• Users Online: 191
  • Print this page
  • Email this page


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 95-101

A Study of Helicobacter pylori in chronic cholecystitis and gallbladder carcinoma


Department of Pathology, Yenepoya Medical College, University Road, Deralakatte, Mangalore, Karnataka, India

Date of Submission02-Feb-2021
Date of Acceptance09-Mar-2021
Date of Web Publication02-Jun-2021

Correspondence Address:
Dr. Prema Saldanha
Department of Pathology, Yenepoya Medical College, University Road, Deralakatte, Mangalore 575018, Karnataka.
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.mgmj_9_21

Rights and Permissions
  Abstract 

Background: Chronic cholecystitis (CC) accounts for more than 90% of cholecystectomies. Some recent work has demonstrated the presence of Helicobacter pylori in bile and the gallbladder of more than three-fourths of the patients with gallbladder carcinoma (GBC) and in more than half of the patients with CC. Objective: To study the histopathological findings and to demonstrate the presence of H. pylori in CC and GBC in our region. Materials and Methods: One hundred fifty cholecystectomy specimens received during two years were examined after obtaining ethical clearance for the study. The specimens were received in 10% neutral buffered formalin. The specimens were processed, paraffin-embedded, and stained with Hematoxylin and Eosinand Giemsa stain, for the detection of H. pylori. Immunohistochemistry (IHC) for H. pylori was done on 35 cases. Results: Of the 150 cases of cholecystectomy specimens, the majority of the patients were in the age group of 41–50 years, with the male:female (M:F) ratio being 1:1.9. The most common lesion was chronic calculous cholecystitis (76%). The spectrum of lesions in our study included chronic acalculouscholecystitis (1.3%), follicular cholecystitis (4.6%), xanthogranulomatous cholecystitis (3.3%), acute over CC (2.6%), eosinophilic cholecystitis (2%), cholesterolosis (2%), choledochal cyst (1.3%), acute calculous cholecystitis (1.3%), empyema (0.66%), and gallbladder carcinoma (GBC; 3.3%). Giemsa stain on 150 cases was negative for H. pylori. On 35 cases an IHC was done; none detected H. pylori, indicating that H. pylori infection does not contribute to the development of gallstones in this region.

Keywords: Carcinoma, chronic cholecystitis, gallbladder, Helicobacter pylori, immunohistochemistry


How to cite this article:
Bashir S, Saldanha P. A Study of Helicobacter pylori in chronic cholecystitis and gallbladder carcinoma. MGM J Med Sci 2021;8:95-101

How to cite this URL:
Bashir S, Saldanha P. A Study of Helicobacter pylori in chronic cholecystitis and gallbladder carcinoma. MGM J Med Sci [serial online] 2021 [cited 2021 Oct 21];8:95-101. Available from: http://www.mgmjms.com/text.asp?2021/8/2/95/317455




  Introduction Top


Chronic cholecystitis (CC) is the most commonly encountered disease of the gallbladder; the overwhelming majority of cholecystectomies are performed for CC. It is associated with cholelithiasis in more than 90% of the cases. It may also develop as a sequela of recurrent acute cholecystitis.[1]

Cholelithiasis produces diverse histopathological changes in gallbladder mucosa, namely acute inflammation, glandular hyperplasia, granulomatous inflammation, cholesterolosis, dysplasia, and carcinoma.[2] Gall stones mainly injure the mucosal columnar epithelium and, thus, cause changes such as metaplasia, dysplasia, and neoplasia.[3],[4],[5] Gallbladder carcinoma (GBC) is an extremely rare though lethal malignancy. It has been linked to various genetic and environmental factors.[6],[7]

Helicobacter pylori is known to cause chronic gastritis, gastric ulcers, duodenal ulcers, and gastric mucosa-associated lymphoid tissue lymphoma (MALToma).[8] Recent work has demonstrated the presence of H. pylori in the bile and gallbladder of 80% of patients with GBC and in more than 45% of patients with CC undergoing surgery.[9]


  Materials and methods Top


A total of 150 specimens of cholecystectomy were examined from October 2017 to June 2019 after Institutional Ethical Review Committee approval. The gallbladder specimens, fixed in 10% formalin, were received in the Pathology Department. Gross findings were recorded; the tissue bits were processed according to the standard protocol and thereafter stained with Hematoxylin and Eosin; and the histopathological findings were recorded. Then, all the cases were subjected to Giemsa stain for demonstration of H. pylori. Thirty-five cases showing moderate to severe inflammation, cases with follicular cholecystitis and adenocarcinoma were selected for immunohistochemistry (IHC) for H. pylori antigen detection. The primary antibody used was a Polyclonal Rabbit antibody-Helicobacter pylori Code IR523 from DAKO. The IHC detection system used was DAKO Real Envision.


  Results Top


Out of the 150 cases of cholecystectomy specimens, the majority of the patient’s age group ranged from three years to 74 years with a sex predilection toward females, with the F:M ratio being 1.9:1. Multiple stones were the most common in 77.33% of the cases, with a maximum number of stones measuring 0.2cm. Mixed types of stones were the most common stones seen in 82.73% of the cases, followed by pure pigment stones seen in 10.79% of the cases and pure cholesterol stones seen in 6.4% of the cases.

The most common lesion was chronic calculous cholecystitis (76%), and the spectrum of lesions in our study included chronic acalculouscholecystitis (1.3%), follicular cholecystitis (4.6%), xanthogranulomatous cholecystitis (3.3%), acute over CC (2.6%), eosinophilic cholecystitis (2%), cholesterolosis (2%), choledochal cyst (1.3%), acute calculous cholecystitis (1.3%), empyema (0.66%), and GBC (3.3%).

The microscopic findings in different gallbladder diseases are summarized in [Table 1] and shown in [Figure 1][Figure 2][Figure 3][Figure 4]. Chronic calculous cholecystitis was the most common lesion encountered in our study and it was seen in 76% of the cases (n = 115). Out of the 150 cases, 148 cases showed chronic lymphocytic inflammatory infiltrate, ranging from mild (82 cases) to moderate (61 cases) and severe (6 cases), respectively.
Table 1: Microscopic findings observed in gallbladder diseases

Click here to view
Figure 1: Follicular cholecystitis showing lymphoid follicles with germinal centers. (H&E 10X)

Click here to view
Figure 2: Eosinophilic cholecystitis (H&E 40X)

Click here to view
Figure 3: Cholesterolosis (H&E 10X)

Click here to view
Figure 4: Xanthogranulomatous cholecystitis (H&E 20X)

Click here to view


GBC was seen in five cases (3.3%): two were adenosquamous, two were adenocarcinoma, and one was squamous cell carcinoma, and all were associated with stones[Figure 5][Figure 6][Figure 7][Figure 8].
Figure 5: Gross specimen of GBC showing thickened wall and loss of velvety mucosa

Click here to view
Figure 6: Gallbladder adenocarcinoma, showing closely packed tumour cells composed of irregular glands. (H&E 4x)

Click here to view
Figure 7: Gross specimen of squamous cell carcinoma of gallbladder

Click here to view
Figure 8: Squamous cell carcinoma of gallbladder showing tumour cells composed of nests of polygonal cells with abundant eosinophilic cytoplasm, vesicular nuclei, and prominent nucleoli (H&E 40x)

Click here to view


In all cases, Giemsa stain was negative for H pylori. Out of these, 35 cases that were selected were negative for H pylori by IHC. The results are shown in [Table 2] and [Figure 9] and [Figure 10].
Table 2: Spectrum of lesions in our study and the prevalence of H. pylori

Click here to view
Figure 9: Giemsa stain negative for H. pylori in gallbladder mucosa (H&E 10x)

Click here to view
Figure 10: Immunohistochemistry negative for H. pylori in gallbladder mucosa (10x)

Click here to view



  Discussion Top


Cholecystectomy specimens are one of the most common samples received in the histopathology department; 90% of cholecystectomies were performed for CC, and 10% of cases represented as calculous cholecystitis.[1]

Cholelithiasis can manifest clinically and histologically as a myriad of disorders encompassing acute cholecystitis, CC, metaplasias, hydrops, mucocele, empyema, gallstone ileus, and carcinoma.[5]

The risk factors for the development of gallstone disease can be categorized as non-modifiable and modifiable. Non-modifiable factors include ethnic background, increasing age, female gender, and family history or genetics; whereas the modifiable ones are obesity, rapid weight loss, and a sedentary lifestyle.[5] Cholecystitis and cholelithiasis appear to be increasing in incidence over the past couple of decades in India and the Western world due to the increased intake of a fatty and high-calorie diet and increased consumption of alcohol.[2] In India, the disease is seven times more common in the North than in South India. Dietary differences in the two regions are suspected to be responsible for the difference in the prevalence rate.[5],[10]

Helicobacter pylori is a gram-negative, S-shaped microorganism that can cause chronic gastritis, gastric ulcers, duodenal ulcers, and gastric malignancies.[8] In recent literature, there is an increasing description of H. pylori in extra-gastric locations and its association with many diseases. Helicobacter species that may colonize the biliary tract have been implicated as a possible cause of hepatobiliary diseases, ranging from CC and primary sclerosing cholangitis to gall bladder carcinoma and primary hepatic carcinoma. Multiple researchers have demonstrated the presence of H. pylori in the bile and gallbladder of more than 75% of patients with GBC and in more than 45% of patients with CC undergoing surgery.[9],[11] Many studies from different parts of the world and India have explored the possibility of Helicobacter infection in gallbladder diseases by identifying H. pylori on H&E, Giemsa stains, Warthin-starry silver stain, IHC, serology, PCR, ELISA, etc.

Gallbladder disease is more common in the middle age group, with female preponderance. In the present study, the youngest age at presentation was three years and the most common age range was between 41 and 50 years. According to a study conducted by Mohan et al,[10] they observed that the age ranged from 10 to 90 years. Kaur et al.[5] showed that age ranged from 31 to 50 years, and Kala et al.[12] found that age ranged from 10 to 69 years. Our study showed that the age ranged between 3 and 74 years. In our study, we had 98 females and 52 males with an F:M ratio of 1.9:1. An almost similar M:F ratio was found in a study conducted by Narayanasamy et al.[13]and Sreeramulu et al.[14]

Chronic calculous cholecystitis was the most common lesion encountered in our study and it was seen in 115 cases (76%), similar to other studies conducted by Kaur et al.,[5] Selvi et al.,[15] Mathur et al.,[16] and Kumar et al.[17] ranging from 45% to 87%. Acute over CC was seen in 2.6% of the cases in our study. This was similar to studies by Kaur et al.,[5] and Mathur,[16] which found 12% of these cases. Follicular cholecystitis and xanthogranulomatous cholecystitis were observed in 4.6% and 3.3%, which was almost similar to the studies conducted by Mathur et al.[16] and Kafle et al.[18] Carcinoma of the gallbladder was seen in 3.33% of the cases. Other studies also showed a lower incidence of carcinoma ranging from 0.78% to 6%.[5],[15],[19],[20-22]

The present study was conducted to ascertain whether H. pylori could be identified in resected gallbladder tissue. However, a few studies from different parts of the world showed that there may be an association between the presence of Helicobacter species and the development of gallbladder diseases. The incidence ranges from 5.8% to 33% [Table 3].[23],[24],[25],[26],[27],[28],[29] Our study did not find the presence of H. pylori in gallbladder mucosa by using Giemsa stain and IHC.
Table 3: Frequency of H. pylori in gallbladder disease in various countries

Click here to view


In India, numerous studies were conducted to ascertain the relationship between the gallbladder and H. pylori. In North India, studies conducted by Misra et al.[30] and Bansal et al.[31] detected H. pylori in 45% and 32.6% of gallbladder samples, respectively [Table 4]. They have suggested that H. pylori colonization in the gallbladder is possible and may play an important role in the pathogenesis of gallbladder diseases. Similar results as ours were seen in one study conducted by Choudhary et al.[32] in 2015, and they could not demonstrate H. pylori in gallbladder mucosa using Giemsa staining.
Table 4: Frequency of H. pylori in gallbladder diseases in North India

Click here to view


In South India, a few studies demonstrated the presence of H. pylori in gallbladder tissue with an incidence ranging from 4.6% to 22.22%,[14],[33-35] and they concluded that H. pylori is a pathogenic entity in gallbladder disease in this population as well. One study conducted by Hedge et al.[33] from Bangalore was not able to find H. pylori in any of their cases by using the PCR technique [Table 5].
Table 5: Frequency of H. pylori in gallbladder diseases in South India

Click here to view


Helicobacter species present in the human biliary tree may play a significant role in the pathogenesis of malignancies of the biliary tract, especially GBC. Bulajic et al.,[36] Kobayashi et al.,[37] Mishra et al.,[11] and Parajuli et al.[38] have shown a higher incidence of Helicobacter species in hepatobiliary malignancy with 80%, 71.24%, 44.44%, and 71.24%, respectively [Table 6].
Table 6: Frequency of H. pylori in gallbladder carcinoma in various countries

Click here to view


There was no evidence of H. pylori infection of the gallbladder on histopathological examination using H&E, Giemsa stain, and IHC in our study, which was similar to two studies conducted in India. The results are conflicting, as some investigators have detected the presence of H. pylori in gallbladder tissues whereas others have not. Accordingly, whether H. pylori participates in the pathogenesis of gallbladder diseases is a question that remains unresolved. Further studies are needed to determine whether Helicobacter spp. is a causative agent of biliary diseases or a cofactor.


  Conclusion Top


Gallbladder disease is one of the most common problems affecting the digestive tract, especially chronic calculous cholecystitis. The prevalence of gallbladder disease is related to many factors. The colonization of bacteria in the human gastrointestinal tract has been a subject of study for decades. The relationship between H. pylori and gallstones has been investigated; however, it is not demonstrated. Helicobacter species detection in human bile has encouraged a growing interest as to whether these organisms truly colonize the biliary tract of humans and can cause hepatobiliary diseases. The pathogenicity of helicobacter species in hepatobiliary disease and carcinogenesis has not been fully elucidated. This study did not find H. pylori in gallbladder diseases in our region.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Adsay VN Gallbladder, extrahepatic biliary tree, and ampulla. In: Mills, S, Greenson, J, Hornick, J, Longacre, T, Reuter, V, Sternberg, S Sternberg’s Diagnostic Surgical Pathology. Philadelphia: Wolters Kluwer Lippincott Williams & Wilkins; 2015; p. 1770-812.  Back to cited text no. 1
    
2.
Njeze GE Gallstones. Nigerian J Surg 2013;19:49-55.  Back to cited text no. 2
    
3.
Awasthi N A retrospective histopathological study of cholecystectomies. Int J Health Allied Sci 2015;4:203-6.  Back to cited text no. 3
    
4.
Sharma H, Sharma M, Gupta G Evaluation of histological changes in chronic cholecystitis and cholelithiasis of the human gallbladder. Int J Anat Res 2014;2:752-6.  Back to cited text no. 4
    
5.
Kaur A, Dubey VK, Mehta KS Gallbladder mucosal changes associated with chronic cholecystitis and their relationship with carcinoma gallbladder. JK Sci 2012;14:89-92.  Back to cited text no. 5
    
6.
Stinton LM, Shaffer EA Epidemiology of gallbladder disease: Cholelithiasis and cancer. Gut Liver 2012;6:172-87.  Back to cited text no. 6
    
7.
Sharma A, Sharma KL, Gupta A, Yadav A, Kumar A Gallbladder cancer epidemiology, pathogenesis, and molecular genetics: Recent update. World J Gastroenterol 2017;23:3978-98.  Back to cited text no. 7
    
8.
Attaallah W, Yener N, Ugurlu M, Manukyan M, Asmaz E, Aktan A Gallstones and concomitant gastric Helicobacter pylori infection. Gastroenterol Res Pract 2013;2013:643109. Doi: http://dx.doi.org/10.1155/2013/643109.  Back to cited text no. 8
    
9.
Fikry A, Kassem A, Shahin D, Shabana H, Mostafa S Helicobacter pylori infection in patients with chronic calcularcholecystitis: A cross-sectional study. J Surg 2014;2:58-62.  Back to cited text no. 9
    
10.
Mohan H, Punia RP, Dhawan SB, Ahal S, Sekhon MS Morphological spectrum of gallstone disease in 1100 cholecystectomies in North India. Indian J Surg 2005;67:140-2.  Back to cited text no. 10
    
11.
Mishra RR, Tewari M, Shukla HS Helicobacter species and pathogenesis of gallbladder cancer. J Gastroenterol Hepatol 2011;34:449-53.  Back to cited text no. 11
    
12.
Kala S, Verma S, Singh P, Saxena N, Singh A, Singh S A prospective study comparing the clinicobiochemical profile in obese and nonobese subjects with gallstone disease. Int J Recent Sci Res 2018;9:26330-4.  Back to cited text no. 12
    
13.
Narayanasamy KDM, Kirankumar B, Karthick R A cross-sectional study on gallstone disease and its risk factors in a tertiary care hospital of South India. JSM Gastroenterol Hepatol 2017;5:1090. Available at: https://www.jscimedcentral.com/Gastroenterology/gastroenterology-5-1090.pdf  Back to cited text no. 13
    
14.
Sreeramulu P, Harish K, Karthik H T, Srinivasan D, Prajeeth R Helicobacter in biliary calculus disease: Histopathological and serological association in a rural population of Southern India. Open Access J Surg 2017;3. doi: 10.19080/OAJS.2017.03.555609.  Back to cited text no. 14
    
15.
Selvi TR, Sinha P, Subramaniam PM, Konapur PG, Prabha CV A clinicopathological study of cholecystitis with special reference to the analysis of cholelithiasis. Int J Basic Med Sci 2011;2:68-72.  Back to cited text no. 15
    
16.
Mathur SK, Duhan A, Singh S, Aggarwal M, Aggarwal G, Sen R, et al. Correlation of gallstone characteristics with mucosal changes in the gallbladder. Trop Gastroenterol 2012;33:39-44.  Back to cited text no. 16
    
17.
Kumar H, Dundy G, Kini H, Tiwari A, Bhardwaj M Spectrum of gallbladder diseases—A comparative study in North vs South Indian population. Indian J Path Oncol 2018;5:273-6.  Back to cited text no. 17
    
18.
Kafle SU, Sinha AK, Pandey SR Histomorphology spectrum of gallbladder pathology in cholecystectomy specimens with a clinical diagnosis of chronic cholecystitis. J Nepal Med Assoc 2013;52:600-7.  Back to cited text no. 18
    
19.
Terada T Histopathologic features and frequency of gallbladder lesions in consecutive 540 cholecystectomies. Int J Clin Exp Pathol 2013;6:91-6.  Back to cited text no. 19
    
20.
Siddiqui FG, Memon AA, Abro AH, Sasoli NA, Ahmad L Routine histopathology of the gallbladder after elective cholecystectomy for gallstones: Waste of resources or a justified act? BMC Surg 2013;13:26. doi: https://doi.org/10.1186/1471-2482-13-26  Back to cited text no. 20
    
21.
Ezhil A, Aruna L, Basheer BA, Sreedhar VV Clinicopathological study of chronic calculous cholecystitis with chemical analysis of gallstones. Int J Res Health Sci 2015;3:435-41.  Back to cited text no. 21
    
22.
Nalli RS, Valarmathi K, Jamila A Gamut of gallbladder lesions—A histomorphological study in a tertiary hospital in South India. Int J Sci Res 2017;6:40-1.  Back to cited text no. 22
    
23.
Silva CP, Pereira-Lima JC, Oliveira AG, Guerra JB, Marques DL, Sarmanho L, et al. Association of the presence of Helicobacter in gallbladder tissue with cholelithiasis and cholecystitis. J Clin Microbiol 2003;41:5615-8.  Back to cited text no. 23
    
24.
Ghazal A, El Sabbagh N, El Riwini M Presence of Helicobacter spp. DNA in the gallbladder of Egyptian patients with gallstone diseases. East Mediterr Health J 2011;17925-9.  Back to cited text no. 24
    
25.
Sabbaghian MS, Ranaudo J, Zeng L, Alongi AP, Perez-Perez G, Shamamian P Identification of Helicobacter spp. in bile and gallbladder tissue of patients with symptomatic gallbladder disease. HPB (Oxford) 2010;12:129-33.  Back to cited text no. 25
    
26.
Yucebilgili K, Mehmetoğlu T, Gucin Z, Salih BA Helicobacter pylori DNA in gallbladder tissue of patients with cholelithiasis and cholecystitis. J Infect Dev Ctries 2009;3:856-9.  Back to cited text no. 26
    
27.
Lee JW, Lee DH, Lee JI, Jeong S, Kwon KS, Kim HG, et al. Identification of Helicobacter pylori in gallstone, bile, and other hepatobiliary tissues of patients with cholecystitis. Gut Liver 2010;4:60-7.  Back to cited text no. 27
    
28.
Arismendi-Morillo G, Cardozo-Ramones V, Torres-Nava G, Romero-Amaro Z Histopathological study of the presence of Helicobacter pylori-type bacteria in surgical specimens from patients with chronic cholecystitis. Gastroenterol Hepatol 2011;34:449-53.  Back to cited text no. 28
    
29.
Motie M, Rezapanah A, Abbasi H, Memar B, Arianpoor A The relationship between cholecystitis and presence of Helicobacter pylori in the gallbladder. Zahedan J Res Med Sci 2017;19. doi: 10.5812/zjrms.9621.  Back to cited text no. 29
    
30.
Misra V, Misra SP, Dwivedi M, Shouche Y, Dharne M, Singh PA Helicobacter pylori in areas of gastric metaplasia in the gallbladder and isolation of H. pylori DNA from gallstones. Pathology 2007;39:419-24.  Back to cited text no. 30
    
31.
Bansal VK, Misra MC, Chaubal G, Gupta SD, Das B, Ahuja V, et al. Helicobacter pylori in gallbladder mucosa in patients with gallbladder disease. Indian J Gastroenterol 2012;31:57-60.  Back to cited text no. 31
    
32.
Chaudhary PK, Goyal S, Mahajan NC, Kansal S, Sinha P Incidence of the presence of H. pylori in cases of cholecystitis and cholelithiasis in a rural medical college & hospital. J Drug Deliv Ther 2015;5:5-8.  Back to cited text no. 32
    
33.
Patnayak R, Reddy V, Jena A, Gavini S, Thota A, Nandyala R, et al. Helicobacter pylori in cholecystectomy specimens—morphological and immunohistochemical assessment. J Clin Diagn Res 2016;10:1-3.  Back to cited text no. 33
    
34.
Hegde AV, Ahamed SF, Sunny A, Vivek R, Anthony RH Pylori in the gallbladder: The answer to the Indian divide? Tropical Gastroenterol 2017;38:108-14.  Back to cited text no. 34
    
35.
Gunasekaran P, Vinson I Helicobacter pylori colonization of gallbladder in patients with symptomatic cholelithiasis. Int Surgery J 2017;4:2194-6.  Back to cited text no. 35
    
36.
Bulajic M, Maisonneuve P, Schneider-Brachert W, Müller P, Reischl U, Stimec B, et al. Helicobacter pylori and the risk of benign and malignant biliary tract disease. Cancer 2002;95:1946-53.  Back to cited text no. 36
    
37.
Kobayashi T, Harada K, Miwa K, Nakanuma Y Helicobacter genus DNA fragments are commonly detectable in bile from patients with extrahepatic biliary diseases and associated with their pathogenesis. Dig Dis Sci 2005;50:862-7. doi: 10.1007/s10620-005-2654-1.  Back to cited text no. 37
    
38.
Parajuli S, Koirala U Incidence of Helicobacter hepaticus and its relationto gallbladder carcinoma. J Pathol Nepal 2011;1:122-5.  Back to cited text no. 38
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and me...
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed904    
    Printed80    
    Emailed0    
    PDF Downloaded110    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]