Acute esophageal and gastric injury: complication of Lugol's solution

Several new technologies have been developed to improve the diagnostic capability of conventional endoscopic techniques. One of these most frequently used methods is chromoendoscopy with Lugol's solution in the esophagus to detect malignant lesions. This method has been used for several decades and is generally considered as a safe method, only a few cases of side effects having been reported. We describe a case of acute esophageal and gastric mucosal damage after application of Lugol's solution during endoscopy in an 84-year-old woman. Endoscopists should be aware of the potential for adverse reactions to iodine staining.

Endoscopic full-thickness plication for the treatment of GERD: long-term multicenter results

BACKGROUND

The purpose of the present study was to assess the long-term safety and durability of effect for endoscopic full-thickness plication for the treatment of symptomatic gastroesophageal reflux disease (GERD). The Plicator (NDO Surgical, Inc., Mansfield, MA) used delivers a transmural suture through the gastric cardia to restructure the antireflux barrier. Published reports have shown the Plicator procedure to be effective in reducing GERD symptoms and medication use at 1 year post-plication.

METHODS

Twenty-nine patients with chronic heartburn requiring maintenance daily anti-secretory therapy were treated at five sites. Patients received a single full-thickness plication in the gastric cardia 1cm below the gastroesophageal junction (GE) junction. Re-treatments were not permitted. Patients were evaluated at baseline for GERD symptoms and medication use. Intermediate (12 month) and long-term subject follow-up (median follow-up: 36.4 months; range, 31.2-43.9 months) were completed to evaluate procedure safety and durability of effect.

RESULTS

Twenty-nine patients completed the 12-month and 36-month follow-up. All procedure-related adverse events occurred acutely, and no new events were observed during extended follow-up. At 36-months post-procedure, 57% (16/28) of baseline proton pump inhibitor (PPI)-dependent patients remained off daily PPI therapy. Treatment effect remained stable from 12- to 36-months, with 21/29 patients off daily PPI at 12 months compared to 17/29 patients at 36-months. Median GERD- Health Related Quality of Life (HRQL) scores remained significantly improved at 36 months versus baseline off-meds scores (8 versus 19, p < 0.001). In addition, the proportion of patients achieving > or = 50% improvement in GERD-HRQL score was consistent from 12 months (59%) to 36 months (55%).

CONCLUSIONS

Endoscopic full-thickness plication can reduce GERD symptoms and medication use for at least 3-years post-procedure. Treatment effect is stable from 1 to 3 years, and there are no long-term procedural adverse effects.

Extracellular signal-regulated kinase 1- and 2-mediated gastric mucosal injury and repair in gastric ischemia-reperfusion of rats

BACKGROUND

The current study was undertaken to investigate the time course of gastric ischemia-reperfusion (GI-R)-induced gastric mucosal injury and repair and whether extracellular signal-regulated kinase 1/2 (ERK1/2) were involved in GI-R-induced gastric mucosal injury and repair.

METHODS

Immunohistochemistry and Western blot analyses were used.

RESULTS

Gastric mucosal injury induced by ischemia alone was mild. However, the injury worsened after reperfusion, reaching a maximum at 1 h, and was accompanied by increased apoptotic cells and decreased proliferative cells. Then, the gastric mucosal cells began to repair the injury by enhanced proliferation, which peaked at 24 h after reperfusion, and by 72 h the damaged gastric mucosa was mostly repaired. The ERK1/2 (nonactivated ERK1/2) protein expression level and distribution profile showed no significant changes during the entire reperfusion phase, but the p-ERK1/2 (activated ERK1/2) level changed dramatically. The p-ERK1/2 protein level was decreased at 0.5 h after reperfusion began, and then gradually increased, peaking after 3 h of reperfusion; these changes in p-ERK1/2 occurred simultaneously in the cytoplasm and nucleus. On the other hand, inhibition of the activation of ERK1/2, induced by PD98059, a specific ERK1/2 upstream inhibitor, aggravated the gastric mucosal injury, and apoptosis was increased and proliferation was reduced in the gastric mucosal cells after the same duration of reperfusion.

CONCLUSIONS

Serious gastric mucosal damage involving apoptotic cells occurred rapidly at an early stage of reperfusion and was closely related to the suppression of ERK1/2 activation. The activated ERK1/2 signaling transduction pathway played an important role. Activated ERK1/2 participated in the regulation of gastric mucosal injury and repair induced by GI-R, and might be mediated by the inhibition of apoptosis and the promotion of proliferation in gastric mucosal cells.

Comparison of outcomes after laparoscopic and open pyloromyotomy at a high-volume pediatric teaching hospital

BACKGROUND/PURPOSE

Laparoscopic pyloromyotomy (LP) is used widely for treatment of hypertrophic pyloric stenosis. We examined the results of pyloromyotomy at a high-volume pediatric teaching hospital to compare outcomes of laparoscopic and open pyloromyotomy (OP).

METHODS

We reviewed the records of all patients who underwent pyloromyotomy at our institution over a 5-year period. Data were collected regarding operative time, time to full feeds, length of hospital stay, complications, and frequency of postoperative emesis.

RESULTS

There were 335 pyloromyotomies: 212 laparoscopic and 123 open. Five patients in the laparoscopic group required conversion to an open procedure. There were no significant differences in operative time (LP, 30.5 minutes; OP, 32.0 minutes), time to full feeds (LP, 22.4 hours; OP, 23.5 hours), frequency of postoperative emesis (LP, 1.8; OP, 2.2), or length of hospital stay (LP, 49.3 hours; OP, 50.5 hours). There were 5 mucosal perforations in the laparoscopic group and 2 in the open group (LP, 2.3%; OP, 1.6%). There were 3 incomplete pyloromyotomies in the laparoscopic group and none in the open group. Four perforations and all incomplete myotomies occurred in the first 2 years after the laparoscopic technique was introduced at our institution. The overall complication rate was similar (LP, 3.7%; OP, 3.2%).

CONCLUSIONS

Laparoscopic pyloromyotomy is a safe and effective alternative to OP. There appears to be an institutional learning curve when the laparoscopic technique is introduced as reflected by slightly higher rates of mucosal injury and incomplete pyloromyotomy.

Melaena as the presenting symptom of gastric mucosal injury due to blunt abdominal trauma

Blunt abdominal trauma is a common cause of admission to the typical trauma centre. Hollow viscus injury from blunt trauma, however, is unusual and rarely involves the stomach. A 15 year old boy sustained a bicycle handle bar injury to the abdomen and presented to the casualty department four days later with melaena. A computed tomography (CT) scan of the abdomen showed normal findings but endoscopy revealed two "kissing" areas of mucosal ulceration on the anterior and posterior wall of the gastric antrum. The patient received a blood transfusion for anaemia but was otherwise treated conservatively and made a full recovery. The authors believe this to be the first reported case of melaena as the primary presenting symptom of gastric ulceration secondary to blunt abdominal trauma. Diagnosis of hollow viscus injuries due to blunt abdominal trauma requires a high index of suspicion and thorough investigation, particularly if the presentation is delayed.

Role of gastric mucosal ascorbic acid in gastric mucosal lesion development in rats with water immersion restraint stress

We examined the role of gastric mucosal ascorbic acid (AA) in gastric mucosal lesion development in rats with water immersion restraint stress (WIRS). When fasted rats were subjected to WIRS for 1, 3 or 6 h, gastric mucosal lesions developed at 3 and 6 h. Gastric mucosal AA concentration decreased at 3 and 6 h after the onset of WIRS, while gastric mucosal non-protein SH concentration decreased at 1, 3, and 6 h and gastric mucosal vitamin E concentration decreased at 6 h. Gastric mucosal lipid peroxide concentration and myeloperoxidase activity increased at 3 and 6 h of WIRS. Pre-administration of AA (250 mg/kg) prevented gastric mucosal development with attenuation of the decreased gastric mucosal AA, non-protein SH and vitamin E concentrations, and the increased gastric mucosal lipid peroxide concentration and myeloperoxidase activity. These results suggest that gastric mucosal AA plays an important role in WIRS-induced gastric mucosal lesion development.

Agonist of peroxisome proliferator-activated receptor gamma (PPAR-gamma): a new compound with potent gastroprotective and ulcer healing properties

Pioglitazone, a specific ligand for peroxisome proliferator-activated receptor gamma (PPAR-gamma), was recently implicated in the control of inflammatory processes and in the modulation of the expression of various cytokines such as tumor necrosis factor alpha (TNF-alpha), but its role in the mechanism of gastric mucosal integrity has not been studied extensively. This study was designed to determine the effect of pioglitazone on gastric mucosal lesions induced in rats by topical application of 100% ethanol and by 3.5 h of water immersion and restraint stress (WRS) with or without pretreatment with indomethacin (5 mg/kg i.p.) to inhibit cyclooxygenase-1 (COX-1) and COX-2 enzyme activities and L-NNA (20 mg/kg i.p.) to suppress nitric oxide (NO)-synthase. In addition, the effect of pioglitazone on ulcer healing in rats with chronic acetic acid ulcers (ulcer area 28 mm2) was determined. Rats were killed 1 h and 3.5 h after ethanol administration or WRS exposure or at day 9 upon ulcer induction, and the number and area of gastric lesions were measured by planimetry, the gastric blood flow (GBF) was determined by H2-gas clearance technique and the mucosal PGE2 generation and gene expression and plasma concentration of TNF-alpha and IL-1beta were also evaluated. Pre-treatment with pioglitazone dose-dependently attenuated gastric lesions induced by 100% ethanol and WRS; the dose reducing these lesions by 50% (ID50) being 10 mg/kg and 7 mg/kg, respectively. The protective effect of pioglitazone was accompanied by the significant rise in the GBF, an increase in PGE2 generation and the significant fall in the plasma TNF-alpha and IL-1beta levels. Strong signals for IL-1beta- and TNF-alpha mRNA were recorded in gastric mucosa exposed to ethanol or WRS, and these effects were significantly decreased by pioglitazone. Indomethacin which suppressed PG generation by about 90%, while augmenting WRS damage, and L-NNA, that suppressed NO-synthase activity, significantly attenuated the protective and hyperaemic activity of this PPAR-gamma ligand. In the chronic study, pioglitazone significantly reduced the area of gastric ulcers on day 9 and significantly raised the GBF at the ulcer margin. The acceleration of ulcer healing by PPAR-gamma ligand was accompanied by a significant increase in the expression of PECAM-1 protein, a marker of angiogenesis. We conclude that (1) pioglitazone exerts a potent gastroprotective and hyperaemic actions on the stomach involving endogenous PG and NO and attenuation of the expression and release of proinflammatory cytokines TNF-alpha and IL-1beta, and (2) PPAR-gamma ligand accelerates ulcer healing, possibly due to the enhancement in angiogenesis at ulcer margin.

A novel gastric lesion model induced in rats by partial gastric vascular ligation

Previous studies have suggested that histamine treatment after gastric vascular ligation induces mucosal damage in the rat stomach. Although ligation of left gastric artery and vein (L-AV) alone did not cause any damage in the stomach within 4 h, but provoked mild lesions due to ischaemia 24 h later. In the present study we demonstrated a new model of gastric lesions induced by L-AV ligation and examined the effects of various anti-ulcer drugs on this lesion model. The gastric lesions induced by L-AV ligation occurred at the corpus and antrum, especially at the corpus-antrum border, when examined 24 h later, and the severity of damage reached maximum 3 days after L-AV ligation. Repeated treatment with omeprazole or sucralfate for 3 days significantly prevented the development of gastric lesions induced by L-AV ligation, in whole mucosa, including the antrum. By contrast, famotidine given for 3 days showed a significant protection against total lesions in the whole mucosa, but had no effect on the antral lesions. Both omeprazole and famotidine dose-dependently decreased gastric acid output while sucralfate raised the intraluminal pH due to the acid-neutralizing action. These results suggest that the pathogenesis of gastric lesions induced by L-AV ligation differs depending on the region, the corpus and the antrum, and the lesions occurred in the latter area seem to be resistant to acid suppression. It is assumed that this new model of gastric lesions is useful for screening the drugs that affect gastric mucosal defense rather than acid secretion.

Indomethacin inactivates gastric peroxidase to induce reactive-oxygen-mediated gastric mucosal injury and curcumin protects it by preventing peroxidase inactivation and scavenging reactive oxygen

We have investigated the mechanism of indomethacin-induced gastric ulcer caused by reactive oxygen species (ROS) and the gastroprotective effect of curcumin thereon. Curcumin dose-dependently blocks indomethacin-induced gastric lesions, showing 82% protection at 25 mg/kg. Indomethacin-induced oxidative damage by ROS as shown by increased lipid peroxidation and thiol depletion is almost completely blocked by curcumin. Indomethacin causes nearly fivefold increase in hydroxyl radical (()OH) and significant inactivation of gastric mucosal peroxidase to elevate endogenous H(2)O(2) and H(2)O(2)-derived ()OH, which is prevented by curcumin. In vitro studies indicate that indomethacin inactivates peroxidase irreversibly only in presence of H(2)O(2) by acting as a suicidal substrate. 5,5-Dimethyl-pyrroline-N-oxide (DMPO) protects the peroxidase, indicating involvement of indomethacin radical in the inactivation. Indomethacin radical was also detected in the peroxidase-indomethacin-H(2)O(2) system as DMPO adduct (a(N) = 15 G, a(beta)(H) = 16 G) by electron spin resonance spectroscopy. Curcumin protects the peroxidase in a concentration-dependent manner and consumes H(2)O(2) for its oxidation as a suitable substrate of the peroxidase, thereby blocking indomethacin oxidation. Curcumin can also scavenge ()OH in vitro. We suggest that curcumin protects gastric damage by efficient removal of H(2)O(2) and H(2)O(2) -derived ()OH by preventing peroxidase inactivation by indomethacin.

The presentation and organization of adaptive cytoprotection in the rat stomach, duodenum, and colon. Dedicated to André Robert the founder of the concept of cytoprotection and adaptive cytoprotection

BACKGROUND

Adaptive cytoprotection could be demonstrated in lesion attenuation within the whole gastrointestinal tract, in particular sequences, with onset and duration longer than the initial short-lasting period (i.e. one hour) defined by Robert in the stomach only.

MATERIAL/METHODS

Adaptive cytoprotection possibly appeared and lesions were attenuated when the stomach, duodenum or colon, in various combinations and sequences, were challenged with initial (mild) and/or final (strong) irritants over a two-week period. Rats were challenged with the mild or strong irritants 25% or 96% ethanol intragastrically 1 ml/rat (stomach) and cysteamine 40 mg or 400 mg/kg subcutaneously (duodenum), or intrarectally (colon). To postulate the prostaglandin relationship known in Robert's cytoprotection and adaptive cytoprotection, indomethacin (1 mg/kg subcutaneously) was given simultaneously with the second challenge.

RESULTS

Administering the mild and strong irritant protocols within the same part of the gastrointestinal tract, adaptive cytoprotection presents in the stomach (1 h to 14 days), duodenum (2 h to 14 days), but not in the colon. With these protocols applied to different parts of the gastrointestinal tract, adaptive cytoprotection cross-reaction was evident in the stomach-duodenum, duodenum-stomach (1 h-14 days and 2 h-14 days), stomach-colon, and duodenum-colon (both 2-24 hours), but not in the colon-stomach or colon-duodenum. This protection was fully antagonized with indomethacin.

CONCLUSIONS

As observed for a day and even weeks, stomach-duodenum-colon adaptive cytoprotection is an important new defensive phenomenon.

Curcuma longa extract protects against gastric ulcers by blocking H2 histamine receptors

Curcuma longa has been commonly used as a traditional remedy for a variety of symptoms such as inflammation, gastritis and gastric ulcer. When C. longa extract was administered per os to pylori-ligated rat stomachs, it reduced gastric acid secretion and protected against the formation of gastric mucosal lesions. We therefore tested whether C. longa extract inhibits gastric ulcers by blocking the H(2) histamine receptor. Dimaprit, a H(2) histamine receptor agonist, induced intracellular cAMP production in U937 and HL-60 promyelocytes. Pretreatment with C. longa extract significantly blocked dimaprit-induced cAMP production in a concentration dependent manner, but had no effect on the elevation of cAMP levels triggered by isoproterenol-induced beta(2)-adrenoceptor activation in U937 cells. To identify the active component(s) of C. longa extract, we sequentially fractionated it by extraction with ethyl acetate, n-butanol and water. We found that the ethyl acetate extract showed the most potent H(2)R antagonistic effect against dimaprit-induced cAMP production. However, curcumin, a major component of C. longa extract, showed no H(2)R blocking effect. C. longa ethanol extract and ethylacetate extract also blocked the binding of [(3)H]-tiotidine to membrane receptors on HL-60 cells. These findings suggest that the extract from C. longa specifically inhibits gastric acid secretion by blocking H(2) histamine receptors in a competitive manner.

Drug injury in the upper gastrointestinal tract: effects of alendronate

Osteoporosis is a disease characterized by an increase in bone resorption and a decline in bone density, which leads to increased susceptibility to bone fractures. Long-term therapy is needed to increase bone mineral density and maintain bone strength. Safe and well-tolerated medical therapies are required for long-term maintenance. Alendronate, an oral bisphosphonate, has been used for treatment of osteoporosis since the mid 1990s; however, recent studies have suggested alendronate can have significant gastrointestinal side effects. Most data suggest that the risk of these effects is low and not significantly higher than with placebo but there are limited reports that suggest otherwise, in both clinical trials and animal studies. Alendronate continues to remain an important mainstay of osteoporosis therapy.

Worsening effect of partial sleep deprivation on indomethacin-induced gastric mucosal damage

The present study was to investigate the roles of cyclooxygenase-1 and -2 (COX-1 and COX-2) and prostaglandin (PG) on gastric mucosal integrity of partially sleep deprived (PSD) rats. A slowly moving drum was used to induce PSD. The PG levels in the gastric mucosa of PSD rats, with or without indomethacin or rofecoxib treatment, were determined. Exogenous prostaglandin E (PGE) analog, misoprostol, was administered to PSD rats to investigate the modulating effect of PG in indomethacin-induced gastric damage. It was observed that COX-1 mRNA and protein were up-regulated in the gastric mucosa of PSD rats. Selective COX-2 inhibition by rofecoxib failed to decrease mucosal PGE2 levels nor to affect mucosal integrity in both PSD and sleep undisturbed rats. However, indomethacin, a COX-1 preferential non-selective COX inhibitor, significantly reduced mucosal PGE2 content and produced more severe mucosal damage in PSD rats than in the controls. The deleterious effect of indomethacin on gastric mucosal integrity of PSD rats was significantly attenuated with the administration of misoprostol. These results suggest that PSD enhances COX-1 biosynthesis of gastroprotective PGE2 as an adaptive response of the stomach to stress. The administration of non-selective COX inhibitors to subjects with chronic sleep deprivation may induce more gastric damages.

Laceration of gastric mucosa associated with dialysis-related amyloidosis

We report a 72-year-old female on long-term hemodialysis, who was admitted to the hospital because of hematemesis. On emergency laparotomy, pylorogastrectomy was performed. The resected specimen showed a giant hematoma and traversing fissure along the lesser curvature of the body of the stomach. Histologically, the specimen showed wide hematoma formation and amyloid deposits in the submucosal layer, especially in the wall of blood vessels. These deposits reacted positively to antihuman beta2-microglobulin antibody. The post-operative course was favorable, and the patient was discharged on the 35th hospital day. In this case, the laceration site on the gastric mucosa was almost intact and did not demonstrate ischemic change, suggesting that the giant hematoma was caused by submucosal vessel rupture, which led to the gastric mucosa laceration. To our knowledge, this is the first case of gastric mucosa laceration associated with dialysis-related amyloidosis.

Pyloromyotomy: a comparison of laparoscopic, circumumbilical, and right upper quadrant operative techniques

BACKGROUND

Ramstedt pyloromyotomy through a right upper quadrant (RUQ) transverse incision has been the traditional treatment for hypertrophic pyloric stenosis. Recently, laparoscopic (LAP) and circumumbilical (UMB) approaches have been introduced as alternative methods to improve cosmesis, but concerns about greater operative times, costs, and complications remain. This study compares the three operative techniques and examines their advantages and complication rates.

STUDY DESIGN

We performed a retrospective review of patients undergoing pyloromyotomy at a children's hospital between January 1997 and June 2003.

RESULTS

Two hundred ninety patients underwent pyloromyotomy by LAP (n = 51), RUQ (n = 190), or UMB (n = 49). Complication rate, time to ad libitum feeding, incidence of emesis, and postoperative length of stay did not differ considerably among groups. Two LAP patients were converted to RUQ. Mucosal perforation occurred in three patients each in the RUQ and UMB groups, but none in the LAP group. Operative times were considerably less for LAP (25 +/- 9 minutes) than for RUQ (32 +/- 9 minutes) and UMB (42 +/- 12 minutes) (p < 0.05, ANOVA, Bonferroni). Charges related to operations and anesthesia were considerably greater for UMB (operation: US 1,574 dollars +/- US 433 dollars; anesthesia: US 731 dollars +/- US 190 dollars) compared with the other two groups (p < 0.05, ANOVA, Bonferroni), but did not differ between LAP (operation: US 1,299 dollars +/- US 311 dollars; anesthesia: US 586 dollars +/- US 137 dollars) and RUQ (operation: US 1,237 dollars +/- US 411 dollars; anesthesia: US 578 dollars +/- US 167 dollars). Data are presented as mean +/- SD.

CONCLUSIONS

Advantages of LAP include a shorter mean operative time without higher complications or costs. UMB is associated with the greatest mean operative time and costs. Laparoscopic pyloromyotomy is a safe and effective approach to the treatment of hypertrophic pyloric stenosis.

Irritative action of alcoholic beverages in rat stomachs: A comparative study with ethanol

The mucosal irritative action of alcoholic beverages such as white wine, Japanese sake and whisky was examined in rat stomachs in vivo and in vitro, in comparison with ethanol. The concentration of ethanol in these alcoholic beverages was 15%. Mucosal application of ethanol (15%) and whisky in the chambered stomach caused a decrease in gastric potential difference (PD), while that of Japanese sake and white wine caused a slight increase but not decrease in PD. Likewise, both ethanol and whisky markedly reduced the cell viability of RGM1 cells after 5 min incubation, whereas neither Japanese sake nor white wine had any effect. In addition, supplementation of glucose, one of the non-alcoholic ingredients of white wine and Japanese sake, antagonized a reduction in both PD and cell viability caused by ethanol. These results suggest that the mucosal irritative action of Japanese sake and white wine is much less than that of ethanol or whisky and that these properties may be, at least partly, due to the glucose contained in these alcoholic beverages.

Gastric mucosa lesions in drowning: its usefulness in forensic pathology

In a retrospective study of 52 autopsy cases of drowning fatalities, death circumstances, macroscopical and histological findings of the stomach mucosa were carefully studied. Results were compared with a control group, composed by 80 cases of different kinds of asphyxia (hanging, chocking and suffocation), skull injuries, sudden cardiac death and poisonings. The spectrum of gastric lesions observed during autopsy in drowning group, are presented. Stomach mucosa tears were found in 21.1% of the cases of drowning, preferably on fundus (54.5%). The control group does not show similar lesions. The physiopathological mechanism of its production, are also discussed. On sight of these results, it is concluded that the macro and microscopical examination of the stomach could be useful as an adjunct procedure for drowning diagnosis. The presence of gastric mucosa lesions has an intravital significance and could be correlated with other anatomical or histological signs of drowning for the diagnosis. In every case, necropsic examination must be carried out as soon as possible in order to avoid putrefactive artifacts.

Comparative gastrointestinal toxicity of selective cyclooxygenase (COX-2) inhibitors

Cyclooxygenase (COX-2) inhibitors were developed with the hope that they will cause fewer gastrointestinal adverse effects. Ability of selective as well as nonselective COX inhibitors to alter ischemia-reperfusion induced damage of gastric mucosa and hapten-induced colitis in rats has been compared. Celecoxib (10, 20 and 40 mg/kg(-l)) was significantly more potent at aggravating ischemia-reperfusion injury as compared to nimesulide. Similarly, celecoxib was found to maximally potentiate TNBS-induced colitis, followed by nimesulide and indomethacin. Celecoxib at its highest dose produced maximum deep histological injury. This paradoxic ulcer and colitis aggravating effect of selective COX-2 inhibitors may be explained by suppression of protective prostaglandins generated as a consequence of COX-2 induction in inflammatory states.

Synergism of Helicobacter pylori infection and stress on the augmentation of gastric mucosal damage and its prevention with alpha-tocopherol

Despite evidence that Helicobacter pylori (H. pylori) infection is closely associated with stress in gastric ulcer patients, the underlying mechanism why ulcer recurrence after stress is augmented especially in patients with H. pylori remains unknown. In this study, we found that oxidative stress played a critical role in the augmented mucosal damage provoked by water immersion restraint stress (WIRS) in H. pylori infection and that an antioxidant, alpha-tocopherol, could ameliorate the aggravation of stress-associated gastric mucosal damage. Two hundred forty SD rats were divided into two groups according to H. pylori inoculation, and after 24 weeks of H. pylori infection, the water immersion restraint stress was imposed for 30, 120, or 480 min, respectively. To evaluate the therapeutic effects of an antioxidant, alpha-tocopherol was administrated 40 mg/kg daily prior to imposing WIRS. Remarkably increased hemorrhagic lesions and bleeding indexes were noted in the H. pylori-infected group with statistical significance (P < 0.05) compared to the noninfected group at the same duration of WIRS. Significantly higher oxidative stress documented by iNOS, lipid peroxides, and GSH level was detected in gastric homogenates of the H. pylori-infected group. Proteomic analysis using 2-dimensional electrophoresis showed a decrease of HSP27 and other chaperone proteins. alpha-Tocopherol pretreatment significantly prevented the gastric mucosal damage, caused by WIRS in the presence of H. pylori. alpha-Tocopherol induced HSP27 expression, which was well correlated with downregulation of iNOS mRNA. Conclusively, the presence of H. pylori caused significant deterioration of stress-induced gastric mucosal lesions through increased oxidative stress and thus antioxidant treatment such as alpha-tocopherol protected the gastric injuries.

A study of 11,003 patients with hypertrophic pyloric stenosis and the association between surgeon and hospital volume and outcomes

AIM

The availability of large clinical databases allows for careful evaluation of surgical practices, indicators of quality improvement, and cost. We used a large clinical database to compare the effect of surgeon and hospital volume for the care of children with hypertrophic pyloric stenosis (HPS).

METHODS

Patients with International Classification of Diseases-9 codes for HPS and pyloromyotomy were selected from the 1994 to 2000 National Inpatient Samples database. Multiple and logistic regression models were used to evaluate the risk-adjusted association between provider volume and outcomes.

RESULTS

Postoperative complications occurred in 2.71% of patients. Patients operated on by low- and intermediate-volume surgeons were more likely to have complications compared with those operated on by high-volume surgeons (95% confidence interval [CI], 1.25-3.78 and 95% CI, 1.25-2.69, respectively). Patients operated at low-volume hospitals were 1.6 times more likely to have complications compared with those operated at intermediate- or high-volume hospitals (95% CI, 1.19-2.20). Procedures performed at high-volume hospitals were less expensive than those at intermediate-volume hospitals by a margin of 910 dollars (95% CI, 443-1377 dollars).

CONCLUSIONS

These data represent the largest study to date on the epidemiology, complication rate, and cost for care for HPS. Patients treated by both high-volume surgeons and at high-volume hospitals have improved outcomes at less cost.

Laparoscopic removal of gastric band after early gastric erosion: case report and review of the literature

Laparoscopic gastric banding is a popular method for treating morbid obesity. One of the most serious complications is band erosion into the gastric lumen. We present the case of a patient who underwent gastric banding and presented with symptoms of gastrointestinal reflux and mild-to-moderate hypertension, fever, and pain. UGI revealed stomach wall erosion and partial migration of the band into the gastric lumen. The band was laparoscopically removed without any further complications. Migration after laparoscopic gastric banding must be immediately addressed to prevent infection. Close monitoring of the band location during adjustments as well as a high index of suspicion is necessary.

Fibrin glue, healing of gastric mucosal injury, and expression of growth factors: results from a human in vivo study

BACKGROUND

Fibrin glue is used in the endoscopic therapy of bleeding ulcerations. Accelerated closure of ulcers has been attributed to this treatment; the biologic reason, however, remains unclear.

METHODS

Two artificial gastric lesions were induced in healthy, Helicobacter pylori negative volunteers and were treated by injection of either saline solution or fibrin glue. After 72 hours, resulting ulcers were measured and biopsy specimens were taken for immunohistochemistry (to identify proliferating cells and small vessels) and assessment of growth factor messenger RNA (mRNA) expression (platelet derived growth factor, vascular endothelial growth factor, fibroblast growth factor 2 [FGF-2]) by real-time reverse transcriptase-polymerase chain reaction (RT-PCR).

RESULTS

After 72 hours, most lesions exposed to fibrin glue were smaller than the corresponding ones treated with saline solution. The ulcer rim was more pronounced; immunohistochemistry revealed more proliferating cells (p < 0.02 compared with saline solution). The number of microvessels also increased, though this difference did not reach statistical significance (p = 0.10). FGF-2 mRNA expression markedly increased (about 7-fold compared with the control [ p < 0.001], and about 5-fold compared with saline solution [ p < 0.015]); whereas, with respect to platelet derived growth factor and vascular endothelial growth factor mRNAs, only small changes occurred.

CONCLUSIONS

Fibrin glue positively modulates gastric ulcer healing by causing an increase in the number of proliferating cells in the ulcer margin and also possibly enhances the density of microvessels. These changes are accompanied by an enhanced expression of FGF-2, which is known to exert beneficial effects on ulcer healing.

Nociceptive transmitter release in the dorsal spinal cord by capsaicin-sensitive fibers after noxious gastric stimulation

Little is known about transmitters that encode noxious gastric stimuli in the spinal cord. The release of glutamate, substance P, and CGRP from the spinal cord was therefore investigated in response to acid injury of the gastric mucosa. Dorsal halves of the caudal thoracic spinal cord (T7-T13) were removed 6 h after oral application of 0.5 M HCl or saline, transferred to a superfusion chamber, and the basal and capsaicin-stimulated (3.3 microM) transmitter release was determined. After acid injury, basal glutamate release increased 134% as compared to saline-treated animals. Capsaicin-stimulated release of CGRP and SP was 48% and 58% lower in acid- than in saline-treated animals, indicating that capsaicin-sensitive fibers in the dorsal spinal cord were already partially depleted by acid treatment. Capsaicin denervation reduced basal glutamate release by 33% after acid injury as compared to non-denervated acid-treated animals. Gastric origin and capsaicin sensitivity of glutamatergic, CGRP- and SP-containing primary afferents in thoracic dorsal root ganglia were then determined by retrograde tracing with True Blue and immunohistochemical labeling with the vanilloid receptor TRPV1. About 65% of True Blue-labeled cells were glutamatergic and more than 73% of this population expressed the TRPV1 receptor. Nearly all True Blue/CGRP (85%)- and True Blue/SP-positive cells (97%) coexpressed TRPV1. We conclude that noxious gastric stimulation with acid induces release of glutamate, SP, and CGRP from capsaicin-sensitive sensory afferents in the dorsal horn of the spinal cord where they may play an important role in gastric nociception and hyperalgesia.