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Diagnosing Gastric Helicobacter Infections in Dogs and Cats

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Diagnosing Gastric Helicobacter Infections in Dogs and Cats Article #4 CE Diagnosing Gastric Helicobacter Infections in Dogs and Cats Michael S. Leib, DVM, MS, DACVIM Robert B. Duncan, DVM, PhD, DACVP Virginia–Maryland Regional College of Veterinary Medicine (Virginia Tech) ABSTRACT: Helicobacter spp are commonly identified in the stomachs of dogs and cats. The role of these bacteria in the pathogenesis of gastritis and chronic vomiting is not presently known. Spiral bacteria can be easily identified by histologic assessment or rapid urease testing of gastric biopsy samples or by evaluating gastric brush cytology specimens. Other diagnostic tests have been conducted in humans and experimentally in dogs and cats.This article reviews the procedures as well as advantages and disadvantages of avail- able diagnostic tests for gastric Helicobacter spp in dogs and cats. piral bacteria were identified in the stom- This article describes the common methods of achs of humans and animals in the late identifying spiral bacteria in the stomachs of 1800s.1 However, it was not until the early dogs and cats. S 2 1980s that Warren and Marshall proposed a Helicobacter spp are gram-negative, micro- relationship between Helicobacter pylori and aerophilic, motile, and curved or spiral bacteria gastric disease in humans.3 Soon after, studies with multiple terminal flagella.12,13 They contain in dogs and cats clearly demonstrated that spi- large quantities of the enzyme urease, which ral bacteria were commonly found in the stom- results in production of ammonia and bicarbon- achs of clinically normal dogs and cats as well ate from urea. This alters the pH surrounding as dogs and cats with signs of gastrointestinal the bacteria and helps them colonize the acidic disease.4–11 However, a direct causal relation- environment of the stomach.12,14 ship between spiral bacteria and gastric disease More than 30 Helicobacter spp have been has not been established in dogs or cats. identified in humans and animals.13 In addition Although the potential pathogenic role of to the species found in the stomach, others have Helicobacter spp in dogs and cats is being inves- been identified in the intestine and liver.15,16 H. tigated, we routinely determine whether the pylori is the most common gastric species in organisms are present in all dogs and cats with humans. It has been shown to be a major cause signs of chronic vomiting. A percentage of of gastritis and peptic ulcers as well as to these patients have been treated for Helicobacter increase the risk of gastric cancer.17,18 Infection spp, and some have responded favorably. We rates in humans can approach 100% in develop- want to emphasize that a thorough diagnostic ing countries and 25% to 60% in developed evaluation to search for other countries.19 Infection is usually acquired in Send comments/questions via email potential causes of vomiting childhood and most often persists for life. Most [email protected], should always be conducted infected humans remain asymptomatic.20 How- fax 800-556-3288, or web before considering Helicobac- ever, peptic ulcers may develop in 10% and gas- CompendiumVet.com ter spp to be etiologic agents. tric cancer in 1% to 2% of those infected. March 2005 221 COMPENDIUM 222 CE Diagnosing Gastric Helicobacter Infections in Dogs and Cats Although H. pylori has been identified in research and serology.14,38–43 Although noninvasive methods as colony cats,21–23 infection of pet dogs and cats with other well as polymerase chain reaction testing, scanning elec- species occurs most commonly. Most Helicobacter spp tron microscopy, and culture of gastric biopsy specimens commonly found in the stomachs of dogs and cats are have been investigated in dogs and cats,8,9,21,23,27,44–50 they larger than H. pylori (1.5 to 3 µm).13 Large spiral bacte- are not routinely available to practitioners. Presently, ria (4 to 10 µm) identified in the stomachs of dogs were clinical diagnosis of Helicobacter infection in dogs and initially called Gastrospirillum hominis. They were later cats requires endoscopic examination or exploratory reclassified as Helicobacter heilmannii.10,12 Other large celiotomy. Spiral bacteria can be identified in gastric gastric spiral bacteria such as Helicobacter felis, Helicobac- biopsy or brush cytology specimens or indirectly by ter bizzozeronii, and Helicobacter salomonis have been rapid urease testing of gastric mucosal samples.5–9,51 identified and are indistinguishable from H. heilmannii Results of histologic evaluation of biopsy samples using routine light microscopy.24–26 Multiple species can require 24 to 72 hours. Results of gastric brush cytology be present in an individual animal.27 and rapid urease testing are available much sooner. Besides the potential role of Helicobacter spp in the pathogenesis of gastritis and chronic vomiting, zoonotic BRUSH CYTOLOGY potential is another reason to identify these species in dogs Gastric brush cytology is the least expensive and most and cats. Although most evidence suggests that the practical diagnostic method and has the quickest turn- zoonotic potential is very low, some evidence supports around time. After an endoscopic examination has been potential zoonotic transmission. H. heilmannii is a rare completed and biopsy samples from the duodenum and cause of gastritis in humans, accounting for approximately stomach have been collected, a brush cytologic specimen Helicobacter spp may cause or contribute to gastritis and vomiting in dogs and cats. 0.1% of cases.28 An epidemiologic survey of humans with can be collected. A guarded cytology brush should be H. heilmannii gastritis showed that contact with dogs and passed through the biopsy channel of the endoscope into cats was a significant risk of infection.28 In addition, there the gastric body along the greater curvature. The cytol- was an association between H. Heilmannii gastritis and ogy brush should be extended from the sheath and gen- gastric lymphoma, although this could be coincidental.29 tly rubbed along the mucosa from the antrum toward the H. pylori has been identified in research colony cats, fundus along the greater curvature. Hemorrhagic areas demonstrating that cats could serve as a reservoir.21,22 Sev- associated with previous biopsy sites should be avoided. eral studies have identified cat ownership as a risk factor The brush should be retracted into the protective sheath for H. pylori infection in humans.30,31 However, other stud- and withdrawn from the endoscope. The brush should ies have shown that contact with dogs or cats is not a risk be extended from the sheath and gently rubbed across factor for H. pylori infection.32–37 Although the potential several glass microscope slides, which are air-dried and for zoonotic transmission appears slight, until this issue is stained with a rapid Wright’s stain. The slide should be conclusively resolved, it seems prudent to determine magnified ×100, immersed in oil, and examined. Areas whether Helicobacter spp are present in dogs and cats dur- with numerous epithelial cells and large amounts of ing diagnostic evaluation of gastric disorders. mucus should initially be viewed. If present, spiral bacte- Invasive methods of diagnosing Helicobacter infection ria should be easily seen. They are usually at least as long in humans include bacterial culture, routine microscopic as the diameter of an erythrocyte, and their classic spiral or ultrastructural examination, polymerase chain reac- shape is obvious (Figure 1). The number of spiral bacte- tion testing, and rapid urease testing of gastric mucosal ria can be highly variable (i.e., from one in every several biopsy specimens, which are usually obtained via fields to massive numbers in most fields). We examine at endoscopy.14,38–40 Noninvasive methods of diagnosis least 10 oil-immersion fields on two slides before the include urea breath testing, fecal antigen determination, specimen is considered negative. Unlike diagnostic tests COMPENDIUM March 2005 Diagnosing Gastric Helicobacter Infections in Dogs and Cats CE 223 Figure 1. Gastric brush cytology specimens stained with Dip Quick Stain Solution (Jorgensen Laboratories, Loveland, CO). 10 µm 10 µm Large numbers of spiral bacteria from a cat. Cellular debris is Higher magnification (of image on left) showing the spiral nature scattered throughout. of the bacteria. that involve using a single (or several) small biopsy sam- ple(s), brush cytology gathers surface mucus and epithe- lial cells from a much larger area, increasing the chance of identifying bacteria. Brush cytology was found to be more sensitive than urease testing or histopathologic examination of gastric tissue in identifying Helicobacter organisms in dogs and cats.6,51,52 RAPID UREASE TEST The rapid urease test detects the presence of bacterial urease produced by Helicobacter spp in a biopsy sam- ple.13,14 We use the CLOtest (Ballard Medical Products, Draper, UT; Figure 2), which is commercially available. Individual tests cost approximately $6. The test consists of agar gel with urea and a pH indicator (i.e., phenol red) in a small, plastic well. Tests should be kept refrig- erated before use. To conduct the test, a biopsy sample Figure 2. Negative and positive results of a CLOtest. obtained from the angularis incisura of the stomach should be pushed into the gel. The test should be main- tained at room temperature and examined frequently for to 30 minutes.7 If the color of the gel has not changed 24 hours. If bacterial urease is present, urea will be within 24 hours, the result should be interpreted as neg- hydrolyzed to ammonia, changing the pH of the gel. ative. A CLOtest with negative results can be reused The gel should turn from yellow to magenta. The rate at within a short period if it is kept at room temperature.53 which the gel changes color is proportional to the num- Urease tests can also be made by placing 10% ber of Helicobacter organisms present.
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