The role of routine immunohistochemistry for Helicobacter pylori in gastric biopsy

doi:10.1016/j.anndiagpath.2010.05.002

Annals of Diagnostic Pathology

Volume 14, Issue 4, August 2010, Pages 256-259

https://doi.org/10.1016/j.anndiagpath.2010.05.002 Get rights and content

Abstract

Helicobacter pylori infection is associated with gastritis, gastric ulcer, gastric adenocarcinoma, and mucosal associated lymphoid tissue lymphoma. Documenting the presence of H pylori in a gastric biopsy is essential for appropriate patient care. Several special stains and immunohistochemistry (IHC) stain for H pylori are available, and many laboratories are routinely using one of them. We introduced routine IHC for H pylori about a year ago, and this study aims to investigate the value of this protocol. A total of 224 patients qualified for the study criteria during this period. The diagnoses were chronic active gastritis (68), chronic gastritis (76), no pathologic abnormality (50), reactive gastropathy (24), and polyps (6). Fifty-four cases were positive for H pylori on IHC, including 50 chronic active gastritis and 4 chronic gastritis. The IHC positive rate was 73.5% (50/68) in chronic active gastritis, 5.3% (4/76) in chronic gastritis, and 0% (0/80) in other diagnoses. The sensitivity/specificity of finding H pylori by blindly reviewing hematoxylin and eosin slides was 100%/100%, 100%/100%, 95%/100%, and 100%/100% from the 4 authors. Our results showed that many gastric biopsies (35.7%, 80/224) had no pathologic abnormality or reactive gastropathy and did not need a routine IHC for H pylori. Hematoxylin and eosin slide review had a very good sensitivity and specificity with all levels of observers. In summary, IHC for H pylori should not be routinely used, especially during these economically challenging times. Immunohistochemistry should be reserved for unexplained gastritis and previously treated patients with likely low organism density.

Introduction

Helicobacter pylori (H pylori) is the major etiologic factor of peptic ulcer diseases and gastritis and is associated with gastric adenocarcinoma and lymphoma [1], [2], [3]. Efficient detection and demonstration of the organisms in biopsy specimens are very important for patient care. Eradication of H pylori infection can facilitate healing of ulcers and leads to regression of early stage mucosa-associated lymphoid tissue lymphoma [4], [5]. Both noninvasive and invasive techniques are available for H pylori detection [6]. The invasive techniques require endoscopy and biopsy. Endoscopic biopsy enables the simultaneous assessment of morphological changes associated with H pylori infections, such as the degree of severity and activity of the gastric inflammation and presence of intestinal metaplasia, dysplasia, lymphomas, or carcinomas.

Various methods are available for the detection of H pylori organisms in biopsy specimens, including rapid urease test (CLOtest), culture, hematoxylin and eosin (H&E), special stains (Gram stain, Giemsa stain, silver stains), and immunohistochemistry (IHC) [6], [7], [8], [9], [10], [11]. These tests vary in their sensitivity and specificity, and the choice of test may be dependent on availability, cost-effectiveness, and laboratory preference [12]. Immunohistochemistry was introduced in our laboratory as an automatic reflex stain on antral biopsies about a year ago, and the goal of this project is to evaluate the value of this new procedure.

Section snippets

Material and method

All gastric biopsies received in the Department of Pathology at Louisiana State University Health Science Center-Shreveport between July 2008 and June 2009 were retrieved from the pathology database with the exclusion of malignant cases. The pathologic diagnoses and information on the presence of H pylori organisms on IHC were extracted from surgical reports. Immunohistochemistry stains were done using a rabbit polyclonal antibody against H pylori (Cell Margue, Ventana, catalogue: 760-2645,

Results

A total of 224 biopsies were qualified for the study, and all had H pylori IHC according to laboratory protocol. The surgical pathology diagnoses of the 224 biopsies were shown in Table 1, and the diagnostic categories included chronic active gastritis (68), chronic gastritis (76), no pathologic abnormality (50), reactive gastropathy (24), and fundic gland polyp (6). Intestinal metaplasia was observed in 18 biopsies, including 6 chronic active gastritis and 12 chronic gastritis. Fifty-four

Discussion

Documentation of the presence of H pylori organisms in a gastric biopsy is very important for standard patient care, and patients with documented H pylori infection are treated aggressively with a combination of proton pump inhibitors and antibiotics [13], [14]. Many special stain methods and IHC have been found to be effective for the detection of H pylori, and pathology laboratories use 1 or 2 staining methods as a routine protocol for easier and quick detection of the organisms [6], [7], [8]

References (18)

CoverT.L. et al.
Helicobacter pylori in health and disease
Gastroenterology
(2009)
WotherspoonA.C. et al.
Regression of primary low-grade B-cell gastric lymphoma of mucosa-associated lymphoid tissue type after eradication of Helicobacter pylori
Lancet
(1993)
AnimJ.T. et al.
Assessment of different methods for staining Helicobacter pylori in endoscopic gastric biopsies
Acta Histochem
(2000)
PeuraD.
Helicobacter pylori: rational management options
Am J Med
(1998)
MbulaiteyeS.M. et al.
Helicobacter pylori associated global gastric cancer burden
Front Biosci
(2009)
FurutaT. et al.
Helicobacter pylori and non-malignant diseases
Helicobacter
(2009)
HuntR.H. et al.
The current role of Helicobacter pylori eradication in clinical practice
Scand J Gastroenterol Suppl
(1995)
RicciC. et al.
Diagnosis of Helicobacter pylori: invasive and non-invasive tests
Best Pract Res Clin Gastroenterol
(2007)
El-ZimaityH.M. et al.
Histologic assessment of Helicobacter pylori status after therapy: comparison of Giemsa, Diff-Quik, and Genta stains
Mod Pathol
(1998)

There are more references available in the full text version of this article.

Cited by (42)

Diagnosis of Helicobacter pylori infection on gastric biopsies: Standard stain, special stain or immunohistochemistry?
2018, Annales de Pathologie
Il n’y a pas de consensus sur l’intérêt de réaliser une technique complémentaire systématique pour le diagnostic d’infection à Helicobacter pylori. Dans notre laboratoire, un crésyl violet était réalisé systématiquement jusqu’en juillet 2014 ; depuis cette date, un crésyl violet ou une immunohistochimie n’est fait(e) qu’à la demande. Nous avons évalué l’intérêt de la coloration par le crésyl violet des biopsies pour diagnostiquer une infection à H. pylori, en comparant une période où cette coloration était systématique à une période où elle était faite à la demande.
Étude rétrospective des biopsies gastriques de 786 patients d’avril à novembre 2014, prélevées en l’absence de lésion endoscopique focale. Pendant la 1^re période, une hématoxyline-éosine et un crésyl violet étaient réalisés sur toutes les biopsies. Pendant la 2^e période, une hématoxyline-éosine était réalisée, puis au besoin un crésyl violet ou une immunohistochimie. Toutes les lames colorées par l’hématoxyline-éosine ont été revues. Nous avons fait une immunohistochimie en cas de gastrite chronique active sans H. pylori sur les colorations standard ou spéciale.
Les biopsies gastriques étaient normales dans 55 % des cas. Il n’y avait pas de différence de fréquence d’H. pylori entre les deux périodes. En cas de gastrite chronique active, H. pylori était dans la majorité des cas visible sur l’hématoxyline-éosine (94 %). Une immunohistochimie ne doit être prescrite qu’en cas de gastrite chronique active sans H. pylori identifié sur l’hématoxyline-éosine, les bactéries étant alors peu nombreuses ou de localisation atypique.
Dans notre expérience, les H. pylori n’étant présent qu’en cas de gastrite active (33 % des biopsies dans notre série) et étant presque toujours identifiables sur la coloration standard à l’H-E (dans 94 % des cas), il n’est pas nécessaire de réaliser systématiquement, sur toutes les biopsies gastriques, une technique complémentaire histo- ou immunohistochimique.
There is no consensus on the benefit of performing a systematic complementary technique for the diagnosis of Helicobacter pylori infection. In our laboratory, a cresyl violet was carried out systematically until July 2014; since that date, a cresyl violet or immunohistochemistry is only made on request. We evaluated the value of cresyl violet staining of gastric biopsies to diagnose H. pylori infection by comparing a period of systematic staining to a time when it was made on demand.
We retrospectively studied the gastric biopsy of 786 consecutive patients from April to November 2014, taken in the absence of focal endoscopic lesion. During the first period, hematoxylin-eosin and cresyl violet were performed on all biopsies. During the second period, hematoxylin-eosin was performed and then, if necessary, cresyl violet or immunohistochemistry. All hematoxylin-eosin stained slides were revised to identify H. pylori. We performed immunohistochemistry in cases of active chronic gastritis without H. pylori identified on hematoxylin-eosin or cresyl violet.
We have shown that gastric biopsy performed in the absence of focal mucosal lesion are normal in 55% of cases. The percentage of H. pylori infection was similar in both groups. In cases of active chronic gastritis, H. pylori infection is visible, in most cases, on hematoxylin-eosin (94%). Immunohistochemistry should be prescribed only in case of chronic active gastritis without H. pylori identified on standard staining, with bacteria rare or atypically located.
In our experiment, H. pylori is present only in case of active gastritis (33% of the biopsies in our series) and being almost always identifiable on the standard staining with H-E (in 94% of the cases), it is not It is not necessary to systematically perform, on all gastric biopsies, a complementary histo- or immunohistochemical technique.
Selective staining of gastric biopsies for H. pylori does not affect detection rates or turnaround time and improves cost compared to reflexive staining
2017, Pathology Research and Practice
Citation Excerpt :
The society recommends that special stains (IHC is preferred if available) only be used in the setting of gastric inflammation when H. pylori is not detectable by H&E or to “rule out” infection in patients with previously treated H. pylori gastritis [2]. While some studies have already demonstrated the unwarranted role reflexive ancillary stains play in the detection of H. pylori infection [2,8,9,11,12], no study has examined the actual impact on H. pylori detection rates, laboratory costs, and turnaround time a laboratory experiences when it switches from a policy of reflexive staining to selective staining. Our institution recently made such a policy change, and the following study examines the affect this change had on these important variables.
To evaluate how reflexive versus selective H. pylori stains affect detection rates, turnaround time (TAT), and cost savings in a real life practice environment following an institutional policy change.
The aforementioned parameters were evaluated in all cases in the year preceding and the year following an institutional policy change from reflexive to selective staining.
1497 patients comprised the reflexive stain (RS) group of which 228 (15.2%) were H. pylori positive. 1629 patients comprised the selective stain (SS) group of which 237 (14.5%) were H. pylori positive. There was no significant difference in H. pylori detection rates between the RS and SS groups (OR = 0.95, 95% CI = 0.78–1.15, p = 0.59). TATs were similarly equivalent with a mean of 52.4 h for the RS cohort and 53.7 h for the SS cohort (p = 0.344), both of which included a resident preview day. We calculated an average laboratory cost savings of $11.68 per case, which saved our department over $15,000 (37%) in the year following the policy change.
Our results support a policy of selective staining for H. pylori as opposed to reflexive staining and go on to show that laboratories that change their policy can expect to generate cost savings without compromising detection rates or TAT.
Prospective identification of Helicobacter pylori in routine gastric biopsies without reflex ancillary stains is cost-efficient for our health care system
2016, Human Pathology
Citation Excerpt :
In 2013, the Gastrointestinal Pathology Society recommended the cessation of reflexive (up-front) histochemical or IHC stains for H pylori in gastric biopsies [9]. Studies have repeatedly shown that pathologists can identify H pylori organisms on the routine H&E-stained slide [11,12]. Nevertheless, many centers, including our own, continued to perform a reflexive ancillary stain (Diff-Quik) on gastric biopsies.
Despite the recommendation of expert gastrointestinal pathologists, private and academic centers (including our own) have continued to use ancillary stains for identification of Helicobacter pylori. For a 1-month period, gastric biopsies were prospectively evaluated for H pylori using routine hematoxylin and eosin (H&E) and a reflex Diff-Quik stain. During this time, 379 gastric biopsies were collected on 326 patients. H pylori organisms were prospectively identified in 23 (7%) patients, all of whom had superficial dense lymphoplasmacytic inflammation expanding the lamina propria. An additional 2 patients with neutrophilic inflammation were found to have H pylori by immunohistochemical staining. One patient diagnosed as having normal gastric mucosa was retrospectively found to have inflammation with rare H pylori organisms originally overlooked on both H&E and Diff-Quik but later identified on immunostain (0.5%). No patients with chemical gastritis (16%) or chronic inflammation (27%) were found to have H pylori. During the study month, 9 immunostains for H pylori were performed in addition to the 379 Diff-Quik. After discontinuation of reflex Diff-Quik, approximately 20 immunostains are performed for H pylori each month, which decreases technical time spent for processing gastric biopsies and reduces cost to the health care system. In our population with a low prevalence of H pylori, reflex staining for organisms is not cost-effective. The organisms can be seen on routine H&E; when suspicious superficial or active inflammation is present without visible organisms, immunohistochemical stains will confirm presence or absence within a day. Discontinuation of up-front ancillary studies is cost-effective without compromising patient care.
Sixth Chinese National Consensus Report on Management of Helicobacter pylori Infection (Treatment Excluded)
2023, Chinese Journal of Gastroenterology
Helicobacter pylori infection in Xinjiang Uyghur Autonomous Region: Prevalence and analysis of related factors
2023, World Journal of Gastroenterology
Tunisian consensus on the management of Helicobacter Pylori infection
2023, Tunisie Medicale

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Annals of Diagnostic Pathology

Abstract

Introduction

Section snippets

Material and method

Results

Discussion

References (18)

Helicobacter pylori in health and disease

Gastroenterology

Regression of primary low-grade B-cell gastric lymphoma of mucosa-associated lymphoid tissue type after eradication of Helicobacter pylori

Lancet

Assessment of different methods for staining Helicobacter pylori in endoscopic gastric biopsies

Acta Histochem

Helicobacter pylori: rational management options

Am J Med

Helicobacter pylori associated global gastric cancer burden

Front Biosci

Helicobacter pylori and non-malignant diseases

Helicobacter

The current role of Helicobacter pylori eradication in clinical practice

Scand J Gastroenterol Suppl

Diagnosis of Helicobacter pylori: invasive and non-invasive tests

Best Pract Res Clin Gastroenterol

Histologic assessment of Helicobacter pylori status after therapy: comparison of Giemsa, Diff-Quik, and Genta stains

Mod Pathol

Cited by (42)

Diagnosis of Helicobacter pylori infection on gastric biopsies: Standard stain, special stain or immunohistochemistry?

Selective staining of gastric biopsies for H. pylori does not affect detection rates or turnaround time and improves cost compared to reflexive staining

Prospective identification of Helicobacter pylori in routine gastric biopsies without reflex ancillary stains is cost-efficient for our health care system

Sixth Chinese National Consensus Report on Management of Helicobacter pylori Infection (Treatment Excluded)

Helicobacter pylori infection in Xinjiang Uyghur Autonomous Region: Prevalence and analysis of related factors

Tunisian consensus on the management of Helicobacter Pylori infection

Original ContributionThe role of routine immunohistochemistry for Helicobacter pylori in gastric biopsy

Abstract

Introduction

Section snippets

Material and method

Results

Discussion

Gastroenterology

Lancet

Acta Histochem

Am J Med

Helicobacter pylori associated global gastric cancer burden

Front Biosci

Helicobacter pylori and non-malignant diseases

Helicobacter

The current role of Helicobacter pylori eradication in clinical practice

Scand J Gastroenterol Suppl

Diagnosis of Helicobacter pylori: invasive and non-invasive tests

Best Pract Res Clin Gastroenterol

Histologic assessment of Helicobacter pylori status after therapy: comparison of Giemsa, Diff-Quik, and Genta stains

Mod Pathol

Original Contribution
The role of routine immunohistochemistry for Helicobacter pylori in gastric biopsy