Helicobacter pylori:

Helicobacter pylori is a motile gram-negative rod that is etiologically linked to the development of chronic
gastritis and most peptic ulcer disease. H. pylori is a urease-producing organism that uses multiple adaptive
features to survive in the acidic environment of the stomach and colonize the gastric mucosa. H. pylori then
stimulates the antral mucosa to release gastrin. There is an associated output of high amounts of acid by the
oxyntic mucosa. As a result of this increased acid load, gastric metaplasia and actual ulceration occur within
the stomach and duodenum.

H. pylori infection is extremely common. It is estimated that worldwide more than one billion people are
infected with H. pylori; prevalence is highest in developing countries. In a study by Dehesa et al., 32% of
asymptomatic Hispanic adult volunteers were found to have H. pylori gastritis by endoscopic biopsy of the
upper gastrointestinal tract.

The acute stages of H. pylori can radiographically mimic gastric cancer at endoscopy, on upper
gastrointestinal series, and on abdominal CT scan. Further more, upon pathologic examination, biopsy
specimens of H. pylori infected tissues can be difficult to distinguish from gastric lymphoma. Given the
frequency of H. pylori in the general population and the widespread use of abdominal CT scanning,
differentiation between common H. pylori infection and gastric cancer and/or lymphoma is extremely
important. The impetus for this case is a case read on-call as "highly suspicious for gastric lymphoma" but
later shown to be biopsy-proven H. pylori gastritis.

Radiologic Overview of the Diagnosis:

Most radiology texts and articles describe the findings of H. pylori gastritis on the fluoroscopic
upper gastrointestinal examination. Very little is written about the appearance of H. pylori gastritis
on CT. However, given the frequency of abdominal CT scans, the CT findings of classic H. pylori
gastritis are important.
Circumferential antral wall thickening or focal thickening of the posterior gastric wall along the
greater curvature.
Average gastric wall thickness 1.5 to 2.0 cm (given adequate distention of the stomach with oral
contrast).
Inflammation of the antrum and body of stomach (mostly the antrum). Decreased gastric wall
attenuation.
Focal ulcerations of the gastric and duodenal mucosa
Absence of significant adenopathy, obliteration of fat planes, and direct extension to other organs.

Key Points:

Helicobacter pylori gastritis is extremely common in the general population and may affect as much
as 32% of asymptomatic people.
The CT findings of H. pylori gastritis include: circumferential antral wall thickening or focal
thickening of the posterior gastric wall, inflammation of the antrum and body of the stomach, focal
areas of ulceration, and the absence of bulky adenopathy or extension to other organs.
The CT appearance of H. pylori gastritis can mimic gastric carcinoma or lymphoma. A recent
retrospective study found that 14 out of 19 CT scans of biopsy-proven H. pylori gastritis were
reported as "suspicious for malignancy" (Urban et al., 1999). Key CT findings of gastric cancer and
gastric lymphoma include:
o Gastric cancer: circumferential or focal thickening of the gastric wall, narrowing of the
gastric lumen, and (sometimes) ulceration.
o Gastric lymphoma: gastric wall thickening (4-5 cm), involvement of more than one portion
of the stomach, and bulky lymphadenopathy.
Given the widespread use of abdominal CT scanning, recognition of H. pylori gastritis and
differentiation between this common inflammatory condition and malignancy is extremely important.

References:
1. Dehesa, et al. High Prevalence of Helicobacter pylori Infection and Histologic Gastritis in
Asymptomatic Hispanics. Journal of Clinical Microbiology, 1991. Vol. 29(6), pp 1128-1131.
2. Gore, et al. Carcinoma of the Stomach and Duodenum. Textbook of Gastrointestinal Radiology. 2nd
Ed. Philadelphia: W.B. Saunders. Pp 601-603.
3. McColl, et al. The Role of H. pylori Infection in the pathophysiology of duodenal ulcer disease.
Journal of Physiologic Pharmacology, 1997. Vol. 48(3), pp 287-295.
4. Urban, et al. Helicobacter pylori Gastritis Mimicking Gastric Carcinoma at CT evaluation. Radiology,
1999. Vol. 79, pp 689-691.
5. Triantafyllopoulou, Maria. eMedicine. Helicobacter pylori Infection. Accessed 8/26/2006.
6. Stat Dx. Online resource. Gastritis, Gastric ulcer, and Helicobacter pylori.