Nasir Farooq Butt  ( West Medical Ward, Mayo Hospital, King Edward Medical University, Lahore, Pakistan. )

We appreciate the reader for the kind insight into our Short Report. Mayo Hospital Lahore is one the largest public-sector hospitals in Pakistan but unfortunately, we don\\\'t have the facilities to do urea breath test (UBT) or stool antigen test to detect H. Pylori infection. Only available method to detect H. Pylori is to do Gastroscopy with biopsy and histopathology. We send our patients to Gastroenterologist who does Gastroscopy along with antral biopsies for H Pylori diagnosis. There has been some controversy over the appropriate biopsy site for detecting H. pylori by biopsy basedmethods, such as culture, histology, or a rapid urease test.Studies evaluating the performance of these diagnostic methods have shown that antral biopsy specimens had excellent sensitivity and specificity (over 90%), in the nonulcer dyspepsia or peptic ulcer patients.¹ Antral or angularis biopsy has also been reported to be more sensitive in the detection of H. pylori when compared to that of the corpus. However, these findings are not applicable to any other disease spectrum, such as gastric ulcer or cancer, where antral biopsy alone was not sufficient, and corpus biopsy was recommended as a better site for H. pylori detection.^1,2 Study done by Lee et al³ demonstrated that two biopsy specimens from the antrum and one biopsy from the incisura angularis provided high diagnostic sensitivity and specificity, with an accuracy greater than 90%. But histological examination of two corpus biopsy specimens showed low sensitivity. Sampling errors, insufficient bacterial load, bacterial clearance, and patchy bacterial distribution are common causes of false negative results in corpus biopsy histology. Furthermore, biopsy specimens from both antrum and corpus showed the same sensitivity as compared with an antrum biopsy in dyspeptic patients. This is because when corpus H. pylori infection occurs, antrum H. pylori infection exists already. Reader has correctly mentioned that latest recommendations to detect H. pylori infection are to take multiple biopsies from two topographical locations, the antrum and the corpus of stomach to decrease false negative cases.⁴ Though there are many studies,^5,6 including ours, in which only antral biopsies are used to detect H. Pylori but we fully agree with the readers\\\' comments that it\\\'s better to take additional biopsies from corpus especially greater curvature to increase the sensitivity of the test.

References

1. Kim CG, Choi IJ, Lee JY, Cho SJ, Nam BH, Kook MC, et al. Biopsy site for detecting Helicobacter pylori infection in patients with gastric cancer. J Gastroenterol Hepatol. 2009 Mar;24: 469-74. doi: 10.1111/j.1440-1746.2008.05679.x.
2. Laheij RJ, de Boer WA, Jansen JB, van Lier HJ, Sneeberger PM, Verbeek AL. Diagnostic performance of biopsy-based methods for determination of Helicobacter pylori infection without a reference standard. J. Clin. Epidemiol. 2000; 53: 742-6.
3. Lee HC, Huang TC, Lin CL, Chen KY, Wang CK, Wu DC. Performance of Routine Helicobacter pylori Invasive Tests in Patients with Dyspepsia. Gastroenterol Res Pract. 2013;2013:184806. doi: 10.1155/2013/184806.
4. Pellicano R, Ribaldone DG, Fagoonee S, Astegiano M, Saracco GM, Mégraud F. A 2016 panorama of Helicobacter pylori infection: key messages for clinicians. Panminerva Med 2016; 58: 304-17.
5. Vafaeimanesh J, Rajabzadeh R, Ahmadi A, Moshtaghi M, Banikarim S, Hajiebrahimi S, et al. Effect of Helicobacter pylori eradication on glycaemia control in patients with type 2 diabetes mellitus and comparison of two therapeutic regimens. Arab J Gastroenterol.
2013;14: 55-58. doi: 10.1016/j.ajg.2013.03.002. Epub 2013 Apr 25.
6. Aslan M, Horoz M, Nazligul Y, Bolukbas C, Bolukbas FF, Selek S, et al. Insulin resistance in H pylori infection and its association with oxidative stress. World J Gastroenterol. 2006; 12: 6865-8.