Abstract
Background
Hepatitis B virus (HBV) is a major global public health issue and the most common etiology of chronic liver disease (CLD). The connection between Helicobacter pylori and patients who are HBsAg positive has not been thoroughly explored and has generated considerable scientific and clinical curiosity, although the debate persists.
Objective
This study aimed to assess serological and virological characteristics of HBsAg + liver disease patients with and without H. pylori infection.
Methods
From April 1, 2021, to March 30, 2022, a hospital-based cross-sectional study was conducted at the University of Gondar Comprehensive Specialized Hospital on 384 known HBsAg + liver disease patients recruited using a convenience sampling technique. All the 384 HBsAg + patients were tested for fecal H. pylori antigen. For HBeAg, HBeAb, and HBV-DNA analysis, we recruited only 50 subsamples randomly. Serological tests were performed using commercially available enzyme immunoassay Architect System kits. For virological investigations, HBV-DNA was extracted using the Abbott mSample Preparation System DNA, and then HBV viral load was determined by real-time PCR. GraphPad Prism 8.02 and SPSS 25 were used for data analysis, considering a statistically significant P-value of 0.05.
Results
H. pylori co-infection was found in 153 (39.8%) of HBsAg + study participants. The prevalence of HBeAg (5/25) and HBV-DNA (15/25) was higher among the H. pylori co-infected patient group, whereas HBeAb prevalence (11/25) was lower in the co-infected group. The levels of HBeAg (p < 0.04), HBeAb (p < 0.01), and HBV viral load (p < 0.006) were increased in H. pylori co-infected patients than in HBV mono-infected patients.
Conclusions
HBeAg and HBV-viral load were higher in H. pylori co-infected HBsAg + patients. These findings suggested that H. pylori has a role in the increment of clinical, serological, and virological parameters in HBsAg + liver diseases.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12879-025-11650-7.
Keywords: HBV, Chronic liver disease, H. pylori, HBV/H. Pylori co-infection, Virological
Introduction
Hepatitis B virus (HBV) is a partially double-stranded hepatotropic DNA virus [1]. It is an enveloped DNA virus that belongs to the family Hepadnaviridae, genus Orthohepadnavirus [2]. The envelope surrounds an icosahedral nucleocapsid, which encloses a partially double-stranded, relaxed circular DNA (rcDNA) genome of ~ 3.2 kilobases [3]. Four partially overlapping open reading frames (ORFs), termed P (polymerase), S (surface), C (core), and X (HBx protein), define the coding capacity of the HBV genome [4]. Mutations in the HBV genome have been observed in all four ORFs in both acute and chronic HBV-infected individuals [5]. A total of ten different genotypes of HBV (A-J) have been reported worldwide [6].
Acute HBV infection in healthy and immune-competent adults causes self-restrictive disease with less than 2–3% progression to serum hepatitis B surface antigen-positive (HBsAg +) chronic hepatitis B (CHB) infections [7]. The reason behind the adaptive replication of HBV in hepatocytes is mainly due to a lack of functional innate DNA-sensing pathways to recognize, control, and clear the virus [8]. The adaptive immune response mediates both viral clearance and liver damage, but HBV appears to cause little or no innate immune activation [9]. Both the inability of the immune system to resolve CHB and the unique replication strategy of HBV to form a stable covalently closed circular DNA (cccDNA) minichromosome in the hepatocyte nucleus enable infection persistence [10].
The natural course of CHB infection can be divided into four chronological phases based on virus-host interactions: The immune-tolerance phase is characterized by active replication of HBV, HBV e antigen (HBeAg) positivity, and normal alanine transferase (ALT) levels. In the immune clearance phase, HBeAg-positive patients have elevated serum ALT levels and fluctuating HBV-DNA levels. The third stage is the inactive carrier state, in which patients clear HBeAg and develop the corresponding antibody to HBeAg (HBeAg seroconversion), with the remission of liver disease [11]. Approximately 20 − 30% of individuals in the inactive carrier state may experience a viral relapse and enter the reactivation phase (fourth stage) during follow-up [12, 13].
HBV is not directly cytopathic for hepatocytes. Unlike other viruses, such as hepatitis C virus (HCV) or human immunodeficiency virus (HIV), which enter a rapid phase of propagation after infection, acute HBV infection is preceded by low HBV DNA and antigens in serum and liver for many weeks before the subsequent amplification and spreading phase of HBV infection [14]. The virus adapts to different mechanisms for persistent infection and is thought to be a ‘stealth virus’, which poorly induces the expression of type 1 interferon [15].
Cirrhosis of the liver is a diffuse condition characterized by fibrosis and nodular formation, with CHB virus infection as one of the causes [16]. The dysfunctional immune responses play an essential role in persistent HBV infection as well as liver inflammation [17]. When comparing the characteristics of immune responses in acute and chronic hepatitis B, the development of chronic HBV infection is associated with the failure of HBV-specific immune responses [18]. Chronic infection of HBV revealed impaired dendritic cell (DC) function, which is reflected by the weakness of both T-cell and B-cell virus-specific immune responses in CHB patients [19].
Persistent exposure of T cells to HBV antigens is crucial for maintaining depressed T cell functionality [20]. The quantitative and functional deficiencies of the HBV-specific T-cell response are well-acknowledged as a primary contributor to viral persistence [21]. The HBV-specific T cell response is modulated during HBV infection by multi-factorial mechanisms, including programmed cell death 1 (PD-1) expression, IL-10, arginase, myeloid suppressor cells, and T regulatory cells [22].
The humoral immune responses will assist in dealing with the virus once it is released from hepatocytes [23]. The released antigens (HBsAg, HBeAg, and HBcAg) will induce the production of their respective antibodies. Hepatitis B core antigen (HBcAg) will not circulate in the blood as it is found in the core of the virus. Anti-HBc antibodies are used to differentiate between acute and chronic HBV infections [24].
H. pylori causes both active and chronic infection and can lead to several disorders, from chronic gastritis to gastric adenocarcinoma, and activates both innate and adaptive immune responses, but the response fails to eradicate the infection [25]. Although it is believed that H. pylori is a type of ‘commensal bacterium”, it cannot be classified as normal flora because all patients with gastro-duodenal H. pylori colonization show histological gastroenteritis [26]. To complete the colonization process and cause harm to the gastric mucosa, the bacterium must overcome the stomach acid barrier and infiltrate the mucus layer [27]. Gastric epithelial cells (GECs) are a primary target for H. pylori infection and actively contribute to the development of acute and chronic inflammation [28].
The greatest feature of H. pylori is its ability to last for years in the gastric epithelium of the host [29]. This adaptive property occurs due to a complex mechanism of H. pylori persistence mediated by proteins, glycoconjugates, and lipids exposed on the surface of this bacterium [30]. Gastric innate immune effectors can either eliminate the bacteria or mobilize adaptive immune responses (e.g., TLRs and cytosolic DNA sensor/adaptor proteins) [31]. Recent studies have shown that H. pylori infection most often results in M1 (Inflammatory) and Mreg (Regulatory) macrophage activation [32]. The recruited macrophages at the site of infection can produce IL-12, which stimulates T-helper 1(Th1) cells and the production of cytokines such as IFN-γ [33].
H. pylori escape identification by pattern recognition receptors (PRR) by multiple methods, including avoidance of recognition by Toll-like receptors (TLRs) and inhibition of c-type lectin and Dendritic cell-specific intercellular adhesion molecule 3-grabbing nonintegrin (DC-SIGN) mediated signaling [34]. Although the acquired immune response to H. pylori is composed of both Th1- and Th2-type cells, cytokine profiles indicate a predominance of a Th1 response [35]. Although H. pylori is an extracellular pathogen, its immune response is biased to the Th1 type [36].
The relationship between H. pylori and liver diseases remains controversial. Recent studies have been trying to investigate the association of H. pylori in the progression of diseases other than gastrointestinal diseases [37]. Chronic inflammation from H. pylori might promote fibrosis progression to cirrhosis and HCC. However, confounders like viral hepatitis or environmental toxins complicate these associations. The presence of Helicobacter species has been reported in the hepatic tissues of patients with different hepatic disorders [38].
H. pylori infection in patients with liver cirrhosis may impact the exacerbation inflammatory injuries in the stomach, which could directly or indirectly lead to a deficiency of liver function [39]. Research conducted in China also showed that the H. pylori-positivity rate is high among patients with CHB, and H. pylori is a putative risk factor in the development of HBV-related complications. This is because H. pylori reach the liver via the bloodstream or the biliary system and then becomes an independent etiological factor causing inflammation [40].
In H. pylori-infected individuals, a Th2 cell-related response induces IgG1 production while a Th1-related response contributes to IgG2 production through IL-2 and IFN-γ secretion [41]. Helicobacter species are regarded as important in the development of hepatobiliary illnesses because they can produce inflammatory, fibrotic, and necrotic damage to the liver, which can progress to HCC [42]. In the present study, we tried to assess the interplay of HBV and H. pylori infections on CHB liver disease progression.
Materials and Methods
Study area, study design, and period
The study was conducted at the University of Gondar Comprehensive Specialized Hospital, located in Gondar city, Amhara National Regional State, Northwest Ethiopia. Gondar City is 738 km Northwest of Addis Ababa, the capital city of Ethiopia. Based on the Central Statistical Agency of Ethiopia (CSA), Gondar City had a total population of 500,788, of whom 300,000 were men and 200,788 were women [43]. The University of Gondar Comprehensive Specialized Hospital is a tertiary care center serving approximately 7 million people in Northwest Ethiopia. A hospital-based cross-sectional study was conducted from April 1, 2021, to March 30, 2022. It was a single-center institution-based study.
Source and Study populations
All HBsAg + liver disease patients attending the University of Gondar Comprehensive Specialized Hospital. HBsAg + patients presented at the University of Gondar Comprehensive Specialized Hospital during the study period and were eligible to study.
Inclusion and Exclusion Criteria
Patients who tested positive for HBsAg and the age of above 18 years old were included in the current study. We excluded patients with clinically confirmed schistosomiasis, and viral hepatitis other than HBV, HIV, and pregnancy.
Sample size and sampling technique
The sample size was determined using the single population proportion formula by considering the prevalence of H. pylori in HBsAg + patients = 50% (p = 0.5), Z
/2 = 1.96, and margin of error = 5% (d = 0.05). There was no previously published data for sample size calculation. Finally, the total sample size became 384 HBsAg + individuals who were recruited using a convenience sampling technique. From the total, 50 subsamples were selected randomly for serological and virological analysis, due to resource constraints and workload issues at their central laboratory.
Data collection and laboratory methods
Demographic and clinical data collection
Demographic and clinical data were collected after the study protocol was approved by the ethical review committee of the University of Gondar. At each data collection unit, trained nurses collected all relevant information (demographic, clinical) using a structured questionnaire in a face-to-face interview with the patient and from the patient’s medical records.
Specimen collection and processing
We collected about eight milliliters (8 ml) of venous blood by serum separator tubes (SST) from the forearms of all eligible patients. The serum was isolated from the collected blood samples by centrifuging at 3500 rpm for 5 min in the serology laboratory and separated into different serum test tubes. The first serum tube (4 ml) was transported to the clinical chemistry lab for biochemical testing. For further serological and virological examination, the second serum was transferred to cryotubes and stored at −80 °C. One aliquot serum (~ l ml) of 50 randomly selected samples was shipped to Leipzig University, Institute of Virology, Germany, with appropriate cold chain conditioning and transportation for additional serological and virological analysis. The samples arrived in Germany after 2 days; they left our laboratory with safe cold chain conditioning, and quality was assured during transportation.
In addition, a stool sample was collected from each CLD patient included in this study for the serological identification of the H. pylori fecal antigen.
Serological assays
Detection of Hepatitis B surface antigen (HBsAg)
All the 384 study participants were confirmed for HBsAg using commercially available HBsAg rapid test kits (Hangzhou ALL TEST Biotech Co., Ltd., China). The rapid test ALL TEST ™ with a reference number (REF IHBSG-302) is a test to qualitatively detect the presence of HBsAg in serum or plasma specimens. The test utilized a combination of monoclonal and polyclonal antibodies to selectively detect elevated levels of HBsAg in serum or plasma. Test kits were validated using known control samples obtained from ELISA-tested blood donors.
Detection of H. pylori stool antigen
All 384 HBsAg + patients were tested for fecal H. pylori antigen. The H. pylori status was defined by the detection of fecal H. pylori antigen using Linear H. pylori Ag cassette, a sandwich lateral flow chromatographic immunoassay (LINEAR CHEMICALS, S.L.U., SPAIN, Barcelona) [44]. The test detects the H. pylori antigen present in the fecal specimen by using specific antibodies. Quality control was run against the assay by using known positive and negative samples obtained from volunteers.
Hepatitis B ‘e’ antigen and antibody (HBeAg and HBeAb) assays
HBeAg and HBeAb tests were conducted among randomly selected 50 HBsAg + cases (25 HBsAg + cases with H. pylori co-infection and 25 HBsAg + cases without H. pylori infection. Hepatitis B ‘e’ antigen (HBeAg) and antibody (HBeAb) were tested using commercially available enzyme immunoassay Architect System kits (Abbott Diagnostics, Wiesbaden, Germany) [45].
Virological assays
DNA extraction and viral load quantification
DNA extraction and detection were also conducted among the 50 HBsAg + cases (25 HBsAg + cases with H. pylori co-infection and 25 HBsAg + cases without H. pylori infection). HBV-DNA was extracted using the Abbott mSample Preparation System DNA on the m2000sp system (Abbott Molecular, Des Plaines, IL, USA) using a 450 µl serum aliquot from HBsAg + cases. The HBV-DNA viral load was determined using the Abbott m2000rt system and a Real-Time HBV PCR assay (Abbott Molecular, Des Plaines, IL, USA) following the manufacturer’s protocol.
Data quality control
Study site assessment and pretest of the tools and assays were done before data collection to optimize the experimental setup. Data collectors were given appropriate training about data collection and related procedures. Positive and negative controls were run against HBsAg and H. pylori tests. Patient samples were collected, shipped, and stored under appropriate conditions and under strict supervision. Standard operating procedures (SOPs) and optimization protocols were followed during serological and virological assays.
Data analysis
Data entry was done via Microsoft Excel 2013. Normally distributed data were expressed as mean ± standard deviation. Statistical analyses were performed using SPSS 25.0 (IBM, New York) or GraphPad Prism 8.0.2. Categorical variables were analyzed by the Chi-square test, and nonparametric tests (Mann-Whitney test) were used for non-normal continuous data by taking a P-value of < 0.05 as statistically significant.
Ethical considerations
The study protocol was reviewed ethically in accordance with the Declaration of Helsinki and approved by the ethical committee of the School of Biomedical and Laboratory Sciences (SBLS) at the University of Gondar. Ethical clearance with a reference number (Ref. No. SBMLS/2759) was obtained. Study participants were asked for their consent to be included in the study. Study participants who tested positive for HBsAg and/or H. pylori during screening were linked to healthcare providers of the UoG hospital. All the information obtained from the study participants was coded to maintain confidentiality.
Results
Demographic characteristics of the study participants
This study included 384 HBsAg + adults, of whom 153 (39.8%) were co-infected with H. pylori. Two hundred and fifty-nine (67.4%) respondents were male, and 268 (69.8%) were from rural areas. Overall, 47.1% of participants were unable to read and write, with 221 (57.6%) of them being farmers. In total, three hundred and seventeen (82.6%) participants were married. Three hundred thirty-nine (88.3%) of participants did not drink alcohol (Table 1).
Table 1.
Socio-demographic characteristics of HBsAg + study participants with and without H. pylori at university of Gondar comprehensive specialized hospital, Northwest Ethiopia, 2022
| Characteristics | H. pylori status | Number(n) | p-value | ||
|---|---|---|---|---|---|
| Positive, n (%) | Negative, n (%) | Total, n (%) | |||
| Sex | Male | 99 (64.7) | 160 (69.2) | 259 (67.4) | 0.01 |
| Female | 54 (35.3) | 71 (31.8) | 125 (32.6) | ||
| Ratio (Male/female) | 1:8:1 | 2.25: 1 | 2.07: 1 | ||
| Age (years) | ≤ 24 | 14 (9.1) | 32 (13.8) | 46 (12) | 0.06 |
| 25–30 | 15 (9.8) | 41 (17.7) | 56 (14.5) | ||
| 31–34 | 15 (9.8) | 15 (64.9) | 30 (7.8) | ||
| 35–39 | 17 (11.1) | 35 (15.1) | 52 (13.5) | ||
| ≥ 40 | 92 (60.1) | 108 (46.7) | 200 (52) | ||
| Residence | Rural | 113 (73.8) | 155 (66.2) | 268 (69.8) | 0.06 |
| Urban | 40 (26.2) | 76 (33.8) | 116 (30.2) | ||
| Level of education | Unable to read and write | 77 (50.3) | 104 (45) | 181 (47.1) | 0.12 |
| Read and write | 42 (27.4) | 74 (32) | 116 (30.2) | ||
| Primary school | 14 (9.1) | 29 (12.5) | 43 (11.2) | ||
| Secondary school | 13 (8.5) | 12 (5.2) | 25 (6.5) | ||
| College and above | 7 (4.6) | 12 (5.2) | 19 (4.9) | ||
| Marital status | Married | 128 (83.7) | 189 (81.8) | 317 (82.6) | 0.08 |
| Single | 18 (11.7) | 28 (12.1) | 46 (12) | ||
| Divorced | 5 (3.3) | 10 (4.3) | 15 (3.9) | ||
| Widowed | 2 (1.3) | 4 (1.7) | 6 (1.5) | ||
| Occupation | Farmer | 93 (60.8) | 128 (55.4) | 221 (57.6) | 0.3 |
| Merchant | 29 (18.9) | 53 (22.9) | 62 (16) | ||
| Housewife | 12 (7.8) | 24 (10.4) | 36 (9.4) | ||
| Employee | 12 (7.8) | 16 (6.9) | 28 (7.3) | ||
| Student | 7 (4.6) | 10 (4.3) | 17 (4.4) | ||
| Smoking habit | Smoker | 7 (4.6) | 5 (2.2) | 12 (4.4) | 0.1 |
| Non-smoker | 146 (95.4) | 226 (97.8) | 372 (95.6) | ||
| Alcohol use | Ever used | 23 (15) | 22 (9.5) | 45 (11.7) | 0.01 |
| Not used | 130 (85) | 209 (90.5) | 339 (88.3) | ||
| Total | 153 (39.8) | 231 (60.2) | 384 (100) | ||
Serological characteristics of study participants
H. pylori Ag, HBeAg, and HBeAb detection
Among the 384 HBsAg + study participants, we found 153 (39.8%) H. pylori fecal antigen-positive cases. HBeAg was found in 8 (16%) of the 50 HBsAg + patients, whereas HBeAb was detected in 26 (52%) patients. Among the 25 H. pylori-positive patients, 5 (20%) HBeAg + cases were found, whereas only 3 (12%) HBeAg + cases were found among the 25 HBsAg+/H. pylori-negative patients. On the other hand, 15 (60%) HBeAb + cases were detected among the 25 HBsAg+/H. pylori-negative patients, and 11(44%) HBeAb + cases were detected in H. pylori-positive patients.
From the 384 HBsAg + patients, 50 cases were selected according to their H. pylori status, which means 25 samples were selected randomly from each group (Fig. 1).
Fig. 1.
Serological and virological characteristics of study participants
Determinations of HBeAg and HBeAb levels
During quantitative measurements, elevated levels of HBeAg and HBeAb were found in H. pylori-positive patients. The mean concentration of HBeAg (142 IU/ml) was significantly increased (p = 0.04) in the H. pylori-positive liver disease patients. The mean concentration of HBeAb (5.2 IU/ml) was also higher among the positive group (Table 2).
Table 2.
Determination of hbeag and hbeab levels among 50 HBsAg + study participants with and without H. pylori at university of Gondar comprehensive specialized hospital, Northwest Ethiopia, 2022
| Parameter | HBsAg+/H. pylori-(Mean ± SEM) | HBsAg+/H. pylori+ (Mean ± SEM) |
P-value |
|---|---|---|---|
| HBeAg level(IU/ml) | 17 ± 16 | 142 ± 85 | 0.04 |
| HBeAb level(IU/ml) | 1.3 ± 3.1 | 5.2 ± 12.5 | 0.10 |
Virological characteristics of study participants
HBV-DNA detection
Overall, 24 out of 50 HBsAg + patients were positive for HBV-DNA. The detection rate of HBV-DNA among the 25 H. pylori-positive patients was 60%, whereas, among the 25 H. pylori-negative patients was 36%. Therefore, the HBV-DNA positivity rate was higher among H. pylori + study group (Fig. 2).
Fig. 2.
Virological characterization of study participants
HBV viral load
From the 24 study participants who had detectable HBV-DNA, a higher level of HBV viral load (7.5 Log10 IU/ml) was detected among the H. pylori-positive patients than among H. pylori-negative ones, and the difference was statistically significant (p = 0.006) (Table 3).
Table 3.
HBV viral load of 50 HBsAg + study participants with and without H. pylori at university of Gondar comprehensive specialized hospital, Northwest Ethiopia, 2022
| Parameter | H. pylori+ (Mean ± SD) |
H. pylori- (Mean ± SD) |
P-value |
|---|---|---|---|
| HBV viral load (Log10 IU/ml) | 7.5 ± 7.2 | 6.3 ± 4.4 | 0.006 |
| Total | 15 | 8 |
Associations among clinical, serological, and virological characteristics
Association between clinical and serological characteristics of study participants
Among the 50 HBsAg + participants, treatment status for HBV (69.2%), traditional medicine used for HBV (26.9%), portal hypertension (76.9%), and hepatic decompensation (23.1%) had a statistically significant difference concerning the serological detection rate of HBeAb. The frequency of ascites among HBsAg + liver disease patients showed no significant difference between HBeAb + and HBeAb- patients (Table 4).
Table 4.
Association between clinical and serological characteristics among 50 HBsAg + study participants at university of Gondar comprehensive specialized hospital, Northwest Ethiopia, 2022
| Characteristics | HBeAb positive, n (%) | HBeAb negative, n (%) | Chi-square P-value |
|
|---|---|---|---|---|
| Treatment status for HBV | Naïve | 18 (69.2) | 17 (70.8) | < 0.001 |
| TDF experienced | 8 (30.8) | 7 (29.2) | ||
|
Traditional medicine for HBV |
Yes | 7 (26.9) | 14 (58.3) | < 0.001 |
| No | 19 (73.1) | 10 (41.7) | ||
| Ascites | Yes | 10 (38.4) | 12 (50) | 0.64 |
| No | 16 (61.6) | 12 (50) | ||
| Portal hypertension | Yes | 20 (76.9) | 12 (50) | < 0.001 |
| No | 6 (23.1) | 12 (50) | ||
| Hepatic decompensation | Yes | 6 (23.1) | 5 (20.8) | < 0.001 |
| No | 20 (76.9) | 19 (79.2) | ||
Association between clinical and virological characteristics of study participants
Similar to the HBeAb detection rate, a chi-square test was conducted to evaluate the detection rate of HBV-DNA between the clinical findings of study participants. Accordingly, treatment status for HBV (66.7%), a traditional medicine used for HBV treatment (54.2%), and hepatic decompensation (25%) had a statistically significant difference (p < 0.004) between HBV-DNA positive and negative study participants (Table 5).
Table 5.
Association between clinical and virological characteristics among 50 HBsAg + study participants at university of Gondar comprehensive specialized hospital, Northwest Ethiopia, 2022
| Characteristics | HBV-DNA positive, n (%) | HBV-DNA negative, n (%) | Chi-square P-value |
|
|---|---|---|---|---|
| Treatment status | Naïve | 16 (66.7) | 19 (73) | < 0.001 |
| TDF experienced | 8 (33.3) | 7 (27) | ||
| Traditional medicine use | Ever used | 13 (54.2) | 8 (30.7) | < 0.001 |
| Never used | 11 (45.8) | 18 (29.3) | ||
| Ascites | Yes | 11 (45.8) | 11 (42) | 0.86 |
| No | 13 (54.2) | 15 (58) | ||
| Hepatic decompensation | Yes | 6 (25) | 10 (38.4) | 0.004 |
| No | 18 (75) | 16 (61.6) | ||
| Variceal bleeding | Yes | 7 (29) | 4 (15.4) | 0.18 |
| No | 17 (71) | 22 (84.6) | ||
Discussion
Infections with HBV and H. pylori are two major public health issues in Ethiopia. Epidemiological studies in Ethiopia have reported a high prevalence of both infections, but there were no previously published reports on the relationship between HBV and H. pylori in liver disease patients and the contribution of H. pylori co-infection, particularly in Northwestern Ethiopia. Assessing the clinical and laboratory features of liver disease patients infected with these important pathogens is crucial for understanding and managing the disease progression in HBV-liver diseases. In the present study, we tried to characterize the clinical, serological, and virological features of HBsAg + liver disease patients with and without H. pylori co-infection.
In the current study, the prevalence of H. pylori infection (39.8%) among HBsAg + patients appeared lower than the overall pooled prevalence in the general Ethiopian population (52.2%) [46]. However, the prevalence of H. pylori infection in the current study population was comparable with similar studies on HBV-related liver disease patients [37, 47]. Previous studies reported a higher H. pylori prevalence in the general population than in liver disease patients. This discrepancy could be due to the repeated exposure of patients to different antibiotics during hospital visits, variations in the sensitivity of fecal H. pylori antigen tests, and the time trend of studies showing a decreasing pattern of H. pylori infection.
The mechanism of H. pylori colonization of the human liver could be explained by bacterial translocation from the stomach through the portal system, especially in the advanced stages of liver disease when portal hypertension develops. Furthermore, the bacteria can reach the liver via circulating phagocytes and macrophages. The present study was in agreement with previous studies that demonstrated that post-inflammatory liver cirrhosis complications were more frequent in H. pylori-infected patients than in the H. pylori-negative patient group, as H. pylori could up-regulate the expression of various inflammatory factors [47–49]. In our study population, HBV-induced complications of liver cirrhosis, such as portal hypertension, variceal bleeding, and HCC were more prevalent in H. pylori co-infected patients than in the HBV-mono-infected group of patients. In this study, hepatic decompensation was also higher among the co-infected group, although it showed no significant difference. These findings confirm our hypothesis that H. pylori co-infection has a synergistic effect on the progression of CHB-related liver diseases [47].
When we compared the prevalence of HBeAg and HBeAb among the two study groups, a higher value of HBeAg was found in the H. pylori co-infected group of patients, whereas HBeAb prevalence was lower in the co-infected group, in agreement with previous similar studies [50]. Although published data on this topic is very scarce, our findings are in line with basic science and clinical explanations. The concentrations of HBeAg and HBeAb were also higher in the group of HBV/H. pylori co-infected patients. A study in China concluded that H. pylori reach the liver via the bloodstream and become an etiological factor causing inflammation, explaining the role of H. pylori co-infection in HBV-related liver diseases [45, 47, 51].
HBV-DNA prevalence was higher in the H. pylori co-infected group of patients in the current investigation, and the mean concentration of HBV viral load was higher in the co-infected group of patients than in the HBV-mono-infected group [50]. H. pylori could induce regulatory B cells associated with increased immunosuppressive cytokines (TGF-beta, IL-10) and regulatory T cells, combined with functional exhaustion of virus-specific T cells expressing programmed death. This was accompanied by a low rate of viral clearance and increased HBV viral load levels in liver disease patients with H. pylori infection [52]. Overall, there was a proportionate increase in ALT &AST levels, portal hypertension, hepatic decompensation, and traditional medicine use along with serological and virological parameters of HBV/H. pylori co-infected patients.
This study had several limitations. Primarily, the small sample size precluded the use of advanced statistical tests. Additionally, we lacked access to molecular and immunological assays and did not employ quantitative fecal antigen testing for H. pylori diagnosis. Furthermore, a scarcity of comparable regional data exists. Consequently, precise value changes might not be fully revealed in HBV/H. pylori co-infected versus HBV mono-infected patients. Nevertheless, this study provides initial insights into the contribution of H. pylori infection among HBV-infected liver disease patients.
Our data reveal that H. pylori co-infection increases HBeAg levels, HBV viral load, and the incidence of portal hypertension, variceal bleeding, and HCC in HBsAg + liver disease patients compared to those with HBV alone. These results establish H. pylori as a significant contributor to worsening clinical, serological, and virological parameters in co-infected individuals. We strongly recommend physicians screen for and eradicate H. pylori in this patient population. Additionally, we call for large-scale studies, active H. pylori screening programs for CHB patients, and mandatory monitoring of HBV virological markers during treatment.
Supplementary Information
Acknowledgements
We would like to express our gratitude to the Department of Immunology and Molecular Biology, School of Biomedical and Laboratory Sciences (SBLS), College of Medicine and Health Sciences (CMHS), University of Gondar, for allowing us to perform this study in our field of interest.
Authors’ contributions
‘’M.B. and Y.B. wrote the main manuscript text. A.M. prepare all figures. Z.A., B.A. and M.L edited the manuscript wrtite up. All authors reviewed the manuscript.‘’.
Funding
The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.
Data availability
All relevant datasets used and/or analyzed in the present work are in the possession of the corresponding author and can be obtained upon reasonable request.
Declarations
Ethics approval and consent to participate
An ethical review document was obtained from the University of Gondar, College of Medicine and Health Sciences Ethics Review Committee. Both written and oral informed consent were secured from each study participant at the time of data collection.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
All relevant datasets used and/or analyzed in the present work are in the possession of the corresponding author and can be obtained upon reasonable request.