H. pylori gastritis & iron deficiency

August 4, 2020

Helicobacter pylori (H. pylori) is a pathogen that is widespread all over the world. Although it infects more than 50% of the world’s population, only 10% – 20% of patients develop clinical manifestations. Several epidemiological studies have revealed an association between H. pylori infection and iron deficiency anaemia.

Helicobacter pylori

H. Pylori is a bacterium which grows in the inner lining of the stomach. An infection occurs due to this colonisation, which can result into stomach cancer. Inter-human contact is the essential way of transmission. Poor socio-economic condition is an important risk factor.

Gastric acidity is the first line of defense mechanism in most of the infections. Nevertheless, this bacteria has an important urease activity that leads to ammonia production in order to protect itself from gastric acidity. It also produces other enzymes, which play a role in the development of the gastric mucosal damage.

Symptoms and Side effects:

  • Infection: In most of the cases the infection happens in childhood. However, they do not usually become symptomatic.
  • Inflammation: The infection will lead to chronic inflammation of the gastric tissue, which is called gastritis. Also, inflammation may happen in the first part of the small intestine, the duodenum. The latter will cause symptoms like stomachaches, fullness, nausea and vomiting. The infection and its side effects will not be cured, unless it is treated with prescribed medications.
  • Ulcers: If not treated, about 10% to 15% of people with H. pylori infection and inflammation develop peptic or duodenal ulcer.
  • Gastric cancer: Not all of the patients with stomach cancer are infected with H. pylori, nor all who are infected by H. pylori will get gastric cancer. Being infected by this bacterium and suffering from related side effects will slightly increase the chance of getting stomach cancer.
  • Vitamin B12 and Iron deficiency: Investigation of men and postmenopausal women with iron deficiency anaemia includes the study of the gastrointestinal tract to detect possible bleeding sources. In premenopausal women, most physicians attribute the condition solely to menstrual blood loss but the gastrointestinal tract should also be investigated.

Diagnosis:

The infection is usually diagnosed after the symptoms arise. Your doctor may ask for:

  • A stool antigen test: Searching for the pathogen’s antigens in stool. This test is useful for follow up as well as initial diagnosis.
  • Urea breath test: The bacterium H. pylori make urea, a natural compound in the body. Making urea, the bacteria creates ammonia and bicarbonate. By detecting them in your breath, the test will confirm the existence of bacteria in your stomach.
  • Endoscopy and biopsy: If the symptoms are worse and you need an endoscopy, then a biopsy may be done during the procedure to test the colonisation of the bacteria directly in pathology.
  • A blood test, checking for antibodies against the bacterium is helpful too. However, it does not tell if you had the infection before, or if it is new, or treated. This means that a blood test is not a good option for follow up, but the stool antigen test is.

Treatment:

Antibiotic therapy: Multiple antibiotics shall be prescribed and used for 14 days and multiple times a day. This treatment plus proton pump inhibitors, H2 receptor antagonist, in different regimens have resulted in eradication of the disease in more than 80% of the cases.

Some studies in humans used antioxidants to eradicate H. pylori. Vitamin C has important effects in bacteria eradication in patients with peptic ulcer. These studies showed that smaller doses of vitamin C for a longer period of time had a better response in comparison with higher doses.

Iron deficiency and H. pylori gastritis

According to a recent meta-analysis, iron deficiency anaemia is significantly more prevalent in paediatric subjects with H. pylori. Many of the non-pregnant premenopausal women have iron storage depletion, and half develop iron deficiency anaemia. Individuals who are at more risk for iron deficiency and suffer from H. pylori infection with or without gastritis, may be at an additional risk for developing iron deficiency anaemia.

Although there are different mechanisms for H. pylori to cause iron deficiency, the main mechanism is the change in normal gastric physiology and iron metabolism and absorption.

Mechanisms:

  • Atrophic body gastritis:

This phenomenon includes atrophy of the gastric body mucosa, hypergastrinemia and hypo-achlorhydria. Anaemia is a unique symptom of presentation in 45% of patients with atrophic body gastritis and that these patients have many distinctive clinical features. Atrophy is a time-related process and H. pylori infection is considered an aetiological factor in the development of it. Additionally, H. pylori infection may constitute a possible cause of iron deficiency anaemia per se, by competing with the host for the absorption of iron. Thus, H. pylori could play a double role, determining the development of atrophy-induced hypo-achlorhydria and constituting an additional factor able to affect the process of iron absorption.

  • H. pylori chronic gastritis:

As mentioned before H. pylori impairs iron and increases the body’s iron demand. A high bacterial load is another possible causes of gastritis. It is demonstrated that the density of bacteria present in the stomach is related to urea breath test results.

The reduction of intragastric ascorbic acid (vitamin C):

Low chloride levels might induce the conversion of ascorbic acid to a less active form which leads to reduction in iron absorption. Most of the patients with positive H. pylori, have reduced vitamin C levels.

The reduction of the ferric to ferrous form, which is fundamental for the absorption of non-haem iron, might be impaired by H. pylori infection.

Increased iron demand: H. pylori infection may also lead to an imbalance of body iron homeostasis by increasing iron demand. As for many other bacteria, iron is an essential growth factor for H. pylori.

conclusion

The association between iron deficiency anaemia and H. pylori infection is so strong that a test and treat strategy for H. pylori infection is strongly recommended by Maastricht III European guidelines in patients with unexplained anaemia. In many cases iron deficiency is relieved by eradication off the virus. Still some need iron supplementation to overcome the need. Irofix, is your best choice for iron supplementation as it has a microencapsulation mechanism which does not irritate your stomach if you are already suffering from an upset stomach from H. pylori!

References:

Annibale B, Capurso G, Martino G, Grossi C, Delle Fave G. Iron deficiency anaemia and Helicobacter pylori infection. Int J Antimicrob Agents. 2000;16(4):515-519. doi:10.1016/s0924-8579(00)00288-0

Savio John, Juan Diego Baltodano, Nilesh Mehta, Katherine Mark, Uma Murthy, Unexplained iron deficiency anemia: does Helicobacter pylori have a role to play?, Gastroenterology Report, Volume 6, Issue 3, August 2018, Pages 215–220, https://doi.org/10.1093/gastro/goy001

Annibale B, Capurso G, Lahner E, et al. Concomitant alterations in intragastric pH and ascorbic acid concentration in patients with Helicobacter pylori gastritis and associated iron deficiency anaemia. Gut. 2003;52(4):496-501. doi:10.1136/gut.52.4.496

 

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