Letter

What is the Relationship between Helicobacter pylori Infection and Gastroesophageal Reflux Disease (GERD)? A Comprehensive Analysis on Iranian Population

Dear Editor,

Helicobacter pylori is a gram-negative, microaerophilic, and rod-shaped bacterium, which is colonized in human gastric-submucosa of approximately 4-4.5 billion people throughout the worldwide (1-2). The bacterium can cause chronic gastritis and increase the risk of developing gastric adenocarcinoma by 10 times, as well as peptic ulcer disease (3). According to the literature, H. pylori infection has clinical benefits in prevention of several diseases such as autoimmune diseases, asthma, celiac, and irritable bowel syndrome (4-7). There are several conflicting reports on the probable association between H. pylori infection and gastroesophageal reflux disease (GERD) (8-9).

GERD is a digestive complication in which acidic stomach juices revert up from the stomach into the esophagus and acidic pH causes tissue damages (10). The prevalence of GERD was lower in countries with high burden of H. pylori infection. H. pylori infection has a protective role in regression of GERD, though the main mechanism is still unclear (11,12). For the first time, we evaluated the impact of H. pylori infection in risk of GERD in an Iranian population with comprehensive statistical analysis.

We performed a systematic literature search using search terms including ‘H. pylori’, ‘Helicobacter pylori’, ‘Gastro-oesophageal reflux diseases’, ‘Reflux oesophagitis’, and ‘Iran’ in several international databases including Medline, Scopus, Embase, and Google Scholar and retrieved all the related articles. Then, the title, abstract, and full-text of relevant reports were screened, and all case-control studies on an Iranian population were included in the study. The required data such as first author, publication year, city, age, gender distribution, number of case and control in each individual studies, frequency of H. pylori infection in each groups, diagnostic methods, and reference numbers were extracted and summarized in the Table 1.

We pooled the data to investigate the probable association between H. pylori infection and GERD by odds ratio (OR) corresponding to 95% confidence intervals (CIs). Furthermore, the association between cagA positive H. pylori strains and GERD risk was also measured in the current analysis. Heterogeneity was dignified by I² index and Cochrane P value test; the random-effects models were applied for the case of significant heterogeneity. Otherwise, the fixed-effects models were used in lack of heterogeneity cases. Moreover, the publication bias was also determined by Begg’s and Egger’s P value test (23).

In the current quantitative analysis, we collected 107 relevant articles in the primary literature search. After reviewing the full-texts, 10 case-control studies were included. These studies were performed between 2003 and 2017 in various cities including Tehran (n=6), Tabriz (n=1), Babol (n=1), Urmia (n=1), and Rafsanjan (n=1). In the eligible studies, we pooled the data of 2,768 human subjects. There were 1,403 cases (mean age: 41.4 years, female: 37.2%, male: 62.8% ) and 1,365 controls (mean age: 40.1 years, female: 39.9%, male: 60.1%). The H. pylori infection rate was 38.6% in cases and 49% in healthy subjects. In these studies, the H. pylori infection was diagnosed based on the conventional microbiology methods, urease breath test, and ELISA. Our results indicated a significant inverse association between H. pylori infection and GERD in an Iranian case (OR: 0.6; 95% CI: 0.50-0.71; P = 0.001; I²: 81.93; Q-Value: 49.82; P = 0.001; Egger’s P =0.69; Begg’s P= 0.72). Interestingly, infection with cagA expressing H. pylori strains can reduced the risk of susceptibility to GERD in the patients by 0.5 fold (OR: 0.54; 95% CI: 0.34-0.86; P = 0.009; I²: 78.2; Q-Value: 9.1; P = 0.01; Egger’s P = 0.53; Begg’s P = 0.5). Therefore, the summary OR showed that H. pylori infection can have an inverse association with developing GERD in an Iranian population (Figure 1).

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Figure 1.

The Odds Ratio at 95% Confidence Interval for the Assessment of Association between H. Pylori Infection and GERD in an Iranian Population.

Figure 1.

The Odds Ratio at 95% Confidence Interval for the Assessment of Association between H. Pylori Infection and GERD in an Iranian Population.

The GERD is one of the common gastrointestinal disorders worldwide. It has been estimated that approximately more than 40% of people have experienced GERD in their lives (24). In recent years, the impact of the H. pylori infection in GERD has gain attention. However, there are conflicting results about the association between the bacterium and GERD (25,26). Therefore, it is necessary to conduct a larger experiment to determine the effect of H. pylori infection in GERD immune-pathogenesis. In the current report, we pooled all available data regarding the evaluation of H. pylori in GERD in an Iranian population. The results suggested that H. pylori infection particularly cagA positive strain can hamper the risk of developing GERD in an Iranian population. Our results confirmed the findings of a meta-analysis by Cremonini et al, indicating a significant association between the absence of H. pylori infection and GERD symptoms (27). Overall, it can be considered that H. pylori infection has an inverse association with developing GERD symptoms.

Conflict of Interests

None.

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