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Risk Factors for Gastric Disease in Pediatric H. Pylori

6 Months
18 Years
Not Enrolling
Helicobacter Infections, Gastritis, Peptic Ulcer

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Trial Information

Risk Factors for Gastric Disease in Pediatric H. Pylori

Discovered in 1982 as a cause of gastroduodenal ulceration, Helicobacter pylori (Hp) is the
major cause of gastritides (e.g. chronic-active) and primary duodenal ulcers in adults and
children. [Warren, 1983 #1180; Whitney, 2000 #1345; Ashorn, 1995 #1179; Asante, 1997 #1173;
Drumm, 1987 #355; Czinn, 1986 #101; Drumm, 1988 #1096; Ernst, 2000 #1351; Goggin, 1998 #986;
Torres, 2000 #1346] Infection with Hp, particularly in susceptible persons, is also strongly
linked to gastric adenocarcinoma cancer and mucosal-associated lymphoid tissue-type (MALT)
lymphomas. [Uemura, 2001 #1409; Alexander, 2000 #1232; Alm, 1999 #1038; Blaser, 1995 #757;
Correa, 1990 #1523; El-Omar, 2000 #1272] The majority of infections worldwide are acquired
in childhood. In the United States, minority populations (African Americans, Hispanics)
have increased seroprevalence rates in all age groups. [Fontham, 1995 #139; Gold, 2001
#1422; Graham, 1991 #235; Staat, 1996 #190; Smoak, 1994 #618] Consensus guidelines for
pediatric Hp infection were first published in 1999, yet there remains an overwhelming
paucity of information regarding both the epidemiology of pediatric Hp infection and
associated diseases. [Gold, 2000 #1347; Drumm, 2000 #1123; Sherman, 1999 #1129; Hunt, 1998
#353] It is not known why some Hp-infected children develop symptoms, and mechanisms
accounting for differences in the inflammatory response and disease in Hp-infected children
are uncharacterized. Using a multicenter study approach to test our hypothesis, this
proposal will provide an in depth examination of the association between host factors, Hp
strain genotype, and the severity of gastric inflammatory response in children. Variation
between age, race/ethnicity, medical/environmental exposures, socioeconomic status and
geographic regions and their effects on disease phenotype in children will be investigated.
These studies will address unanswered questions about the earliest stages in the
pathobiology of Hp infection that are essential to improve our ability to manage this
infection in children, and potentially, identify and understand "at risk groups" to prevent
more severe disease sequelae in adults. Understanding the evolution of the host response to
Hp infection is needed to develop prevention strategies or new therapies, and allow a better
definition of the pathobiology of this human pathogen that causes significant morbidity,
suffering, and economic impact in our society.

In our 5 years of NIH funding, we enrolled a cohort of 486 children from 3 sites (Atlanta,
Cleveland, Miami); 184 (38%) were Hp-infected. We made novel observations regarding
environmental exposures, pilot validation of a symptom assessment instrument, pediatric Hp
strain genotype/disease phenotype relationships, and disease paradigms not previously
described in the pediatric population; i.e., atrophic gastritis and intestinal metaplasia
associated with Hp infection. Overall hypothesis for competitive renewal: gastroduodenal
disease (e.g., duodenal ulcer) in Hp-infected children is associated with specific host
factors (i.e., race/ethnicity), environmental exposures, and infection by Hp strains
carrying specific virulence genes contained within the cag pathogenicity island. These
combined factors drive either a predominant Th2 gastric mucosal response with antral
predominant severe mucosal inflammation (i.e., ulcer disease) or a Th1 response resulting in
a more chronic, corpus-predominant inflammatory infiltrate (i.e., atrophy).

Specific aims:

Aim 1: Further characterize specific host factors and environmental exposures contributing
to symptomatic childhood infection by emphasizing targeted enrollment of patients from
multiple centers in specific age, gender and demographic strata to facilitate detection of
significant differences in symptomatic and asymptomatic Hp-infected children not attained
previously and follow-up of 2 established specific cohorts to ascertain immune response
natural history.

Aim 2: Utilize gene-array technology for whole genome assessment of bacterial virulence
genes and specific bacterial gene expression to allow characterization of virulence proteins
associated with pediatric Hp infection. The Hp isolated from the prospectively enrolled
infected children (cases) in Aim 1, Hp strains obtained in follow-up of the two established
cohorts who remain infected, as well as a retrospective analysis of 125 banked pediatric
isolates linked to clinical, demographic and epidemiological data will be characterized.
Specific emphasis will be on the analysis of isolates found in the following three disease
categories: ulcers, gastritis, atrophic gastritis.

Aim 3: Further characterize the gastric mucosal host inflammatory response in Hp-infected

The Updated Sydney system will be applied to assess severity of gastric histopathology, and
immunohistochemistry performed on formalin-fixed, paraffin embedded tissues to phenotype
mucosal disease (i.e., character, severity) in newly enrolled cases in specific age, gender
and demographic strata and the two "novel" cohorts established in our previous studies; i)
atrophic gastritis cohort; ii) esophageal and gastric disease cohort, affording insight into
the natural history of the immune response in Hp-infected children in two different disease
paradigms. Both molecular methods and a novel micro ELISPOT performed on PBMCS and gastric
T-cells to determine Th1, Th2 or balanced Th1/Th2 response will be used to further
characterize the Hp-infected child's immune phenotype. During the latter 2 years of the
proposed studies, PBMC chemokine response will then be compared to the mucosal/cellular
response using RT-PCR and gene array. The data obtained from aims 1 and 3 will be
integrated with that obtained in aim 2 (Hp-strain genotype) in order to develop a model to
predict disease outcome based on host demographics, strain type and inflammatory/immune
response. These studies are critical to understand and better predict the gastroduodenal
disease sequelae and overall pathobiology of Hp infection in humans.

Inclusion Criteria:

- Using the power determinations for age, gender and demographic characteristics, the
investigators will screen all patients undergoing diagnostic upper endoscopy at:

- Children's Healthcare of Atlanta (Egleston and Scottish Rite Children's
Hospitals), Atlanta, GA

- Rainbow Babies and Children's Hospital, Cleveland, OH

- Miami Children's Hospital, Miami, FL.

- Patients will be enrolled over the first 3 years of the study, and then based on
interim univariate analysis. The investigators also will perform follow-up
evaluations (i.e., clinically-indicated) on the two novel cohorts identified during
the first 5 years of funding:

- the atrophic gastritis Hp-infected cohort

- the esophagitis/gastritis cohort, in order to assess the natural history of
gastroduodenal inflammation in the Hp-infected child.

Exclusion Criteria:

- Patients who have taken antibiotics within one month of endoscopy will be excluded,
as preceding antibiotic therapy will confound ability to determine Hp infection

- In the previous five years, the investigators initially eliminated children taking
proton pump inhibitors (PPIs) (e.g., omeprazole); Na+/H+ ATPase channel inhibitors.
PPIs have a minimum inhibitory concentration (MIC) against Hp in vitro, and therefore
may reduce the overall bacterial load, diminishing the ability to detect infection,
and resolve gastroduodenal mucosal inflammation, confounding characterization of
cellular host response to Hp infection. However, due to the pervasive use of PPIs in
the pediatric population, and the exclusion of potential cases, the investigators
improved their culture sensitivity techniques and are able to successfully detect the
organism in the setting of a child on a PPI. This will be taken into account when
characterizing the gastric mucosal inflammatory phenotype and comparative analyses
are performed.

Type of Study:


Study Design:


Principal Investigator

Benjamin D. Gold, M.D.

Investigator Role:

Principal Investigator

Investigator Affiliation:

Emory University


United States: Federal Government

Study ID:

DK53708 (completed)



Start Date:

October 1997

Completion Date:

December 2007

Related Keywords:

  • Helicobacter Infections
  • Gastritis
  • Peptic Ulcer
  • gastric disease
  • H. pylori
  • children
  • Helicobacter pylori
  • child
  • epidemiology
  • Gastritis
  • Peptic Ulcer
  • Stomach Diseases
  • Ulcer
  • Helicobacter Infections



Miami Children's Hospital; Division of Pediatric Gastroenterology Miami, Florida  33105
Emory University School of Medicine; Emory Children's Center Atlanta, Georgia  30322
Case Western Reserve University; Rainbow Babies and Children's Hospital Cleveland, Ohio  44106