Endoscopic changes in the gastrointestinal tract in children with helicobacteriosis

Shokhida Tolkunovna Turdieva

doi:10.4103/bbrj.bbrj_2_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 6 | Issue : 3 | Page : 448-453

Endoscopic changes in the gastrointestinal tract in children with helicobacteriosis

Shokhida Tolkunovna Turdieva
Department of Outpatient Care, Tashkent Pediatric Medical Institute, Tashkent, Uzbekistan

Date of Submission	03-Jan-2022
Date of Decision	09-Feb-2022
Date of Acceptance	02-Apr-2022
Date of Web Publication	17-Sep-2022

Correspondence Address:
Shokhida Tolkunovna Turdieva
100140, 223, Bogi-shamol St., Tashkent
Uzbekistan

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bbrj.bbrj_2_22

Abstract

Background: All over the world, chronic gastroduodenal pathology (CGDP) occurs in children from 3.2% to 52% and takes 2nd place after diseases of the respiratory system. The main pathogen is Helicobacter pylori (HP), and the problem of studying endoscopic changes in the stomach and duodenum in n these children remains relevant. This study investigated changes observed by esophagogastroduodenoscopy (EGD) examination of the mucous layer of the upper digestive tract in children CGDP and its features in HP infection. Methods: A total of 128 children aged 6 to 15 years exhibited CGDP. All patients underwent EGD, with a description of the visible mucous membrane of the stomach and duodenum. Research on HP infection was carried out by two methods: a breath test and an immunochromatographic faecal test. Results: It was noted that the rate of Helicobacter pylori infection was higher in patients with ulcerative lesions of the gastrointestinal tract than in patients with inflammatory processes (on average 1: 0.6). A high prevalence of gastroesophageal and duodenogastric reflux was revealed in patients with HP infection. In children with HP infection, atrophic lesions of the antrum and body of the stomach, bulbar and distal duodenum prevailed. Conclusions: Gastric ulcers and duodenal ulcers developed 94% more often in children with HP infection than in HP-uninfected patients (P<0.005), and atrophic changes in the mucous layer of the stomach and intestines were 4 times more common against the background of the more common gastroduodenal (by 77.6%) and duodenogastric (by 67.4%) reflux.

Keywords: Children, endoscopy, gastritis, gastroduodenitis, Helicobacter pylori, peptic ulcer

How to cite this article:
Turdieva ST. Endoscopic changes in the gastrointestinal tract in children with helicobacteriosis. Biomed Biotechnol Res J 2022;6:448-53

How to cite this URL:
Turdieva ST. Endoscopic changes in the gastrointestinal tract in children with helicobacteriosis. Biomed Biotechnol Res J [serial online] 2022 [cited 2023 Mar 26];6:448-53. Available from: https://www.bmbtrj.org/text.asp?2022/6/3/448/356154

Introduction

Scientific works in recent years have shown that the incidence of diseases of the digestive system in children is steadily increasing.^[1] Timely evaluation of the effectiveness of treatment of children with chronic gastroduodenal pathology (CGDP) remains one of the most pressing problems of pediatric gastroenterology.^[2],[3] Given the high importance of Helicobacter pylori (HP) among the predictors of CGDP, effective treatment of this infection is one of the priority areas in the field of gastroenterology.^[4],[5] Against this background, the incidence and prevalence of inflammatory diseases of the stomach and intestines are growing at a high rate worldwide, including in African countries, the Middle East, and the Asia-Pacific region.^[6],[7] In European countries, the incidence of HP infection among children ranges from 3.2% to 48%, and in the USA, it ranges from 24% to 80%.^[8] According to other sources, half of the world's population is affected.^[9] In various regions of the countries of Central Asia, this figure reaches 75%.^[2] At the same time, the problem of studying endoscopic changes in the stomach and duodenum in children with CGDP caused by HP remains relevant.

Study aims

This study investigated changes in endofibrogastroduodenoscopy (EFGDS) examination of the mucous layer of the upper digestive tract in children with CGDP associated with HP.

Ethical review

Ethical issue-number of projects approval No. 1 (dated April 20, 2017, protocol No. 3, Ethics Committee under the Ministry of Health of the Republic of Uzbekistan) cutting research in 400 children with the child development grant program (CGDP). This permit covers clinical (objective examination with palpation, percussion, and auscultation), laboratory (studies for growth hormone, HP, and general analysis of peripheral blood), instrumental studies (esofibrogastroscopy, ultrasound), and “Patients consent form”. The ethical standards are in accordance with the guidelines provided by the CPCSEA and World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Humans for studies involving human beings.

Research was registered on the site ClinicalTrials.gov PRS (ID: NCT04702542. https://clinicaltrials.gov/ct2/show/NCT04702542).

Patients consent form

At the same time, before the clinical examination of patients, their parents and guardians were informed about the examination being carried out, the essence of the clinical examination was explained, after which they took the written permission of the parents and guardians to examine their sick children and adolescents. The patient's data and a list of clinical examinations were indicated in the “Patients consent form.” At the first request of parents and guardians, clinical examination of patients was terminated. All examination results were simultaneously recorded in the patients' outpatient documentation.

Methods

Study design

The study design consisted of several stages: initial, research, and final approaches. To improve the quality of research, STARD method was used (https://pubs.rsna.org/doi/full/10.1148/radiol. 2015151516).

At the initial stage, criteria for the selection of patients were developed; some contracts were drawn up for conducting clinical, laboratory, and instrumental studies in a clinical setting; and other contracts were drawn up with urban and rural family polyclinics and private diagnostic clinics for conducting clinical and laboratory studies.

An agreement was made with the clinic of the Tashkent Pediatric Medical Institute to conduct clinical and laboratory research. In the research phase, clinical and laboratory studies of children and adolescents were carried out on an outpatient basis together with a narrow range of pediatric specialists (pediatric gastroenterologists, pediatricians, and physiotherapists).

We examined children and adolescents with CGDP – n = 286 aged 6–15 years living in the city of Tashkent. The average age was 11.6 ± 2.17 years. In total, 211 (53.28%) male patients and 185 (46.72%) female patients were included.

Eligibility criteria

Inclusion criteria

Children and adolescents aged 6–15 years
Children with CGDP: Chronic gastritis (CG), chronic gastroduodenitis (CGD), chronic duodenitis (CD), and gastric and intestinal ulcers (study group) of both sexes
Children without acute inflammatory diseases of the internal organs.

Exclusion criteria

Children under 6 years old and adolescents over 15 years old
The presence of chronic somatic diseases
The presence of psychosomatic and neurological disorders
The presence of neurological disorders.

Research methods

The clinical study was carried out in the polyclinic of the Yunusabad District of Tashkent, together with the Tashkent Pediatric Medical Institute clinic. All examined children underwent general clinical studies (complete blood count, urinalysis).

All patients underwent EFGDS, with a description of the visible mucous membrane of the stomach and duodenum, according to the criteria of the generally accepted Sydney classification (1990, with modification in 1996). Endoscopic examination was carried out without biopsy, based on the recommendation of the European Society for Pediatric Gastroenterology Hepatology and Nutrition and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (2017), on limiting biopsy in children, except for metaplastic changes.^[10],[11]

The criteria for diagnosing CGDP comprised data obtained from the following: anamnesis of the patients' life and illness; results of instrumental and functional (study of gastric secretion-fractional probing, EFGDS, with pH-metry, ultrasound examination of abdominal organs; and clinical and laboratory (general blood test, coprology with identification of worm eggs) examination.

Research for HP infection was based on a qualitative determination of this pathogen and was carried out by two mutually unrelated methods: a breath test (HELIK® test system with an indicator tube, Association of Medicine and Analytics LLC) and an immunochromatographic fecal test, quantitative determination of the pathogen was not carried out. The patient was considered HP infected if there was a positive result in both tests. With a positive result in only one test, the patient was sent for final diagnosis through an invasive diagnostic method involving an enzyme immunoassay to determine the concentration of IgG antibodies to HP antigens in blood serum.

Statistical analyses

Mathematical and statistical data processing was carried out using Microsoft Excel 7.0 for Windows-XP with the determination of the arithmetic mean (M) and standard deviation(s). When characterizing the statistical significance of the differences, Student's t-test was used, with the determination of the confidence interval limit based on the student's distribution table. The results obtained during the study of schoolchildren with CGDP were assessed as statistically significant at a probability level of P < 0.005. The comparison was carried out between the groups of patients infected and not infected with HP.

Limitation of study

The criteria for limiting the examination of children were:

A refusal of parents and guardians from further examination of the child
Hospitalization of the patient for inpatient treatment due to deterioration of the condition
Detection of an oncological disease in a patient during the endoscopic examination
Due to a change in the patient's place of residence (moving to another region)
The use of medications by the patient that affects the change in endoscopic results.

After an initial endoscopic examination, with confirmation of CGDP, patients received appropriate treatment. This article only describes the results of the initial endoscopic examination of patients before appropriate treatment.

Results

In the course of the study, the most common clinical forms of CGDP were identified and qualified according to ICD-10; in particular, CGD was diagnosed in 174 (60.84%) patients, CG of various forms in 43 (15.03%) patients, CD in 22 (7.69%) patients, gastric ulcer (GU) in 8 (2.8%) patients, and duodenal ulcer (DU) in 39 (13.64%) patients among a total of 286 examined.

Depending on the presence of HP infection, all patients were divided into two study groups: Group I – patients with HP infection – 165 (57.7% of 286) and Group II – patients without HP infection-121 (42.3% of 286). Based on the purpose of the research, we conducted a study of the incidence of HP infection among 286 children and adolescents with CGDP. According to the results of a twofold, interrelated study for HP infection, it was diagnosed in 57.7% (N = 165) of patients. Among patients with CGDP, the highest detection rate of HP was observed in cases of gastric and DUs, ranging from 71.79% to 87.50%, and the lowest detection rate was observed in CD (45.45%). It was noted that the rate of HP infection was higher in patients with ulcerative lesions of the gastrointestinal tract (GIT) than in patients with inflammatory processes (on average 1: 0.6).

EFGDS was performed in all patients with CGDP (n = 286). The description of the endoscopic examination began with the esophagus of the GIT. At the same time, in 48.60% (n = 139 of 286) of patients, the presence of esophageal pathology in the form of esophagitis was determined, which in combination with gastroesophageal reflux (GER) accounted for 46.85% (n = 134 of 286) in patients with CGDP or 96.40% (n = 134 of 139) of all patients with esophagitis. According to the results of our study, GER was most often noted among patients with GU – 80% (n = 6 of 8) and CG – 67.4% (n = 29 of 43) and was least often noted in patients with CD – 18.2% (n = 4 of 22) and DU – 7.69% (n = 3 of 39). Considering the obtained data depending on HP infection, we noted the prevalence of GER in patients with HP infection; in particular, among patients with GER, 77.61% (n = 104 of 134) were diagnosed with HP infection [Table 1].

Table 1: The Helicobacter pylori infected among children and adolescents with chronic gastroduodenal pathology

Click here to view

Duodenogastric reflux (DGR) was also one of the most common endoscopic signs of CGDP in schoolchildren – 16.01% (n = 46 of 286). DGR in patients with CGD was diagnosed in 12.7% (n = 22 of 174) of cases. At the same time, DGR, in contrast to GER, was most often observed among patients with DUs – 52.9% (n = 9 of 17) and CD – 27.3% (n = 6 of 22). If we consider the incidence of GER depending on HP infection, it can be stated that HP infection was present in 67.39% of patients with DGR. At the same time, the data obtained showed that the incidence of HP infection varied from the clinical form of CGDP. In particular, the incidence of HP infection with CG was much higher than that with CD (58.1% versus 45.5%). This fact may be associated with the HP biocycle, since being a conditionally aerobic microorganism, it is mainly found on the surface of the mucous membrane of the gastric antrum, which was confirmed by our research.

The EFGDS study made it possible to describe the general picture of inflammation, its localization, the nature of its prevalence, and signs of mucosal atrophy (or hypertrophy). In particular, in patients with CGD, nonatrophic antral lesions prevailed (78.16% of n = 174), and against the background of HP infection, this prevalence was 81.05% (n = 77 of 95), which indicates a high antral lesion caused by HP infection. In additional, 89 (93.7%) patients of 95 infected with HP with CGD were diagnosed with anthropylorobulbitis. In these patients, the characteristic signs were inflammatory edema and hyperemia of the mucous membrane against the background of mild contact bleeding, hemorrhage, and wall erosion.

A similar picture was also noted among patients with CG. In particular, against the background of HP infection in 30 (69.8%) of 43 patients, the inflammatory process was localized in the antrum of the stomach. In these patients, the endoscopic picture in chronic nonatrophic antral gastritis was characterized by pronounced hyperemia and edema of the mucous membrane of this part of the stomach, the presence of submucous hemorrhages, and hyperplasia of the folds. A total of 41.86% (n = 18 of 43) of patients with chronic superficial gastritis exhibited widespread lesions in the antrum and body of the stomach, of whom 66.67% (n = 12 of 18) were HP-infected patients. In these patients, against the background of pallor, smoothness and thinning of the mucosa, with translucency of the vessels of the submucosa, increased vulnerability of the mucosa, and bleeding were noted; these signs were not observed in patients without HP infection.

In atrophic gastroduodenitis (n = 38), the main symptom was thinning of the intestinal mucosa and pallor. In 76.32% of cases, these changes were focal, in 82.76%, lesions of the duodenal bulb were detected, and in 17.24%, lesions of the distal intestine were detected. With the lesioning of the duodenal bulb, a long linear scar, which deformed the duodenum, was visible in the bulb.

At the same time, erosive bulbitis was rarely detected (n = 8; 3.2%); all these patients were adolescents, and therefore, erosive bulbitis has an age-related characteristic of occurrence. Against this background, the picture of distal atrophic gastroduodenitis is accompanied by the development of inflammatory edema in the area of the Fatteri papilla (papillitis).

This process led to delayed evacuation not only from the duodenum itself but also of pancreatic juice and bile, which was characterized by the simultaneous detection of a case of biliary dyskinesia (n = 5) and impaired exocrine pancreatic function (n = 3). It should be noted that the deformation of the bulb, detected with EFGDS, was not always associated with the development of fibrosis of the duodenal wall and often had a functional nature (tendency to hyperkinesis, spasm). In these cases, the introduction of antispasmodics led to the disappearance of signs of deformity.

When examining the structure of GUs, uncomplicated ulcers noted, that is, they had a rounded shape, with smooth and clearly defined high edges. Around the ulcer, the mucous membrane was edematous and hyperemic and had the appearance of a raised ridge, which clearly delimited from the surrounding mucosa and rose above it. The bottom of the ulcer was covered with a yellowish-gray coating. The peculiarities of the endoscopic picture in GU were that the bottom of the ulcer had a smooth structure; the edges were wave-like, raised, and dense; the serous membrane in the area of the ulcer was thickened; and the ulcer was localized mainly on the lesser curvature, the lower third of the body, and the angle of the stomach, measuring from 10 to 40 mm. It was found that the more proximally the ulcer was located, the larger its size was. It should be noted that GUs lead to an increase in cicatricial changes in the stomach and aggravate the violation of its tissue tropism. Moreover, the newly formed scar tissue was easily destroyed during the next exacerbation. During the analysis of the features of duodenal ulcerative lesions, it was determined that the ulcer defect was localized in the duodenal bulb in 78.6% (n = 22 of 28) of patients with HP infection and in the postbulbar department in only 21.4% (n = 6 of 28) of such patients. At the same time, in 81.8% (n = 9 of 11) of patients without HP infection, the lesion was located in the postbulbar region, and this percentage was four times higher than that of patients with HP infection. In addition, periulcerous inflammation in the form of superficial duodenitis was observed in all patients with DUs, regardless of HP infection, and the ulcerative defects were 5–10 mm in size.

According to the results of our study, endoscopic signs of inflammation of the mucous layer of the stomach and duodenum were edema, hyperemia, and sometimes, contact bleeding as well as hemorrhages. The atrophic mucous layer is characterized by its thinning and pallor against the background of transillumination of the submucous-layer vessels. For nonatrophic antral gastritis, delayed gastric evacuation, antral stasis, and pyloric spasm were more characteristic. For chronic atrophic gastritis, hypotension of the gastric wall, DGR, and decreased motility were more characteristic.

Discussion

The problem of diagnosis and timely initiation of treatment for HP infection in children and adolescents has been and remains one of the urgent problems of modern pediatrics. Many scientific and literary publications are devoted to the problem of studying the peculiarities of HP infection in children, but at the same time, the issue of studying endoscopic changes in the mucous layer of the GIT in this pathology remains a poorly studied concept.^[12],[13] In infected people, microbial colonization is asymptomatic, and the infection accompanied by clinical manifestations caused by the development of chronic inflammation of the gastric mucosa in only 10%–15% of people.^[2] According to the results of our study, 57.7% of patients with CGDP were diagnosed with HP infection; therefore, HP should be considered one of the important predictors of this pathology, and against the background of other pathology predictors, the significance of HP in the development of CGDP in children and adolescents is palpable.^[3],[14]

According to Park et al., various virulence factors are associated with gastric pathologies; in particular, a vacuolizing cytotoxin, cytotoxin-associated gene A, and cag pathogenicity island and outer-membrane proteins (OMPLA, BabA, and OipA)^[15] induce apoptosis in epithelial cells of the gastric mucosa through a mitochondria-dependent pathway, which is discharged in the endoscopic picture of the coolant, in the form of the severity of the inflammatory process.

At the same time, HP itself does not have a pathomorphological effect, and the main mechanism of activation of opportunistic microflora in the esophagogastroduodenal zone is a violation of the integrity of the mucous membrane and the development of microcirculatory disorders. In addition, dystrophic and inflammatory-necrotic processes lead to a decrease in barrier function, which creates favorable conditions for the development of infection, and the pathogenetic effect should be considered in association with other factors affecting the mucous membrane of the GIT, with involvement in the pathological process of the esophagus.^[4],[16]

Therefore, it is important to combine the presence of CGDP with esophagitis in the endoscopic examination, which we observed in the course of our study. In particular, in our EFGDS monitoring study, we noted simultaneous inflammatory lesions of the stomach (CG, CGD) and esophagus (37.3%). In 48.6% of patients with CGDP, the presence of oesophageal pathology in the form of esophagitis was determined, and in 96.4% of such patients, combination with GER was identified. Therefore, GER remains the main factor in the development of esophagitis. Consequently, the various pathological signs of the gastroduodenal zone do not occur in isolation and in most cases, are of a combined nature, that is, there is a simultaneous damage to various parts of the mucous membrane of the esophagogastroduodenal region.

Muhammad Miftahussurur et al. support a similar opinion, noting the presence of an association between antral atrophic gastritis and GER (P = 0.030) and the presence of a direct relationship between these conditions and HP infection.^[17] At the same time, according to Leung and Hon, (2019), the development of reflux esophagitis is not associated with HP infection, but the course of the disease has certain features under conditions of HP infection. As the authors note, HP is a factor contributing to activation of the pathophysiological mechanisms of GER disease development: inflammation spreading to the cardiac portion of the stomach leads to a decrease in the tone of nerve conduction; against the background of HP-associated antral gastritis, an increase in the level of hydrochloric acid in the gastric contents observed and delayed gastric emptying and HP infection are diagnosed in 45% of cases in patients with GER.^[11]

Therefore, this issue can be considered controversial. According to the results and interpretation of our study, the incidence of GER and DGR was high among schoolchildren with CGDP (up to 77.61%, P < 0.05 in relation to the total number of patients).

Another important aspect is the pathomorphological changes in the mucous layer of the GIT. In particular, in the zones of gastric mucosal atrophy, contamination by HP significantly decreases, associated with decreased secretion of mucus and a change in its composition. The author also reports a gradual increase in the frequency of atrophy detection in chronic hepatitis with an increase in the age category of patients (from 3.8% to 17, 72%).^[16],[18]

Yang et al., in a study of children with CG, observed colonization of the gastric mucosa with highly pathogenic strains of HP, which led to an expansion of the zone of its damage.^[19] As our studies have shown, 66.67% (n = 12 of 18) of patients with type B atrophic gastritis were diagnosed with HP infection with pronounced visual signs of atrophy, which is a much higher proportion than that observed by these authors. Perhaps, this difference is due to the ages of the subjects.

In addition, according to Zhu et al., hypertrophic gastritis is more typical for patients of older age groups.^[20] In our study, in 4.65% of schoolchildren (n = 2 of 43), endoscopic examination revealed the presence of hypertrophic gastritis with HP infection, which indicates an earlier development of pathology in HP infections, as stated by other scientists.^[10],[21]

At the same time, according to Tang et al., GUs and DUs are diagnosed much less frequently in children than in adults, and in schoolchildren, these diseases are diagnosed in 13.3% of cases.^[22] According to the results of our study, peptic ulcer diseases among all clinical forms of CGDP in total amounted to 16.43%, while 87.50% of patients with GU and 71.79% with DU were diagnosed with HP infection. Consequently, the role of HP in the formation of ulcerative pathology of the gastroduodenal region increases every year, and the problem of investigating the effect of HP on the state of the mucous layer of the GIT remains relevant and requires further study.

Conclusions

Endoscopy is the best option for describing changes in the mucous layer of the upper GIT in helicobacteriosis in children to develop a therapeutic plan
Among children with HP infection, GUs and duodenal ulcers developed 94% more often than in HP-uninfected patients
In children with HP infection, atrophic changes in the mucous layer of the stomach and intestines were four times more common against the background of the more common gastroduodenal (by 77.6%) and duodenogastric (by 67.4%) reflux in relation to patients without HP infection.

Important note

The article is devoted to an urgent problem in the field of health of children and adolescents, the study of chronic gastroduodenal diseases. In recent years, among the noninfectious diseases of children and adolescents, there has been an increase in many nosological forms of pathology of the gastrointestinal tract. As noted in the 2015 World Health Organization's Global Strategy for Women's, Children's, and Adolescent Health (2016-2030), “... 70% of adult deaths from noncommunicable diseases are caused by risk factors that began exposure during adolescence...” (WHO, 2016).

The pathology of the gastrointestinal tract takes the second place in the structure of childhood morbidity, and 70%–90% of all gastroenterological pathology is accounted for by chronic gastritis and gastroduodenitis. Despite the high achievements in medicine, the problem of chronic gastroduodenal pathology in children and adolescents remains a poorly studied problem. In recent years, this problem has attracted great interest among pediatricians and gastroenterologists.

Purpose of the study: This study investigated changes in endofibrogastroduodenoscopy (EFGDS) examination of the mucous layer of the upper digestive tract in children with chronic gastroduodenal pathology associated with HP.

Acknowledgment

The author is grateful to the rector of the Tashkent Pediatric Medical Institute, Professor Daminov B.T., for general support in conducting and organizing this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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