Effect of sucralfate on the normal human gastric mucosa. Endoscopic, histologic, and ultrastructural assessment

Twelve healthy volunteers were given a single sucralfate tablet (1 gm) orally. For 60 min after ingestion they were examined endoscopically for the localization and disintegration of the tablet in the stomach, and biopsies were taken to determine the effect of sucralfate on the histology and ultrastructure of the normal gastric mucosa. After ingestion, the sucralfate tablet had disintegrated and firmly adhered to a relatively small mucosal area of the greater curvature covering 5 +/- 2 and 7 +/- 2 cm2 at 15 and 30 minutes, and 9 +/- 3 cm2 at 60 minutes after drug ingestion. Histologic and ultrastructural examination of the mucosa in direct contact with sucralfate revealed distinct changes in the surface epithelial cells: mucus release, vacuolization, and exfoliation of some of the cells. Endoscopy offers a unique opportunity for the study of gastroduodenal effects and disposition of orally administered drugs.

The mechanism of protective, therapeutic and prophylactic actions of sucralfate

Sucralfate, a non-systemic drug, speeds the healing of peptic ulcers, prevents their recurrence and prevents stress ulcerations in critically ill patients. In animal experiments sucralfate protects the gastric mucosa against damage produced by ulcerogenic and necrotizing agents. Sucralfate does not inhibit gastric acid secretion and has a minimal neutralizing capacity. The basis for the acute protective action of sucralfate is its effect on the normal gastric mucosa enhancing the natural defensive mechanisms, stimulating mucus, bicarbonate and prostaglandin release and mucosal cell renewal. Therapeutic action of sucralfate is most likely the result of A) local action on ulcerated areas of the mucosa by formation of a protective barrier reducing pepsin and H+injury; B) binding of pepsin and bile acids; and C) trophic effect on the entire mucosa which facilitates healing and re-epithelialization. Long term prophylactic efficacy of sucralfate is probably due to its chronic trophic action on the gastric mucosa. Quantitive and qualitative increase in the surface epithelial and proliferative zone cells enhance the defensive capabilities of the mucosa increasing mucus, bicarbonate, and prostaglandin release and cell renewal.

Cytoprotective drugs. Focus on essential fatty acids and sucralfate

Cytoprotection has been defined as an ability of prostaglandins to prevent gastric mucosal injury produced by a variety of ulcerogenic and necrotizing agents without inhibition of gastric acid secretion or without neutralizing intragastric acidity. Since the first demonstration of cytoprotection by prostaglandins many other agents have been claimed to be cytoprotective. Essential fatty acids: arachidonic and linoleic, licorice products, sucralfate, antacids and sulfhydryl compounds all possess cytoprotective properties. All of these compounds are able to prevent or reduce gastric mucosal necrosis produced by absolute ethanol, a necrotizing agent which injures mucosa independently of the luminal pH. Gastric mucosal protection by essential fatty acids is mediated by their conversion by the gastric mucosa to protective prostaglandins. Sucralfate and antacids are also cytoprotective compounds which stimulate release of endogenous prostaglandins from the gastric mucosa.

Does sucralfate affect the normal gastric mucosa? Histologic, ultrastructural, and functional assessment in the rat

Although the action of sucralfate on ulcerated mucosa has been demonstrated, its effect on the histology, ultrastructure, and function of normal gastric mucosa is unknown. We investigated the effect of acute administration of sucralfate on the gastric mucosal history, ultrastructure, mucosal potential difference, and luminal release of prostaglandin E2. At 15 min, 1 h, and 3 h after intragastric instillation of sucralfate, whitish incrustations of the drug were firmly adhering to the glandular mucosa. Mucosal histology after sucralfate administration demonstrated the following: disruption and exfoliation of some of the surface epithelial cells, mucosal hyperemia, prominent release of mucus from the surface epithelial cells, and edema of lamina propria and submucosa. These changes were most prominent in the areas where sucralfate was in contact with the mucosal surface. Scanning and transmission electron microscopy confirmed the above changes. Sucralfate produced a drop in gastric mucosal potential difference and a significant increase in luminal release of prostaglandin E2. Sucralfate produces distinct morphologic and functional changes in the normal gastric mucosa, which may account for its preventive and therapeutic efficacy.

Propranolol reduces ethanol-induced gastric mucosal damage in portal hypertensive rats

In a standardized rat model of portal hypertension, we investigated the effects of propranolol on alcohol-induced gastric mucosal damage. Portal hypertensive rats pretreated with 2 mg propranolol, compared with those receiving saline, had significantly reduced portal pressures (24 +/- 1 vs 32 +/- 1 cm saline), macroscopic mucosal damage (24 +/- 1 vs 39 +/- 4% of mucosa), and histologic deep necrosis (36 +/- 2 vs 61 +/- 4% of mucosal length). Increased dosage of propranolol to 4 mg did not produce any further reduction of portal pressure or mucosal damage. Central venous and systemic arterial pressures were not significantly altered by propranolol. The extent of mucosal damage correlated with levels of portal pressure (P less than 0.01) in portal hypertensive rats. Sham-operated normotensive rats had less macroscopic mucosal damage (26 +/- 4%) than portal hypertensive rats, and propranolol did not affect the extent of ethanol-induced damage or portal pressures in these animals. We conclude: (1) Propranolol is effective in reducing extent of ethanol-induced gastric mucosal damage in portal hypertensive rats, but not in sham-operated controls; (2) this effect correlates with reduction of portal pressure; and (3) our study supports the clinical impression that reducing portal pressure may be one approach for the prevention and therapy of gastric mucosal damage in portal hypertension.

Is arachidonic acid protected gastric mucosa more resistant to rechallenge with a second dose of ethanol?

In our previous studies we found that pretreatment with arachidonic acid protects the gastric mucosa against ethanol-induced injury. In the present experiments we studied whether: gastric mucosa protected with arachidonic acid against ethanol injury is more resistant to a subsequent second ethanol injury, and whether a second ethanol dose produces further damage of the nonprotected damaged gastric mucosa in a control group. We found that: rechallenge with a second ethanol dose increases the extent of gastric mucosal necrosis in control rats; once protected (with arachidonic acid) the gastric mucosa is more resistant to subsequent ethanol rechallenge but some deep necrosis occurs and restoration of the surface epithelium is somewhat impaired when compared to the initial injury and repair. Thus, pretreatment of the gastric mucosa with a prostaglandin precursor dietary essential fatty acid confers excellent protection against alcohol damage with some residual protective activity against a subsequent rechallenge with alcohol.

Protection against alcohol-induced gastric mucosal injury by aluminum-containing compounds--sucralfate, antacids, and aluminum sulfate

Previously, we demonstrated that both antacids and sucralfate can protect the gastric mucosa against alcohol injury. Since these compounds contain aluminum, we studied whether other aluminum compounds have cytoprotective properties as well. Fasted rats were pretreated intragastrically with A) 0.9% NaCl, B) sucralfate, C) aluminum-magnesium antacid gel, D) Al2(SO4)3, E) Al(OH)3, and 1 h later they received 2 ml 100% ethanol by gavage. The stomach was removed and assessed for injury 3 h after ethanol administration. Control (group A) rats had 39 +/- 3% gross mucosal injury, which was reduced to 5 +/- 1% with sucralfate, 7 +/- 1% with Al2(SO4)3, 12 +/- 2% with Al(OH)3, and 16 +/- 2% with aluminum-magnesium antacid gel pretreatment. Microscopic surface epithelial injury and submucosal edema were seen in all five groups, while deep mucosal necrosis was largely prevented by pretreatment in groups B to E. These findings indicate that aluminum in a wide variety of molecular forms can protect the gastric mucosa against alcohol injury.

Prostaglandin protection of the human gastric mucosa against alcohol-induced injury. Endoscopic, histologic, and functional assessment

We studied whether pretreatment with prostaglandin (16,16-dimethyl (dm) prostaglandin E2) may protect the human gastric mucosa against alcohol-induced injury. Healthy volunteers received (via an endoscope) intragastric pretreatment with either: A) placebo or B) 16,16 dm prostaglandin E2, 1 microgram/kg, and 15 min later 40 ml 60% alcohol was sprayed directly on gastric mucosa.

STUDIES

endoscopic appearance of the gastric mucosa was evaluated and scored (scale 0-5) by two investigators, gastric mucosal potential difference (PD) was continuously recorded, and mucosal biopsies were obtained at 30 min after alcohol for histologic examination. Alcohol instillation in subjects pretreated with placebo (group A) produced within 30 min prominent endoscopic hemorrhagic lesions (grade 4.8 +/- 0.2). Histologic examination showed exfoliation of the surface epithelium, extensive edema of lamina propria, and deep hemorrhagic necrotic lesions in 86% +/- 10 of specimens. These morphologic changes coincided with a sudden drop in gastric PD of 42 mV. Prostaglandin pretreatment (group B) significantly reduced alcohol-induced endoscopically visible lesions (grade 3.1 +/- 0.2, P less than 0.01 vs group A). Histologically, prostaglandins reduced deep hemorrhagic erosions (4.5-fold reduction) and subepithelial hemorrhages, but did not prevent exfoliation of the surface epithelium and gastric PD drop. Thus, prostaglandin administration to human volunteers effectively reduced alcohol injury to the gastric mucosa.

Comparison of antacid, sucralfate, cimetidine, and ranitidine in protection of the gastric mucosa against ethanol injury

The abilities of antacid (Mylanta II), sucralfate, cimetidine, and ranitidine to protect the gastric mucosa against ethanol-induced necrosis were compared in a standardized, experimental rat model. Fasted rats received pretreatment with either saline, Mylanta II, 500 mg/kg of sucralfate, 50 mg/kg of cimetidine, or 50 mg/kg of ranitidine. This was followed one hour later by intragastric administration of 2 ml of 100 percent ethanol. Gastric mucosal injury was assessed four hours after administration of ethanol by quantitation of gross mucosal necrosis, assessment of mucosal histology, and determination of intragastric blood and protein concentrations. Pretreatment with Mylanta II or sucralfate significantly reduced ethanol-induced gastric mucosal necrosis. The protective effect of sucralfate was six to 10 times greater than that of Mylanta II. H2-receptor antagonists increased ethanol-induced gastric mucosal necrosis.

Protective effect of sucralfate against alcohol-induced gastric mucosal injury in the rat. Macroscopic, histologic, ultrastructural, and functional time sequence analysis

Histologic or ultrastructural evidence of the ability of sucralfate to protect the gastric mucosa against ethanol injury is lacking. Therefore we analyzed morphologic and functional changes in the mucosa of 120 rats receiving, intragastrically, 2 ml of either sucralfate 500 mg/kg body wt or a control solution and 1 h later 2 ml of 100% ethanol. At 15 min, 1, 4, 6, and 24 h after ethanol instillation, mucosal changes were assessed by macroscopic examination, quantitative histology, scanning electron microscopy, recordings of gastric potential difference, and measurements of volume, pH, and electrolytes in the gastric contents. Between 15 min and 24 h after ethanol instillation, macroscopic necrotic lesions in controls involved greater than 33% of mucosal area and in the sucralfate-treated group less than 4% (p less than 0.001 for each period). In controls, ethanol instillation produced surface epithelial cell disruption and deep (greater than 0.2 mm) mucosal necrosis involving greater than 55% +/- 3% of the mucosal length. In sucralfate-pretreated animals, disruption of the surface epithelium was present at 15 min, 1 h, and 4 h after ethanol instillation, but deep necrotic lesions were virtually absent (0%-2%; p less than 0.001 vs. controls) during the entire study period. The surface epithelium was mostly reestablished by 6 h after ethanol instillation in the sucralfate group but not in the controls. We concluded that sucralfate protects the gastric mucosa against ethanol-induced injury by preventing deep mucosal necrosis and as a consequence the mucosal proliferative zone cells rapidly restitute mucosal integrity.

Prostaglandin protection of the gastric mucosa against alcohol injury--a dynamic time-related process. Role of the mucosal proliferative zone

The aim of the present study was first to resolve controversies regarding the extent of prostaglandin protection ("cytoprotection") of the gastric mucosa against injury produced by 100% ethanol and second to determine time sequence and histologic, ultrastructural, and functional features of this protection. Fasted rats received intragastrically (A) 0.9% NaCl alone as a control, (B) 5 micrograms/kg of 16,16-dimethyl prostaglandin E2 dissolved in 0.9% NaCl, and (C) 100 micrograms/kg of 16,16-dimethyl prostaglandin E2 dissolved in 0.9% NaCl. Thirty minutes later, 2 ml of 100% ethanol was instilled. The gastric mucosa was assessed macroscopically, by quantitative histology, and by scanning and transmission electron microscopy for [3H]thymidine uptake, mitotic activity, ion fluxes, and gastric potential difference determined at several time intervals (between 10 min and 16 h) after ethanol administration. Between 10 min and 16 h after ethanol administration macroscopic necrosis involved 27% +/- 3% to 41% +/- 4% of the mucosal area in controls (group A), but necrosis was prevented in groups receiving 16,16-dimethyl prostaglandin E2 (groups B and C). In the control group, histology and electron microscopy showed extensive disruption of the surface epithelium and deep necrosis (greater than 0.2 mm) involving greater than 46% +/- 4% of the mucosa between 15 min and 16 h after ethanol administration. Deep necrotic lesions were completely prevented by either dose of 16,16-dimethyl prostaglandin E2 (groups B and C). The mucosal proliferative zone was severely damaged in controls (68% +/- 5%) within the first hour after ethanol administration, whereas 16,16-dimethyl prostaglandin E2 protected the zone from damage (less than 5% +/- 1%). Neither dose of 16,16-dimethyl prostaglandin E2 prevented the occurrence of initial (at 15-30 min) morphologic and functional disruption of the surface epithelium after ethanol administration. However, initial disruption of the surface epithelium by 16,16-dimethyl prostaglandin E2 (groups B and C) was followed by migration of cells from the mucosal proliferative zone; the result was prompt restoration of the surface epithelium and resumption of its barrier and transport functions.

16,16-dimethyl-PGE2 protection against alpha-naphthylisothiocyanate-induced experimental cholangitis in the rat

Male rats were treated with subcutaneous vehicle or 16,16-dimethyl-PGE2 (dmPGE2, 100 micrograms per kg), 24, 18 and 0.5 hr prior to and 6, 24 and 30 hr after challenge with oral alpha-naphthylisothiocyanate (ANIT, 30 mg per kg). Forty-eight hours after challenge, rats were sacrificed by decapitation; serum and liver samples were taken for biochemical and histological analysis, respectively. Rats treated with vehicle (2% ethanol in saline) and ANIT exhibited elevations in alkaline phosphatase, SGPT and bilirubin as well as cholangitis and mild parenchymal necrosis. Rats treated with dmPGE2 and ANIT had normal serum biochemical findings, no necrosis and only mild proliferation of bile duct epithelium. Thus, dmPGE2 may be able to protect the rat liver against the deleterious effects of orally administered ANIT.

Bile acid-induced gastric mucosal injury: significance of portal hypertension and mucosal capillary permeability

Rats with portal vein occlusion (PVO) were studied to determine severity of taurocholate-induced gastric mucosal injury during portal hypertension and following its resolution by collaterals. During the portal hypertensive state, after intragastric taurocholate, PVO rats compared with sham-operated controls had significantly greater macroscopic damage (14 +/- 1 vs 3 +/- 1% of total mucosa) and histologic deep necrosis (25 +/- 4 vs 3 +/- 1% of mucosal length). Gastric mucosal capillary permeability was also significantly greater in PVO rats, as assessed by increased appearance of intravenous Evans blue dye in gastric wall and contents. After 21 days of PVO portal pressures returned to normal. At this time taurocholate-induced gastric mucosal damage and capillary leak became similar in PVO and sham-operated rats. It is concluded that the portal hypertensive state alone predisposes to severe gastric mucosal damage and capillary leak.

Effect of 16,16 dimethyl prostaglandin E2 on aspirin induced damage to rat gastric epithelial cells in tissue culture

Prostaglandins (PGs) protect gastric mucosa against damage produced by acetylsalicylic acid (ASA). Whether this effect of prostaglandins is truly cytoprotective and whether cAMP plays an important role in this effect is uncertain. We studied the effect of: (1) 16,16 dimethyl prostaglandin E2 (dmPGE2), isobutylmethyl xanthine (IMX), and dibutyryl cAMP (DBcAMP) on ASA-induced damage to monolayer cultures of rat gastric mucosa composed primarily of mucus cells; (2) dmPGE2 on ASA absorption into the cultured cells. Cell damage was quantitated by 51Cr-release and trypan blue staining. Ten millimoles ASA significantly increased 51Cr-release (indicating cell damage) at pH 5.0, but not at pH 7.4. DmPGE2 significantly reduced ASA-induced increase of 51Cr-release. Isobutylmethyl xanthine did not change the rate of 51Cr-release caused by ASA plus dmPGE2. Dibutyryl cAMP did not significantly alter 51Cr-release caused by ASA. A dose response study of ASA damage showed close correlation between 51Cr-release and trypan blue staining (r = 0.93). Dimethyl prostaglandin E2 did not affect 14C-ASA incorporation by the cells at either pH 7.4 or pH 5.0. We conclude that: (1) dmPGE2 exerts a cytoprotective effect on cultured rat gastric cells; (2) cAMP does not play an important role in such cytoprotection; (3) this protection is not because of interference with ASA absorption by prostaglandin.

The gastric mucosa in portal hypertension: effects of topical bile acid

Clinical observations suggest that patients with portal hypertension are more prone to erosive gastritis. To test this hypothesis we investigated gastric mucosa of rats with portal hypertension (produced by staged portal vein occlusion) and sham-operated controls before and after intragastric taurocholate. Portal pressure was 36 +/- 3 cm saline in portal hypertensive rats compared with 16 +/- 2 cm in controls (P less than 0.01). Before taurocholate no macroscopic or histologic spontaneous mucosal damage was present, but portal hypertensive rats had extensive submucosal edema. Three hours after intragastric taurocholate (2 ml, 80 mM in 0.1 N HCl), macroscopic injury comprised 13.7 +/- 1.1% of mucosal surface in portal hypertensive rats compared with 3.6 +/- 0.6% in controls (P less than 0.01) confirmed also by histologic morphometry. H+ back-diffusion was 402 +/- 40 microEq/h in portal hypertensive rats and 217 +/- 30 microEq/h in controls (P less than 0.01). We conclude taurocholate induced gastric mucosal injury is enhanced by portal hypertension. Greater H+ back-diffusion in portal hypertensive rats suggests increased mucosal permeability contributed by submucosal edema. We confirm quantitatively in an experimental model that portal hypertension predisposes to gastric mucosal injury.

Sucralfate protection of the gastric mucosa against ethanol-induced injury: a prostaglandin-mediated process?

We studied whether sucralfate's protection of the gastric mucosa against ethanol induced injury in the rat is prostaglandin mediated. Rats received intragastric pretreatment: i) saline, ii) sucralfate, and iii) indomethacin-sucralfate. One hour later gastric contents were obtained for measurements of prostaglandin E2 and 2 ml of 100% ethanol were instilled. Rats were sacrificed 1 h later. The gastric mucosa was assessed: a) macroscopically by planimetry, b) by quantitative histology, and c) by measurements of gastric volume, pH and sodium. We found that sucralfate significantly increased gastric luminal release of prostaglandin E2. The increase was completely abolished by indomethacin pretreatment. Sucralfate protected the gastric mucosa against ethanol injury reducing macroscopic and histologic necrosis. Indomethacin (prostaglandin synthetase inhibitor) given 2 h prior to sucralfate markedly abolished its protective action against ethanol induced necrosis by 70%. These findings indicate that prostaglandins mediate some of the protective action of sucralfate. Sucralfate appears to have additional protective action which is prostaglandin independent.

Arachidonic acid protection of gastric mucosa against alcohol injury: sequential analysis of morphologic and functional changes

We have shown previously that arachidonic acid (AA) prevents gastric mucosal injury by ethanol (ETOH). The present study was designed to determine the sequence of morphological and functional changes in the gastric mucosa during ETOH-induced injury and AA-promoted protection. Fasted male rats received intragastrically 1 ml of vehicle (PL) or 1 ml of 120 mM AA followed 1 hr later by 2 ml of absolute ETOH. Mucosal changes were assessed at 10, 15, and 30 min and 1, 2, 3, 6, and 15 hr after ETOH: (1) macroscopically, histologically, and by scanning EM; and (2) by determinations of (a) mitotic activity and 3H-thymidine incorporation in vivo, (b) gastric volume, pH, and electrolytes, and (c) gastric PD. Macroscopic necrotic changes were present in PL-but not AA-pretreated animals throughout the 15 hr after ETOH. Histological examination and scanning EM showed desquamation of the surface epithelium at 10 min to 2 hr and deep necrotic lesions throughout the 15 hr after ETOH in PL-pretreated animals. In AA-pretreated rats, deep necrotic lesions did not occur, but desquamation of the surface epithelium was seen during the initial 30 min after ETOH. A continuous layer of the surface epithelium was restored within 3 hr after ETOH in AA group, with resumption of the transport and barrier functions. The main feature of AA protection of gastric mucosa against ETOH injury is preservation of the mucosal proliferative zone.

A monolayer culture of human gastric epithelial cells

Our aim was to develop a fibroblast-free monolayer culture of human gastric mucosal cells, using the specimens obtained by routine endoscopic biopsy. Human gastric mucosa obtained from normal volunteers by endoscopic biopsy was dissociated from collagenase and hyaluronidase. Dissociated cells were cultured in supplemented Coon's modified Ham's F-12 medium. Within 24 hr of inoculation, the cells were attached to the culture dishes. This was followed by cellular outgrowth. On phase-contrast microscopy, all cells had epithelial characteristics and fibroblasts were not observed. Ninety percent of cells contained periodic acid Schiff reaction-positive mucous granules after diastase digestion consistent with mucous epithelial cells. Two percent of the cells gave a strong reaction for succinic dehydrogenase activity (parietal cells). Immunohistochemical staining for pepsinogen in cultured cells was negative. On EM, microvilli-like projections, junctional complexes, Golgi apparatus, and mucous granules were apparent in the majority of cells. Mitotic figures were observed by day 3 with Giemsa staining. Autoradiographically, these cells were able to incorporate [3H]TdR into the nuclei. Cells were capable of synthesizing DNA, and this function was inhibited by cycloheximide. Cells could be cultured for up to two weeks without fibroblast contamination. A method of primary monolayer culture of human gastric mucosa obtained by a routine endoscopic biopsy has been successfully developed.