Celiac Disease in Patients With H. pylori Colonization
Celiac Disease in Patients With H. pylori Colonization
After the exclusions detailed above, we identified 142,729 patients with duodenal biopsies during the 4.5 years spanning January 1, 2008–June 30, 2012, and any gastric biopsy going back to January 1, 2003. We excluded 263 patients who had a history of CD in the clinical indication field of the endoscopy report but had a normal duodenal biopsy, which left 142,466 patients. When the data set was restricted to those patients whose gastric and duodenal biopsies were performed during the same procedure, 136,179 persons remained.
The characteristics of patients are shown in Table 1. The mean age was 51 (standard deviation, 18) years, and 89,940 patients (66%) were female. The prevalence of CD was stable during the time period of this analysis (1.9% and 2.1% in the years 2008–2010 and 2011–2012, respectively), as was the prevalence of H. pylori (8.8% and 9.0% in the years 2008–2010 and 2011–2012, respectively). Of the 2,689 patients with histological evidence of CD, gastric H. pylori was detected in 117 (4.4%) patients. H. pylori was significantly less common in CD patients than among patients without CD (8.8%; P < 0.0001 (Table 2)). After adjustment for age, gender, and Medicaid enrollment status, the inverse relationship between CD and H. pylori changed little (adjusted odds ratio (aOR) = 0.48, 95% confidence interval (CI): 0.40, 0.58) (see Table 2). In contrast, the prevalence of H. pylori was higher among persons who had IEL and normal villous architecture (13.3%), an association that remained significant after adjustment for the same covariates.
Results of analyses stratified by age group, gender, and Medicaid enrollment are shown in Table 3. The prevalence of H. pylori was greatest in older subjects, men, and Medicaid enrollees. The inverse relationship between H. pylori and CD was similar in most age strata. The relationships were similar in men and women. The association was diminished among patients enrolled in Medicaid, though the confidence intervals were wide. The prevalences of CD and H. pylori by age group are shown in Figure 1. H. pylori prevalence increased with age, while CD prevalence was highest in the younger age strata, although this trend was not apparent among men. Despite the positive correlation between H. pylori and IEL, the prevalence of the latter declined with age (Figure 2). Results of analysis stratified by the most common clinical indications for endoscopy are shown in Table 4. While the prevalences of CD and H. pylori varied by indication, the inverse relationships were present and similar in magnitude regardless of the indication for the procedure.
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Figure 1.
Prevalences of Helicobacter pylori infection and celiac disease, by age and gender, among patients with biopsy specimens submitted to Miraca Life Sciences (Irving, Texas) during the period January 1, 2008–June 30, 2012. A) men; B) women. Solid line, celiac disease; dashed line, H. pylori.
(Enlarge Image)
Figure 2.
Prevalences of Helicobacter pylori infection and intraepithelial lymphocytosis, by age and gender, among patients with biopsy specimens submitted to Miraca Life Sciences (Irving, Texas) during the period January 1, 2008–June 30, 2012. A) men; B) women. Solid line, intraepithelial lymphocytosis; dashed line, H. pylori.
Repeating the multivariate analysis, now including all patients with a duodenal biopsy and concurrent or previous gastric biopsy (n = 142,466), the inverse relationship between CD and H. pylori remained essentially unchanged (aOR = 0.48, 95% CI: 0.40, 0.58). The positive relationship between H. pylori and IEL with normal villous architecture was similarly stable in this sensitivity analysis (aOR = 1.71, 95% CI: 1.58, 1.85).
Residential zip code was available for 47,440 patients residing in 6,232 zip codes (35% of the cohort). In the subsets for whom zip code data were available, the multivariate analysis was rerun without adjustment for zip-code-level characteristics. The association between CD and H. pylori remained similar in magnitude and direction (aOR = 0.55, 95% CI: 0.41, 0.74) to that observed in the full data set.
Results for quartiles of median household income, percentage of black residents, and percentage of Hispanic residents are shown in Table 5. There was a modest positive association between median income quartile and CD prevalence and an inverse relationship between median income quartile and H. pylori prevalence. Both percentage of black residents and percentage of Hispanic residents were positively associated with H. pylori prevalence and negatively associated with CD prevalence (see Table 5). The correlation between median income and percentage of black residents was modest (r = −0.27), and the correlation between median income and percentage of Hispanic residents was similar (r = −0.24). However, the correlation between percentage of black residents and percentage of Hispanic residents was negligible (r = −0.03). Therefore, all 3 variables (median income quartile, percentage of black residents, and percentage of Hispanic residents) were included in the adjusted model.
Analyses using generalized estimating equations and adjusting for zip-code-level data showed that the inverse relationship between CD and H. pylori remained strong (aOR = 0.59, 95% CI: 0.44, 0.78). Additional analyses that further incorporated inverse probability weights for availability of the zip code data found similar results (aOR = 0.56, 95% CI: 0.47, 0.67).
Results
After the exclusions detailed above, we identified 142,729 patients with duodenal biopsies during the 4.5 years spanning January 1, 2008–June 30, 2012, and any gastric biopsy going back to January 1, 2003. We excluded 263 patients who had a history of CD in the clinical indication field of the endoscopy report but had a normal duodenal biopsy, which left 142,466 patients. When the data set was restricted to those patients whose gastric and duodenal biopsies were performed during the same procedure, 136,179 persons remained.
The characteristics of patients are shown in Table 1. The mean age was 51 (standard deviation, 18) years, and 89,940 patients (66%) were female. The prevalence of CD was stable during the time period of this analysis (1.9% and 2.1% in the years 2008–2010 and 2011–2012, respectively), as was the prevalence of H. pylori (8.8% and 9.0% in the years 2008–2010 and 2011–2012, respectively). Of the 2,689 patients with histological evidence of CD, gastric H. pylori was detected in 117 (4.4%) patients. H. pylori was significantly less common in CD patients than among patients without CD (8.8%; P < 0.0001 (Table 2)). After adjustment for age, gender, and Medicaid enrollment status, the inverse relationship between CD and H. pylori changed little (adjusted odds ratio (aOR) = 0.48, 95% confidence interval (CI): 0.40, 0.58) (see Table 2). In contrast, the prevalence of H. pylori was higher among persons who had IEL and normal villous architecture (13.3%), an association that remained significant after adjustment for the same covariates.
Results of analyses stratified by age group, gender, and Medicaid enrollment are shown in Table 3. The prevalence of H. pylori was greatest in older subjects, men, and Medicaid enrollees. The inverse relationship between H. pylori and CD was similar in most age strata. The relationships were similar in men and women. The association was diminished among patients enrolled in Medicaid, though the confidence intervals were wide. The prevalences of CD and H. pylori by age group are shown in Figure 1. H. pylori prevalence increased with age, while CD prevalence was highest in the younger age strata, although this trend was not apparent among men. Despite the positive correlation between H. pylori and IEL, the prevalence of the latter declined with age (Figure 2). Results of analysis stratified by the most common clinical indications for endoscopy are shown in Table 4. While the prevalences of CD and H. pylori varied by indication, the inverse relationships were present and similar in magnitude regardless of the indication for the procedure.
(Enlarge Image)
Figure 1.
Prevalences of Helicobacter pylori infection and celiac disease, by age and gender, among patients with biopsy specimens submitted to Miraca Life Sciences (Irving, Texas) during the period January 1, 2008–June 30, 2012. A) men; B) women. Solid line, celiac disease; dashed line, H. pylori.
(Enlarge Image)
Figure 2.
Prevalences of Helicobacter pylori infection and intraepithelial lymphocytosis, by age and gender, among patients with biopsy specimens submitted to Miraca Life Sciences (Irving, Texas) during the period January 1, 2008–June 30, 2012. A) men; B) women. Solid line, intraepithelial lymphocytosis; dashed line, H. pylori.
Repeating the multivariate analysis, now including all patients with a duodenal biopsy and concurrent or previous gastric biopsy (n = 142,466), the inverse relationship between CD and H. pylori remained essentially unchanged (aOR = 0.48, 95% CI: 0.40, 0.58). The positive relationship between H. pylori and IEL with normal villous architecture was similarly stable in this sensitivity analysis (aOR = 1.71, 95% CI: 1.58, 1.85).
Adjustment for Residential zip-code Racial, Ethnic, and Socioeconomic Data
Residential zip code was available for 47,440 patients residing in 6,232 zip codes (35% of the cohort). In the subsets for whom zip code data were available, the multivariate analysis was rerun without adjustment for zip-code-level characteristics. The association between CD and H. pylori remained similar in magnitude and direction (aOR = 0.55, 95% CI: 0.41, 0.74) to that observed in the full data set.
Results for quartiles of median household income, percentage of black residents, and percentage of Hispanic residents are shown in Table 5. There was a modest positive association between median income quartile and CD prevalence and an inverse relationship between median income quartile and H. pylori prevalence. Both percentage of black residents and percentage of Hispanic residents were positively associated with H. pylori prevalence and negatively associated with CD prevalence (see Table 5). The correlation between median income and percentage of black residents was modest (r = −0.27), and the correlation between median income and percentage of Hispanic residents was similar (r = −0.24). However, the correlation between percentage of black residents and percentage of Hispanic residents was negligible (r = −0.03). Therefore, all 3 variables (median income quartile, percentage of black residents, and percentage of Hispanic residents) were included in the adjusted model.
Analyses using generalized estimating equations and adjusting for zip-code-level data showed that the inverse relationship between CD and H. pylori remained strong (aOR = 0.59, 95% CI: 0.44, 0.78). Additional analyses that further incorporated inverse probability weights for availability of the zip code data found similar results (aOR = 0.56, 95% CI: 0.47, 0.67).
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