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Effect of H. Pylori infection on the expression of cox-2 in gastric mucosa
GASTROENTEROLOGY Vol. 114, No. 4
A282 AGA ABSTRACTS
• Gl156 GASTRIC ANTISECRETORY DRUG-INDUCED ACHLORHYDRIA CAUSES DECREASES IN SERUM VITAMIN B~2 LEVELS IN PATIENTS WITH ZOLLINGER-ELLISON SYNDROME (ZES): A PROSPECTIVE STUDY. J. Serran0, F. Gibril, F. Yu, S.U. Goebel, R.T. Jensen, NIH, Bethesda, MD. Markedly decreased acid secretion is known to decrease vitamin B~2 absorption. However, it is controversial whether prolonged treatment with potent gastric antisecretory drugs will caused decreased serum vitamin Btz levels (Bt2 levels). This could be a potentially important problem in conditions such as GERD or ZES, requiring continuous long-term treatment. In a previous study we reported that B~z levels, but not serum folate levels, determined at one time correlated inversely with the length of omeprazole treatment in patients with ZES. In the present study to provide insights into the possible effects of long-term acid suppression on B~2 levels in a given patient, we have analyzed sequential results from 68 patients with ZES who were followed for at least 5 years. Patients had yearly B~ levels and determinations of acid secretory control taken one hour before the next dose of antisecretory drug. The mean age of the patients was 55 ± 1 yrs, there were 22 females and 46 males, and the total duration of gastric antisecretory treatment was 14 _+0.5 yrs. Fifty-two patients were being treated with omeprazole (mean time ± 1SEM=5 ± 1 yrs) and 17 patients with histamine Hz inhibitors. The mean initial B~2 level was 439 ± 21 pg/ml (normal=165-1000 pg/ml) and the last Ba2 level, a mean of 6.3 ± 1.2 yrs later, was 427 ± 21 pg/ml, was not significantly different. The patients had a mean basal acid output of 25 ± 2 mEq/h and M A n of 54-+ 4 mEq/h. The patients' acid secretory rate on antisecretory drug for each of the last 5 years was reviewed and 21/68 (30%) had complete achlorhydria defined as no basal acid secretion during each of the last 3 years. The B~ levels over the 6.3 ± 1.1 yrs from the first to the last Bl~ level in the achlorhydric patients showed a highly significant (p=0.001) decrease from 419 _+38 to 305 ± 24 pg/ml. In contrast, for the 47 patients without complete achlorhydria over a 6.3 ± 1.2 year period of antisecretory drug treatment, the B~2 levels did not change significantly (447 ± 26 vs 480 ± 35 pg/ml). A significantly higher proportion (p=0.002) [18/21 (86%)] of patients with complete achlorhydria had a decrease in their B~2 levels over this time period compared to the patients without achlorhydria [22/47 (47%)]. These results demonstrate that profound acid inhibition, which occurs in 32% of patients with ZES, lead to a highly significant decrease in serum vitamin levels over a 6-year period. In other studies > 80% of patients with GERD treated long-term with potent antisecretory drugs also have such acid hyposecretion that hypergastrinemia develops. These results suggest that in patients with such conditions as ZES or GERD undergoing prolonged daily treatment with potent gastric acid suppressants such as omeprazole or lansoprazole, routine monitoring of B~2levels should be considered. • Gl157 BLEEDING DUODENAL ULCER PATIENTS ARE ASSOCIATED WITH A POLIMORPHYSM OF THE ENDOTHELAL CONSTITUTIVE NITRIC OXIDE SYNTHASE GENE. M.T. Serrano, A. Lanas, E. Piazuelo, S. Santolaria, R. Benito, R. Safnz. U.M.I. Services of Gastroenterology and Microbiology. Universitary Clinic Hospital. Zaragoza. Spain. Nitric oxide (NO) can exert both protective and proinflammatory actions in the gastrointestinal tract. NO modulates gastric mucosal blood flow, stimulates gastric mucus and NO donors protect against mucosal injury induced by different agents. Moreover, enhanced gastric NO synthase (NOS) activity has been shown to be increased in duodenal ulcer (DU) patients. Polymorphisms of the ecNOS gen has been associated with some pathological conditions. Objective: To determine the genotype and allele frequencies of the ecNOS gene in peptic ulcer patients. Methods: ecNOS alleles of a previously described polymorphism (Nat Med 1996.) were studied from genomic DNA obtained from 198 ulcer patients (144 DU and 54 GU; 130 had had a previous bleeding episode) and 130 healthy controls. H. pylori infection was confirmed by both histology and CLO-test in patients and breath test and/or serology in controls. Results: Hp infection was present in 91.6% of DU, 81.2% of GU and 65.5% of controls (p < 0.001). 43.3% DU and 86% GU had used NSAIDs. Genotype (ab, bb, aa) and allele frecuency were similar for both peptic ulcer patients and controls. Also, no differences were found when patients and controls were analyzed according to the presence of H. pylori infection or NSAID use. However, DU patients with a history of recent upper GI bleeding were less frequently carriers of allele "a" (O.R.=2.08; 95% CI=1.05-4.039; p=0.03) Group Controls Peptic Ulcer GU DU Bleeding DU * p < 0.05
n 130 195 51 144 87
Genotype n (%) ab bb 38 (29.2) 91 (70) 44 (22.6) 150 (76.9) 15 (29.4) 36 (70.6) 29 (20.1) 114 (79.2) 15 (17.2)* 72 (82.8)
Allele Frequency ( % ) aa a b 1 (0.8) 15.4 84.6 1 (0.5) 11.8 88.2 0 (0) 14.7 85.3 1 (0.7) 10.7 89.3 0 (0) 8,6" 91.4
Conclusion: This polymorphism of the ecNOS gene might be associated with
a susceptibility of duodenal ulcer patients to bleeding. This research was made possible by a grant from the University of Zaragoza
•Gl158
CO-DETECTION OF HELICOBACTER PYLORI AND OF ITS RESISTANCE TO CLARITHROMYCIN BY PCR DIRECTLY FROM BIOPSY MATERIAL. E. Sevin 1, D. Lamarque2, J.C. Delchier2, C.L Soussy1, J. TankoviO. Service de Bacteriologic-Virologic-Hygiene I and Service d'Hrpato-gastroentrrologie2, HSpital Henri Mondor, 94010 Cr&eil, France. In France, the triple regimen amoxicillin-clarithromycin-proton pump inhibitor is recommended for use in eradication therapy of H. pylori, with a success rate of 70-80%. Resistance to clarithromycin is frequently implicated in treatment failure. H. pylori being a fastidious slow-growing bacterium, susceptibility testing by microbiologic methods takes at least one week. The genetic basis of clarithromycin resistance in H. pylori has been elucidated: in most cases, resistance is due to occurrence of a A2143G or A2144G point mutation in the 23S ribosomal RNA gene, leading to a loss of affinity of the drug for its ribosomal target. We have developed a rapid diagnostic test (less than 24 hours) based on PCR-RFLP (restriction fragment length polymorphism) and permitting, directly from gastric biopsy samples, to detect H. pylori and to test its suceptibility to clarithromycin. A 629-bp fragment of the 23S rRNA gene of H. pylori is amplified by PCR and the abovementioned mutations are detected with restriction enzymes BsaI and BbsI. 35 gastric samples were tested in parallel by standard microbiologic methods (culture and clarithromycin susceptibility testing with E-test strips) and by PCR-RFLP. The 10 culture-negative samples were also PCR-negative. 16 out of the 25 culture-positive samples (64%) were PCR-positive. RFLP analysis could be done in 12 cases and the results were in agreement with those of the E-test: susceptibility in 5 cases, resistance in 7 (6 A2144G mutations and 1 A2143G mutation). This PCR-RFLP test, if optimized, could be used in routine for rapid cladthromycin susceptibility testing without the need for culture. • Gl159
DIAGNOSIS OF GASTRIC H. PYLORI USING A SELF-CONTAINED INGESTIBLE pH PROBE WITH RADIO TRANSMITTER. M. Seyedi, G. Ghuloom, A.F. Cutler. Dept. of Medicine, Sinai Hospital, Wayne State University, Detroit, MI. Both rapid urease tests and breath tests indirectly identify H. pylori by its urease activity and the production of ammonia. Ingestion of urea in the presence of H. pylori should induce a rise in gastric pH. A noninvasive, accurate, in-office test which identifies the rise in pH may aid in bacterial diagnosis. Aim: To determine ifH. pylori infection can be detected using urea and a radio transmitter equipped pH probe. Methods: Twenty-three patients, twelve with active H. pylori infection documented by positive serology and either positive gastric histology or [13C] urea breath test, were asked to swallow a capsule containing a disposable self-contained pH probe with radio transmitter. No patient had recent ingestion of proton pump inhibitors, H2 blockers, bismuth, sucralfate or antibiotics. After allowing fifteen minutes for migration of the probe into the stomach and stable baseline pH readings, 125 mg of urea mixed with water was ingested. Gastric pH was then recorded for up to 40 minutes. Results: The probe remained in the stomach during baseline readings in 20123 patients as documented by stable low pH recordings. Rapid passage into the duodenum in 3 patients was evidenced by a prompt rise to pH > 6. In 6/11 H. pylori positive patients, there was a rise in pH ranging from 0.5 to 2.5. There was no change in pH after urea ingestion in 7/9 H. pylori negative patients. The remaining 2 H. pylori negative patients recorded pH rises of 0.5 and 1.25. The mean change in pH for the H. pylori positive and negative groups was 0.7 and 0.2, respectively (p=0.11 between groups). Using an increase in pH of > 0.5 as a marker for infection, the ingestible probe had a sensitivity of 55%, specificity of 78%, positive predictive value of 75% and negative predictive value of 58% for detection of 14. pylori in the 20 patients. Conclusions: The pH probe is not accurate enough in the present form for clinical use. An increase in the amount of ingested urea or the use of a string to position the probe may improve test accuracy. This research was funded in part by Great Smokies Diagnostic Lab, Asheville, NC • Gl160
EFFECT OF H. PYLORI INFECTION ON THE EXPRESSION OF COX-2 IN GASTRIC MUCOSA. AA Shah, L Cullen, A O'Neill, Anna Ali, T Keane, DJ Fitzgerald, FE Murray. Royal College Of Surgeons In Ireland And Beaumont Hospital, Dublin INTRODUCTION: Selective cyclo-oxygenase (COX)-2 inhibitors have been developed on the assumption that COX-1 is the primary isoform responsible for the production of cytoprotective prostaglandins (PGEz and PGI2) in the stomach. In contrast COX-2 is induced at the sites of inflammation. Using H. pylori infection as a model of inflammation, this study was designed to evaluate the effects of H. pylori infection on prostanoid synthesis and expression of COX-2 in human gastric mueosa. AIMS: 1. To determine the effect of H. pylori infection on prostanoid synthesis in the gastric mucosa. 2. Effect of various agents like aspirin, NS-398 (selective COX-2 inhibitor) and lipo- polysaccharide. 3. To determine the expression of COX-2 in human gastric mucosa. PATIENTS AND METHODS: We examined the formation of prostaglandin (PGE2) and prostacyclin (PG12) in gastric biopsies, obtained from 21 patients undergoing routine endoscopy. H. pylori was detected by CLO test, histology and culture. Biopsy samples were incubated at 37°C for varying length of time in the presence and absence of NS-398, selective COX-2 inhibitor or aspirin. Samples were also treated with endotoxin in order to induce COX-2
Esophageal, Gastric, and Duodenal Disorders A283
April 1998 expression. Tissue was also analysed for COX-2 expression in vivo by PCR and immuno-histochemistry. RESULTS: In 15 out of 21 patients H. pylori was detected by at least two of the three methods described above. The effect of H. pylori infection on POE2 and 6 keto PGFjet in ng/mgof protein was as follows: POE2 Hp +ve: Hp -ve:
Control 190 ± 30 64±19
Aspirin 27 ± 6.6 13±6
NS-398 148 ± 26 62±21
LPS 137 ± 25 63±22
LPS + ASA 20.3 ± 6 8.5±5
6keto PGF let Hp +ve: Hp -ve:
Control 245 ± 87 89±24
Aspirin 53 ± 43 15±3
NS-398 197 ± 41 102±18
LPS 289 ± 83 112±29
LPS + ASA 13 ± 4.2 10±8
PCR analysis in 10 patients. 6 Hp infected showed expression of COX-2. Immunohistochemistry in all patients irrespective of Hp status expressedCOX-2. CONCLUSION: Higher level of prostaglandin function in patients who were H. pylori infected which was significantly inhibited by aspirin, but was unaltered by NS-398 and LPS. However expression of COX-2 was detected by PCR and immuno-histochemistry. Our data showed that COX-I is inducible in the stomach in response to Hp infection while COX-2 is constitutively expressed. • Gl161 N1MESULIDE, A SELECTIVE COX-2 INHIBITOR, CAUSES LESS GASTROINTESTINAL DAMAGE COMPARED WITH NAPROXEN: A PROSPECTIVE STUDY IN HUMAN VOLUNTEERS. AA Shah, FE Murray, B Thjodleifsson, E Oddsson, H Gudjonsson, DI Fitzgerald, I Bjarnason. Beaumont Hospital and Royal College of Surgeons, Dublin, Ireland; Icelandic University National Hospital, Reykjavik, Iceland and Kings College School of Medicine and Dentistry, London, UK. Complications of NSAID induced gastrointestinal damage remain the commonest cause of iatrogenic hospital admission. Selective cyclooxygenase2 (COX-2) inhibitors, which preferentially inhibit peripheral COX-2 compared with gastroprotective COX-1 uninhibited, potentially may reduce the burden of morbidity and mortality associated with NSAID use. The aim of this study was to compare the gastroduodenal toxicity of nimesulide, a selective COX-2 inhibitor with naproxen, in a study utilizing endoscopy in healthy human volunteers. Thirty six healthy white volunteers aged >- 39 years were recruited (mean 48.4yrs. SD 7.5 yrs, 67% male). A prospective randomized double-blind, double-dummy study was performed in two centres. Subjects received in random order in a crossover fashion naproxen 500mg bid and nimesulide 100mg bid for two weeks, with a intervening washout period of two weeks. Prior to and at the end of therapy, subjects were evaluated by endoscopy to assess gastroduodenal mucosal damage (modified Lanza scale and a 150mm visual analogue scale (VAS)). Results are expressed as median (IQR). Following two weeks of treatment with either agent, gastric damage associated with nimesulide was significantly less compared with naproxen. Median gastric Lanza score following treatment period with nimesulide was 0 (0-2) and following naproxen was 3 (2-3), (p < 0.001). The gastric erosions VAS following treatment with nirnesulide was 0 (0-12) compared with 58 (21-98) following naproxen (p < 0.001). Duodenal mucosal damage was less marked than gastric damage, but was also significantly reduced in the nimesulide treated group (p=0.009). Nimesulide, a selective COX-2 inhibitor, caused significantly less gastrnduodenal mucosal damage compared with naproxen. Use of selective COX-2 inhibitors may be associated with less morbidity than unselective NSAIDs. This study was supported by a grant from Helsinn Healthcare.
Aim:
Patientsand Methods:
Results:
Summary:
Gl162 DIFFERENTIAL EXPRESSION OF e-jun AND c-mye PROTOONCOGENES DURING GASTRIC ULCER DEVELOPMENT. M. Shahin l, T. Pohle l, J. Konturek 1, D. Schuppan 2, H. Herbst 3, W. Domschke l Dept. of Medicine B, Univ. of Mtinsterl; Dept. of Medicine I, Univ. of Erlangen2; Dept. of Pathology, Univ. of Hamburg3, Germany Background: Recent evidence supports the hypothesis that cellular protooncogenes (c-one-genes) have key roles in the biochemical pathway controlling cell proliferation. Specific transcriptional patterns of c-one-genes expression during physiologic cellular growth and differentiation have been demonstrated for a variety of cell types in adults and developing tissues. Therefore the analysis of differential activation of parenchymal and nonparenchymal gastric cells and their interactions seems pivotal for understanding the mechanisms occurring during tissue restoration after injury. Aim: Our objective was to investigate the alterations occurring in c-jun and c-myc*oncogenes expression during the early hours of gastric ulcer development and healing. Methods: We used the well established acetic acid induced ulcer model in rat. Animals were sacrificed 2, 4, 8, 12, 24 and 48 hours after ulcer induction. C-jun and c-myc transcriptional activities were assessed by in situ hybridization utilizing 35S-labelled RNA probes. Results: In comparison to controls c-jun hybridization signals were down regulated in the lamina propria 2 hrs after ulcer induction, while c-myc signals were mostly found in the submucosa and serosa. Reinduction of c-jun transcriptional activity was documented in the region of neck cells and around
subrnucosal blood vessels. C-jun RNA-expression reached its maximal level after 24 hrs at the ulcer margin. C-myc transcripts were of lower intensity at all time points. Conclusion: The enhanced expression of c-jun and c-myc-oncogenes early after ischemic injury of the gastric mucosa represents an important marker for cellular activation and proliferation accompanying tissue repair reactions. The differential expression in terms of intensity and localization points to a distinct role of both oncogenes during ulcer development and the early healing phase. • Gl163 LOW INCIDENCE OF INFECTION IN PATIENT WITH DUODENAL ULCER AND CHRONIC LIVER DISEASE. W. Shahin*, M.Z. Abdel-Baset, A.K. Nassar, M.M. Atta and S.M. Kabil. Depart. of Hepatology. Univ. of Benha, Egypt. *Univ. of Iowa. Iowa City, Iowa 52242.
H. PYLORI
INTRODUCTION: Chronic Liver Disease (CLD) is associated with an increased frequency and impaired healing of peptic ulcer with H2-blockers. The factors involved in this increased frequency and resistance to treatment is poorly understood H. pylori and mucosal changes due to portal hypertension are possible factors. AIM: We studied the clinical features, presence of helicobacter pylori and response to treatment (Omeprazole 40 mg/day for 4 weeks) in patients who presented with symptomaticpeptic ulcer both with and without chronic liver disease METHODS: Sixty nine consecutive patients with duodenal ulcer were divided in two groups; chronic liver disease (CLD)(43 patients, 30 males, 44.7+/-10.3 years) and control group (26 patients, 17 males, 40.5+/-11.2 years). The groups were similar as regards age, sex and sociodemographic characters. Patients underwent a complete history, physical examination, liver function tests and endoscopy at entry and 4 weeks later after treatment. Antral biopsies were stained by H&E and Giernsa stains. RESULTS: 49% of CLD with ulcer patients did not have H. pylori infection.
IGr°up
INn" Pain iBleeding iH'pyl°ri I%°fHealing
CLD 43 71% 24% Control 26 69% 23% * All non-healed were H.P positive 0
51.2% 96.2%
90.7%* 80.8%
Hematemesis was a constant feature of the CLD patients who bled as compared with control. CONCLUSIONS: H. pylori is present in only ~/2 of the CLD patients with duodenal ulcer compared to 96% in control group suggesting the presence of a possible specific pathological factor other than H. pylori. Omeprazole overcame the resistance to treatment previously seen with H2-blockers in duodenal ulcer with CLD. • GU64 LANSOPRAZOLE EFFECTIVELY SUPPRESSES INTRAGASTRIC ACIDITY WREN ADMINISTERED GASTROSTOMY AS INTACT GRANULES IN ORANGE JUICE. V. K. Sharma. E. A. Ugheoke, R. Vasudeva, C. W. Howden, University of South Carolina, Columbia, SC Lansoprazole is usually given as capsules of enteric-coated granules. Some patients, including those with feeding tubes, may not be able to take this formulation. When given as intact granules via a nasogastric tube, lansoprazole has comparable bioavailability to the conventional capsule formulation (1). No data exist on the effectiveness of non-encapsulated intact granules of lansoprazole in suppressing intragastric acidity. Purpose: To study the effectiveness of non-encapsulated intact lansoprazole granules given gastrostomy in controlling intragastric acidity. Methods: 6 men (mean age 68.7; sd 5.2)with established gastrostomies were studied. Any acidsuppressing medicines were stopped 1 week prior to study. A baseline 24-hour intragastric pH study was obtained using a probe placed through the gastrostomy as previously described. (2). Lansoprazole 30 mg was administered with orange juice gastrostomy every morning. A repeat 24-hour intragastric pH study was performed after 7 days of once-daily dosing. Baseline (day 0) and day 7 data were compared using Student's t-test (paired; 2 tailed).
VIA
via
per
Results: Mean pH Median pH % of 24 hour period pH > 2 % of 24 hour period pH > 3 % of 24 hour period pH > 4 % of 24 hour period pH > 5
Baseline 2.1 1.6 43.0 26.9 14.5 7.5
Day 7 4.7 5.1 94.0 86.0 71.0 50.9
P value 0.001 < 0.001 < 0.001 < 0.001 0.002 0.01
Mean intragastric pH rose in each patient (range at baseline=l.4-2.6; at day 7=3.9-5.7). Conclusions: Lansoprazole effectively controls intragastric acidity when given gastrostomy as intact granules in orange juice. The level of acid suppression is similar to that seen with the conventional capsule formulation. [1] Chun 1996; 18:833-42 [2] Sharma 1997; 92:848-51 This study was supported by TAP Pharmaceuticals, Inc., Deerfield, IL.
via et al., ClinTher et al.,AmJ Gastroenterol
A282 AGA ABSTRACTS
• Gl156 GASTRIC ANTISECRETORY DRUG-INDUCED ACHLORHYDRIA CAUSES DECREASES IN SERUM VITAMIN B~2 LEVELS IN PATIENTS WITH ZOLLINGER-ELLISON SYNDROME (ZES): A PROSPECTIVE STUDY. J. Serran0, F. Gibril, F. Yu, S.U. Goebel, R.T. Jensen, NIH, Bethesda, MD. Markedly decreased acid secretion is known to decrease vitamin B~2 absorption. However, it is controversial whether prolonged treatment with potent gastric antisecretory drugs will caused decreased serum vitamin Btz levels (Bt2 levels). This could be a potentially important problem in conditions such as GERD or ZES, requiring continuous long-term treatment. In a previous study we reported that B~z levels, but not serum folate levels, determined at one time correlated inversely with the length of omeprazole treatment in patients with ZES. In the present study to provide insights into the possible effects of long-term acid suppression on B~2 levels in a given patient, we have analyzed sequential results from 68 patients with ZES who were followed for at least 5 years. Patients had yearly B~ levels and determinations of acid secretory control taken one hour before the next dose of antisecretory drug. The mean age of the patients was 55 ± 1 yrs, there were 22 females and 46 males, and the total duration of gastric antisecretory treatment was 14 _+0.5 yrs. Fifty-two patients were being treated with omeprazole (mean time ± 1SEM=5 ± 1 yrs) and 17 patients with histamine Hz inhibitors. The mean initial B~2 level was 439 ± 21 pg/ml (normal=165-1000 pg/ml) and the last Ba2 level, a mean of 6.3 ± 1.2 yrs later, was 427 ± 21 pg/ml, was not significantly different. The patients had a mean basal acid output of 25 ± 2 mEq/h and M A n of 54-+ 4 mEq/h. The patients' acid secretory rate on antisecretory drug for each of the last 5 years was reviewed and 21/68 (30%) had complete achlorhydria defined as no basal acid secretion during each of the last 3 years. The B~ levels over the 6.3 ± 1.1 yrs from the first to the last Bl~ level in the achlorhydric patients showed a highly significant (p=0.001) decrease from 419 _+38 to 305 ± 24 pg/ml. In contrast, for the 47 patients without complete achlorhydria over a 6.3 ± 1.2 year period of antisecretory drug treatment, the B~2 levels did not change significantly (447 ± 26 vs 480 ± 35 pg/ml). A significantly higher proportion (p=0.002) [18/21 (86%)] of patients with complete achlorhydria had a decrease in their B~2 levels over this time period compared to the patients without achlorhydria [22/47 (47%)]. These results demonstrate that profound acid inhibition, which occurs in 32% of patients with ZES, lead to a highly significant decrease in serum vitamin levels over a 6-year period. In other studies > 80% of patients with GERD treated long-term with potent antisecretory drugs also have such acid hyposecretion that hypergastrinemia develops. These results suggest that in patients with such conditions as ZES or GERD undergoing prolonged daily treatment with potent gastric acid suppressants such as omeprazole or lansoprazole, routine monitoring of B~2levels should be considered. • Gl157 BLEEDING DUODENAL ULCER PATIENTS ARE ASSOCIATED WITH A POLIMORPHYSM OF THE ENDOTHELAL CONSTITUTIVE NITRIC OXIDE SYNTHASE GENE. M.T. Serrano, A. Lanas, E. Piazuelo, S. Santolaria, R. Benito, R. Safnz. U.M.I. Services of Gastroenterology and Microbiology. Universitary Clinic Hospital. Zaragoza. Spain. Nitric oxide (NO) can exert both protective and proinflammatory actions in the gastrointestinal tract. NO modulates gastric mucosal blood flow, stimulates gastric mucus and NO donors protect against mucosal injury induced by different agents. Moreover, enhanced gastric NO synthase (NOS) activity has been shown to be increased in duodenal ulcer (DU) patients. Polymorphisms of the ecNOS gen has been associated with some pathological conditions. Objective: To determine the genotype and allele frequencies of the ecNOS gene in peptic ulcer patients. Methods: ecNOS alleles of a previously described polymorphism (Nat Med 1996.) were studied from genomic DNA obtained from 198 ulcer patients (144 DU and 54 GU; 130 had had a previous bleeding episode) and 130 healthy controls. H. pylori infection was confirmed by both histology and CLO-test in patients and breath test and/or serology in controls. Results: Hp infection was present in 91.6% of DU, 81.2% of GU and 65.5% of controls (p < 0.001). 43.3% DU and 86% GU had used NSAIDs. Genotype (ab, bb, aa) and allele frecuency were similar for both peptic ulcer patients and controls. Also, no differences were found when patients and controls were analyzed according to the presence of H. pylori infection or NSAID use. However, DU patients with a history of recent upper GI bleeding were less frequently carriers of allele "a" (O.R.=2.08; 95% CI=1.05-4.039; p=0.03) Group Controls Peptic Ulcer GU DU Bleeding DU * p < 0.05
n 130 195 51 144 87
Genotype n (%) ab bb 38 (29.2) 91 (70) 44 (22.6) 150 (76.9) 15 (29.4) 36 (70.6) 29 (20.1) 114 (79.2) 15 (17.2)* 72 (82.8)
Allele Frequency ( % ) aa a b 1 (0.8) 15.4 84.6 1 (0.5) 11.8 88.2 0 (0) 14.7 85.3 1 (0.7) 10.7 89.3 0 (0) 8,6" 91.4
Conclusion: This polymorphism of the ecNOS gene might be associated with
a susceptibility of duodenal ulcer patients to bleeding. This research was made possible by a grant from the University of Zaragoza
•Gl158
CO-DETECTION OF HELICOBACTER PYLORI AND OF ITS RESISTANCE TO CLARITHROMYCIN BY PCR DIRECTLY FROM BIOPSY MATERIAL. E. Sevin 1, D. Lamarque2, J.C. Delchier2, C.L Soussy1, J. TankoviO. Service de Bacteriologic-Virologic-Hygiene I and Service d'Hrpato-gastroentrrologie2, HSpital Henri Mondor, 94010 Cr&eil, France. In France, the triple regimen amoxicillin-clarithromycin-proton pump inhibitor is recommended for use in eradication therapy of H. pylori, with a success rate of 70-80%. Resistance to clarithromycin is frequently implicated in treatment failure. H. pylori being a fastidious slow-growing bacterium, susceptibility testing by microbiologic methods takes at least one week. The genetic basis of clarithromycin resistance in H. pylori has been elucidated: in most cases, resistance is due to occurrence of a A2143G or A2144G point mutation in the 23S ribosomal RNA gene, leading to a loss of affinity of the drug for its ribosomal target. We have developed a rapid diagnostic test (less than 24 hours) based on PCR-RFLP (restriction fragment length polymorphism) and permitting, directly from gastric biopsy samples, to detect H. pylori and to test its suceptibility to clarithromycin. A 629-bp fragment of the 23S rRNA gene of H. pylori is amplified by PCR and the abovementioned mutations are detected with restriction enzymes BsaI and BbsI. 35 gastric samples were tested in parallel by standard microbiologic methods (culture and clarithromycin susceptibility testing with E-test strips) and by PCR-RFLP. The 10 culture-negative samples were also PCR-negative. 16 out of the 25 culture-positive samples (64%) were PCR-positive. RFLP analysis could be done in 12 cases and the results were in agreement with those of the E-test: susceptibility in 5 cases, resistance in 7 (6 A2144G mutations and 1 A2143G mutation). This PCR-RFLP test, if optimized, could be used in routine for rapid cladthromycin susceptibility testing without the need for culture. • Gl159
DIAGNOSIS OF GASTRIC H. PYLORI USING A SELF-CONTAINED INGESTIBLE pH PROBE WITH RADIO TRANSMITTER. M. Seyedi, G. Ghuloom, A.F. Cutler. Dept. of Medicine, Sinai Hospital, Wayne State University, Detroit, MI. Both rapid urease tests and breath tests indirectly identify H. pylori by its urease activity and the production of ammonia. Ingestion of urea in the presence of H. pylori should induce a rise in gastric pH. A noninvasive, accurate, in-office test which identifies the rise in pH may aid in bacterial diagnosis. Aim: To determine ifH. pylori infection can be detected using urea and a radio transmitter equipped pH probe. Methods: Twenty-three patients, twelve with active H. pylori infection documented by positive serology and either positive gastric histology or [13C] urea breath test, were asked to swallow a capsule containing a disposable self-contained pH probe with radio transmitter. No patient had recent ingestion of proton pump inhibitors, H2 blockers, bismuth, sucralfate or antibiotics. After allowing fifteen minutes for migration of the probe into the stomach and stable baseline pH readings, 125 mg of urea mixed with water was ingested. Gastric pH was then recorded for up to 40 minutes. Results: The probe remained in the stomach during baseline readings in 20123 patients as documented by stable low pH recordings. Rapid passage into the duodenum in 3 patients was evidenced by a prompt rise to pH > 6. In 6/11 H. pylori positive patients, there was a rise in pH ranging from 0.5 to 2.5. There was no change in pH after urea ingestion in 7/9 H. pylori negative patients. The remaining 2 H. pylori negative patients recorded pH rises of 0.5 and 1.25. The mean change in pH for the H. pylori positive and negative groups was 0.7 and 0.2, respectively (p=0.11 between groups). Using an increase in pH of > 0.5 as a marker for infection, the ingestible probe had a sensitivity of 55%, specificity of 78%, positive predictive value of 75% and negative predictive value of 58% for detection of 14. pylori in the 20 patients. Conclusions: The pH probe is not accurate enough in the present form for clinical use. An increase in the amount of ingested urea or the use of a string to position the probe may improve test accuracy. This research was funded in part by Great Smokies Diagnostic Lab, Asheville, NC • Gl160
EFFECT OF H. PYLORI INFECTION ON THE EXPRESSION OF COX-2 IN GASTRIC MUCOSA. AA Shah, L Cullen, A O'Neill, Anna Ali, T Keane, DJ Fitzgerald, FE Murray. Royal College Of Surgeons In Ireland And Beaumont Hospital, Dublin INTRODUCTION: Selective cyclo-oxygenase (COX)-2 inhibitors have been developed on the assumption that COX-1 is the primary isoform responsible for the production of cytoprotective prostaglandins (PGEz and PGI2) in the stomach. In contrast COX-2 is induced at the sites of inflammation. Using H. pylori infection as a model of inflammation, this study was designed to evaluate the effects of H. pylori infection on prostanoid synthesis and expression of COX-2 in human gastric mueosa. AIMS: 1. To determine the effect of H. pylori infection on prostanoid synthesis in the gastric mucosa. 2. Effect of various agents like aspirin, NS-398 (selective COX-2 inhibitor) and lipo- polysaccharide. 3. To determine the expression of COX-2 in human gastric mucosa. PATIENTS AND METHODS: We examined the formation of prostaglandin (PGE2) and prostacyclin (PG12) in gastric biopsies, obtained from 21 patients undergoing routine endoscopy. H. pylori was detected by CLO test, histology and culture. Biopsy samples were incubated at 37°C for varying length of time in the presence and absence of NS-398, selective COX-2 inhibitor or aspirin. Samples were also treated with endotoxin in order to induce COX-2
Esophageal, Gastric, and Duodenal Disorders A283
April 1998 expression. Tissue was also analysed for COX-2 expression in vivo by PCR and immuno-histochemistry. RESULTS: In 15 out of 21 patients H. pylori was detected by at least two of the three methods described above. The effect of H. pylori infection on POE2 and 6 keto PGFjet in ng/mgof protein was as follows: POE2 Hp +ve: Hp -ve:
Control 190 ± 30 64±19
Aspirin 27 ± 6.6 13±6
NS-398 148 ± 26 62±21
LPS 137 ± 25 63±22
LPS + ASA 20.3 ± 6 8.5±5
6keto PGF let Hp +ve: Hp -ve:
Control 245 ± 87 89±24
Aspirin 53 ± 43 15±3
NS-398 197 ± 41 102±18
LPS 289 ± 83 112±29
LPS + ASA 13 ± 4.2 10±8
PCR analysis in 10 patients. 6 Hp infected showed expression of COX-2. Immunohistochemistry in all patients irrespective of Hp status expressedCOX-2. CONCLUSION: Higher level of prostaglandin function in patients who were H. pylori infected which was significantly inhibited by aspirin, but was unaltered by NS-398 and LPS. However expression of COX-2 was detected by PCR and immuno-histochemistry. Our data showed that COX-I is inducible in the stomach in response to Hp infection while COX-2 is constitutively expressed. • Gl161 N1MESULIDE, A SELECTIVE COX-2 INHIBITOR, CAUSES LESS GASTROINTESTINAL DAMAGE COMPARED WITH NAPROXEN: A PROSPECTIVE STUDY IN HUMAN VOLUNTEERS. AA Shah, FE Murray, B Thjodleifsson, E Oddsson, H Gudjonsson, DI Fitzgerald, I Bjarnason. Beaumont Hospital and Royal College of Surgeons, Dublin, Ireland; Icelandic University National Hospital, Reykjavik, Iceland and Kings College School of Medicine and Dentistry, London, UK. Complications of NSAID induced gastrointestinal damage remain the commonest cause of iatrogenic hospital admission. Selective cyclooxygenase2 (COX-2) inhibitors, which preferentially inhibit peripheral COX-2 compared with gastroprotective COX-1 uninhibited, potentially may reduce the burden of morbidity and mortality associated with NSAID use. The aim of this study was to compare the gastroduodenal toxicity of nimesulide, a selective COX-2 inhibitor with naproxen, in a study utilizing endoscopy in healthy human volunteers. Thirty six healthy white volunteers aged >- 39 years were recruited (mean 48.4yrs. SD 7.5 yrs, 67% male). A prospective randomized double-blind, double-dummy study was performed in two centres. Subjects received in random order in a crossover fashion naproxen 500mg bid and nimesulide 100mg bid for two weeks, with a intervening washout period of two weeks. Prior to and at the end of therapy, subjects were evaluated by endoscopy to assess gastroduodenal mucosal damage (modified Lanza scale and a 150mm visual analogue scale (VAS)). Results are expressed as median (IQR). Following two weeks of treatment with either agent, gastric damage associated with nimesulide was significantly less compared with naproxen. Median gastric Lanza score following treatment period with nimesulide was 0 (0-2) and following naproxen was 3 (2-3), (p < 0.001). The gastric erosions VAS following treatment with nirnesulide was 0 (0-12) compared with 58 (21-98) following naproxen (p < 0.001). Duodenal mucosal damage was less marked than gastric damage, but was also significantly reduced in the nimesulide treated group (p=0.009). Nimesulide, a selective COX-2 inhibitor, caused significantly less gastrnduodenal mucosal damage compared with naproxen. Use of selective COX-2 inhibitors may be associated with less morbidity than unselective NSAIDs. This study was supported by a grant from Helsinn Healthcare.
Aim:
Patientsand Methods:
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Summary:
Gl162 DIFFERENTIAL EXPRESSION OF e-jun AND c-mye PROTOONCOGENES DURING GASTRIC ULCER DEVELOPMENT. M. Shahin l, T. Pohle l, J. Konturek 1, D. Schuppan 2, H. Herbst 3, W. Domschke l Dept. of Medicine B, Univ. of Mtinsterl; Dept. of Medicine I, Univ. of Erlangen2; Dept. of Pathology, Univ. of Hamburg3, Germany Background: Recent evidence supports the hypothesis that cellular protooncogenes (c-one-genes) have key roles in the biochemical pathway controlling cell proliferation. Specific transcriptional patterns of c-one-genes expression during physiologic cellular growth and differentiation have been demonstrated for a variety of cell types in adults and developing tissues. Therefore the analysis of differential activation of parenchymal and nonparenchymal gastric cells and their interactions seems pivotal for understanding the mechanisms occurring during tissue restoration after injury. Aim: Our objective was to investigate the alterations occurring in c-jun and c-myc*oncogenes expression during the early hours of gastric ulcer development and healing. Methods: We used the well established acetic acid induced ulcer model in rat. Animals were sacrificed 2, 4, 8, 12, 24 and 48 hours after ulcer induction. C-jun and c-myc transcriptional activities were assessed by in situ hybridization utilizing 35S-labelled RNA probes. Results: In comparison to controls c-jun hybridization signals were down regulated in the lamina propria 2 hrs after ulcer induction, while c-myc signals were mostly found in the submucosa and serosa. Reinduction of c-jun transcriptional activity was documented in the region of neck cells and around
subrnucosal blood vessels. C-jun RNA-expression reached its maximal level after 24 hrs at the ulcer margin. C-myc transcripts were of lower intensity at all time points. Conclusion: The enhanced expression of c-jun and c-myc-oncogenes early after ischemic injury of the gastric mucosa represents an important marker for cellular activation and proliferation accompanying tissue repair reactions. The differential expression in terms of intensity and localization points to a distinct role of both oncogenes during ulcer development and the early healing phase. • Gl163 LOW INCIDENCE OF INFECTION IN PATIENT WITH DUODENAL ULCER AND CHRONIC LIVER DISEASE. W. Shahin*, M.Z. Abdel-Baset, A.K. Nassar, M.M. Atta and S.M. Kabil. Depart. of Hepatology. Univ. of Benha, Egypt. *Univ. of Iowa. Iowa City, Iowa 52242.
H. PYLORI
INTRODUCTION: Chronic Liver Disease (CLD) is associated with an increased frequency and impaired healing of peptic ulcer with H2-blockers. The factors involved in this increased frequency and resistance to treatment is poorly understood H. pylori and mucosal changes due to portal hypertension are possible factors. AIM: We studied the clinical features, presence of helicobacter pylori and response to treatment (Omeprazole 40 mg/day for 4 weeks) in patients who presented with symptomaticpeptic ulcer both with and without chronic liver disease METHODS: Sixty nine consecutive patients with duodenal ulcer were divided in two groups; chronic liver disease (CLD)(43 patients, 30 males, 44.7+/-10.3 years) and control group (26 patients, 17 males, 40.5+/-11.2 years). The groups were similar as regards age, sex and sociodemographic characters. Patients underwent a complete history, physical examination, liver function tests and endoscopy at entry and 4 weeks later after treatment. Antral biopsies were stained by H&E and Giernsa stains. RESULTS: 49% of CLD with ulcer patients did not have H. pylori infection.
IGr°up
INn" Pain iBleeding iH'pyl°ri I%°fHealing
CLD 43 71% 24% Control 26 69% 23% * All non-healed were H.P positive 0
51.2% 96.2%
90.7%* 80.8%
Hematemesis was a constant feature of the CLD patients who bled as compared with control. CONCLUSIONS: H. pylori is present in only ~/2 of the CLD patients with duodenal ulcer compared to 96% in control group suggesting the presence of a possible specific pathological factor other than H. pylori. Omeprazole overcame the resistance to treatment previously seen with H2-blockers in duodenal ulcer with CLD. • GU64 LANSOPRAZOLE EFFECTIVELY SUPPRESSES INTRAGASTRIC ACIDITY WREN ADMINISTERED GASTROSTOMY AS INTACT GRANULES IN ORANGE JUICE. V. K. Sharma. E. A. Ugheoke, R. Vasudeva, C. W. Howden, University of South Carolina, Columbia, SC Lansoprazole is usually given as capsules of enteric-coated granules. Some patients, including those with feeding tubes, may not be able to take this formulation. When given as intact granules via a nasogastric tube, lansoprazole has comparable bioavailability to the conventional capsule formulation (1). No data exist on the effectiveness of non-encapsulated intact granules of lansoprazole in suppressing intragastric acidity. Purpose: To study the effectiveness of non-encapsulated intact lansoprazole granules given gastrostomy in controlling intragastric acidity. Methods: 6 men (mean age 68.7; sd 5.2)with established gastrostomies were studied. Any acidsuppressing medicines were stopped 1 week prior to study. A baseline 24-hour intragastric pH study was obtained using a probe placed through the gastrostomy as previously described. (2). Lansoprazole 30 mg was administered with orange juice gastrostomy every morning. A repeat 24-hour intragastric pH study was performed after 7 days of once-daily dosing. Baseline (day 0) and day 7 data were compared using Student's t-test (paired; 2 tailed).
VIA
via
per
Results: Mean pH Median pH % of 24 hour period pH > 2 % of 24 hour period pH > 3 % of 24 hour period pH > 4 % of 24 hour period pH > 5
Baseline 2.1 1.6 43.0 26.9 14.5 7.5
Day 7 4.7 5.1 94.0 86.0 71.0 50.9
P value 0.001 < 0.001 < 0.001 < 0.001 0.002 0.01
Mean intragastric pH rose in each patient (range at baseline=l.4-2.6; at day 7=3.9-5.7). Conclusions: Lansoprazole effectively controls intragastric acidity when given gastrostomy as intact granules in orange juice. The level of acid suppression is similar to that seen with the conventional capsule formulation. [1] Chun 1996; 18:833-42 [2] Sharma 1997; 92:848-51 This study was supported by TAP Pharmaceuticals, Inc., Deerfield, IL.
via et al., ClinTher et al.,AmJ Gastroenterol