- Email: [email protected]
Lymphoid follicles in gastric mucosa of Helicobacter pylori infected patients regress after eradication treatment
April 1995
Esophageal, Gastric, and Duodenal Disorders
• A PREDICTIVE MODEL OF MUCOSAL DAMAGE IN GERD USING AREA UNDER THE CURVE ESTIMATION OF HYDROGEN ION ACTIVITY (AUC H~. M.Barrientos, G Tougas, D ~ n g , S Sontag, R H Hunt. McMaster University, Hamilton, Canada, Hines VA Hospital, Hines IL. Gastroesophageal reflux disease (GERD) results from acid exposure of esophageal mueosa over time. Aims: We tested the hypothesis that AUC for hydrogen ion activity (IT activity) could be a more accurate predictor of mucosal damage than time below pH 4 and propose a model based on the AUC of IT activity to predict the grade of esophageal mucosal damage in GERD. Methods From 33 continuous 24-h esophageal pH recording,s the AUC of IT activity was calcalated and correlated with Savary-Miller grades of esophagitis obtained at endoscopy. A mathematical model was constructed, to analyse and express the relative importance of AUC for each grade of esophagitis. The model was based on the power function of the AUC of IT activity for 24 hours, using two parameters (130 and 131). An increment of the relative importance of AUC (130)is proportional to the absolute increase of W activity, while B1 represents the order of increase of IT activity to maintain the proportionality of AUC with each grade of esophagitis. Results: Parameters
Grade 1 (n=16)
Grade 2 (n=8)
Grade 3 (n=5)
Grade 4 (n=4)
AUC **
67.1± 19
142.6-a:38
473.5±76
868.1 ±170
Be**
0.58±.13
0,66±0.09
2.56±0.61
1.46±0.15
B1 **
0.43"4-.02
0.54-+0,02
0.78±0.02
.84±0,01
(~n x mmo~)
**= p<0.001, Kruskal-Wallis Test- (Mean +SE) The mea.n values of AUC I-F activity for each grade of csophagitis are significantly different (p<0.001). The lowest mean AUC value corresponds to grade 1 and the highest to grade 4. In grade 1 and 2, the values ofB 0 and B~ are low, indicating the correlation of AUC to low values o f H ÷ activity. In grade 4,13i is near unity indicating correlation of AUC to high values of I--Factivity. Larger values of Bo also confirm the importance of AUC for high values of IT activity. Conclusions. The AUC for IT activity can predict esophageal mucosal damage and the endoscopic grade of esopbegitis. The fie and g~ values suggest that at low H+-activity, GERD is a two component disease, The significance of the power law model suggests that GERD is dominated by a~ characteristic size scale whose pattern can be analyzed by using the fractal dimension concept.
• EVALUATION OF MANOMETRIC AND CLINICAL FINDINGS IN PRIMARY ACHALASIA VERSUS SECONDARY ESOPHAGEAL CANCER-INDUCED ACHALASIA, RM Bashir. KA Mahcr, SB Benjamin. Georgetown University
Medical Center, Washington, D,C. Previous data h a w sugg~ted specific manomctrie findings in canear-induced secondary achalasia; however, others have demonstrated the inability of clinical and manometric criteria to distinguish between primary and secondaryachalasia. Puroose: Our goal was to examine specific manom~Uieand clinical findings in primary anhalasia as compared with secondary esophagealcancer-induced achalasia and identify any discernible differences or patterns. Metho4~: We retrospectively reviewed all esophageal manomctry records and tracings of patients diagnosed with achalasla over the past 5 years. Patients wore divided int0~'wo groups: primary achalasia and seoondary esophageal caneer-iaduced achalasia, All patients had undergone esophagnscopyprior to manometric testing. Secondary achainsia patients had histologic evidence of esophageal cancer without significant stenosis. Five specific manometric findings were calculated for each patient: lower esophageal sphincter pressure (LESP). percent of lower esophageal sphincter (LES) relaxation, duration of LES relaxation, presenea of peristalsis oftbe esophageal body, and the e s o p l ~ o g a . ~ ¢ pressure gradient, Results: See table (all values am mean _+SEM). PATIENT CHARACTERISTICS
PRIMARY(nffiSl)
SECONDARY(nffit)
P-valuee _
Ao£ 57.9 + 5.3 yrs 62.7 +_3.4 yrs NS LESP 34.7 + 3.75 mmHg 30.3 + 4.77 mmHg NS PERCENTLES RELAXATION 51.8 + 4.2% 75.1 + 5.2% P<.03 DURATIONLES RELAXATION 7.9 +.89 seconds 9.6 + 1.22 seconds NS APERISTALSlS 100% 100% NS E~DpHAOOOASTRICGRADIENT +3.7 + .56 mmHg +3.3 + .99 mmHg NS Of the 57 patients studied, 51 had primary achalasia; 6 had secondary achalasia. The mean age, LESP, esophagagastrie gradient, and duration of LES relaxation were similar in each group. All 57 patients were aperistaltic. Secondary achalasia patients demonstrated a greater mean degree of LES relaxation when compared with primary achalasia patients (1><.03). Symptomatically, primary achalasia patients presanted with dysphagia (67%), chest pain (24o%), dyspepsia (12o%), and nausea/vomiting (6%); secondary cancer patients presented with dysphagia (100%), o and nausea ( 17o%). Conclusions: 1) Manometric findings are dyspepsia (17)A), generally similar for primary and secondary cancer-induced achalasia; however, patients with secondary achalasia may demonstrate a greater degree of LES relaxation.2) Symptomatically, primary and secondary achalasia patients are not clearly distinguishahle.
DOES GASTRO-ESOPHAGEAL REFLUX (GER) CAUSE PALATAL DENTAL EROSION~ DW Bartlett, DF Evans*, A Anggiansah; and BGN Smith. Dept's of Conservative Dentistry and Surgery, UMDS, Guy's Hospital London Bridge and *Gastrointestinal Science Research Unit ,London Hospital Medical College,UK. Palatal dental erosion is known to be a caused by anorexia and bulimia nervosa and chronic alcoholism. Palatal erosion is a common problem in dentistry often requiring expensive restorations to repair the function and appearance of teeth. GER has been associated with palatal erosion, but to date there have not been any studies linking oral pH to esophageal pH in patients presenting with palatal erosion. The aim of this study was to investigate patients for GER attending the Guy's Dental Hospital with evidence of palatal dental erosion. Twenty six subjects with palatal erosion (age range 15-74) were studied for a minimum of 18 hours. The severity Of the dental erosion in each subject was assessed clinically by a recognised tooth wear index. A control group of 12 subjects with no evidence of GER or palatal erosion w e r e also investigated in the same manner. Distal and proximal esophageal pH were monitored by a dual channel antimony electrodes at 5cm and 20cm above the lower esophageal sphincter positioned by manometry. Simultaneously, oral pH was monitored by pH sensitive radio-telemetrlc capsule (RTC) held palatally in a soft acrylic appliance and signals were detected by a headband aerial, data were recorded on two separate recorders worn around the waist. GER ;was analysed for % time
LYMPHOID FOLLICLES IN GASTRIC MUCOSAOF IIELICOBACTER PYLORI INFECTED PATIENTS REGRESS AFTER ERADICATIONTREATMENT. Battaglia G*. Louis PE*, Donisi PM*, Benvenuti ME*, Leandro Ggg, Pasini M*, Glen M§, Bergamasco Me, Di Marie F°. Units of Gastroenterology*, Pathology *, Radioimmueology§ and Microbiology" OOCCRR "SS Giovanni e Paolo" Venezia; IRCCSM "S. de Bellis" Castellana G. (Ba); Division of GastrcentrelogyQPad,ova; Italy. Back2rouud. Lymphoid follicles are believed to be absem in the normal gastric mucesa. Their presence has been described in chronic active antml gastritis, a condition virtually always determined by. Itelicobacter pylori infection. The ' development of this Mucosa Associated Lymphoid Tissue (MALT) seems to be a necessary step for the onset of the primary MALT lymphoma. Previuos studies demonstrated, on small samples, thaf eradication of Hel/cobacter priori infection provokes a slow decrease of number of lymphoid follicles and, mostly, a regression of low grade B cell gastric MALToma, Aim of the study. We aimed to test the ipothesis that the cure of t[eltcobacter pylori infection affects the persistence of lymphoid follicles in the gastric mucosa. Methods. patients infected by Helicobacter Rvlori were eligible for the study. At baseline endoscopy at least 2 biopsies of the antrum and 2 from the corpus were obtained. Hematessilin
A55
Esophageal, Gastric, and Duodenal Disorders
• A PREDICTIVE MODEL OF MUCOSAL DAMAGE IN GERD USING AREA UNDER THE CURVE ESTIMATION OF HYDROGEN ION ACTIVITY (AUC H~. M.Barrientos, G Tougas, D ~ n g , S Sontag, R H Hunt. McMaster University, Hamilton, Canada, Hines VA Hospital, Hines IL. Gastroesophageal reflux disease (GERD) results from acid exposure of esophageal mueosa over time. Aims: We tested the hypothesis that AUC for hydrogen ion activity (IT activity) could be a more accurate predictor of mucosal damage than time below pH 4 and propose a model based on the AUC of IT activity to predict the grade of esophageal mucosal damage in GERD. Methods From 33 continuous 24-h esophageal pH recording,s the AUC of IT activity was calcalated and correlated with Savary-Miller grades of esophagitis obtained at endoscopy. A mathematical model was constructed, to analyse and express the relative importance of AUC for each grade of esophagitis. The model was based on the power function of the AUC of IT activity for 24 hours, using two parameters (130 and 131). An increment of the relative importance of AUC (130)is proportional to the absolute increase of W activity, while B1 represents the order of increase of IT activity to maintain the proportionality of AUC with each grade of esophagitis. Results: Parameters
Grade 1 (n=16)
Grade 2 (n=8)
Grade 3 (n=5)
Grade 4 (n=4)
AUC **
67.1± 19
142.6-a:38
473.5±76
868.1 ±170
Be**
0.58±.13
0,66±0.09
2.56±0.61
1.46±0.15
B1 **
0.43"4-.02
0.54-+0,02
0.78±0.02
.84±0,01
(~n x mmo~)
**= p<0.001, Kruskal-Wallis Test- (Mean +SE) The mea.n values of AUC I-F activity for each grade of csophagitis are significantly different (p<0.001). The lowest mean AUC value corresponds to grade 1 and the highest to grade 4. In grade 1 and 2, the values ofB 0 and B~ are low, indicating the correlation of AUC to low values o f H ÷ activity. In grade 4,13i is near unity indicating correlation of AUC to high values of I--Factivity. Larger values of Bo also confirm the importance of AUC for high values of IT activity. Conclusions. The AUC for IT activity can predict esophageal mucosal damage and the endoscopic grade of esopbegitis. The fie and g~ values suggest that at low H+-activity, GERD is a two component disease, The significance of the power law model suggests that GERD is dominated by a~ characteristic size scale whose pattern can be analyzed by using the fractal dimension concept.
• EVALUATION OF MANOMETRIC AND CLINICAL FINDINGS IN PRIMARY ACHALASIA VERSUS SECONDARY ESOPHAGEAL CANCER-INDUCED ACHALASIA, RM Bashir. KA Mahcr, SB Benjamin. Georgetown University
Medical Center, Washington, D,C. Previous data h a w sugg~ted specific manomctrie findings in canear-induced secondary achalasia; however, others have demonstrated the inability of clinical and manometric criteria to distinguish between primary and secondaryachalasia. Puroose: Our goal was to examine specific manom~Uieand clinical findings in primary anhalasia as compared with secondary esophagealcancer-induced achalasia and identify any discernible differences or patterns. Metho4~: We retrospectively reviewed all esophageal manomctry records and tracings of patients diagnosed with achalasla over the past 5 years. Patients wore divided int0~'wo groups: primary achalasia and seoondary esophageal caneer-iaduced achalasia, All patients had undergone esophagnscopyprior to manometric testing. Secondary achainsia patients had histologic evidence of esophageal cancer without significant stenosis. Five specific manometric findings were calculated for each patient: lower esophageal sphincter pressure (LESP). percent of lower esophageal sphincter (LES) relaxation, duration of LES relaxation, presenea of peristalsis oftbe esophageal body, and the e s o p l ~ o g a . ~ ¢ pressure gradient, Results: See table (all values am mean _+SEM). PATIENT CHARACTERISTICS
PRIMARY(nffiSl)
SECONDARY(nffit)
P-valuee _
Ao£ 57.9 + 5.3 yrs 62.7 +_3.4 yrs NS LESP 34.7 + 3.75 mmHg 30.3 + 4.77 mmHg NS PERCENTLES RELAXATION 51.8 + 4.2% 75.1 + 5.2% P<.03 DURATIONLES RELAXATION 7.9 +.89 seconds 9.6 + 1.22 seconds NS APERISTALSlS 100% 100% NS E~DpHAOOOASTRICGRADIENT +3.7 + .56 mmHg +3.3 + .99 mmHg NS Of the 57 patients studied, 51 had primary achalasia; 6 had secondary achalasia. The mean age, LESP, esophagagastrie gradient, and duration of LES relaxation were similar in each group. All 57 patients were aperistaltic. Secondary achalasia patients demonstrated a greater mean degree of LES relaxation when compared with primary achalasia patients (1><.03). Symptomatically, primary achalasia patients presanted with dysphagia (67%), chest pain (24o%), dyspepsia (12o%), and nausea/vomiting (6%); secondary cancer patients presented with dysphagia (100%), o and nausea ( 17o%). Conclusions: 1) Manometric findings are dyspepsia (17)A), generally similar for primary and secondary cancer-induced achalasia; however, patients with secondary achalasia may demonstrate a greater degree of LES relaxation.2) Symptomatically, primary and secondary achalasia patients are not clearly distinguishahle.
DOES GASTRO-ESOPHAGEAL REFLUX (GER) CAUSE PALATAL DENTAL EROSION~ DW Bartlett, DF Evans*, A Anggiansah; and BGN Smith. Dept's of Conservative Dentistry and Surgery, UMDS, Guy's Hospital London Bridge and *Gastrointestinal Science Research Unit ,London Hospital Medical College,UK. Palatal dental erosion is known to be a caused by anorexia and bulimia nervosa and chronic alcoholism. Palatal erosion is a common problem in dentistry often requiring expensive restorations to repair the function and appearance of teeth. GER has been associated with palatal erosion, but to date there have not been any studies linking oral pH to esophageal pH in patients presenting with palatal erosion. The aim of this study was to investigate patients for GER attending the Guy's Dental Hospital with evidence of palatal dental erosion. Twenty six subjects with palatal erosion (age range 15-74) were studied for a minimum of 18 hours. The severity Of the dental erosion in each subject was assessed clinically by a recognised tooth wear index. A control group of 12 subjects with no evidence of GER or palatal erosion w e r e also investigated in the same manner. Distal and proximal esophageal pH were monitored by a dual channel antimony electrodes at 5cm and 20cm above the lower esophageal sphincter positioned by manometry. Simultaneously, oral pH was monitored by pH sensitive radio-telemetrlc capsule (RTC) held palatally in a soft acrylic appliance and signals were detected by a headband aerial, data were recorded on two separate recorders worn around the waist. GER ;was analysed for % time
LYMPHOID FOLLICLES IN GASTRIC MUCOSAOF IIELICOBACTER PYLORI INFECTED PATIENTS REGRESS AFTER ERADICATIONTREATMENT. Battaglia G*. Louis PE*, Donisi PM*, Benvenuti ME*, Leandro Ggg, Pasini M*, Glen M§, Bergamasco Me, Di Marie F°. Units of Gastroenterology*, Pathology *, Radioimmueology§ and Microbiology" OOCCRR "SS Giovanni e Paolo" Venezia; IRCCSM "S. de Bellis" Castellana G. (Ba); Division of GastrcentrelogyQPad,ova; Italy. Back2rouud. Lymphoid follicles are believed to be absem in the normal gastric mucesa. Their presence has been described in chronic active antml gastritis, a condition virtually always determined by. Itelicobacter pylori infection. The ' development of this Mucosa Associated Lymphoid Tissue (MALT) seems to be a necessary step for the onset of the primary MALT lymphoma. Previuos studies demonstrated, on small samples, thaf eradication of Hel/cobacter priori infection provokes a slow decrease of number of lymphoid follicles and, mostly, a regression of low grade B cell gastric MALToma, Aim of the study. We aimed to test the ipothesis that the cure of t[eltcobacter pylori infection affects the persistence of lymphoid follicles in the gastric mucosa. Methods. patients infected by Helicobacter Rvlori were eligible for the study. At baseline endoscopy at least 2 biopsies of the antrum and 2 from the corpus were obtained. Hematessilin
A55