Clinical Outcome Controversy in Helicobacter pylori Infection

H. pylori infection can manifest as intestinal and extraintestinal disease. In this review, we summarize several bacterial virulence are key in determining the pattern of acid secretion and gastritis. The acid level factor that or gastric cancer. However, there is variance prevalence in some countries which can be explained through a enough to trigger idiopathic thrombocytopenic purpura (ITP). Additional triggers are needed to obtain an antiof H. pylori infection remains controversial. H. pylori is not only a single cause, but the host and environmental


untuk mendapatkan respons autoimun anti-platelet di ITP terkait dengan H. pylori. Oleh karena itu, perbedaan dalam manifestasi klinis infeksi H. pylori tetap kontroversial. H. pylori bukan hanya penyebab tunggal, tetapi faktor inang dan lingkungan juga berkontribusi untuk menghasilkan respons yang berbeda.
Kata kunci: H. pylori, manifestasi klinis, intestinal and extraintestinal disease patients without any gender bias. 7 The typical pattern of pain in duodenal ulcers is that pain occurs 90 minutes to 3 hours after eating and often disappears with antacids or food (hunger pain food relief), whereas pain in gastric ulcers is often triggered by food. 7 H. pylori infection is related with an increased risk of peptic ulcer 3 to 4 fold and people infected with H. pylori will experience peptic ulcer is about 10-15% of. 8 Duodenal ulcer initiated by H. pylori arises due to the presence of non-atrophic corpus gastritis and antraldecrease in somatostatin production which causes a results in hypergastrinemia ( Figure 1A). The mechanism of decreased somatostatin secretion may include three potential mechanisms. First, antral H. pylori gastritis can change the function of gastrin and D cells through local production of specific cytokines. H. pylori infection causes severe antral gastritis through mucosal or production of N-methyl histamine, a selective H3 receptor agonist, by H. pylori. Gastrin, in turn, stimulates which leads to an increase in acid secretion. Third, H. pylori increases the mucosal surface pH based on high urease activity and ammonia synthesis. Low antral pH is an important physiological stimulus for the synthesis and release of antral somatostatin. 8 So therefore, H. pylori should not be able to colonize the normal duodenum because it is inhibited by bile, can colonize due to the and ulceration. 7,9 In gastric ulcer, acid hypersecretion lasts about 8 weeks and is caused by an increase in parietal cell mass and hypergastrinemia-induced ECL causing somatostatin levels, thereby releasing inhibition of G cells and parietal cells to maximize gastric acid output. Over time, predominant corpus gastritis in chronically infected patients reduces the amount of acid and causes atrophy of the glands of the specks with loss of parietal cells. Resulting irreversible achlorhydria and is associated with gastric ulcers ( Figure 1B). The

INTRODUCTION
Helicobacter pylori is a gram-negative spiral bacterium and include as the class I carcinogenic agent. 1,2 H. pylori colonizes in the gastric almost 50% of the world's human population throughout their lives if not treated. The prevalence of H. pylori infection is between 30-50% in developed countries and between 85-95% in developing countries. 3 Indonesia is reported to have a low prevalence of H. pylori infection compared to other countries in Asia. A study of 267 islands in Indonesia found that the prevalence of H. pylori infection was only 22.1%. 4 H. pylori infection can manifest as intestinal and extraintestinal disease. Intestinal diseases consist of peptic ulcer, chronic gastritis, gastroesophageal tissue (MALT) lymphoma and gastric cancer; whereas extraintestinal diseases are related to cardiopulmonary, hematologic, metabolic, neurological and dermatological systems, also autoimmune diseases including idiopathic thrombocytopenic purpura (ITP). 5 Interestingly, epidemiological data show that there are contrasts in the clinical manifestations of H. pylori. from duodenal ulcer, while some others experience gastroesophageal reflux disease (GERD), gastric cancer, MALT lymphoma and ITP, but others do not. In this review we summarize several factors that cause H. pylori infection.

Duodenal and Gastric Ulcer
Ulcers are characterized as lost of continuity in a portion of the walls of the digestive tract that penetrates the muscular mucosa with a diameter of at minimal 0.5 cm, with depth to submucosa. 6 Peptic ulcer consists of duodenal and gastric ulcer. Although the incidence tends to decrease, duodenal ulcer is estimated to occur in 3.5%, while gastric ulcer is estimated 2.4%. Duodenal ulcer is usually diagnosed in men and young age, whereas gastric ulcer occurs more often in older process of peptic ulcers is generally observed in the transition zone between the antrum and the corpus in the minor curvatura, which may be related to severe epithelial damage and to ulceration. It is not clear why H. pylori pattern of pan-gastritis or corpus in some people, but antral predominance in others. One possibility is that it occurs similar to autoimmune gastritis caused by ATPase in the gastric. Interestingly, the involvement of acidity is supported by the observation that long-term gastric acid inhibition can result in a shift from antral- 7,8 Genetic polymorphisms in conjunction to bacteria and/or environmental factors. Duodenal ulcer is related (A). Gastric ulcer related with pan gastritis or corporal gastritis and decreased or normal acid secretion (B). 8 are key in determining the pattern of acid secretion and gastritis. East Asian CagA-positive strains can mainly induce corpus pangastritis or predominant gastritis with hypochlorhidria. 9 Likewise strains with long intact dupA are related with an increased risk of gastric ulcer. Whereas patients infected with oipA strains, 12-bp cagA insertions, vacA d1 and dupA increased risk of duodenal ulcer (Table 1). 8 Hosts with the IL-1B-511 ulcer, whereas IL-10-592-A/A had a significantly higher frequency in gastric ulcer patients. 8  Interestingly, H. pylori infection is lower in developed countries such as North America, Western Europe and Australia, while GERD and its complications are more common in these countries. In contrast, the frequency of H. pylori infection is higher in developing countries such as South America, Eastern Europe, Africa, China and India while GERD and its severity are lower in these countries. 11 The existence of the negative correlation between the prevalence of GERD with H. pylori infection raises the suspicion that H. pylori prevent the occurrence of GERD. It is also supported that patients with H. pylori-positive peptic ulcers are more likely to develop GERD than patients with H. pylorinegative gastric ulcers. 12 But after further analysis, the H. pylori infection itself. Gastritis predominant in the gastric in the initial phase will produce higher acid and trigger GERD. Whereas gastritis with antrum predominance has lower acid levels, thus, the risk of GERD is lower. 10 The genetic polymorphisms of IL-1B and IL-1RN are inversely proportional to the risk of GERD in H. pylori genotypes are related to gastric cancer, hypochlorhidria and corpus atrophy. 9,11 including the IL-1RN-1, IL-1B-511-T, and IL-1B-31-C allele, can be considered protective against GERD. emphasized in the presence of H. pylori infection that the IL-1B-511-T allele is related with reflux oesophagitis. 9,11 A few genetic risk factors for GERD, including polymorphisms in the G-protein beta 3 (GNB3) subunit, glutathione S-transferase P1, IL-10, CYP2C19, DNA repair genes and cyclin D1, may be involved. The interaction between the virulence of H. pylori infection and genetic factors may be the cause for the low prevalence of GERD in Asian states. 9,11 Gastric Cancer and Non Gastric Cancer H. pylori is the cause of gastric adenocarcinoma. Gastric adenocarcinoma is divided into intestinal changes leading to intestinal type cancer starting with chronic gastritis, followed by gastric atrophy and carcinoma. 13 There were 21,000 new cases of gastric cancer in the United States and 10,570 Americans died in 2010. 1 Interestingly, there is a population infected with H. pylori in Africa by 91%, but has a very low prevalence of gastric cancer. Similar patterns are reported in South Asian countries such as India and Bangladesh. In contrast, in East Asian countries such as Japan, China and Korea; there is a positive relationship between the prevalence of gastric cancer and H. pylori infection. This variance can be explained through a combination of several factors including age at infection, virulence factors of H. pylori environmental factors. 14 CagA protein is injected into the host cell via The CagA protein subtype is based on the presence of the Glu-Pro-Ile-Tyr-Ala motif (EPIYA). Variations in amino acid sequences consist of EPIYA motifs that identify 4 subtypes, namely APIYA-A, EPIYA-B, EPIYA-C and EPIYA-D followed by CagA which are separated into Western-types (ABC, ABCC, ABCCC) or East-Asian type (ABD). East-Asian-type homology 2 domain from Src homology 2 containing protein-thyrosine phosphatase (SHP2) as well as a better ability to induce the hummingbird phenotype compared to Western-type CagA. Both types are CagA-negative infections. H. pylori East-Asian type CagA is also associated with greater mucosal 2 Thus, patients infected with H. pylori CagA positive and East-Asian type CagA tend to have a higher risk of developing gastric cancer than the negative one.
VacA was recognized as vacuolating cytotoxin, functioning vacuation of epithelial cells in vitro. VacA have multiple functions, including initiation of infection, lymphocyte modulation, changing membrane permeability in mammalian epithelial cells. 2 vacA genotypes are related with the risk of clinical manifestations such as peptic ulcer or gastric cancer. Genes are divided into two types based on vacA s1m1 genotype is related with the most cytotoxic strain and is associated with an increased risk of gastric cancer. This is supported by the relationship between the vacA s1m1 genotype and peptic ulcer or gastric carcinoma in the Middle East, Latin America, and several African states. 15 Studies in Spain report that strains of vacA s1 and m1 tend to develop preneoplastic gastric lesions. In the Portuguese population, s1m1 is related with an increased risk of gastric carcinoma. 2 of IL-8 in the gastric mucosa via interplay with AP-1, nuclear factor-kappaB (NF-B) transcription factors and ISRE-like elements. OipA's ability to increase NF-B activity is an independent PAI cag. A study shows an increased risk of peptic ulcer and gastric cancer. 2 The representation of the antigen-binding adhesin (BabA) blood group, which adheres to monofucosilat (ABO) and diphosylate (Lewisb) can be thought of as determining the solidity of H. pylori colonization. In humans, a BabA-positive strain is related with a 2-fold increase in gastric atrophy compared to BabA-negative strain infection. This surveillance is appropriate with studies that show that BabA-positive strains colony are denser and create more IL-8 secretion in the mucosa than BabA-negative strains. It is crucial to note that CagA, BabA and OipA can be expressed together. 2 from diet or smoking, alcohol consumption, low socioeconomic status, obesity, old age and previous gastric surgery are associated with increased gastric cancer. 13,14 Salt and H. pylori that salt damages the gastric mucosa which allows infection and persistence of H. pylori, increasing susceptibility to tumorigenesis. 14 The nitrate diet at high pH and subsequently responds with amines and is turned to carcinogens. The amount of salivary nitrates and nitrites is positively associated with the high prevalence of gastric cancer in endemic areas in other states. 16

Mucosa-associated Lymphoid Tissue (MALT) Lymphoma and non MALT Lymphoma
Primary gastric lymphoma is the most common extranodal site of non-Hodgkin's lymphoma and ranges from 30% to 40% of all extranodal lymphomas. It also represents 4% to 20% of all non-Hodgkin's lymphomas and about 5% of primary gastric neoplasms. The frequent histological subtype in primary gastric lymphoma is marginal B cell zone lymphoma of MALT lymphoma. 17 The incidence of development of primary gastric lymphoma is 2-3 times higher in men than women. 17 Clinical manifestations vary from nausea, vomiting, dyspepsia, epigastric pain to massive anemia, pyloric stenosis, and weight loss. 17 MALT gastric lymphoma is very strongly related with H. pylori infection. During H. pylori infection, normal B cells are transformed into malignant clones through three translocations of chromosomes t (11; 18) (q21; q21), t (1; 14) (p22; q32) and t (14; 18) (q32; q21), results in the activation of kappa B nuclear and immunity. Studies show that t (11; 18) (q21; q21) is found more frequently in patients with a CagApositive H. pylori strain that determines occurrence of MALT lymphoma. However, conventional cagA and vacA between gastric cancer and MALT lymphoma. Further analysis of complete sequences of protein from CagA and VacA could recognize four loci in CagA, and three loci in VacA that could potentially cause MALT lymphoma or gastric cancer in the long term.

Idiopathic thrombocytopenic purpura (ITP) and non ITP
ITP is defined as an autoimmune disorder characterized by immunologic destruction of normal platelets. H. pylori infection is a secondary cause of ITP. 19,20 The prevalence of H. pylori infection in patients with ITP is higher than healthy individuals of the same age group and gender. 19 At least 70% of cases diagnosed in childhood will heal fully within six months, even no treatment. One third of the remaining chronic cases will fully recover during the mild thrombocytopenia. Thrombocytopenia purpura is usually prolonged in adults and the chance of complete remission is 20-40. 21 Several authors have looked for differences in hereditary factors in ITP patients with or without H. pylori infection. Several studies examined HLA-DQB1 and DRB1 alleles in Italian patients with ITP and found that H. pylori-positive patients had higher DRB1*11 frequencies, DRB1*14, and DQB1*03, and lower DRB1*03 frequencies, compared with H. pylori-negative patients. Nevertheless, several studies H. pylori infection and HLA-DQB1 or DRB1alleles in Japanese related with H. pylori infection in patients diagnosed before 50 years old. 19,22 In addition, there were no with and without H. pylori infection. Serum chemokine levels, including monocyte chemoattractant protein-1, are regulated in the activation of T cells that are normally expressed and secreted, and epithelial cell-derived patients with H. pylori infection compared to negative, although this increase in chemokine levels was also monitored in individuals who had digestive disorders associated with H. pylori but did not have ITP. 19 One interesting hypothesis is the theory of molecular mimicry with the production of cross-reactive antibodies that respond on H. pylori components and platelet surface antigens. Several studies have shown that eluted platelets in H. pylori-infected ITP patients recognize CagA protein in immunoblots, but unrecognized in non-ITP-infected H. pylori patients. 23 One study even reported that monoclonal antibodies produced for H. pylori urease B respond with GP IIb/IIIa expressed on the platelet surface. 24 In other potential mechanism, H. pylori infection can macrophages and lead the formation of autoantibodies.
in circulating monocytes was downregulated in ITP patients infected with H. pylori. Therefore, H. pylori can receptor inhibitors. 19,25 In addition, some strains of H. pylori cause platelet aggregation that depends on the interaction of von Willebrand factor and IgG antibodies for H. pylori with the appropriate receptors, GP Ib and H. pylori antibodies can operate on platelets by binding to H. pylori, von Willebrand factor, and GP Ib, such as antiplatelet autoantibodies. H. pylori infection alone is not enough to trigger ITP. Additional triggers are needed to obtain an anti-platelet autoimmune response at ITP associated with H. pylori. 19 Several studies reported an association in 1998 patients after eradication of H. pylori. 19,22 is present in the next few reports and is summarized in a systematic review of 24 observational studies and 1 control study involving 1,555 patients. Several studies have found that 50% of adults have an increased platelet response after H. pylori eradication therapy, especially in those with mild ITP. A systematic review of 11 controlled studies obtained platelet count responses in 51% of patients infected with H. pylori versus an 8.8% increase in platelets in negative control H. pylori, which further strengthened the causal relationship. In a follow-up study 8 years after eradication therapy, no recurrence occurred. 19

CONCLUSION
H. pylori infection remains controversial. H. pylori is not only a single cause, but host and environmental factors ACKNOWLEDGMENT This study was funded by grants from Penelitian Skema Penelitian Dasar in 2020, Ministry of research, Technology and Higher Education of the Republic of Indonesia (584/UN3.14/PT/2020).