pylori subclones with different cagA EPIYA motif variants in the same biopsy specimen, may be more aggressive than a single ancestral find more strains acting alone. In an early study it has been suggested that the majority see more of Swedish clinical isolates of H. pylori from patients of higher age (>63 years old) represent single strain infections. However, in younger ages multiple strain infection may be more common [51]. Furthermore, it has been discussed that different subclones of each strain, some of which might be cagA-positive or -negative, may coexist, possibly colonising different areas of the stomach during different

periods of life-long H pylori infection [51]. In this context, the aim of this study was to investigate a possible association between the presence of H. pylori cagA EPIYA motifs and disease outcome. We found an association between H. pylori DNA isolated from the same biopsy specimen and generating two or more cagA EPIYA motif variant Captisol in vivo amplicons and peptic ulcer OR = 2.77 (1.10-7.00). Gastric atrophy was associated with

two or more EPIYA-C motifs in the cagA gene of the biopsy (corpus and antrum only) H. pylori strains, OR = 1.86 (1.05-3.30). Previous studies have also found this correlation [14, 27] and it has been suggested that a higher number of EPIYA-C motifs enables Amisulpride a higher degree of phosphorylation, and, hence, increases the risk of gastric cancer and gastric intestinal metaplasia [28]. One explanatory mechanism in this aspect may be the interaction of CagA with the protein ASPP2, which normally activates p53 to induce apoptosis. CagA inhibits ASPP2, leading to an increased cell survival and enhanced transformation of the cell [48]. Other studies have shown an association of gastric cancer and atrophy to the s1 genotype [35], the s1m1 genotype [36], or the i1 genotype [27, 37–39]. In the present study, we detected

a higher frequency of atrophy among the vacA s1d1m1 genotype than among other genotypes. However, none of these results were statistically significant, which could be due to small or unevenly distributed groups of samples (type II error). Miernyk and co-workers observed an increased risk of developing peptic ulcer disease in s1m1 compared to s1m2/s2m2 vacA genotype [52]. Our study shows a tendency towards a similar association, although not statistically significant. Conclusions In summary, H. pylori strains with variation in the number of cagA EPIYA motif variants present in the same biopsy were associated with the occurrence of peptic ulcer. Similarly, two or more EPIYA-C motifs were associated with atrophy in the gastric mucosa. No statistically significant association between vacA genotypes and gastroduodenal pathogenesis was observed.