Dear Editor, We read with interest the article by Çimen et al. examining the relationship between Helicobacter pylori (HP) positivity and colon polyps. This topic remains clinically relevant because Hong et al. reported that HP infection was associated with an increased risk of colorectal adenoma in a cross-sectional study and meta-analysis.1 Wu et al. further showed in a systematic review and meta-analysis that HP infection was associated with an increased risk of colorectal neoplasia.2 In a large pathology-based study, Sonnenberg and Genta also identified HP as a risk factor for colonic neoplasms.3 Papastergiou et al. subsequently reviewed the field and emphasised that the possible causal link between HP and colorectal neoplasia remains biologically plausible but unresolved.4 Kim et al. reported that HP infection was an independent risk factor for both early and advanced colorectal neoplasms.5 Choi et al. later confirmed in another systematic review and meta-analysis that patients with HP infection had an increased risk of colorectal neoplasia.6 More recently, Lu et al. also found a positive association between HP infection and colorectal polyps in a meta-analysis of observational studies.7 However, we believe that the current analytic design does not fully support the study question implied by the title. The central issue is that the final analysis included only patients who already had colorectal polyps and underwent polypectomy. Therefore, the study does not compare patients with versus without polyps and cannot directly evaluate whether HP positivity is associated with the occurrence of colorectal polyps. Rather, it examines whether polyp characteristics differ by HP status among individuals who all already have the outcome of interest. Under such a design, the absence of differences in polyp number, size, subtype or localisation should not be interpreted as evidence against an association between HP and colorectal polyps themselves. A second concern relates to outcome handling and analytic units. The authors state that polyp type and localisation were grouped individually because multiple polyps were present, indicating that a single patient could contribute to more than one histopathologic or locational category. In addition, categories such as ‘colitis’ and ‘colonic mucosa’ were analysed alongside conventional polyp histologies. This approach introduces substantial heterogeneity into the outcome definition and may dilute a biologically meaningful association, particularly if HP is more plausibly related to true neoplastic lesions than to inflammatory, non-neoplastic or technically mistargeted findings. For these reasons, the study may be more appropriately interpreted as a descriptive comparison of lesion characteristics within a selected polyp cohort, rather than a direct test of the relationship between HP positivity and colorectal polyp occurrence. Future studies addressing this question would benefit from including a true non-polyp control group and restricting primary analyses to clearly defined neoplastic colorectal lesions. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Ying Liu (Fri,) studied this question.