Dr Temitope Oke, a gastroenterologist at University College Hospital (UCH), Ibadan, in this interview by SADE OGUNTOLA, reveals that some cases of stomach ulcers are linked to drinking sources, especially within the municipal setting, families and the community. Excerpts:
CAN H. pylori, the germ causing stomach ulcer, be contacted by drinking well water or other surface water?
When wells and boreholes are designed improperly, they can become quickly contaminated by surface water contaminated with Helicobacter pylori. But its common mode of transmission is through the feaco-oral route. An infected individual who goes to the toilet and doesn’t observe good hygienic practice can contaminate his hand and use that same hand to prepare food for others. That is the source of infection, especially in families and the community.
It is a common assumption that all borehole water and bottled water are potable. So, when does drinking water become a potential reservoir for H. pylori?
This depends on the source of the water; we don’t know the source of most of this bottled or sachet water that we all assume to be potable. Of course, contamination may have taken place in its production facility if strict control measures are not maintained. H. pylori is known to survive in the harshest of conditions, including the stomach environment, which has a lot of acid and where many organisms cannot survive. Moreover, studies have also found that it can also survive in groundwater, like borehole water and in surface water.
A study in Port Harcourt also found borehole water as one of the risk factors for people with H. pylori infection. They couldn’t go on to check, but other studies have also been able to do that.
The organism is sometimes very hard to culture, especially in water settings, but where some studies have been done, they have also found that the source, especially within the municipal setting or borehole setting, could also cause H. pylori infection, especially within families and the community too.
Are there other environmental conditions that can make this water-borne disease thrive in Nigeria’s environment? Then, who stands at a higher risk of contacting this infection?
Well, people working close to the soil or involved in soil-related occupations or businesses, as well as people staying in crowded areas, crowded conditions, or engaged in unhygienic practices, especially during the rainy season, where there is spillage of sewage, could also be a risk for H. pylori infection.
Medical personnel who oversee procedures that are invasive concerning the gastrointestinal tract also stand a risk for H. pylori infection when they don’t take prescribed precautionary measures in the course of attending to their clients in the hospital.
Of course, if a family member is infected with H. pylori, the risk is high that other family members could have it because it has a high level of cross-infection. Those who work in sanitary systems and have to clean up toilets and the food sector, especially those who work in restaurants, also have a higher risk of acquiring the infection and passing it on to other people.
What are the signs and symptoms of H. pylori infection?
Usually, the bacteria colonise the stomach, and so it is able to survive its acid content. It has a mechanism by which it takes acid away from itself. But the body recognises it as a foreigner in the stomach, and in trying to get rid of it, it ends up causing damage to the lining of the stomach. This results in symptoms, including abdominal pain that is experienced when eating or fasting, depending on where the organism is located.
If it is located within the lower part of the stomach, a lot of pain will be felt during fasting. So, the patient has to eat most of the time. That is related to a duodenal ulcer. The pain could also be after a meal, and that can make the person want to stop eating. That is related to peptic ulcers.
But in the stomach, where it tries to mark off acid from itself, there is a pain when the patient is allowed to put in any type of meal, and that can make the person want to stop feeding, which over time might lead to some weight loss.
Other symptoms include bloating because the tummy becomes a little bit aggressive and irritated, and heartburn due to acid reflux. Over time, if it continues to live within the stomach and continues to instigate inflammation, destruction and damage, it could lead to cancer, especially cancer of the stomach. The World Health Organisation (WHO) has already named H. pylori a major risk factor for stomach cancer.
What are studies saying about the contribution of H. pylori to the incidence of stomach ulcers and stomach cancer?
Globally, many studies have been done on these, UCH Ibadan included, which show that H. pylori is a major risk factor for stomach cancers and ulcers. Recently, we looked at some specimens that were going through endoscopy. We found that many of them with H. pylori infection also had a lot of precancerous lesions. There are things that we see that tell us that this person is close to developing cancer.
Can H. pylori be cured? Is it also preventable?
For preventing infections, the predisposing factors must be avoided. Major predisposing factors for H. pylori include contaminated water sources and eating meals that are contaminated. So, one needs to observe hygienic practices, especially when it comes to taking water and meals outside. The best thing is to eat home-cooked meals.
Of course, there are tests individuals can take to check if they have the H. pylori infection and where it is located. For instance, the H. pylori antibody blood test can tell whether the person has had a previous infection. Also, a stool antigen test can help determine whether there is an infection. Once this has been established, it can be eliminated using a medication known as H. pylori eradication therapy, which combines the use of two different antibiotic regimens with a proton pump inhibitor, an acid-blocking medication.
The drugs are taken for one or two weeks, and usually, in more than 70 of the 80 percent of patients, they lead to the eradication of the organism.
Can there be a re-infection after it is cured?
Re-infection is possible if the person does not maintain proper hygiene after using the toilet. If one doesn’t clean up as well as one should, that can lead to re-infection. Also, if one is taking poorly cooked meals or living in an area where hygienic practices are poorly observed, the risk of re-infection also increases.
Do many Nigerians experience complications of H. pylori infection, like ulcers?
The risk of complications like ulcers occurring from H. pylori is very high. Even days after ingesting the germ, there is already inflammation going on, which included stomach ulcers. And researchers found out that H. pylori infection increases the prevalence of not only stomach ulcers but also duodenal ulcers, which are also one of the major causes of upper gastrointestinal bleeding. This can be deadly in many instances. The best thing is to nip the H. pylori infection in the bud as soon as the infection occurs.
Unfortunately, some people do not even experience any symptoms, even though they have a H. pylori infection. Those are the people who just come up with what we call stomach cancer. That is why a yearly check for the infection is very important. A H. pylori stool antigen test is cost-effective and once this is done, we can eradicate the bacteria and prevent a gamut of complications like ulcers, bleeding and cancer.
Who is mostly at risk of this infection? Are children exempted?
Children too are at risk because the immune system is developing; they are still subject to whatever adults give them. They don’t get to choose what meals they take and what meals they can’t take. So if the adult is infected, most likely they can also transfer this infection to the children. So, these children could have an infection. Over time, they grow into adults with ulcers. We have seen stomach cancer in less than 40 years. This might have been because of an infection that they acquired when they were young that now leads to ulcers or even cancer.
Is there anything that the government can do to reduce the incidence of H. pylori? Are tests for H. pylori commonly available?
The government needs to ensure the municipal water runs and that the water supplied is not contaminated with H. pylori. That’s one of the things that should be looked at. Second, if everyone is enrolled in the National Health Insurance System, then everyone within that system will be able to get the test done. This test is not expensive and then we can treat those with the infection. For instance, a policy can be made that the test should be done before job recruitment or resumption at school. And if they are infected, one can treat them as soon as possible.
Is it possible to screen the general population for H. pylori so that we can eradicate the infection at once?
Screening of the general population is carried out in places where gastric and stomach cancers are at a very high prevalence. But trying to do it for the whole population will consume a lot of money.
On the other hand, some people can take examinations in order to enrol in school, the military, or to be hired, and afterward they can receive treatment to stop the development of cancer or ulcers.
Can an individual be a carrier for H. pylori?
Yes, that is very possible, especially for those who work in restaurants and chefs in restaurants that do observe unhygienic practices. They can contaminate a lot of food and infect so many people coming to eat. So, they can be a form of carrier or a reservoir. But they also have a risk; there’s no protection. There’s no ability to control the bacteria. Over time, if the bacteria persists in this so-called carrier, it can lead to ulcers and cancers.