The Comparision of Serum Malondialdehyde Level Between H. Pylori Positive and H. Pylori Negative Gastritis Patients

Background: Helicobacter pylori is the most common cause of chronic gastritis in the world, meanwhile gastritis caused by NSAIDs is the most encountered type of gastritis. Increased free radicals caused by Helicobacter pylori can cause damage in gastric mucous. Tissue damage due to free radicals can be examined by measuring malondialdehyde compound. There are many studies that proves the increased malondialdehyde in gastritis, but those studies commonly done in animal experimentation and malondialdehyde examination in gastric mucous.Method: This is a cross-sectional study of 40 dyspepsia patients who came to endoscopic unit of Adam Malik General Hospital Medan and networking hospitals by using Rome III criteria. Further examination with gastroscopy and biopsy was done to determine gastritis. H. pylori examination was done by using Campylobacter-like organism test (CLO) test. Serum malondiasldehyde level was examined with high performance liquid chromatography (HPLC) method.Results: From total of 40 patients,24 (60%) were men and 16 (40%) were women with an average age of 47 years, the majority of the ethnic was Bataknese (57.5%). From 20 patients with H.pylori (+), the average level of malondialdehyde was 1.58 umol/mL while in 20 other patients with H.pylori (-), malondialdehyde level was 1.19 umol/mL with p value 0.013.We found the mean serum levels of malondialdehyde was higher in H. pylori positive gastritis than H. pylori negative.Conclusion: Serum Malondialdehyde level was significantly higher in patient with positive H.pylori gastritis compared to H. pylori negative gastritis.


INTRODUCTION
Gastritis is an inflammation process in gastric mucous and submucous as a response to acute or chronic injury. Helicobacter pylori infection is the most common cause of active chronic gastritis in the world, meanwhile chemical gastritis due to NSAID is the second most common risk factor in gastritis. 1 H. pylori prevalence in the western world keep decreasing due to improvement of quality of life, good hygiene, lower density, and antibiotic usage. Meanwhile in Asia, H. pylori infection rate is very high, including Indonesia. 2,3 Reactive Oxygen Species that was produced by the bacteria is one of many important factor whereas oxydative stress has an important role in the pathogenesis of worsening gastritis and gatric ulcer. 4 H. pylori infection will cause neutrofil and macrofage/monosit recruitment which in turn increase free radical that implied in gastric mucous damage. Radical Anion Superoxyde (O2-) resulted by neutrofil infiltration to cellular lipid membrane which produce lipid peroksidase that metabolized to malondialdehyde. Lipid tissue damage due to free radical that can be measured with malodialdehyde compound measurement which is a lipid peroxidase product. Free radical production indirectly measured by lipid peroksidase level. Malondialdehyde is a biomarker to assess oxydative stress condition. 5 Turkkan et al proved that severe chronic inflammation correlate with higher malondialdehyde level in study subject. 6 Navvabi et al that studies H. pylori effect on oxydative stress in chronic gastritis patient showed that malodialdehyde and oxydised glutation level increased significantly in H. pylori patient, meanwhile total antioxydant level and reduced glutathion significantly decreased. 7 Many studies have proved the role of free radical to gastritis. But, many of these studies usually done in animal and the malondialdehyde level was examined from gastric mucous. The aim of this study is to compare serum malondialdehyde level in H. pylori positive gastritis and H. pylori negative gastritis patients.

METHOD
This is a descriptive analytic study with cross sectional design, which is done from April to June 2017 and was conducted in Endoscopy Unit Adam Malik General Hospital Medan and Faculty Medicine of Universitas Sumatera Utara. Patients age 18 years and older who diagnosed with gastritis from endoscopic and histopathologic examinations were enrolled in this study. The exclusion criteria were patients who have received previous treatment for H. pylori infection in the last six months, use of proton pump inhibitor (PPI) and H2 receptor antagonist during 2 days before the study, and currently on antibiotic theraphy for H. pylori eradication, diabetes melitus, hypertension, obesity, renal failure, hepatitis, liver cirhossis, coronary artery disease, congestive heart failure, rheumatic disease, infection diseases, gastrointestinal bleeding, peptic ulcer and malignant diseases.
The sample size was determined by using the formula of unpaired numerical comparative analytical 2 groups, with 95% confidence level, 90% power, and 10% increment to avoid design error, 20 samples are needed in each group. With the total sample size is 40 people.
Affiliate hospital after approval from ethical commission and related institute. Dyspepsia patient, defined with Rome III criteria, was then examined by using endoscopy and biopsy. To detect H. pylori, serology examination (CLO) was done. Malondialdehyde examination was done by HPLC examination (high performance liquid chromatography). Data was analyzed by using Mann Whitney Test with standard deviation (a) 0.05. The data was processed and analyzed by using SPSS version 22.

RESULTS
This study include 40 patient that has fulfilled inclusion criteria dan divided to two group, each with 20 patient in H. pylori (+) gastritis patient and 20 patient in H. pylori (-) gastritis patient. 24 patient (60%) was male and 16 (40%) patient was female with average age 48 years old. Median malodndialdehyde level was 1.27 ng/mL. Baseline characteristic and clinical profile of the subject was showed in Table 1.

This study includes 40 patient which has fulfilled
inclusion criteria and divided into 2 group with 20 patient each group based on the presence of H. pylori infection. Male subject is more commonly found in H. pylori (+) gastritis which is 12 (60%) patient meanwhile in H. pylori (-) gastritis the amount of male and female was the same which is 10 patient (50%). This is consistent with Naja F study which include 1,306 patient where H. pylori positve gastritis was more common in male compared to female (56.1% : 43.9% ). 8 But this is reversed from studies by Zhu where from 5,417 sample with H. pylori (+), female patient was more frequent than male (64.47:38.26 ). 9 Draker et al studies about reactive oxygen species activity and lipid peroksidase in H. pylori gastritis, from 161 subject, male patients was more frequent than female with average age 47 years old. 10 After statistic analysis was done, this study shows that average malondialdehyde level was higher in H. pylori (+) gastritis which is 1 12 Drake et al states that malondialdehyde level was higher significantly in gastritis patient mucous in H. pylori patient with chronic gastritis compared to normal histology. H. pylori gastritis with more severe inflammation has significantly higher malondialdehyde level (p < 0.05) and in patient with neutrophil infiltration From this data, the mean malondialdehyde level in H. pylori (+) patient was 1.58 and the H. pylori (-) was 1.19 with p 0.013. This is shown in Table 2 and Figure 1. in grade 2 or 3 gastric mucous has significantly higher malondialdehyde compared to normal (p < 0.05). 10 Turkkan proves that more severe chronic inflammation has significantly higher malondialdehyde level in study subject (p = 0.04). 6 Aksoy et al report that average malondialdehyde concentration in preeclampsia patient with H pylori (+) was significantly higher compared to H. pylori (-).
Preeclampsia patient has higher serum malondialdehyde level compared to healthy pregnant woman, 80% preeclampsia women infected by H. pylori, meanwhile prevalence of H. pylori infection in healthy pregnant woman was 60% (OR = 2.86), so it is suspected that increased serum MDA concentration in preeclampsia woman was due to H. pylori infection. 13 Navvabi et al that studies H. pylori effect to oxydative stress in chronic gastritis patient shows that malondialdehyde and oxidized glutathione level was increased significantly in H. pylori patient, meanwhile total antioxidant and reduced glutathione level was decreased significantly. 7 Khanzode et al that study gastritis patient and gastric cancer showed consistent result, which is increased serum malondialdehyde level significantly in patient with H. pylori infection compared to control. 14 This study also showed that malondialdehyde level was significantly higher in gastric cancer patient compared to gastritis. Up until now, MDA level still didn't have a normal value which can be used as standard. MDA level can be affected by age, enzyme activities (superoxide dismutase, catalase, and glutathione perioxidase), antioxidant supplement (vitamine C, E, βeta-karoten, etc), diseases and environment (pollution and radiation). Malondialdehyde level as a biomarker to assess oxydative stress in each disease was diffferent. 15

CONCLUSION
Serum Malondialdehyde level was significantly higher in patient with positive H. pylori gastritis compared to H. pylori negative gastritis.