Helicobacter pylori Infection and Reflux Esophagitis in Children With Chronic Asthma

In this issue of the journal, a group of 6 investigators from Ufa (population 1,000,000), located on the western slopes of the Ural Mountains in Southeastern European Russia in the republic of Bashkortostan, report their findings in 42 young asthmatic teens (mean age =13) who had endoscopy for dyspepsia. The investigators found that only 7 of the 22 teens with H. pylori infection also had esophagitis (26%), while all 20 of the 20 H. pylori negative children (100%) had concomitant esophagitis. This 4-fold increased prevalence of esophagitis in patients who are not infected with H. pylori was sufficient for the investigators to conclude that H. pylori infection protected against reflux esophagitis. Although some may quibble on the use of histology criteria to define esophagitis, at least both groups—the kids with the H. pylori bug and the kids without the H. pylori bug—were assessed using the same criteria. To prepare their hypothesis, the investigators—led by Alexander A. Nijevitch, MD—introduce us to the conflicting data regarding the relationship between gastroesophageal reflux (GER) and infection with H. pylori, macroscopic versus microscopic reflux esophagitis, GER and asthma, bronchodilator treatment and GER, and H. pylori infection and allergic asthma. 1 When all is said and done, the authors hypothesize the following: “Failure to acquire H. pylori can enhance esophagitis risk in children with chronic asthma.” Now, take away the fact that these are kids, and the fact that these kids have asthma, and you are back to the Manifesto of Labenz, which states that in adult Germans, H. pylori infection protects against GER, while eradication of H. pylori infection promotes GER. 2 We could stop here and conclude that teenage Russians are similar to adult Germans in regards to the inverse relationship between reflux esophagitis and H. pylori infection. The world is changing. Russia and Germany are getting on quite well lately, and the Russian teens are expected someday to grow to be adults. At first glance, the very well documented findings of Nijevitch and his group are not surprising. But wait! Since the end of the cold war, the world has become much more complicated. Global trade, the environment, war, terrorism, and fundamentalism have emerged all at the same time to create chaos, panic, and confusion. The confusion created by these movements, however, pales in comparison to the confusion generated by trying to understand the relationship between GER and asthma. And now, along come the Russians to confuse even more the GER/asthma issue by tossing in the H. pylori bug as a potential confounding factor. In order to make sense out of all the conflicting information, we need to simplify all the data, the hypotheses, and the possibilities. Simplification #1: A recent meta-analysis by Laine and Sugg. H. pylori was eradicated in 621 adults but not eradicated in 544 adults. 3 Eradication of H. pylori had no significant effect on development of esophagitis in patients without previous GER symptoms. Simple conclusions: H. pylori infection does not prevent esophagitis Eradication of H. pylori does not promote esophagitis Simplification #2: There are 4 possible relationships between GER and asthma. 4 Simple conclusions: GER causes asthma Asthma causes GER Asthma and GER are both present and each negatively affects the other Asthma and GER are both present but unrelated Simplification #3: Numerous studies show improvement in asthma after treatment of GER. Simple conclusion: Anti-reflux surgery in asthmatics with GER improves overall asthma. 5,6 Simplification #4: The current study. 1 Putting aside the small numbers of patients, and accepting as significant the statistical trend of the pulmonary symptoms, the simple conclusion is as follows: H. pylori infection prevents esophagitis Lack of H. pylori infection promotes esophagitis H. pylori infection worsens asthma (just a little bit) Simplification #5: The inconsistencies. GER causes asthma (by way of aspiration) Anti-reflux surgery prevents GER from causing asthma (by way of aspiration) H. pylori infection prevents GER from causing asthma (by way of aspiration) But, H. pylori infection worsens asthma. How can we explain this paradox? If GER is related to asthma because of aspiration (or even by way of a vagal reflex mechanism), how can we explain the fact that patients with less GER because of the H. pylori infection actually have worse asthma? This is the question that currently remains unanswered. In their discussion, however, the authors offer a number of possible and plausible explanations both for and against a potential role of H. pylori in influencing asthma. The discussion is thorough and well thought out. For anyone with an inquisitive mind who is interested in the juicy, poorly understood love triangle between GER, asthma, and H. pylori, this discussion has it all: from the high prevalence of H. pylori in underdeveloped countries, with their almost zero prevalence of asthma, to the potential role of bacterial infection (eg, H. pylori) in influencing T-helpers to the Th 1 subtype, which suppresses the atopic Th 2 response. The authors are well aware of the limitations of their study. They address with courage each and every limitation, and they discuss them in a positive light. The authors' recognition of potential new areas of research in the GER/asthma field should be helpful to investigators who are still young and whose minds have not yet closed. There are, of course, bound to be some criticisms of the study. These criticisms might include the methods used to define reflux esophagitis, the definition of reflux and asthma, the absence of endoscopic follow up, and the small changes in pulmonary function. These criticisms have been addressed by the authors themselves and should not detract from the potential new information and new questions that the study provides. “The most exquisite folly is made of wisdom spun too fine.” Benjamin Franklin. Without doubt, the controversy among investigators from different disciplines on the exact role of H. pylori infection in asthmatics with GER is likely to remain heated. In this regard, the 6 investigators from Ufa—Nijevitch, Loguinovskaya, Tyrtyshnaya, Sataev, Ogorodnikova, and Nuriakhmetova—have provided the fuel to keep the pulmonologists, gastroenterologists, and pediatricians (and even the French, Germans, Russians, and Americans) fighting among themselves. It would certainly be a tribute to these 6 Russian physicians if the results of their efforts stimulated further research into the very poorly understood relationship between H. pylori infection, gastroesophageal reflux, and asthma.