvarcz E, Palmér M, Ingberg CM, Aman J, Berne C. Increased prevalence of upper gastrointestinal symptoms in long-term type 1 diabetes mellitus. Diabet Med 1996;13:478-81.
Spångéus A, El-Salhy M, Suhr O, Eriksson J, Lithner F. Prevalence of gastrointestinal symptoms in young and middle-aged diabetic patients. Scand J Gastroenterol 1999;34:1196-202.
Malaty HM, Graham DY. Importance of childhood socioeconomic status on the current prevalence of Helicobacter pylori
infection. Gut 1994;35:742-5.
Patel P, Mendall MA, Khulusi S, Northfield TC, Strachan DP. Helicobacter pylori
infection in childhood: Risk factors and effect on growth. BMJ 1994;309:1119-23.
Talley SJ, Bytzer P, Hammer J, Young L, Jones M, Horowitz M. Psychological distress is linked to gastrointestinal symptoms in diabetes mellitus. Am J Gastroenterol 2001;96:1033-8.
Wredling R, Stålhammar J, Adamson U, Berne C, Larsson Y, Ostman J. Well-being and treatment satisfaction in adults with diabetes: A Swedish population-based study. Qual Life Res 1995;4:515-22.
Eslick GD. Gastrointestinal symptoms and obesity: A meta-analysis. Obes Rev 2012;13:469-79.
Delgado-Aros S, Locke GR 3rd
, Camilleri M, Talley NJ, Fett S, Zinsmeister AR, et al.
Obesity is associated with increased risk of gastrointestinal symptoms: A population-based study. Am J Gastroenterol 2004;99:1801-6.
Chirila I, Drug VL, Petrariu FD, Gavat V. Overweight and gastrointestinal symptoms among adults of working age in Iasi City, Romania. Rev Med Chir Soc Med Nat Iasi 2012;116:268-73.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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