Helicobacter Pylori
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Gut, 1991,32,137-140 137 Gastritis due to spiral shaped bacteria other than Helicobacterpylori: clinical, histological, and Gut: first published as 10.1136/gut.32.2.137 on 1 February 1991. Downloaded from ultrastructural findings K L Heilmann, F Borchard Abstract toxylin and eosin solution. Besides studying the An intensive histological search for biopsy specimens for morphological changes Helicobacter pylon in gastric biopsy under low and high power magnification, all specimens has led to the detection of other slides were screened by one observer (KLH) spiral shaped bacteria in the human gastric under oil for the presence of bacterial organisms. mucosa. The clinical and morphological find- By this method it is possible to identify H pylon' ings of 39 cases (0.25% of all gastric biopsies without special stains.8 After identification of performed in the observation period) are spiral shaped bacteria in the specimens, they reported for 34 patients (87.2%) complaining of were stained with Gram, Giemsa, Steiner, and upper abdominal discomfort. Five patients Whartin-Starry silver stains. Tissue for electron (12.8%) had chronic gastritis and 34 (87.2%) microscopy was fixed in buffered glutaraldehyde chronic active gastritis. The organisms were and postfixed in 0s04. Semi-thin sections were seen by light microscopy deep in the gastric screened for spiral shaped bacteria and selected foveolae and intracellularly. The scanning and ultrathin sections further analysed in a Zeiss-EM transmission electron microscopic findings 109 electron microscope. For scanning electron show bacteria which invade and damage microscopy, formalin fixed biopsy specimens gastric mucosal cells. These organisms are were postfixed in a similar way, dried with the similar to the spiral shaped bacteria found in critical point method, and coated with gold. The the stomachs of cats and dogs and non-human specimens were viewed by the Philips SEM 515 primates. In eight patients organisms were not scanning electron microscope. detected after four weeks of treatment with bismuth salts. The disappearance of the http://gut.bmj.com/ organisms coincided with resolution of the Results chronic active gastritis and the symptoms. INCIDENCE AND LOCATION OF BACTERIA The 39 cases represent 0.25% of all antral The ecological niche in the gastric mucosa is biopsies performed in the observation period probably able to harbour other bacteria besides (n= 15 180). Spiral shaped bacteria were the well known Helicobacterpylon'. These 'other' observed in the antrum in all patients and in five on September 25, 2021 by guest. Protected copyright. organisms share some properties with H pylon. of 25 patients in the fundus. Chronic active type They are helical in shape, have flagellae, produce B gastritis was present in 34 patients in the antral urease, and their presence is associated with a mucosa. In four patients there was only a chronic active type B gastritis. 1-7 lymphoplasmacytic infiltrate. As in H pylon' We present the clinical, morphological, and associated gastritis the graiiulocytes were fre- ultrastructural findings for 39 patients infected with those spiral bacteria. Patients and methods Of the 39 patients 24 were men, mean age 54.2 years (range 20-76), and 15 were women, mean age 50.6 years (range 19-79) living in different Institute ofPathology, parts of Germany. Thirty four patients (87.2%) Municipal Hospital, complained ofdyspeptic symptoms such as post- Landshut, West prandial discomfort, epigastric pain, vomiting, Germany K L Heilmann heartburn, and dysphagia, lasting from one month to two years. Four patients were asympto- Institute ofPathology, matic and one patient had diarrhoea due to University ofDusseldorf, pancreatic The West Germany insufficiency. endoscopic F Borchard appearances in the antral and corpus mucosa Correspondence to: Prof were normal. There was no duodenal or gastric Dr F Borchard, Zentrum fuer ulcer or tumorous lesion at the time of biopsy. A Pathologie der Heinrich- Heine-Universitat, biopsy urease test was performed in five patients Moorenstrasse 5, 4000 and was positive after 20 minutes. Duesseldorf 1, FRG. In our institution all gastric biopsy particles Professor Heilmann died after are fixed in 4% neutral formalin, embedded in this paper was accepted. Figure 1: Gastrospirillum hominis in a gastric pit in the Accepted for publication paraplast, and cut in 3 [im thick sections. The antral musoca. (Haematoxylin and eosin. Original 12 March 1990 slides are stained routinely by an alcohol haema- magnification x800.) 138 Heilmann, Borchard with bismuth subsalicylate and were free of symptoms four weeks after the initial diagnosis. Biopsies in these cases, performed between eight and 16 weeks, showed only scattered lympho- Gut: first published as 10.1136/gut.32.2.137 on 1 February 1991. Downloaded from cytes and a few plasma cells in the lamina propria, but no granulocytes and no colonisation by spiral shaped bacteria (Table). TRANSMISSION ELECTRON MICROSCOPY In two patients ultrastructural studies were per- formed. The spiral shaped bacteria were seen in biopsy specimens of the antral mucosa (Fig 3) and corpus mucosa (Fig 4). The diameter may Figure 2: Several vary: it usually averages 0-65 lim, but the Gastrospirillum hominis in maximum width was 0.9 ,um. The amplitude is the middle of the corpus about 0-8 ,im. Usually up to four spirals are in mucosa partly invading 4 the plane of section; therefore, the actual length parietal cells. (Steiner silver T stain. Original could not be determined by this method. The magnification x800.) ends are partly pointed, partly blunt. At the blunt end of the organisms an insertion complex is visible with up to 12 flagellae (Figs 3 and 4 quently located in the superficial epithelial cells. (inserts)). In the region of the insertions the Twenty three ofthe 25 fundic specimens showed bacterial cell wall shows undulation. The mild inactive gastritis and the remaining two flagellae have swollen ends. Their variable form, cases chronic active gastritis. with a partial parallel course and partial cord-like The organisms are about 7-10 [im long and twisting, suggest the motility ofthese organelles. have four to six spirals. They may occur as single The sickle shaped area next to the insertion organisms or in small groups located underneath complex (Figs 3 and 4) shows less densely packed the mucous layer, above the surface cells, and granular material than elsewhere in the bac- deep in the lumen of the foveolae (Fig 1). They terium, but also dense granular structure may are generally less numerous than H pylori and occur here. The cell wall is trilaminar (Fig 3). never cover the entire surface. There is no There are no axial filaments and no periplasmic adherence to the surface cells and no special fibres as in Spirochaetales. The bacteria were seen relation to the intercellular tight junctions. In the on the surface of antral and corpus mucosa, http://gut.bmj.com/ corpus mucosa spiral shaped bacteria can be below the mucus, sometimes in close contact to identified by the silver stain deep in the mucosa, the membranes of surface mucous cells or antral in the lumen of the glands, and even in parietal mucopeptic cells without a preference for tight cells (Fig 2). In one patient with severe chronic junctions. At the point of contact degenerative active gastritis H pylori could be identified in changes of the cell membrane and the microvilli addition to the spiral shaped bacteria. The become apparent (Fig 5). The microvilli show organisms are weakly stained by haematoxylin kinking and partial destruction. In the lower on September 25, 2021 by guest. Protected copyright. and eosin, are Gram negative, and display their mucosa of the corpus the spiral shaped bacteria structural characteristics well in the Giemsa, invade the canaliculi of parietal cells where as Steiner, and Whartin-Starry silver stain. many as five can be seen, without obvious damage to their host cells. Bacteria, however, also invade the parietal cells, causing signs of SERIAL STUDIES cellular damage such as mitochondrial swelling One patient was biopsied 10 years before the last (Fig 4). In the lower mucosa the bacteria invade biopsy was done. In that earlier biopsy identical mucopeptic cells and rarely endocrine cells. The organisms could be identified. There was a mild infected cells react with swelling of the mito- chronic active gastritis and a history of duodenal chondria, the formation of cytoplasmic empty ulcer. Another patient was biopsied four years vacuoles around the bacteria, and microvesicular before and showed retrospectively spiral shaped disintegration of organelles, probably partly of bacteria associated with chronic active gastritis lysosomal origin. Once disintegration of a bac- and a gastric ulcer. Eight patients were treated terium was seen. Effect oftreatment with bismuth salts on Gastrospirillum hominis and the cellular infiltrate SCANNING ELECTRON MICROSCOPY Lymphocytesl The organisms were aggregated in small clusters Patients G hominis Granulocytes plasma cells of 3-10 bacteria, some without any contact, Interval A partly lying parallel and close to each other (Fig Age (years) Sex Treatment B A B A B (days) 6). While most of the organisms were straight, 28 F Bismuth subsalicylate/28 + - + + - + + 55 bent forms were also noted. The bacteria have an 41 F Bismuth subsalicylate/28 + - + + - + + + 45 50 F Bismuth subsalicylate/28 + - + - + + 138 average length of 6-17 iim (range 4.8-6.7 iim) 21 M Bismuth subsalicylate/28 + - + - + + 30 and a thickness of about 1 ,um. 26 M Bismuth subsalicylate/28 + - + + - + + + 30 50 M Bismuth subsalicylate/28 + - + + - + + + 50 52 M Bismuth subsalicylate/28 + - ++ - + + - 79 60 M Bismuth subsalicylate/28 + - + + - + + + 35 Discussion B=before treatment; A=after treatment. The identification of spiral bacterial organisms Gastritis due to spiral shaped bacteria 139 chronic gastritis. It was proposed that these spiral organisms should be called 'Gastrospinrllum hominis.' Until now, the colonisation of the Gut: first published as 10.1136/gut.32.2.137 on 1 February 1991.