Relationship between gastroesophageal junction adenocarcinoma and Helicobacter pylori infection in Japan

BACKGROUND/AIMS

The relationship between gastroesophageal junction adenocarcinoma (GEJA) and Helicobacter pylori infection is not well defined; thus, we retrospectively investigated this relationship.

METHODS

We examined 852 cases (646 men) of gastric cancer. GEJA was defined as type II according to the classification system of Siewert and Stein. We compared the prevalence of H. pylori infection and corporal gastritis in GEJA patients with distal gastric cancer.

RESULTS

GEJA was observed in 80 (including 6 cases of Barrett's esophageal cancer) of the 852 cases of gastric cancer examined (9.4%). The rate of H. pylori infection was significantly lower in patients with GEJA than in patients with distal gastric cancer (73.8 vs. 94.1%, p < 0.05). The prevalence of corporal gastritis was also significantly lower in patients with GEJA than in patients with distal gastric cancer (80.7 vs. 94.6%, p < 0.05). Concurrent H. pylori infection and corporal gastritis were not observed in patients with Barrett's esophageal cancer.

CONCLUSION

Our study demonstrated that GEJA has 2 etiologic types; one of these types is associated with H. pylori infection and resembles distal gastric cancer, and the other one is not associated with H. pylori infection or Barrett's esophageal cancer.

A Study on the Efficacy of Proton Pump Inhibitors in Helicobacter pylori-Negative Primary Care Patients with Dyspepsia in Japan

Background/Aims

There have been few studies on the efficacy of proton pump inhibitors and the doses required to treat dyspeptic symptoms observed in clinical practice. The aim of this study was to compare the efficacy of different doses of omeprazole and different administration methods in Helicobacter pylori-negative, dyspeptic patients.

Methods

Patients with chronic upper abdominal symptoms within the previous 3 months were randomly divided into three groups: a daily, omeprazole 20 mg treatment group (OPZ20, n=61); a daily, omeprazole 10 mg treatment group (OPZ10, n=72); and an on-demand omeprazole 20 mg treatment group (on-demand, n=62). After 4 weeks of administration of the drug, symptom improvement rates were evaluated based on the Overall Global Severity score.

Results

The rates of symptom improvement after 4 weeks of treatment were 65.6% (40/61) in the OPZ20 group, 47.2% (34/72) in the OPZ10 group, and 50.0% (31/62) in the on-demand group. The OPZ20 group exhibited a significantly higher improvement rate (p=0.034) than the OPZ10 group. The OPZ20 group had significant improvements in regurgitation, postprandial fullness, vomiting, and bloating compared with the OPZ10 group.

Conclusions

Daily treatment with 20 mg of omeprazole was efficient in treating upper abdominal symptoms. Trial registration: ClinicalTrials.gov, number UMIN000002621.

Esophageal motor dysfunction plays a key role in GERD with globus sensation--analysis of factors promoting resistance to PPI therapy

OBJECTIVE

Patients with gastroesophageal reflux disease (GERD) also have various extra-esophageal symptoms. Laryngopharyngeal reflux disease (LPRD) is a subtype of GERD associated with globus sensation, but proton pump inhibitor (PPI) therapy achieves disappointing results. This study investigated esophageal motility in GERD patients with globus sensation who were resistant to PPI therapy.

DESIGN

The subjects were 350 patients with globus sensation. All patients underwent both laryngoscopy and upper gastrointestinal endoscopy to exclude organic disease. After 4 weeks of treatment with rabeprazole sodium (20 mg daily), the patients were divided into PPI-responsive and PPI-resistant groups. Then we investigated esophageal motility in the PPI-resistant group by a multichannel intraluminal impedance and manometry study.

RESULTS

A total of 119 patients (55.6%) were resistant to PPI therapy, among whom 57 patients (47.9%) had abnormal esophageal motility. They included 36 patients (66.4%) with ineffective esophageal motility, 9 patients (14.4%) with achalasia, 6 patients (9.6%) with diffuse esophageal spasm, 5 patients (8%) with nutcracker esophagus, and 1 patient (1.6%) with hypertensive lower esophageal sphincter. There were significant differences of upper esophageal sphincter pressure and esophageal body peristalsis between the patients with PPI-resistant LPRD and healthy controls matched for age and sex.

CONCLUSION

Among patients with PPI-resistant LPRD, 47.9% had abnormal esophageal motility.

H. pylori eradication did not improve dysregulation of specific oncogenic miRNAs in intestinal metaplastic glands

BACKGROUND

Many microRNAs (miRNAs) are differentially expressed in Helicobacter pylori-infected gastric mucosa and in gastric cancer tissue.

AIM

We aimed to compare the effect of H. pylori eradication on gastric mucosal miRNAs in subjects in a high-risk group for gastric cancer compared to controls.

METHODS

Patients with a recent history of endoscopic resection for early gastric cancer and sex- and age-matched non-cancer controls were enrolled. The expression of 21 miRNAs was examined using gastric mucosal biopsy specimens and microdissected gastric glands from the lesser and greater curvatures of the gastric corpus both before and one year after H. pylori eradication.

RESULTS

Twenty patients and 14 controls were enrolled. The expression of oncogenic miRNAs (miR-17/92 and the miR-106b-93-25 cluster, miR-21, miR-194, and miR-196) was significantly higher in the gastric mucosa of the cancer group than in the controls. H. pylori eradication resulted in a significant fall in the expression of oncogenic miRNAs only in the controls, whereas miR-223 expression was decreased and let-7d expression was increased in both groups. miR-196 was expressed only in intestinal metaplastic glands. The expression of oncogenic miRNAs was significantly higher in the intestinal metaplastic glands than in the non-intestinal metaplastic glands irrespective of H. pylori eradication. In neither group did H. pylori eradication significantly change any miRNA expression in the intestinal metaplastic glands.

CONCLUSION

Dysregulation of specific miRNAs is present in H. pylori-induced corpus gastritis. H. pylori eradication improved miRNA dysregulation, but not in intestinal metaplastic glands or in the gastric mucosa of patients in a high-risk group for gastric cancer.

Therapeutic efficacy of acotiamide in patients with functional dyspepsia based on enhanced postprandial gastric accommodation and emptying: randomized controlled study evaluation by real-time ultrasonography

BACKGROUND

Improvement in subjective symptoms has been reported in functional dyspepsia (FD) patients administered with acotiamide. Improvement was confirmed in meal-related symptoms, such as postprandial fullness, upper abdominal bloating, and early satiety. We examined the mechanism underlying the effects of acotiamide on gastric accommodation reflex (GAR) and gastroduodenal motility in FD patients.

METHODS

Thirty-four FD patients (mean age, 40.4 years) were examined ultrasonographically before and after 14-18 days of acotiamide (100 mg t.i.d.) or placebo administration. To assess GAR, expansion rate in cross-sectional area of the proximal stomach was measured after every 100-mL ingestion, using a straw, of up to 400 mL of a liquid meal (consommé soup, 13.1 kcal; 400 mL) in a supine position. Next, we measured gastric emptying rate (GER), motility index (MI, antral contractions), and reflux index (RI, duodenogastric reflux) to assess gastroduodenal motility. Patients also completed a survey based on the seven-point Likert scale both before and after drug administration.

KEY RESULTS

Of the 37 cases, 19 and 18 were administered with acotiamide and placebo A respectively, significant difference was observed in GAR between the acotiamide and placebo groups (21.7%vs 4.4%) after 400 mL ingestion. GER significantly accelerated after treatment in the acotiamide group (P = 0.012), no significant differences were observed in MI and RI between the two groups. Improvement rates were 35.3 and 11.8% for the acotiamide and placebo groups.

CONCLUSIONS & INFERENCES

Acotiamide significantly enhances GAR and GER in FD patients. Acotiamide may have therapeutic potential for FD patients.

Association of SLCO1B1 1b with peptic ulcer amongst Japanese patients taking low-dose aspirin

BACKGROUND

In the recent case-control study, we showed an inverse association between peptic ulcer and angiotensin type 1 receptor (AT1R) blockers (ARBs) or HMG-Co A reductase inhibitors (statins). The aim was to evaluate whether the genotypes of uptake and efflux transporters of ARBs and statins relate to the presence of peptic ulcer and/or ulcer bleeding associated with aspirin use.

METHODS

Patients taking 100mg of enteric-coated aspirin for cardiovascular diseases who also participated in endoscopic surveillance were studied. SLCO1B, ABCC2, ABCG2, and MDR1 genotypes were determined by PCR or PCR-RFLP.

RESULTS

492 patients enrolled including 78 with peptic ulcer. The frequencies of the SLCO1B1 521TT genotype were significantly higher in the ulcer group (p=0.006) compared to the controls. After adjustment for significant factors, the SLCO1B1 1b haplotype was significantly associated with peptic ulcer (OR, 3.64; 95% CI, 1.81-7.29).

CONCLUSIONS

SLCO1B1 1b haplotype may identify patients at increased risk for aspirin-induced peptic ulcer.

Generation of dyspeptic symptoms by direct acid and water infusion into the stomachs of functional dyspepsia patients and healthy subjects

BACKGROUND

The mechanisms of the development of symptoms in functional dyspepsia (FD) patients have not been fully elucidated. We previously reported that acid directly infused into the stomach causes dyspeptic symptoms in asymptomatic healthy controls (HCs); however, the response to acid infusion of FD patients was not determined.

AIM

To investigate the severity of dyspeptic symptoms induced by direct acid infusion in FD subjects and HCs.

METHODS

This was a multi-centre, cross-over, randomised, double-blind study in 23 FD subjects and 32 HCs. FD was defined using the Rome III criteria. All subjects were Helicobacter pylori negative. Each subject received two tests; 0.1 mol/L hydrochloric acid and water infused into the stomach. The presence and severity of 12 dyspeptic symptoms were assessed using a visual analogue scale.

RESULTS

The proportion of subjects developing symptoms by acid or water infusion was significantly greater in FD subjects than HCs. All of the FD subjects experienced at least one symptom by water or acid infusion. In the FD subjects, the severity of symptoms was significantly greater with acid infusion than water infusion. The severity of symptoms in total and the scores for eight of the 12 symptoms induced by acid infusion was significantly greater in FD subjects than in HCs.

CONCLUSIONS

The severity of dyspeptic symptom generation induced by direct acid infusion into the stomach was significantly greater in functional dyspepsia subjects than in healthy controls, suggesting that hypersensitivity to acid is one of the important mechanisms of the development of symptoms in functional dyspepsia patients.

Temporal association of serum progesterone concentrations and vaginal cytology in walruses (Odobenus rosmarus)

Concentrations of serum estradiol-17β and progesterone were monitored in six female walruses using an enzyme immunoassay. Progesterone concentrations increased from March to May in females aged 6 y or older, and subsequently declined (October). No significant elevation of estradiol-17β concentration was detected before an elevation of progesterone concentration. Vaginal smears from four females were examined with Papanicolaou staining. In all females, most epithelial cells were basophilic intermediate-superficial cells; no color change from basophilic to eosinophilic of the cells was detected. Meanwhile, the percentage of anucleate cells in vaginal smears reached its highest value before the elevation of progesterone concentration, followed by an increase in the percentage of leukocytes. We inferred that the change in populations of anucleate cells and leukocytes in vaginal smears reflected ovarian status and CL formation in female walruses.

Histological evaluation of patients with gastritis at high risk of developing gastric cancer using a conventional index

Although gastric cancer (GCa) is strongly associated with Helicobacter pylori infection, only some H. pylori-positive subjects develop gastric cancer. The aim of this study is to identify H. pylori-positive subjects at high risk of developing GCa by assessment of the histopathological findings in the non-cancer-containing mucosa of patients with and without GCa. The subjects were 35 patients with diffuse-type gastric cancer (D-GCa), 55 with intestinal-type gastric cancer (I-GCa), and 99 H. pylori-positive controls without GCa. Two specimens were taken from the greater curvature of the antrum and the middle body. Histopathological gradings were evaluated using the updated Sydney System, and the risk of GCa was evaluated using a modified Meining's gastric cancer risk index (GCRI). Among the H. pylori-positive controls, corpus gastritis was seen in 98.0% (97/99) and corpus atrophic gastritis in 78.8% (78/99). The mean GCRI for the D-GCa (5.514±2.03) and I-GCa (6.836±2.08) groups was significantly greater than that for the H. pylori-positive controls (4.071±2.07; p=0.0005, p<0.0001). In addition, the mean GCRI for the I-GCa group was significantly greater than that for the D-GCa group (p<0.005). The GCRI-positive rate was significantly higher in subjects with GCa than in H. pylori-positive controls (D-GCa: p<0.005, I-GCa: p<0.0001). Many H. pylori-positive Japanese still carry a high risk for gastric cancer. However, H. pylori-positive patients at high risk of developing GCa (not only intestinal-type but also diffuse-type) may be detected using a simple GCRI.

Use of an external real-time image viewer coupled with prespecified actions enhanced the complete examinations for capsule endoscopy

BACKGROUND AND AIM

  The clinical utility of capsule endoscopy (CE) is often limited by incomplete small-bowel transit. The aim was to determine whether the use of an external real-time viewer could reduce delays caused by delayed gastric emptying of the capsule or delayed intestinal transit and also improve the rate of positive findings.

METHODS

  We compared the proportion of completed exams and positive results among a group of patients studied before introduction of real-time viewer and a group in which capsule transit through the esophagus, stomach, and small bowel was regularly monitored and actions (e.g. administration of water or intravenous metoclopramide) were taken if it was delayed.

RESULTS

  One hundred procedures in the viewer group and 100 control procedures in the age-matched controls were analyzed. In the viewer group, additional water intake (22 cases) and/or administration of metoclopramide (26 cases) were required. Endoscopic-assisted duodenal placement of the capsule was required in three cases. Overall one-third (n=33) of cases required viewer-prompted interventions. The completion rate (86% vs 66%, P=0.002) and the rate of positive findings (80% vs 67%, P=0.04) were significantly higher in the viewer group compared to the no viewer group.

CONCLUSIONS

  Checking the progress of the capsule with the external real-time viewer improved the diagnostic yield and completion rate of CE.

[Proton pump inhibitor H2 receptor antagonist]

Recently, Japanese guidelines for the treatment and prevention of peptic ulcers were established by the Japanese Society of Gastroenterology. Herein, we focus on proton pump inhibitor(PPI) and H2 receptor antagonist (H2RA) for prophylaxis and treatment of peptic ulcer associated with NSAIDs including low dose of aspirin. Double dose of H2RAs are effective at preventing chronic NSAID related ulcers, however, the effect is not superior to PPI. Full-dose misoprostol and PPI are clinically equivalent, although the potential adverse effects of misoprostol are a major cause of poor compliance. Overall, PPIs have the best profile of efficacy and side-effects for the healing and prevention of NSAID-associated ulcers, especially in the patients with high risk, such as history of peptic ulcer.

Does short-segment columnar-lined esophagus elongate during a mean follow-up period of 5.7 years?

BACKGROUND

The length of Barrett's esophagus is considered to be important because it is associated with the risk of neoplasia. In Japan, there is a high prevalence of short-segment columnar-lined esophagus (SS-CLE). The natural history of SS-CLE is not fully understood, so the aim of the present study was to investigate the chronological changes of SS-CLE.

METHODS

The subjects were 500 consecutive patients with SS-CLE (327 men and 173 women; mean age: 64.0 years) diagnosed between January 2001 and July 2002 at our hospital based on the definition of SS-CLE proposed by the Japanese Society for Esophageal Diseases. Follow-up endoscopy was carried out annually for a mean period of 5.7 ± 1.2 years. The cumulative probability of SS-CLE showing elongation was estimated by the Kaplan-Meier method, and factors related to endoscopic findings making an independent contribution to elongation were determined with Cox's proportional hazard model.

RESULTS

Elongation of SS-CLE occurred in 29 patients (5.8%) during the follow-up period and the cumulative 5-year probability of elongation was 16.6%. There was no progression of SS-CLE to Barrett's adenocarcinoma. The absence of atrophic gastritis (adjusted odds ratio (aOR): 23.4; 95%CI [6.5, 83.8]), the presence of reflux esophagitis (aOR: 4.53; 95%CI [1.2, 16.4]), and the flame-shaped type of SS-CLE (aOR: 22.4; 95%CI [7.8, 64.0]) were found to be independent contributors to the elongation of SS-CLE.

CONCLUSIONS

The present study demonstrated that SS-CLE remains stable in length over time, especially in patients without atrophic gastritis, as well as in those with reflux esophagitis and/or flame-shaped SS-CLE at initial examination.

High-protein diet suppresses corpus atrophic gastritis in Helicobacter pylori infected Mongolian gerbils

To investigate the effect of a high-protein diet on corpus atrophic gastritis in Helicobacter pylori-infected Mongolian gerbils, H. pylori was administered orally to 5-wk-old Mongolian gerbils; and the animals were then fed a control diet (Group C); a high-fat diet (Group F: 40% fat); a high-protein diet (Group P: 32% protein); or a high-fat, high-protein diet (Group FP: 40% fat, 32% protein) for 50 wk beginning at 7 wk of age. In uninfected animals, the mucosal thickness of the corpus was significantly greater in Group P and Group FP than in Group C (P < 0.05). In infected animals, the serum gastrin level was significantly decreased in Group FP and marginally significantly decreased in Group P (P = 0.057) in comparison to Group C. The mucosal thickness of the corpus was significantly greater in Group P and Group FP than in Group C (P < 0.05). Mean inflammation and atrophy scores in the corpus were significantly lower in the high-protein groups (Groups P and FP) than in the control groups (Groups C and F; both inflammation and atrophy: P < 0.05). In conclusion, long-term administration of a high-protein diet suppresses corpus atrophic gastritis in H. pylori-infected Mongolian gerbils.

Impaired gastric response to modified sham feeding in patients with postprandial distress syndrome

BACKGROUND

Impaired vagal function has been reported to be important in some patients with functional dyspepsia (FD). However, the pathophysiologic mechanisms influencing the cephalic phase of vagal activity in FD are incompletely understood. The aim of this study was to investigate the gastric response to modified sham feeding (MSF) on ultrasound and cardiovascular autonomic function in FD patients.

METHODS

Nineteen patients with postprandial distress syndrome (PDS, 11 men and eight women; mean age: 48.2 years) and 26 healthy subjects (HS, 13 men and 13 women; mean age: 45.0 years) were studied prospectively. Firstly, cardiovascular autonomic function was assessed by spectral analysis of RR interval variability. Antral contraction was then evaluated by ultrasonography after MSF was performed to stimulate the cephalic phase of vagal activity.

KEY RESULTS

Spectral analysis of RR interval variability showed that the high-frequency component was significantly smaller in the patients than in the HS (P<0.01). The frequency of antral contraction in response to MSF over 15 min was also significantly lower in the PDS patients than in the HS. The 15-min integrated antral contractile response (area under the contraction vs time curve) was significantly smaller in the PDS patients than in the HS (P<0.01). Univariate analysis revealed a modest correlation between the high-frequency component of RR interval variability and the area under the contraction vs time curve (n=46, r=0.49, P<0.01).

CONCLUSIONS & INFERENCES

Autonomic abnormalities affecting the cephalic phase of vagal activity may be important in the pathogenesis of FD.

Evaluation of RAPID(®) 5 Access software for examination of capsule endoscopies and reading of the capsule by an endoscopy nurse

BACKGROUND

Since capsule endoscopy (CE) is time consuming, one possible cost-effective strategy could be the use of an expert endoscopic assistant and available software to select images. Aims were to examine the clinical utility of RAPID(®) 5 Access software and find the optimum setting mode for reading. We also evaluated whether a nurse could preview the CE video and detect significant lesions accurately.

METHODS

The capsule images in 14 volunteers with known mucosal injury induced by low dose aspirin and in 30 patients who were known to have a variety of significant lesions were selected. Using three setting modes of RAPID(®) 5 Access software, the detection rate and reading time for CE images by two well-trained physicians and one expert nurse were compared.

RESULTS

There was no significant difference in detection rate among the three readers. The detection rate using Quickview RAPID(®) 5 Access was significantly higher than that using RAPID(®) Reader version 4.1. Comparison among the three modes of RAPID(®) 5 Access showed that auto mode as well as displaying a single image at 12 fps was superior in the detection rate of denuded redness, while its reading time was longer compared to the other modes. Some significant lesions were not detected by using Quickview and Quadview modes.

CONCLUSIONS

RAPID(®) 5 Access improves diagnostic yield, reducing reading time; however, it is still unacceptable because of the diagnostic miss rate and may be useful as an ancillary reading tool. Developing further improved software and training expert assistants for reading capsule images are necessary.

Changes of upper gastrointestinal symptoms and endoscopic findings in Japan over 25 years

BACKGROUND AND AIMS

In Japan, the prevalence of Helicobacter pylori infection has decreased recently, but there has been little longitudinal research on the changes of symptoms and endoscopic findings over many years. The aim of this study was to evaluate the changes in endoscopic findings and symptoms over time in patients undergoing upper gastrointestinal endoscopy for assessment of upper abdominal symptoms.

METHODS

Over a period of 25 years, between 1981 and 2005, we performed three investigations (1981-2, 1990-1 and 2004-5) on the symptoms and endoscopic findings of patients undergoing endoscopy at Kawasaki Medical School Hospital for the assessment of upper abdominal symptoms.

RESULTS

The most common complaint for all ages was "discomfort and/or pain". Over time, the percentage of patients complaining of "heartburn" increased almost 5-fold. With respect to endoscopic findings, the prevalence of peptic ulcers decreased, whereas the detection of no abnormalities and the detection of erosive esophagitis increased.

CONCLUSION

In the future in Japan, there will be fewer patients with peptic ulcers and more patients with gastro-esophageal reflux disease or dyspeptic patients who display no endoscopic abnormal findings.

Efficacy of mosapride citrate in proximal gastric accommodation and gastrointestinal motility in healthy volunteers: a double-blind placebo-controlled ultrasonographic study

BACKGROUND

Mosapride citrate, a 5-hydroxytryptamine-4 receptor agonist, enhances antral contractions and gastric emptying, but its effects on proximal gastric accommodation and gastroduodenal motility have not been fully studied. The aim of the present study was to clarify the effects of mosapride citrate on proximal gastric accommodation and gastroduodenal motility in healthy volunteers, using ultrasonography.

METHODS

Fourteen healthy volunteers (mean age 25.3 years) were treated for 14 days with mosapride citrate (15 mg b.d.) or a placebo in a double-blind randomized fashion. Before and after drug treatment, ultrasonographic assessment of gastroduodenal motility was performed. For assessment of the gastric accommodation reflex, the cross-sectional area of the proximal stomach was measured after the incremental ingestion, with a straw, of up to 400 ml of a liquid meal (consommé soup: 13.1 kcal, 400 ml); this was done with the subject in a supine position. Gastric emptying, antral contractions, and the duodenogastric reflux were observed as described previously.

RESULTS

In the subjects treated with mosapride citrate, the expansion rate of the cross-sectional area of the proximal stomach was significantly greater after the ingestion of 400 ml as compared to that of the subjects treated with the placebo. Similarly, gastric emptying and antral contractions increased significantly in the mosapride citrate group as compared to the placebo group. Although the duodenogastric reflux tended to decrease in the mosapride citrate group, it showed no significant difference between the two groups.

CONCLUSIONS

This study shows that mosapride citrate enhances the meal-induced gastric accommodation reflex and promotes adequate gastroduodenal coordination and motility in healthy volunteers.