DISCUSSION
Colon cancer is one of the leading causes of cancer related mortality
and morbidities worldwide. Studies were conducted regarding its etiology
exploring the place of a high-fat animal-based diet, consumption of
low-fiber foods, smoking (21). There were recent studies focusing on the
probability of infectious agents, especially H. pylori, as well. H.
pylori infection is considered as the most important risk factor in
gastric IM development (4,21,22). Sporadic colorectal cancers mostly
originate from adenomatous polyps. With early diagnosis and treatment of
colorectal polyps, a significant decrease can be achieved in the
incidence and mortality of colorectal cancers (7,23).
The latest research has focused on the role of infectious agents in the
prevention of colorectal cancers and the polyp – cancer spectrum
(24,25). Although it is not fully understood how H. pylori infection
increases the risk of colorectal neoplasia, according to the most
commonly described pathogenesis, IM occurs after a long term H. pylori
infection, and IM replaces normal gastric cells both in the corpus and
the antrum (26). The reduced gastric acid secretion triggered by IM
causes hypergastrinemia, which may contribute to colorectal
carcinogenesis. In addition, hypochlorhydria affects protein absorption
and causes bacterial overgrowth, hence causing an increase in the
metabolites and unabsorbed nutrients; and these events may contribute to
the formation of colonic diseases and colorectal carcinogenesis (27,28).
The association between H. pylori infection and colorectal neoplasia was
first reported in 1997 (9). It was shown in several previous studies
that there was a positive correlation between H. pylori infection and
colorectal neoplasia (11,29-31). In addition, this correlation was
supported in other studies (16,32-34). In their 11-study meta analysis,
Zumkeller et al. stated that H. pylori infection caused a minor
increase in colorectal cancer risk (35). In our study, it was seen that
there was not a significant association between H. pylori infection and
gender and age. Contrary to other publications stating that there was a
correlation between H. pylori and colorectal neoplasia, in our study, a
correlation was not found between H. pylori infection and colon neoplasm
risk (p=0.310). This outcome supports the publications reporting that H.
pylori does not increase the colorectal neoplasia risk.
AG and IM prevalence was found to be significantly higher in males in
comparison with females (36). There were many studies reporting that 50
years of age and above was an independent risk factor, and IM incidence
increased in proportion to age (37,38). Similar to these studies, in our
study, IM incidence was found as 41% in the group aged under 50, and
59% in the group aged 50 and over. Besides, IM incidence was found to
be higher in male patients in comparison with female patients.
In a comprehensive case-control study conducted on 156.000 registered
patients, a positive correlation was presented between IM and colorectal
adenomas (13). In their 2016 study conducted on 1641 patients aged 40
and over in China, Ye et al. analyzed gastric and colorectal
biopsy results and found that Hp infection was significantly associated
with a higher risk of colorectal adenoma (39). In addition, an increase
in the colorectal adenoma risk was seen in IM positive cases. Moreover,
in a more recent study, it was found that individuals with IM had a
higher risk of having high-grade intraepithelial neoplasia (40). There
are very few studies evaluating the association between H. pylori and IM
in our country. In our study, it was found that the IM positive group of
patients had a significantly higher risk of colorectal neoplasia in
comparison with the IM negative group of patients. There was not any
significant difference in terms of colon neoplasia incidence in the
analysis of four subgroups including both IM and HP. This result of the
group analysis conducted according to the presence of IM supports other
publications stating that IM brings a higher risk of colorectal adenoma.
Having a limited number of patients in the groups might be the reason
why the subgroup analysis gave this result.
In conclusion, even though our study supports the notion that H. pylori
infection increases the risk of colorectal neoplasia, this still remains
a controversial issue. However, IM, which is considered a chronic
sequela of H. pylori and a precursor lesion for gastric adenocarcinoma,
was found to be a risk factor for colorectal neoplasia, similar to
findings of many previous studies. In our study, although H. pylori
infection was not found to be a risk factor for colorectal neoplasia, it
can be accepted as a potential risk factor for colorectal neoplasia
development with IM. Therefore, patients with H. pylori infection and IM
could be encouraged for colonoscopic examination in early stages of life
to lower the colorectal neoplasia risk. However, it is obvious that
there is a need for large-scale studies on this matter.
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