Helicobacter Pylori and Non-Alcoholic Fatty Liver Disease: Is There a Relationship?

Background and Aim: researchers proposed a connection between H pylori and obesity, diabetes, and improper lipid metabolism. The studies have discovered that H pylori infection is one of the elements for Non-Alcoholic Fatty liver Disease (NAFLD) to progress and that getting rid of Helicobacter pylori ( H pylori ) can partially stop the evolution of NAFLD. Other research, however, argues that there is no definitive link between H pylori infection and NAFLD. We aimed to investigate the prevalence of H pylori infection in NAFLD. Materials and Methods: This study was conducted on 110 patients diagnosed with NAFLD by ultrasound and fibroscan. They were assessed for the diagnosis of H. pylori infection by H. pylori antigen in stool. Results: The patients were classified into H pylori +ve group and H pylori -ve group. There was a significant difference between both groups regarding sex (p = 0.01) and diabetes mellitus (p = 0.000) and no significant difference between both groups as regard smoking, hypertension, and BMI . There was significant difference between both groups regarding steatosis (p = 0.0001) and fibrosis grade (p = 0.0001) Conclusion: the prevalence of H. Pylori has increased in NAFLD; also , H. pylori may be an independent risk factor for NAFLD.


Introduction
Non-alcoholic fatty liver disease (NAFLD) is distinguished by liver injury due to metabolic stress, identified by diffuse hepatocyte macrovascular fatty lesions [1].
The prevalence of NAFLD is rising yearly, with a worldwide incidence rate between 20% and 30% [2]. Complex hereditary variables, improper lipid metabolism, and insulin resistance are the key characteristics of the etiology of NAFLD [3].

Original research
Another research, however, argues that there is no definitive link between H pylori infection and NAFLD and that treating the infection does not stop the disease's progression [10].
As a result, this study further investigated the precise connection between NAFLD and H pylori infection.

Patients and Methods
The study included 110 patients over or equal to 18 who attended Tanta tropical medicine outpatient clinic between October 2021, and the cases were collected. They had evidence of NAFLD in the US and fibroscan, however patients aged < 18 years, pregnant women unwilling to participate in our study, and patients with a history of dyslipidemia or previous history of drugs (e.g., corticosteroids, PPI, antibiotics, contraceptive pills) or prior history of alcohol consumption(more than 40g of alcohol (or four units) per day )or a previous history of viral hepatitis or with a history of gastrectomy, or history of auto-immune hepatitis or any other forms of chronic liver disease were excluded from the study. Patients with a previous history of respiratory, heart failure, or renal diseases were also excluded from the study. Are excluded from this study.
These patients were categorized into two groups, H pylori +ve and H pylori -ve, according to the H pylori antigen test in the stool.
All the patients were subjected to: • Full history taking • Anthropometric measures: weight, length, BMI, • There are many diagnostic tests of H. pylori as (H. pylori antigen in the stool after stoppage of PPI and antibiotics two weeks before the test, urea breath test, serology, biopsy urease testing, histopathology, bacterial culture, and sensitivity testing). Our study uses H. pylori antigen in the stool as it is cheap and easy.
• Fasting Blood glucose level and or HbA1C.
• PCR for HCV to exclude viral hepatitis.

Original research
• The diagnosis of NAFLD requires (1) evidence of hepatic steatosis (HS) by imaging or histology, (2) no significant alcohol consumption, (3) no competing causes of HS, and (4) no coexisting causes of chronic liver disease [11].
Fibroscan was used to assess the stages of fibrosis and steatosis using Dimensional ultrasound TE (transient elastography). Liver fibrosis and steatosis can be staged using Dimensional ultrasound TE (transient elastography) (Fibroscan), which measures the velocity of a low-frequency (50 Hz) elastic shear wave propagating through the liver. This velocity is directly related to tissue stiffness, called the elastic modules (expressed as E=3qv2, where v is the shear velocity and q is the tissue density, assumed to be constant).
The stiffer the tissue, the faster the shear wave propagates.
The results are expressed in Kilopascals (KPa) and range from 1.5 to 75 KPa with average values around 5 KPa, higher in men and patients with low or high body mass index (BMI) The CAP score (Controlled attenuation parameter) is measured in decibels per meter (dB/m) and ranges from 100-400 The stiffness of the liver is measured by the fibrosis score, which indicates scarring.
• A fibrosis score of F0 to F1 (2 to 7 kPa) means the liver has little or no scarring.
• A fibrosis score of F2 (7.5 to 10 kPa) indicates moderate scarring that has spread outside the liver. • A fibrosis score of F3 (10 to 14 kPa) indicates severe scarring, which has spread and disrupts normal blood flow. • A fibrosis score of F4 (14 kPa or higher) means late-stage scarring or cirrhosis, where the scarring is permanent and the damage is irreversible • Ultrasound on abdomen and pelvis for evaluation of liver condition.
All patients signed written informed consent. The Ethical Committee of the Faculty of Medicine at Tanta University approved the study with approval code 35012/11/21.

Statistical analysis:
The organization, tabulation, presentation, and data analysis were performed using SPSS IBM Chicago, version 23. Qualitative data were divided into categories and presented as frequency number and percentage, with the chi-square test used to determine the relationship between groups. Quantitative data were presented as mean ± SD, and the relationship between groups was done using an independent student t-test. The level of significance adopted was p < 0.05.

Results
The  There were variations between both groups regarding triglyceride, LDL, and HDL but not statistically significant. Both groups had a substantial difference regarding cholesterol, ALT, AST, FBS, and HA1C (Table 3). There was a significant difference between the two groups regarding steatosis and fibrosis grade, which are determined by fibroscan (Table 4).

Discussion
The prevalence of H. Pylori changed among countries generally. The prevalence is about 30% in developed countries and about 80% in developing countries [12].
Some studies discussed the relationship between H. pylori infection and NAFLD. A meta-analysis showed a significant increase in the risk of NAFLD in the patients infected with H. pylori [13]. However, different results were presented [14].
In our study, the prevalence of NAFLD was significantly higher in the H. pylori (+ve) There was a significant increase in ALT and AST in the H. pylori +ve group than in the H. pylori −ve group.  also found a significant difference between both groups regarding AST and ALT [17].
Regarding BMI, there were no significant differences between both groups, but some studies discovered an association between H. pylori infection and BMI and a more unfavorable metabolic profile [21].
There were no significant differences between both groups as regard triglyceride, Ultrasonography examination of the liver is not sensitive enough to detect mild liver steatosis in diagnosing NAFLD [10].
In lower degrees of fatty infiltration, the sensitivity of ultrasound decreases, the sensitivity of ultrasound is 80% in the presence of ≥30% fatty infiltration, compared with a sensitivity of 55% when the fat content in the liver is 10% to 19% [24].

Original research
In our study, there was a significant difference between both groups regarding the ultrasonography examination of the liver; the more echogenic liver was present in H. pyloripositive patients than in H. pylori-negative patients.
Steatosis is detected in ultrasonography when more than 20% of hepatocytes contain histologically visible fat droplets [25].
There was a statistically significant difference between both groups as regard liver fibrosis in this study, and this is the same results of Sumida Y et al., 2015 who found that the hepatic fibrosis grades were higher in H. pylori seropositive patients [17] On the other hand, Polyzos S et al., 2013 found no significant difference in fibrosis stages in both groups, with and without infection [26].
Polyzos S et al., 2013 found no significant difference between both groups regarding steatosis grades, which is different from our results, as we reported that patients with H.
The small number of patients limited this study, so we need large-scale research. Also, our analysis depends on imaging and Fibroscan assessment to diagnose NAFLD and not on liver biopsy, which is the gold standard for evaluating the stages of fibrosis and necroinflammatory grades.
In conclusion, the prevalence of H. Pylori has increased in NAFLD. Also, H. pylori may be an independent risk factor for NAFLD.