ࡱ>  ()mT wbjbj VJoop%"""""$"OLOLOLPL+M"v/N(WN"yNyNyNXOnO zOݷ߷߷߷߷߷߷l~߷"OTOXOOO߷ ""yNyN OH"yN"yNݷ Oݷ L"" :IOLN3H,ƹ0{ "OOO"")OL""OL M!:   ZDRAVSTVENI FAKULTET UNIVERZITET U ZENICI DIPLOMSKI RAD Helicobacter Pylori u ambulanti PZZ-Pore . Studije razdoblja 08/2013-08/2014. Mentor: Kandidat: Prof.dr.sc Salih Tandir.dr.med. Iria Rabar Pore , 2014 godina SADR}AJ 1. Uvod 5 1.1 Epidemiologija Helicobacter pylori 6 1.2 Bioloake zna ajke Helicobacter Pylori 8 1.3 imbenici rizika 9 1.4 Na in airenja 9 1.5 Dijagnostika infekcije koju uzrokuje Helicobacter Pylori 10 1.6. Lije enje i eradikacija Helicobacter Pylori 11 1.7. Bolesti uzrokovane Helicobacter pylori 12 2. Cilj i svrha rada 15 3. Materijal i metode rada 16 4. Rezultati rada 17 5. Diskusija 22 6. Zaklju ci 24 7. Literatura 25 SA}ETAK Helicobacter pylori je bakterija koja ima zna ajnu ulogu u nastanku i razvoju svih vrsta gastritisa i najveeg broja pepti kih ulkusa, radi se o vjerojatno naj eaoj infekciji na svijetu koja je uzro no povezana s jednom od kroni nih bolesti najviae prevalencije - ulkusnom bolesti. Uz to je Helicobacter pylori etioloaki vezan uz razvoj malignih bolesti ~eluca, karcinoma i MALT limfoma po onomu ato predstavlja i koliku va~nost ima za klini ku medicinu i javno zdravstvo. Zabrinjavajue je ato dugi niz godina ne moraju postojati nikakvi simptomi koji bi ukazivali na prisutnost bakterije u ~elucu. Klju ne rije i: Helicobacter pylori, controla. Cilj i svrha rada: Cilj diplomskog rada je da se prika~e ponaaanje Helicobacter pylori u ambulanti PZZ- Pore , u periodu 08/2013- 08/20014, broj inficiranih pacijenata, u estalosti po godianjim dobima, spolu, socijalnom statusu, prema tipu oboljenja nakon inficiranosti, te prema tipu pregleda koji se koristio kako bi se dokazala prisutnost bakterije. Materijal i metode rada: Ovim istra~ivanjen je obuhvaena populacija inficirana s Helicobacter pylori u ambulanti PZZ- Pore  u razdoblju 08/2013 do 08/2014 godine. Podaci za istra~iva ki dio ovog rada su uzeti iz ambulante PZZ-Pore . Podaci su statisti ki obraeni i predstavljeni tabelarno, grafi ki i tekstualno. Istra~ivanje ima retrospektivan karakter. Rezultati ovog ispitivanja pokazuju da je Helicobacter pylori danas najrasprostranjenija infekcija na svijetu, te ima zna ajan i kompleksan utjecaj na zdravlje stanovniatva, a uz to, dokazat e se da je Helicobacter pylori etioloaki vezana uz razvoj raznih kroni nih bolesti probavnog trakta. SUMMARY Helicobacter pylori is a bacterium that plays a significant role in the formation and the development of all kinds of gastritis and the highest number of peptic ulcers. It is probably the most common infection on global level which is causally linked to one of the highest prevalence chronic diseases - the ulcer disease. Furthermore, the Helicobacter pylori is connected etiologically to the development of malignant stomach diseases, cancers and MALT lymphoma in accordance of its representation and the impact it has to the clinical medicine and the public health. A worrying fact is that it could be asymptomatic, failing to show any symptoms at all that could indicate the bacterium's presence in the stomach, for many years. Key words: Helicobacter pylori, control. Aim and purpose: The thesis' aim is to show the Helicobacter pylori behaviour in the Primary health care facility in Pore , during August 2013 - August 2014, the number of infected patients, the frequency of infection according to seasons, sex, social status, type of disease after the infection, and according to the type of visit applied to prove the bacterium presence. Materials and methods applied: This research was conducted on the population infected with Helicobacter pylori in the Primary health care facility in Pore  during August 2013 to August 2014. The data for the research part of this project have been provided by the Primary health care facility - Pore , have been statistically elaborated and represented in tabular, graphical and textual form. The research has a retrospective form. The results of this study indicate that Helicobacter pylori is nowadays the most widespread infection on global level, and has therefore a significant and complex influence on the population's health, and it will be therefore proven that Helicobacter pylori is etiologically connected with the development of various digestive tract chronic diseases. 1. UVOD U svijetu u kojem ~ivimo pronalaze se beskona ne evolucijske mogunosti, koje su do danas bile nepoznate, a koje u ozbiljnoj mjeri ugro~avaju naae zdravlje. Jedno od tih je Helicobacter Pylori, bakterija koja inficira i dovodi do upale ~elu ane sluznice. Prije viae od 100 godina prvi put su u ~elucu ovjeka i ~ivotinja zamijeene spiralne bakterije. Smatralo se da je prisustvo ovih bakterija prije posljedica kontaminacije nego prave kolonizacije. Helicobacter pylori otkrili su sasvim slu ajno australski lije nici B. Marshall i R. Warren 1983. godine nakon produ~ene inkubacije kolonije bakterija tijekom uskranjih blagdana. No, dokazati da bakterija uzrokuje infekciju ~eluca nije bilo lako. Tek kada je B. Marshall svjesno i hrabro popio otopinu koja je sadr~avala bakteriju i tjedan dana nakon toga dobio simptome infekcije, pretpostavka o postojanju infektivnog agensa kao moguem uzroku upale sluznice ~eluca je dokazana. Istra~ivanja koja su povezivala bolest ~elu ane sluznice i spiralnih bakterija zapo ela su s uspjeanom izolacijom iz ~elu anog biopti kog tkiva 1983. godine (1). Njihove naknadne studije o bakteriji dovele su do Nobelove nagrade za fiziologiju i medicinu 2005. godine. U samom po etku spiralna bakterija je svrstana u rod Campylobacter i dobila je naziv CLO (eng. campilobacter-like organism), a zatim campylobacter pyloridis. 1989. g. smjeatena je u novi rod Helicobacter. U navedenom rodu je svrstano viae od 23 vrste, a od toga je 7 adaptiranih na ~eludac ovjeka, 15 na crijevo, a 1 je pronaena na obje lokacije. Helicobacter pylori je bakterija koja ima zna ajnu ulogu u nastanku i razvoju svih vrsta gastritisa i najveeg broja pepti kih ulkusa, radi se o vjerojatno naj eaoj infekciji na svijetu koja je uzro no povezana s jednom od kroni nih bolesti najviae prevalencije - ulkusnom bolesti. Uz to je Helicobacter pylori etioloaki vezan uz razvoj malignih bolesti ~eluca, karcinoma i MALT limfoma po onomu ato predstavlja i koliku va~nost ima za klini ku medicinu i javno zdravstvo. Zabrinjavajue je ato dugi niz godina ne moraju postojati nikakvi simptomi koji bi ukazivali na prisutnost bakterije u ~elucu. Danas ima dokaza da Helicobacter pylori igra kriti nu ulogu u razli itim izvan~elu anim bolestima. Enterohepati ke vrste Helicobacter pylori po raznim pretpostavkama igraju va~nu ulogu kod hepatocelularnog karcinoma kao i upalnih bolesti crijeva. Helicobacter pylori ima velikog udjela kod idiopatske trombocitopeni ne purpure i sideropeni ne anemije. Postoji sve viae dokaza koji potencijalno povezuju Helicobacter pylori s kardiovaskularnim bolestima (3). Infekcija je zastupljenija u osoba koje ~ive u loaim socioekonomskim uvjetima. Procjenjuje se da je inficirano viae od 50% odraslih stanovnika u razvijenim i 80%-90% stanovnika zemalja u razvoju (3). U estalost infekcije Helicobacter Pylori u razvijenim zemljama je izmeu 3% i 10% godianje. Helicobacter Pylori je jedina bakterija koja moze pre~ivjeti u nepogodnoj kiseloj sredini u ~elucu. 1.1 Epidemiologija Helicobacter pylori Helicobacter pylori je danas najrasprostranjenija infekcija na svijetu. Procijenjuje se da je polovina svjetske populacije zara~ena ovom bakterijom. Meutim, postoje velike geografske, starosne razlike i razlike izmeu ekonomski razvijenih zemalja i zemalja u razvoju u u estalosti infekcije. Genetska predispozicija takoer utje e kako na incidenciju, tako i na prevalenciju infekcije. Do infekcije dolazi vrlo rano, u djetinjstvu i ostaje do~ivotna osim ako se ne lije i. Zaraza je eaa u djece koja pohaaju predakolske ustanove gdje je presudan upravo taj neposredni kontakt meu djecom. Danas se mo~e rei da Helicobacter pylori infekcija ima epidemioloake osobine prete~no svih bakterijskih infekcija tog doba. Najvea je u estalost u predakolskom uzrastu. Mogunost oboljenja u pojedinim obiteljima apsolutno je u zavisnosti od broja lanova. Vea je inficiranost u uvjetima ni~eg socioekonomskog standarda i stupnja obrazovanja. Porast inficiranosti u djetinjstvu se kree izmeu 20% i 80% za svaku godinu starosti, dok kod odraslih svaka godina starosti viae, nosi sa sobom 1% 3% veu incidenciju. Socioekonomske prilike i ~ivotni uvjeti znatno utje u na incidenciju javljanja infekcije. Naime, u razvijenim zapadnim zemljama u estalost infekcije raste za oko 3% sa svakom dekadom ~ivota. Prevalencija infekcije u zemljama u razvoju je vrlo visoka i iznosi oko 80% odrasle populacije, za razliku od razvijenih zemalja gde je postotak znatno ni~i i kree se oko 40%. Usporedbe radi, u Europi prevalencija Helicobacter pylori infekcije kod osoba od aezdeset godina starosti je ista kao kod dvadesetogodianjaka u zemljama u razvoju. U Hrvatskoj je to 68 % ali je viaa u sjevernim kontinentalnim podru jima s visokom stopom raka ~eluca nego u priobalnom podru ju. (1,2) U estalost infekcije postepeno opada paralelno sa poboljaanjem ~ivotnog standarda i razli ita je meu pojedinim dr~avama isto kao i meu populacijama unutar iste dr~ave. Socijalno-ekonomski status je najva~niji indikator u estalosti infekcije s Helicobacter pylori. ovjek je glavni rezervoar za Helicobacter pylori, prijenosi se oralno-oralno ili fekalno-oralno u izravnom bliskom dodiru izmeu osoba u prenapu enoj zajednici niskog higijenskog standarda. Viai ~ivotni standard, viai nivo edukacije i bolji sanitarni uvjeti rezultiraju ni~om u estaloau infekcije. Dokazalo se da ato je infekcija prisutnija u ranijoj dobi, to su vee mogunosti oboljenja od karcinoma ~eluca i ulkusa. Takva injenica implicira kako je obitelj potencijalni faktor rizika oboljenja. 1.2 Bioloake zna ajke Helicobacter Pylori Bakterija je specific na za ljudsku vrstu, ali i u raznih sisavaca nalaze se srodne bakterije. Naseljava probavni sustav od zubnih plakova do dvanaesterca. Moz e se izolirati iz fecesa. Prenosi se fekalno-oralnim ili oralno-oralnim putem, izgleda i da se moz e s iriti vodom, a najc es ce putem sirovog voca i povrca. H. pylori je malen, zavinut gram-negativni atapi duljine 2-4 (m, airine 0,5-1 (m, lagano spiralno savijen poput slova S. U starijoj kulturi u tkivu mo~e poprimiti kokoidni oblik mikroaerofilan, osjetljiv na suaenje i posebnih zahtjeva za rast, optimalne temperature 35-37 (C. ph vrijednost pri kojoj mo~e rasti je 4,5-7,5. Helicobacter pylori je vrlo pokretan zahvaljujui multiplim flagelima. (1,4) Izlu uje mnogo enzima (ureaza, katalaza, oksidaza, mucinaza, proteaza, fosfolipaza). U patogenezi infekcije najva~nija je ureaza, enzim koji se izlu uje u velikoj koli ini te je najva~niji egzoenzim Helicobacter pylori. Najva~niji je iz razloga ato ureaza omoguuje dijeljenje uree na amonijak i bikarbonat, alkalizira mikrookolinu te joj time omoguuje opstanak na tako niskim ph vrijednostima. U nastanku infekcije zna ajan je i vakuolirajui citotoksin koji je izra~en samo u nekih tipova (tip I H. pylori). Proizvodi i katalazu koja ga s titi od reaktivnih kisikovih radikala. Izgleda da sve bakterije nemaju jednaku virulenciju. (4) H. pylori izaziva akutnu i kroni nu upalu s razvojem humoralne i stani ne imunosti, koja meutim, ne dovodi do njegove eradikacije. Osjetljiv je na amoksicilin, tetracikline i makrolide, dok se na metronidazol javlja rezistencija u visokom postotku. 1.3 imbenici rizika Posebno je opasna kombinacija inficiranost Helicobacter pylori uz istovremeno puaenje, konzumaciju alkohola, nezdrave hrane kao i nekih lijekova poput salicilata, hormonalnih preparata, antibiotika i narkotika, jer dolazi do kontinuiranog oateivanja sluznice ~eluca te erozije tkiva ~eluca. Suvremeni, esto predinami an i stresan na in ~ivota umno~ava problem jer je poznato da stres poti e izlu ivanje ~elu ane kiseline koja oate uje ~elu anu sluznicu. 1.4 Na in airenja Do infekcija tom bakterijom naj eae dolazi u djetinjstvu, ali se simptomi javljaju uglavnom u odrasloj dobi. Jedini nosilac te bakterije je ovjek. Na in prijenosa Helicobacter pylori joa nije potpuno istra~en, no sve dosadaanje spoznaje govore u prilog tome da se bakterija prenosi izravno od zara~ene osobe na zdravu: ( " gastro-oralnim (~eludac-usta) putem preko povraenog sadr~aja te nedovoljno sterilnim endoskopskim instrumentima tijekom endoskopije; " oralno-oralnim (usta-usta) putem sline i ranica u sluznici usne aupljine; " fekalno-oralnim (stolica-usta) putem iz stolice zara~ene osobe prljavim rukama.( Iako je Helicobacter pylori dokazana u vodi, hrani i mlijeku, izgleda da to nema zna ajniju ulogu u prijenosu koliko injenica da je u estalost vea u ni~im socioekonomskim sredinama gdje se stje e ve u djetinjstvu. Infekcija je eaa kod djece koja krevet dijele s drugom djecom, roditeljima ili drugim srodnicima, u sredinama u kojima se koristi zajedni ki pribor za jelo ili majka dudu varalicu prethodno stavlja u usta. Infekcija tom bakterijom eaa je i kod djece koja pohaaju predakolske ustanove ili su smjeatene u specijalne ustanove za zbrinjavanje djece. 1.5 Dijagnostika infekcije Ima viae dijagnosti kih postupaka kojima se mo~e utvrditi infekcija bakterijom Helicobacter pylori. Jedna skupina postupaka posredno dokazuje da je bakterija prisutna u organizmu. U tu skupinu postupaka spadaju: - urea izdisajni test - dokazuje se prisutnost bakterije u ~elucu njezinom aktivnosti u razgradnji uree. Test je jednostavan i pouzdan i provodi se iz uzoraka izdahnutog zraka prije i nakon uzimanja otopine 13C uree. - pregled uzoraka krvi ili sline - dokazuje se postojanje specifi nih antitijela u krvi ili slini zara~ene osobe. S obzirom na to da antitijela mogu biti prisutna u organizmu joa godinama nakon izlje enja od infekcije bakterijom H. pylori, ne koristi se u kontroli uspjeanosti provedenog lije enja od ove infekcije. - pregled stolice - dokazuje se postojanje antigena u stolici bolesnika. Druga skupina dijagnosti kih postupaka provodi se u sklopu specijalisti ke gastroenteroloake obrade koja uklju uje provoenje endoskopskog pregleda jednjaka, ~eluca i dvanaesterca. Prilikom endoskopskog pregleda uzimaju se uzorci tkiva u kojima se laboratorijski dokazuje prisutnost ove bakterije. Ovakav na in dokazivanja prisutnosti bakterije u organizmu preporu uje se svim bolesnicima koji imaju simptome koji upuuju na infekciju, a stariji su od 45 godina. 1.6 Lije enje Za eradikaciju bakterije Helicobacter pylori primjenjuje se antibiotska terapija (kombinacija dva antibiotika) u trajanju od uglavnom 7 dana te protusekretorni lijekovi tzv. inhibitori protonske pumpe (omeprazol, esomeprazol, lanzoprazol, pantoprazol, rabeprazol) koji smanjuju lu enje ~elu ane kiseline tijekom najmanje 2 mjeseca. Danas postoje mnogobrojni terapijski re~imi s razli itim vrstama antibiotika i razli itom du~inom trajanja lije enja ovisno o klini koj manifestaciji bolesti, opem stanju bolesnika i fazi u koji se bolest nalazi. U slu aju neuspjeha terapije i/ili reinfekcije, lije enje se ponavlja drugom kombinacijom antibiotika uz jedan od inhibitora protonske pumpe. Uz terapiju je potrebno provesti i higijensko-dijetetski re~im ishrane. Potrebno je izbjegavati kavu, aj, alkohol, gazirana pia i puaenje. Uzimanje probiotika koji sadr~e Lactobacillus acidophillus zna ajno poveava uspjeh eradikacijske terapije. Kod malog broja bolesnika subjektivni simptomi zadr~avaju se i nakon uspjeano provedene eradikacijske terapije zbog postojanja komorbiditeta poput refluksne bolesti jednjaka, a ponekad je potrebno i do godina dana do potpunog povla enja upalnih promjena u sluznici ~eluca. Mogua je i reinfekcija u razdoblju od 1 do 3 godine nakon zavraetka lije enja. Do sada ni kod jednog terapijskog protokola nije zabilje~en 100%-tni u inak na eradikaciju Helicobacter pylori, uspjeanost lje enja treba provjeriti i pratiti. 1.7 Bolesti uzrokovane Helicobacter pylori Iako je Helicobacter pylori naj eai uzro nik kroni nog gastritisa odnosno uzro nik naj eae infekcije u ljudi airom svijeta, spoznaja o akutnoj fazi te infekcije ima vrlo malo. Nakon inkubacije u trajanju od 3 do 7 dana javljaju se kod odreenog broja bolesnika simptomi dispepsije (bol u epigastriju, mu nina, povraanje, osjeaj te~ine i nadutosti) i traju obi no 1 do 4 dana. U veine bolesnika histoloaki se tada mo~e nai neutrofilni gastritis. Izuzetno, u ovoj ranoj fazi mo~e doi do hipersekrecije solne kiseline. eae, u oko 50% bolesnika, uz va~nu neutrofilnu infiltraciju i korpusa ~eluca, nastupa prolazna hipoklorhidrija. Nalaz sekrecije solne kiseline obi no se normalizira unutar 4 mjeseca, a u odreenog broja bolesnika tada nastupa hipersekrecija. Pratei dalje ove bolesnike, postalo je jasno da ova akutna infekcija, u pravilu, prelazi u kroni nu, a tijek je bolesti pritom naj eae bez posebnih simptoma. Premda je u malobrojnih bolesnika Helicobacter pylori spontano nestao sa ~elu ane sluznice, u veine bolesnika ta infekcija, ako se ne lije i traje vrlo dugo, uglavnom do~ivotno. Otkrie uloge infekcije Helicobacter pylori bitno je promijenilo mnoge stavove o etiologiji i patogenezi velikoga broja bolesti gornjeg dijela probavnog sustava. To je otkrie dovelo i dalje dovodi do stvaranja novih patohistoloakih i klini kih klasifikacija ovih bolesti, mijenja dijagnosti ke algoritme, a to je posebno va~no jer bitno utje e i mijenja uobi ajene terapijske postupke. Izuzetna varijabilnost ove bakterije, posebno glede imbenika njezine virulencije, uvelike odreuje buduu reakciju domaina, o emu izravno ovisi klini ka slika bolesti. Klini ka slika bolesti uglavnom ovisi o smjeataju Helicobacter pylori na ~elu anoj sluznici. Naj eae se nalazi na podru ju antruma a neato rjee na korpusu. Ako se nae u dvanaestercu, tada je to na mjestima ~elu ane metaplazije. Na jednjaku ili na drugim dijelovima probavnog sustava mo~e takoer naseljavati oto ie ~elu anog ektopi nog epitela. Infekcija Helicobacter pylori znatno poveava rizik od razvitka pepti ne bolesti (4-10 puta), jednako kad je rije  o ~elu anom ulkusu, kao i o ulkusu na dvanaestercu. Ulcerogeno djelovanje te infekcije vezano je za oateenje sluzni ne barijere s postupnim razaranjem dijelova same sluznice sve do razvoja atrofije, oslobaanje niza toksi nih metabolita tijekom kolonizacije sluznice, stimuliranje lu enja solne kiseline i razvoj ~elu ane metaplazije u bulbusu dvanaesterca. Prema definiciji, gastroezofagealna refluksna bolest  GERB nastaje zbog patoloaki poja ana refluksa ~elu anog sadr~aja u jednjak s posljedi nim pretjeranim izlaganjem jednjaka agresivnim sastojcima tog sadr~aja. GERB je jedna od naj eaih bolesti gornjeg dijela gastrointestinalnog sustava. Prisutna je u svim svjetskim populacijama, a osobito je esta u razvijenim zemljama. Zadnjih je godina primijeeno da prevalencija GERB-a raste, posebno u zapadnim zemljama i kree se od 5% do 25%. I incidencija pokazuje linearan porast, takoer je naglaaena u dobro industrijski razvijenim zemljama. Spoznaje o infekciji s Helicobacter pylori koje su temeljito promjenile, kako spoznaje, tako i klini ki i terapijski pristup nizu bolesti ~eluca i dvanaesterca, dovele su i do promjena u shvaanju etiopatogeneze GERB-a. Upravo taj odnos infekcije Helicobacter pylori i GERB-a je danas u ~ariatu interesa. Razlog upravo i le~i u injenici da se posljednjih desetljea nesumljivo poveava broj oboljelih od GERB-a u razvijenim zemljama, i to upravo tamo gdje se nedvojbeno smanjuje zara~enost populacije s Helicobacter pylori. }elu ani je karcinom i dalje na drugom mjestu svih uzroka smrti od zloudnih bolesti. Smatra se da je ovaj trend pada rizika od razvoja ~elu anog karcinoma spontan, ovisan uglavnom o poboljaanju socioekonomskih imbenika u pu anstvu, poboljaanja standarda ~ivljenja i kvalitetnije prehrane sa smanjenjem uporabe soli, posebno pri konzerviranju hrane. Novije epidemioloake studije, meutim, intenzivno istra~uju povezanost infekcije Helicobacter pylori s nastankon ~elu anog karcinoma. MALT-limfomi, stalna prenapregnutost imunoloakog sustava uzrokovana kontinuiranom infekcijom Helicobacter pylori ~elu ane sluznice, dovodi ve pri gastritisu do opse~nog nagomilavanja limfoidnih stanica u lamini propriji ~elu ane sluznice, mogu se nai ak i limfati ni folikuli, koji ina e nisu prisutni u zdravoj ~elu anoj sluznici. Infekcija Helicobacter pylori isto je tako povezana s bolestima izvan probavnog sustava, genetski predisponiranih osoba, infekcija Helicobacter pylori dovodi do limfo-mononuklearne aktivacije, a mo~e pokrenuti i procese autoimunosti usmjerene protiv drugih tkiva izvan probavnog sustava, kao ato su periferne krvne ~ile, ko~a ili tkivo atitnja e. 2. CILJ I SVRHA RADA Cilj diplomskog rada je ispitati ponaaanje Helicobacter pylori u ambulanti PZZ- Pore , u periodu 08/2013- 08/20014, ispitati broj inficiranih pacijenata, ispitati u estalost po godianjim dobima, spolu, socijalnom statusu, prema tipu oboljenja nakon inficiranosti, te prema tipu pregleda koji se koristio kako bi se dokazala prisutnost bakterije. 3. MATERIJAL I METODA RADA Ovim istra~ivanjen je obuhvaena populacija inficirana Helicobacter pylori u ambulanti PZZ- Pore  u razdoblju 08/2013 do 08/2014 godine. Podaci za istra~iva ki dio ovog rada su uzeti iz ambulante PZZ-Pore . Podaci su statisti ki obraeni i predastavljeni tabelarno, grafi ki i tekstualno. Istra~ivanje ima retrospektivan karakter. 4. REZULTATI RADA Tablica 1. Trend inficiranosti po dobi i spolu Dob}eneMuakarciBroj ispitanikado 29931230-391752240-4928124050-5926154160 i viae352459Ukupno11559174 Tablica prikazuje broj inficiranih bakterijom Helicobacter pylori u ambulanti PZZ-Pore  u razdoblju od kolovoza 2013 godine do kolovoza 2014 godine razvrstanih po spolu i dobi. Iz tablice se is itava kako je broj inficiranih mnogo vei u poodmakloj dobi, te je vei broj inficiranih u ~ena nego u muakaraca. Tako je vidljivo da je najvei broj inficiranosti meu ~enskom populacijom sa 115 od ukupno 174 slu ajeva. Posmatrajui dobnu strukturu, uo ava se da je najvei broj inficiranih u dobi iznad 60 godina, a najmanje inficiranih je u dobnoj skupini ispod 29 godina. Tablica 2. Zastupljenost dijagnosti kih pregleda Dijagnosti ki preglediBroj ispitanika%Pregled stolice16896,5Pregled serum 52,9Biopsija10,6Ukupno174100 Tablica 2. Na ovoj tablici dat je prikaz koriatenih dijagnosti kih pregleda kako bi se dokazala prisutnost infekcije bakterijom Helicobacter pylori. Najkoriatenija provjera je analiza stolice zbog jednostavnosti izvoenja. Tablica 3. U estalost oboljevanja nakon inficiranosti DijagnozaBroj ispitanika%Gastritis 21,1Gastritis i duodenitis4224,1Gastroduodenitis10,6Gerbs12471,3Gerbs s ezofagitisom42,3Bolest jednjaka nespecific.10,6Ukupno174100 Ova tablica prikazuje oboljele u postocima prema dijagnozi. Zna ajno je najzastupljenija posljedica inficiranoau s Helicobacter pylori Gerbs, s udjelom od 71,3 % u ukupnom broju oboljelih. Koliko je postotak zna ajan pokazuje injenica da je sljedee najzastupljenije oboljenje gastritis i duodenitis s postotkom od 24,1 %. Grafikon 1. Oboljenja prema socijalnim kategorijama EMBED Excel.Chart.8 Grafikon prikazuje u estalost oboljenja pojedinih socijalnih kategorija, pa je vidljivo kako je najzastupljenija kategorija, radni ka s udjelom 49,4 % od ukupnog broja oboljelih. Sljedea po zastupljenosti, ali ne i neva~na kategorija jesu umirovljenici, s postotkom od 30,4 %, a nadalje nezaposleni s 11 %, poslodavci s 5,2 %, te najmanje zastupljene kategorije  doseljenika iz BiH s 3,4 % i socijalnih slu ajeva s 0,6 %. Grafikon 2. U estalost inficiranih po godianjim dobima EMBED Excel.Chart.8 Zna ajno je napomenuti da se najvei broj od 61 inficiranih dogaa zimi. Takoer se is itava kako nemamo zna ajne razlike izmeu proljea i ljeta. Najmanje inficiranih imamo u jesen, 24 osobe. 5. DISKUSIJA Helicobacter pylori je danas najrasprostranjenija infekcija na svijetu, te ima zna ajni i kompleksni utjecaj na zdravstveno stanovniatvo. Uz to je Helicobacter pylori etioloaki vezana uz razvoj raznih kroni nih bolesti probavnog trakta. Na zdravstveno stanje stanovniatva utje u i razne socioekonomske i demografske karakteristike kao starosna dob, spol i socijalni status. Ovisno o razvijenosti sredine i ekonomske prilike, te navike i kulturu ~ivljenja stanovniatvo je manje ili viae eksponirano moguoj infekciji Helicobacter pylori. Cilj ovog rada je bio upravo to da se prika~e ponaaanje bakterije i njena zastupljenost obzirom na spol, starosnu dob, godianjem dobu, socijalnom statusu, prema oboljenjima koja izaziva, te kako se naj eae otkriva u ambulanti PZZ-Pore  u razdoblju od 08/2013 do 08/2014 godine na uzorku od 174 oboljela. Iz istra~ivanja je vidljivo da je ~enska populacija osjetno zastupljenija od muake i to s postotkom od visokih 66,1 %. Isto tako, broj inficiranih mnogo je vei u poodmakloj dobi gdje iznosi 33,9 % kod osoba sa 60 i viae godina. Za ostale starosne skupine taj podatak je neato ni~i te redom iznosi 23,6 % za osobe imeu 50-59 godina, 23 % za skupinu 40-49 godina, 12,6 % za skupinu 30-39 godina te 6,9 % za skupinu do 29 godina starosti. Nadalje, istra~ivanje je pokazalo kako je naj eai koriateni dijagnosti ki pregled bio analiza stolice s u estaloau od 95,6 %. To je najpristupa nija seroloaka metoda zbog svoje jednostavnosti, to nosti, brzine izvoenja, a ujedno je i najprihvatljivija pacijentima. Pregled seruma koristilo je 2,9 % pacijenata, dok je biopsiju u inilo tek 0,6 % pacijenata. `to se ti e tipa bolesti kojom oboljevaju zara~eni bakterijom Helicobacter pylori vidi se kako je najzastupljenija posljedica inficiranosti Gerbs s udjelom od 71,3 % u ukupnom broju oboljelih. Sljedee najzastupljenije oboljenje je gastritis i duodenitis s postotkom od 24,1 %, a najmanje zna ajna oboljenja su bolest jednjaka i gastroduodenitis s minimalnim postocima od 0,6 %. Va~no je napomenuti kako se u istra~ivanom razdoblju nije registrirao niti jedan slu aj ulkusne bolesti. Najzastupljenije socijalne kategorije su radni ka s udjelom 49,4 % od ukupnog broja oboljelih i umirovljeni ka s postotkom od 30,4 %, a najmanje zastupljene kategorije ona doseljenika iz BiH s 3,4 % i socijalnih slu ajeva s 0,6 %. Godianje doba s najveim brojem oboljelih je svakako zima s udjelom od 35,1 % od ukupnog broja. Slijede je proljee s 26,4% i ljeto s 24,7 %, te jesen s najmanjim postotkom od 13,8 % oboljelih. 6. ZAKLJU CI - Istra~ivanje obuhvaa ambulantu PZZ-Pore  u razdoblju od 08/2013 do 08/2014 godine na uzorku od 174 oboljele osobe. - Konstatirano je da su u veem postotku oboljevale ~ene. Najviae oboljelih nalazimo u starosnoj grupi od 60 i viae godina. - Najkoriateniji pregled bio je pregled stolice. - Zna ajno je napomenuti kako je Gerbs bilo naj eae dijagnosticirano oboljenje povezano bakterijom Helicobacter pylori. - Neophodno je napomenuti da u istra~enom razdoblju nije primjeena ulkusna bolest. - Najugro~enija socioekonomska kategorija bili su radnici. - Zima je bila godianje doba u kojem se najviae oboljevalo, dok kod ostalih godianjih doba nisu primijeene zna ajne razlike. - Nakon dokazane infekcije Helicobacter pylori, potrebno je provesti eradikacijsku terapiju, izlje enje helicobacter pylori infekcije znatno smanjuje rizik od pojave i razvoja raznih kroni nih bolesti probavnog trakta. - Izlje enje Helicobacter pylori infekcije mo~e rezultirati zna ajnim poboljaanjem klini kog stanja. 7. LITERATURA 1.Medicinska mikrobiologija. Selma Uzunovi-Kamberovi. Zenica 2009. 2. Alba Posse R S., Toledo R A.,Viana Cabral M. Helicobacter pylori: Clinica, Diagnostico y Tratamiento. Revista de Posgrado de la VIa Catedra de Medicina - N 158  Junio 2006 3. World Health Organization. Water Recration an Disease. http//www.who.int (3.08.2014) 4. Kaleni S. Helicobacter pylori-epidemiologija i bioloake zna ajle. Medicus.Vol. 5, Br.1, Zagreb 1996. 5. Helicobacter pylori i pepti ki ulcus: sadaanji polo~aj. Medicus. Vol.1, Br 2, Zagreb 1992. 6. Jaki-Razumovi~ J., Rustemovi N. Detekcija Helicobacter pylori u histoloakim uzorcima. Medicus. Vol. 21, Br. 2, Zagreb 2012. 7. M.V. Vukadinovi, C. Prohaska Poto mik,( B. `eni. Infektoloaki Glasnik. Dinamika titra specifi nih IgG protutijela u lije enju Helicobacter pylori infekcije primjenom terapijskog protokola s azitromicinom. Vol.25, No.4. Prosinac 2005. 9. Karaka S., Tandir S., Epidemiologija. Zenica: Print GS Travnik, 2009     PAGE  PAGE 5 *RTtv& . 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s s s s s s ss%齣쭊묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉묉뮌rr t s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s sr)ƴ﯍묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊묊﯌뮍{ t s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s sq,뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊ﰌ믍w t s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s sq,៿腳겔뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊뭊ﰌ믍y s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s sr0ߖm꺠﯋쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쭌쯏| t s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s ss5ޘ\樂í쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌쮌찏t s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s sr9ؚKϿﰍ%s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s ss=Ҙ¿̗9]5q s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s tB꽺ǖ9MêBp s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s sF踶Ŗ:>̺Oq s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s tH鷵Ę?3uﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﰏﲑYr s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s uM箬F.dﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﱏﳑk s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s uQ檩H.W歽ﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﱐﳒx s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s uS櫩I-HDzﱏs s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s vZ垜I.;(s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s v_嘖I.2nﱐ8q s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s ua䗕I02]çﱐNr s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s sveK23N꡸ʲi v s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s svfL35Cоx r s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s svmM359x|q s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s swoއM475b¦+q s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s swr܂P486S즺ư?s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s swu|zX789E] v s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s swvus[8::;{z r s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s sw}qo[8:9:j{r s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s svqp[9;;;[Ů3t s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s swmk[9;;;N̺M t r s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s ssw눭hf]<===Am t s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s ssw늮hf_?@@?@vt s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s srw덯`aa?@@?Bi¦% t s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s srx钲YZ}a?@@@AY˵Ku r s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s sszꕶXX{aABBBAJu t t s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s sry阶TS|aBCCCBD!~ s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s 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