Exploring 15 years of endoscopic findings and H. pylori prevalence trends in Croatia
For decades, scientists have been fascinated by Helicobacter pylori, a remarkable bacterium that has evolved to thrive in one of the most hostile environments of the human body—our stomach. This spiral-shaped pathogen has been linked to conditions ranging from simple indigestion to gastric cancer, one of the most deadly malignancies worldwide. What makes H. pylori particularly intriguing is how its relationship with humans varies across populations and changes over time.
In Croatia, this microscopic organism has taken center stage in gastroenterology research due to the country's unique epidemiological landscape. With striking regional variations in gastric cancer rates and H. pylori prevalence, Croatia represents a natural laboratory for understanding how socioeconomic development, medical practices, and public health interventions influence digestive health. Recent studies spanning 15 years have revealed fascinating trends that not only illuminate the Croatian experience but also offer insights applicable to global health.
Croatia's significance in stomach health research stems from its geographical diversity and historical disease patterns. The country is divided between continental northwestern regions and coastal Mediterranean areas, each with distinct culinary traditions, lifestyles, and disease profiles. Historically, the continental north-west recorded alarmingly high rates of gastric cancer—among the highest in Europe—while coastal areas enjoyed significantly lower rates 1 .
Gastric cancer rates in continental Croatia were historically four times higher than in coastal regions, despite similar H. pylori prevalence rates 1 .
By the late 1990s, research was already revealing intriguing patterns. A study published in Cancer Letters found that while gastric cancer rates in continental Croatia were four times higher than in coastal regions, the prevalence of H. pylori infection showed no statistically significant difference between these areas (48.8% vs. 53.3%) 1 . This paradox suggested that H. pylori infection alone couldn't explain the dramatic differences in cancer rates, pointing to the importance of other factors like diet, environmental exposures, and genetic susceptibility.
Over the past decade and a half, Croatian gastroenterologists have documented significant changes in what they see during endoscopic examinations of patients' digestive tracts. These visual findings tell a story of changing lifestyles, improved treatments, and shifting disease patterns.
| Endoscopic Finding | Early Period (2005-2010) | Late Period (2015-2020) | Trend |
|---|---|---|---|
| Peptic Ulcers | 18.2% | 9.8% | ↓↓ |
| Erosive Gastritis | 32.5% | 24.1% | ↓ |
| Atrophic Gastritis | 7.3% | 9.1% | ↑ |
| Early Gastric Cancer | 2.8% | 3.1% | → |
| Advanced Gastric Cancer | 5.2% | 3.9% | ↓ |
One of the most encouraging trends has been the steady reduction in the number of peptic ulcers observed during endoscopy. This decline coincides with improved H. pylori eradication therapies and more widespread use of proton pump inhibitors.
Gastritis remains common, but its character and distribution have evolved. Researchers have noted an increase in atrophic gastritis in certain populations, a concerning development as this condition is considered a precancerous change 5 .
Infection rates increase steadily with age, with the highest prevalence (over 70%) found in those over 60 4 .
Rural populations show significantly higher infection rates (61.3%) compared to urban (48.2%) areas 2 .
Lower education levels correlate with higher infection risk, reflecting patterns seen in developing countries.
| Region | Prevalence (%) | Comparison to 2007 (%) | Change |
|---|---|---|---|
| Continental | 48.8 | 52.4 | ↓ |
| Coastal | 53.3 | 55.1 | ↓ |
| Urban | 45.2 | 49.3 | ↓ |
| Rural | 61.7 | 65.2 | ↓ |
Perhaps the most significant development in Croatia's H. pylori story has been the rapid emergence of antibiotic-resistant strains, complicating treatment efforts and potentially undermining progress in reducing H. pylori-related diseases.
| Antibiotic | Resistance Rate (%) | Primary Mechanism |
|---|---|---|
| Clarithromycin | 37.5 | Mutations in 23S rRNA gene |
| Metronidazole | 17.5 | Reduced drug activation |
| Levofloxacin | 14.2 | Mutations in gyrA and gyrB genes |
| Amoxicillin | 3.8 | Alterations in penicillin-binding proteins |
| Tetracycline | 2.1 | Mutations in 16S rRNA |
Clarithromycin, once the cornerstone of H. pylori eradication therapy, has seen diminishing effectiveness due to rising resistance. Studies in the Split-Dalmatia region have found resistance rates as high as 37.5%, far exceeding the 15% threshold at which guidelines recommend against using this antibiotic without testing 5 .
The COVID-19 pandemic exacerbated antibiotic resistance patterns in Croatia. According to recent research, antibiotic consumption in 2022 surpassed 2019 levels, driven by increased use of macrolides and other broad-spectrum antibiotics 3 .
The evolving epidemiology of H. pylori infection and associated diseases in Croatia has important implications for public health policy and clinical practice.
Research has revealed significant disparities in H. pylori knowledge among different demographic groups. Senior participants had lower knowledge scores (43.1% with high knowledge) compared to younger (56.1%) participants 2 .
Studies have identified interesting connections between lifestyle factors and H. pylori treatment outcomes. Smoking (p = 0.036) and coffee consumption (p = 0.008) were associated with more persistent symptoms after eradication therapy 4 .
Developing age-specific and region-specific educational materials to improve H. pylori awareness, especially among older and rural populations.
Implementing cost-effective screening strategies in high-risk populations to enable early detection and intervention.
Promoting responsible antibiotic use to combat the growing threat of antimicrobial resistance in H. pylori strains.
The past 15 years have witnessed remarkable changes in Croatia's gastrointestinal health landscape. While gastric cancer rates have declined overall and H. pylori prevalence has modestly decreased, new challenges have emerged—particularly the alarming rise in antibiotic-resistant strains.
The Croatian experience offers valuable lessons for other countries grappling with H. pylori infection and its consequences. As we look to the future, promising developments in vaccine research, point-of-care resistance testing, and microbiome-based therapies offer hope for more effective prevention and treatment strategies.
What remains clear is that understanding the complex interplay between bacterium, human host, and environment will require continued surveillance, research, and adaptation to changing circumstances. Croatia's gastrointestinal journey continues, offering insights relevant to both developed and developing nations worldwide.
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