Acid suppression: optimizing therapy for gastroduodenal ulcer healing, gastroesophageal reflux disease, and stress-related erosive syndrome

Gastroesophageal reflux disease in children and adolescents: when and how to treat

Gastroesophageal reflux (GER) is a common presenting complaint in children and adults, and is a frequent reason for physician consultation. GER disease (GERD), whilst benign in the majority of cases, is frequently a chronic condition that has been shown to result in significantly reduced quality of life in children and adolescents. Furthermore, there is emerging evidence that the prevalence of GERD is rising and may have links to adult obesity and other morbidities. Consequently, accurate diagnosis, appropriate management strategies, and timely referral to specialist services are important principles in the effective management of GERD. Acid-suppressive drugs are effective therapies but are one of the most costly classes of drugs prescribed. Therefore, not only is an accurate diagnosis important to the patient, but it is also of significant interest from a public health and resource utilization standpoint.

Gastroprotective effect of Achyranthes aspera Linn. leaf on rats

OBJECTIVE

The study was aimed at evaluating the antiulcer activity of ethanolic extract of Achyranthes aspera (EEAA) leaf.

METHODS

The anti-ulcer assays were performed on pylorus ligation and chronic ethanol induced ulcer model. The effects of the EEAA on gastric content volume, pH, free acidity, total acidity and ulcer index were evaluated.

RESULTS

The percentage of ulcer protection (59.55% and 35.58%) was significantly (P < 0.001) higher in the groups treated with the high dose of EEAA (600 mg/kg), it also reduced the volume of gastric juice and total acidity whereas, gastric pH was increased significantly.

CONCLUSIONS

The results of this study show significant gastroprotective activity of EEAA may be due to presence of phyto-constituents like flavanoids, saponins and tannins.

Gastro-oesophageal reflux disease: beyond proton pump inhibitor therapy

Gastro-oesophageal reflux disease (GORD or GERD) is a very common disorder, and advancement in drug development over the years has markedly improved disease management. Proton pump inhibitors (PPIs) remain the mainstay of treatment for GERD due to their profound and consistent inhibitory effect on acid secretion. However, PPIs do not reduce the number of reflux events and do not provide long-term cure for GERD. In addition, although the safety profile of PPIs is excellent, recent population-based studies have suggested that long-term PPI use may be associated with a variety of adverse events. They include osteoporosis-related hip and spine fractures, community-acquired and nosocomial pneumonia, various enteric and non-enteric infections, fundic gland polyps and many others. Consequently, there is growing interest by patients and physicians alike in current, as well as future, non-PPI-related therapeutic strategies for GERD. This includes repositioning histamine H(2) receptor antagonists and prokinetics in our current GERD therapeutic algorithms and a resurgence of non-medical therapeutic modalities for GERD, such as anti-reflux surgery, endoscopic treatment, alternative and complementary medicine and psychological interventions. Furthermore, there will be renewed efforts in further developing new medical and non-medical therapeutic modalities for GERD.

Antiulcer effect of the methanolic extract of Tamarindus indica seeds in different experimental models

Background:

Peptic ulcer is a global health problem of the gastrointestinal tract characterized by mucosal damage secondary to pepsin and gastric acid secretion which occurs due to due to an imbalance between offensive and defensive factors.

Objective:

The present study was carried out with methanolic extract of the seed coat of Tamarindus indica Linn. to evaluate its antiulcer potential on ibuprofen, alcohol and pyloric ligation induced gastric lesions.

Materials and Methods:

Doses of 100 mg/kg & 200 mg/kg of methanolic extract wre administered orally to rats of different groups. Ranitidine at a dose of 50 mg/kg was used as a standard drug for these gastric ulcer models. The gastric content was collected and the volume was measured. The ulceration index was determined by examining the inner lining of each stomach. Furthermore, the effect was assessed by free acidity, pepsin activity, total carbohydrate (TC), protein content (PK).

Result:

The result showed that the methanolic extract of seed coats of Tamarindus indica significantly reduce the total volume of gastric juice, free and total acidity of gastric secretion (P < 0.01) in pylorus ligation induced ulcer model as is comparable with the standard drug ranitidine. There was also a significant reduction in ulcer index (P < 0.01) as compared to control group.

Conclusion:

The methanolic extracts of seed coat of Tamarindus indica can be used as a new source of antiulcer agent in animals.

Pharmacological management of GERD: where does it stand now?

Gastroesophageal reflux disease (GERD) is very common and advances in drug development over recent years have markedly improved GERD management. A wide range of medications are currently used in GERD treatment, including antacids, Gaviscon, sucralfate, histamine-2 receptor antagonists and prokinetics. However, proton pump inhibitors (PPIs) remain the mainstay of treatment for GERD owing to their profound and consistent inhibitory effect on acid secretion. Despite the presence of a wide armamentarium of therapeutic modalities for GERD, many areas of unmet needs remain. Drug development has focused primarily on improving PPI efficacy, reducing the transient lower esophageal sphincter relaxation rate, attenuating esophageal sensitivity and developing esophageal mucosal protectants.

Proton pump inhibitors and rebound acid hypersecretion

Rebound acid hypersecretion is defined as an increase in gastric acid secretion above pre-treatment levels after cessation of antisecretory therapy. Proton pump inhibitors (PPIs) have been proved to be more effective than histamine-2 receptor antagonists in suppressing intragastric acidity and have therefore become the main choice for management of acid-related complaints. Recent studies have shown that PPI therapy-elicited rebound acid hypersecretion could in turn induce acid-related symptoms. This makes it difficult for patients to cease PPI therapy. Hypergastrinemia is an important mechanism that leads to rebound acid hypersecretion. To reduce the occurrence of rebound acid hypersecretion, efforts should be made to restrict indications for using PPIs.

Use of proton-pump inhibitors and their associated risks among frail elderly nursing home residents

OBJECTIVE

The aim of this study is to investigate the use of proton-pump inhibitors (PPI) and their associated risks among frail elderly nursing home residents.

DESIGN

A cross-sectional study.

SETTING

General practice.

SUBJECTS

An assessment of residents (n = 1987, mean age 83.7 years) in all nursing homes in Helsinki was carried out in February 2003. Data included demographic characteristics, symptoms such as diarrhea, vomiting and constipation, use of various drugs, and medical diagnoses.

OUTCOME

Coded data analysis with NCSS statistical program. Multivariate logistic regression analysis served to determine which variables were independently associated with diarrhea; variables which were statistically significant or near p < 0.05 in univariate analyses were included.

RESULTS

Altogether 433 residents were on PPIs. The factors associated with regular PPI use in univariate analyses included poor functional status, higher number of comorbidities, higher number of medications and lactose intolerance. The users had suffered from a prior ventricular or duodenal ulcer, cancer and coronary heart disease more often than the non-users. In accordance with our hypothesis, the users of PPIs more often had diarrhea (19.7%) than the non-users (12.9%) (p < 0.001), and they had a prior hip fracture (28.5%) more often than the non-users (19.4%) (p < 0.001). In logistic regression analysis the use of PPIs had an independent association with diarrhea (OR 1.60 (95% CI 1.20 to 2.15).

CONCLUSION

Physicians should avoid unnecessary long-term use of PPIs, particularly among frail elderly long-term care patients.

1-[5-(2-Fluorophenyl)-1-(pyridin-3-ylsulfonyl)-1H-pyrrol-3-yl]-N-methylmethanamine monofumarate (TAK-438), a novel and potent potassium-competitive acid blocker for the treatment of acid-related diseases

Proton pump inhibitors (PPIs) are widely used in the treatment of acid-related diseases. However, several unmet medical needs, such as suppression of night-time acid secretion and rapid symptom relief, remain. In this study, we investigated the pharmacological effects of 1-[5-(2-fluorophenyl)-1-(pyridin-3-ylsulfonyl)-1H-pyrrol-3-yl]-N-methylmethanamine monofumarate (TAK-438), a novel potassium-competitive acid blocker (P-CAB), on gastric acid secretion in comparison with lansoprazole, a typical PPI, and SCH28080 [3-(cyanomethyl)-2-methyl,8-(phenylmethoxy)imidazo(1,2-a)pyridine], a prototype of P-CAB. TAK-438, SCH28080, and lansoprazole inhibited H(+),K(+)-ATPase activity in porcine gastric microsomes with IC(50) values of 0.019, 0.14, and 7.6 μM, respectively, at pH 6.5. The inhibitory activity of TAK-438 was unaffected by ambient pH, whereas the inhibitory activities of SCH28080 and lansoprazole were weaker at pH 7.5. The inhibition by TAK-438 and SCH28080 was reversible and achieved in a K(+)-competitive manner, quite different from that by lansoprazole. TAK-438, at a dose of 4 mg/kg (as the free base) orally, completely inhibited basal and 2-deoxy-d-glucose-stimulated gastric acid secretion in rats, and its effect on both was stronger than that of lansoprazole. TAK-438 increased the pH of gastric perfusate to a higher value than did lansoprazole or SCH28080, and the effect of TAK-438 was sustained longer than that of lansoprazole or SCH28080. These results indicate that TAK-438 exerts a more potent and longer-lasting inhibitory action on gastric acid secretion than either lansoprazole or SCH28080. TAK-438 is a novel antisecretory drug that may provide a new option for the patients with acid-related disease that is refractory to, or inadequately controlled by, treatment with PPIs.

[Guidelines of treatment for non-bleeding peptic ulcer disease]

Over the past century, since the introduction of non steroidal anti-inflammatory drugs (NSAID), antacid, histamine H2-receptor antagonists (H2RA), proton pump inhibitors (PPI), and discovery of Helicobacter pylori infection, the paradigm of peptic ulcer disease has changed with marked decrease in morbidity and mortality. However, peptic ulcer disease still occupies a position as a major health problem with increase of aged population and NSAIDs usage. In daily general practice, the management of peptic ulcer disease is directed according to the presence of bleeding or not. For non-bleeding peptic ulcer disease, proper acid suppression and the correction of underlying causes such as Helicobacter pylori infection and NSAID use is the main stay of treatment. Though a complete understanding of pathophysiology and a perfect treatment strategy are still a challenge, this guideline aims to provide practical recommendations based on evidences or consensus of experts through in-depth literature review and expert meeting.

The expression of heme oxygenase-1 induced by lansoprazole

Our previous studies have demonstrated that lansoprazole inhibits acute inflammatory reactions as well as intestinal mucosal injuries induced by ischemia-reperfusion or indomethacin administration in rats. Thus, proton pump inhibitors such as lansoprazole have been demonstrated to prevent gastrointestinal mucosal injury by mechanisms independent of acid inhibition. In our in vitro study, lansoprazole induced the expression of heme oxygenase-1 (HO-1) on rat gastric epithelial cells (RGM-1 cells), and exerted anti-inflammatory effect on the dependent of HO-1 expression. Furthermore, NF-E2-related factor-2 (Nrf2) played an important role in HO-1 expression induced by lansoprazole. In this review, we focused on lansoprazole-induced HO-1 expression, its anti-inflammatory action, and the role of Nrf2 in its expression.

The use of neem for controlling gastric hyperacidity and ulcer

H(2)-receptor blockers and proton pump inhibitors are now used extensively to control gastric and duodenal ulcer, inflammation and pain, but these drugs have limitations and are not always affordable. The development of novel nontoxic antiulcer drugs, including from medicinal plants, is therefore desirable, and Azadirachta indica A. Juss, commonly known as Neem, is known to have potent gastroprotective and antiulcer effects. This review deals with the pharmacological and biochemical studies carried out regarding the antiulcer activities of Neem extracts and their mechanism of action, including the inhibition of acid secretion. A comparison with ranitidine and omeprazole in some animal models has been included and clinical studies, where available, have also been incorporated, along with a safety evaluation. Neem bark extract has the potential for the development of novel medicines for the therapeutic control of gastric hyperacidity and ulcer.

False-positive secretin stimulation test for gastrinoma associated with the use of proton pump inhibitor therapy

We report the case of a 22-year-old woman who was referred for evaluation of possible Zollinger-Ellison syndrome because of hypergastrinemia and a positive secretin stimulation test. She was being treated with proton pump inhibitors (PPIs) for severe gastroesophageal reflux disease during her initial evaluation. At cessation of PPI therapy, her fasting serum gastrin levels normalized, as did her response to secretin injection. Previous reports describing false-positive secretin tests have been limited to cases of hypergastrinemia in the setting of chronic atrophic gastritis, presumably a result of achlorhydria. This case represents a clearly documented instance of PPI-related hypergastrinemia with a false-positive secretin test, with subsequent normalization of serum gastrin and a negative secretin test after withdrawal of PPI therapy. The current case emphasizes the need to assess the acid secretory status of individuals with hypergastrinemia and to discontinue the use of potent antisecretory agents, principally PPIs, to avoid the erroneous diagnosis of gastrinoma and before embarking on expensive and potentially invasive evaluations for the purpose of tumor localization.

GERD or not GERD: the fussy infant

A global evidence-based consensus has defined gastroesophageal reflux disease (GERD) as 'a condition, which develops when the reflux of stomach contents causes troublesome symptoms and/or complications.' The manifestations of GERD can be divided into esophageal and extraesophageal syndromes, and include vomiting, poor weight gain, dysphagia, abdominal or substernal/retrosternal pain, esophagitis and respiratory disorders. The extraesophageal syndromes have been divided into established and proposed associations: established would include cough, laryngitis, asthma and dental erosion ascribable to reflux, whereas proposed associations would include pharyngitis, sinusitis, idiopathic pulmonary fibrosis and recurrent otitis media. Uninvestigated patients with esophageal symptoms without evidence of esophageal injury would be considered to have asymptomatic esophageal syndromes, whereas those with demonstrable injury are considered to have esophageal syndromes with esophageal injury. Therefore, this allows symptoms to define the disease but permits further characterization if mucosal injury is found. Within the syndromes with associated injury are reflux esophagitis, stricture, Barrett's esophagitis and adenocarcinoma. This review will address definitions of GER and GERD-associated symptoms and treatment options.

Helicobacter pylori eradication therapy may facilitate gastric ulcer healing after endoscopic mucosal resection: a prospective randomized study

BACKGROUND AND AIM

It remains unclear whether Helicobacter pylori eradication therapy affects the healing rate of iatrogenic ulcers following endoscopic mucosal resection (EMR) for gastric tumors. The aim of our study was to prospectively evaluate the effect of H. pylori eradication therapy on gastric ulcer healing after EMR.

METHODS

After EMR, patients were randomly assigned to either the H. pylori eradication group (Hp group) (lansoprazole 30 mg, amoxicillin 1000 mg, and clarithromycin 500 mg, twice a day for 7 days) or the noneradication group (proton pump inhibitor, PPI group) (lansoprazole 30 mg, twice a day for 7 days). Four weeks after EMR, the ulcer stages and size were compared between the two groups. Moreover, ulcer-related symptoms, bleeding rates, adverse effects, and drug compliance were compared.

RESULTS

A total of 64 patients were enrolled. Of these, 17 patients were excluded from the study. The two groups were comparable in terms of baseline clinicopathologic characteristics. Four weeks after EMR, the two groups did not differ with respect to ulcer stage (p = .475) or ulcer-related symptoms (p = .399). However, the ulcer reduction ratio was significantly higher in the Hp group (0.028 +/- 0.024 vs. 0.065 +/- 0.055, p < .05). No differences were observed between the two groups with regard to drug compliance, adverse drug event rates, or bleeding rates.

CONCLUSIONS

Our results suggest that H. pylori eradication therapy might improve the ulcer healing rate after EMR.

Natural Products as Gastroprotective and Antiulcer Agents: Recent Developments

Peptic ulcer, one of the most common gastrointestinal diseases, is a chronic inflammatory disease characterized by ulceration in the regions of the upper gastrointestinal tract where parietal cells are found and where they secrete hydrochloric acid and pepsin. The anatomical sites where ulcer occurs commonly are stomach and duodenum, causing gastric and duodenal ulcer, respectively. Physiopathology of ulcer is due to an imbalance between aggressive factors, such as acid, pepsin, Helicobacter pylori and non-steroidal anti-inflammatory agents, and local mucosal defensive factors, such as mucus bicarbonate, blood flow and prostaglandins. Several drugs are widely used to prevent or treat gastro-duodenal ulcers. These include H2-receptor antagonists, proton pump inhibitors and cytoprotectives. Due to problems associated with recurrence after treatment, there is therefore the need to seek alternative drug sources against ulcers. In recent years, a widespread search has been launched to identify new gastroprotective drugs from natural sources. The aim of the present review is to highlight the recent advances in current knowledge on natural products as gastroprotective and antiulcer agents and consider the future perspectives for the use of these compounds.

A randomized, double-blind, placebo-controlled clinical study of the histamine H2-receptor antagonist famotidine in Japanese patients with nonerosive reflux disease

BACKGROUND

To investigate whether histamine H2-receptor antagonists are sufficient to treat heartburn in nonerosive reflux disease in Japanese, who produce less gastric acid than Westerners, the efficacy of famotidine in Japanese nonerosive reflux disease patients was studied in a double-blind, placebo-controlled, parallel group-comparative, multicenter study.

METHODS

The Los Angeles classification system with Japanese modifications was used to assess the severity of nonerosive reflux disease. Famotidine (10-or 20-mg doses) or placebo was administered to patients twice daily for 8 weeks. Heartburn symptoms were recorded daily by patients.

RESULTS

A total of 528 patients participated in the study. The percentage of days without heartburn, the primary end point of the efficacy evaluation, was 62% for 40 mg and 59% for 20 mg of famotidine, and 55% for placebo, with a statistically significant difference between the 40-mg dose and placebo (P = 0.001; significance level, 0.025 one-sided). Famotidine at both doses provided immediate relief from heartburn, and relief persisted throughout the 8-week study with the 40-mg dose.

CONCLUSIONS

The results indicate that famotidine relieves heartburn symptoms in Japanese nonerosive reflux disease patients.

Patient Compliance with Proton Pump Inhibitor Therapy in an Otolaryngology Practice

Objectives:

Proton pump inhibitors (PPIs) are used for the treatment of numerous otolaryngological disorders. It has been demonstrated that administration of the medication 15 to 45 minutes before a meal optimizes acid suppression. The rate of compliance with optimal PPI dosage patterns in an otolaryngology practice is not known. We sought to determine the rate of PPI compliance in patients seen in an otolaryngology practice.

Methods:

We conducted an interview at a tertiary voice and swallowing center of 200 consecutive patients who were taking PPIs.

Results:

Overall, 54% of patients took their PPI in an optimal manner. The rate of compliance was significantly higher for patients who had their PPI prescribed by an otolaryngologist (62%) than for patients whose PPI was prescribed by a non-otolaryngologist (40%).

Conclusions:

Nearly half of all patients seen at a voice and swallowing center were not compliant with optimal PPI usage. This percentage is similar to that found for other long-term medications. Patient education can lead to higher rates of compliance, improved acid control, and possibly improved treatment outcomes.

Inhibition of gastric acid secretion by a standardized aqueous extract of Cecropia glaziovii Sneth and underlying mechanism

Cecropia glazioui Sneth (Cecropiaceae) is used in folk medicine in tropical and subtropical Latin America as cardiotonic, diuretic, hypotensive, anti-inflammatory and anti-asthmatic. The hypotensive/antihypertensive activity of the plant aqueous extract (AE) and isolated butanolic fraction (BuF) has been confirmed and putatively related to calcium channels blockade in vascular smooth musculature [Lapa, A.J., Lima-Landman, M.T.R., Cysneiros, R.M, Borges, A.C.R., Souccar, C., Barreta, I.P., Lima, T.C.M., 1999. The Brazilian folk medicine program to validate medicinal plants - a topic in new antihypertensive drug research. In: Hostettman, K., Gupta, M.P., Marston, A. (Eds.), Proceedings Volume, IOCD/CYTED Symposium, Panamá City, Panamá, 23-26 February 1997. Chemistry, Biological and Pharmacological Properties of Medicinal Plants from the Americas. Harwood Academic Publishers, Amsterdam, pp. 185-196; Lima-Landman, M.T., Borges, A.C., Cysneiros, R.M., De Lima, T.C., Souccar, C., Lapa, A.J., 2007. Antihypertensive effect of a standardized aqueous extract of Cecropia glaziovii Sneth in rats: an in vivo approach to the hypotensive mechanism. Phytomedicine 14, 314-320]. Bronchodilation and antidepressant-like activities of both AE and BuF have been also shown [Delarcina, S., Lima-Landman, M.T., Souccar, C., Cysneiros, R.M., Tanae, M.M., Lapa, A.J., 2007. Inhibition of histamine-induced bronchospasm in guinea pigs treated with Cecropia glaziovi Sneth and correlation with the in vitro activity in tracheal muscles. Phytomedicine 14, 328-332; Rocha, F.F., Lima-Landman, M.T., Souccar, C., Tanae, M.M., De Lima, T.C., Lapa, A.J., 2007. Antidepressant-like effect of Cecropia glazioui Sneth and its constituents -in vivo and in vitro characterization of the underlying mechanism. Phytomedicine 14, 396-402]. This study reports the antiulcer and antisecretory gastric acid activities of the plant AE, its BuF and isolated compounds with the possible mechanism involved. Both AE and BuF were assayed on gastric acid secretion of pylorus-ligated mice, on acute models of gastric mucosal lesions, and on rabbit gastric H(+), K(+)-ATPase preparations. Intraduodenal injection of AE or BuF (0.5-2.0g/kg, i.d) produced a dose-related decrease of the basal gastric acid secretion in 4-h pylorus-ligated mice. At 1.0g/kg, BuF decreased the volume (28%) and total acidity (33%) of the basal acid secretion, and reversed the histamine (2.5mg/kg, s.c.)- or bethanecol (1.0mg/kg, s.c.)-induced acid secretion to basal values, indicating inhibition of the gastric proton pump. Pretreatment of mice with the BuF (0.05-0.5g/kg, p.o.) protected against gastric mucosal lesions induced by 75% ethanol, indomethacin (30mg/kg, s.c.) or restraint at 4 degrees C. BuF also decreased the gastric H(+), K(+)-ATPase activity in vitro proportionately to the concentration (IC(50)=58.8microg/ml). The compounds isolated from BuF, consisting mainly of cathechins, procyanidins and flavonoids [Tanae, M.M., Lima-Landman, M.T.R., De Lima, T.C.M., Souccar, C., Lapa, A.J., 2007. Chemical standardization of the aqueous extract of Cecropia glaziovii Sneth endowed with antihypertensive, bronchodilator, antacid secretion and antidepressant-like activities. Phytomedicine 14, 309-313], inhibited the in vitro gastric H(+), K(+)-ATPase activity at equieffective concentrations to that of BuF. The results indicate that C. glazioui constituents inhibit the gastric proton pump; this effect may account for the effective antisecretory and antiulcer activities of the standardized plant extract.

Control of gastric acid secretion in health and disease

Recent milestones in the understanding of gastric acid secretion and treatment of acid-peptic disorders include the (1) discovery of histamine H(2)-receptors and development of histamine H(2)-receptor antagonists, (2) identification of H(+)K(+)-ATPase as the parietal cell proton pump and development of proton pump inhibitors, and (3) identification of Helicobacter pylori as the major cause of duodenal ulcer and development of effective eradication regimens. This review emphasizes the importance and relevance of gastric acid secretion and its regulation in health and disease. We review the physiology and pathophysiology of acid secretion as well as evidence regarding its inhibition in the management of acid-related clinical conditions.

Lansoprazole protects and heals gastric mucosa from non-steroidal anti-inflammatory drug (NSAID)-induced gastropathy by inhibiting mitochondrial as well as Fas-mediated death pathways with concurrent induction of mucosal cell renewal

We have investigated the mechanism of antiapoptotic and cell renewal effects of lansoprazole, a proton pump inhibitor, to protect and heal gastric mucosal injury in vivo induced by indomethacin, a non-steroidal anti-inflammatory drug (NSAID). Lansoprazole prevents indomethacin-induced gastric damage by blocking activation of mitochondrial and Fas pathways of apoptosis. Lansoprazole prevents indomethacin-induced up-regulation of proapoptotic Bax and Bak and down-regulation of antiapoptotic Bcl-2 and Bcl(xL) to maintain the normal proapoptotic/antiapoptotic ratio and thereby arrests indomethacin-induced mitochondrial translocation of Bax and collapse of mitochondrial membrane potential followed by cytochrome c release and caspase-9 activation. Lansoprazole also inhibits indomethacin-induced Fas-mediated mucosal cell death by down-regulating Fas or FasL expression and inhibiting caspase-8 activation. Lansoprazole favors mucosal cell renewal simultaneously by stimulating gene expression of prosurvival proliferating cell nuclear antigen, survivin, epidermal growth factor, and basic fibroblast growth factor. The up-regulation of Flt-1 further indicates that lansoprazole activates vascular epidermal growth factor-mediated controlled angiogenesis to repair gastric mucosa. Lansoprazole also stimulates the healing of already formed ulcers induced by indomethacin. Time course study of healing indicates that it switches off the mitochondrial death pathway completely but not the Fas pathway. However, lansoprazole heals mucosal lesions almost completely after overcoming the persisting Fas pathway, probably by favoring the prosurvival genes expression. This study thus provides the detailed mechanism of antiapoptotic and prosurvival effects of lansoprazole for offering gastroprotection against indomethacin-induced gastropathy.

Diagnosis and treatment of gastrinoma in the era of proton pump inhibitors

The Zollinger-Ellison syndrome is characterized pathophysiologically by a significant hypergastrinemia derived from a gastrin-secreting neuroendocrine tumor with a primary location in the pancreas or duodenum. Chronic hypergastrinemia in turn triggers gastric acid hypersecretion yielding in chronic or recurrent or refractory peptic ulcer disease and/or chronic diarrhea. One half of patients with ZES will have distant metastases in the liver by the time the diagnosis is established and one half of all patients with ZES will experience chronic diarrhea as chief complaint rather than peptic ulcer-related symptoms and signs. Gastrinomas have been reported to either manifest sporadically or to occur in conjunction with the genetic background of the MEN-I syndrome. Diagnosis is based on the patients history which is typically characterized by recurrent episodes of peptic ulcer disease or by severe reflux esophagitis and/or diarrhea or by acid-related symptoms which fail to respond to standard treatment regimens. Upper gastrointestinal tract endoscopy will provide evidence for peptic ulcer disease in anatomical regions located aborally the duodenal bulb within the descending part of the duodenum or even farther distally within the jejunum. Peptic ulcers frequently occur in groups indicating some substantial acid hypersecretion. A gastric pH > 2 is mutually exclusive for ZES. Increased serum gastrin levels confirm the diagnosis biochemically. Gastrin secretion can be determined in the basal state or following stimulation with secretin or calcium. High sensitivity and specificity for the diagnosis of ZES is provided by determining the ratio of basal versus pentagastrin-stimulated gastric acid secretion: The ratio of BAO / MAO > 0.6 is highly specific for gastrinoma. To localize the gastrin-secreting tumor computer-assisted tomography, endoscopic ultrasound, and somatostatin receptor scintigraphy provide useful help but most recently, endoscopic ultrasound with high resolution transducers appear to improve preoperative site localization. If modern imaging techniques fail to elucidate the site of the tumor, intraoperative diaphany may help to detect gastrinomas within the duodenal wall. Definitive treatment will only be achieved by total surgical resection of the gastrin-producing tumor in the pancreas or duodenum including dissection of the regional lymph nodes. Control of symptoms will have to be achieved by administration of highly potent proton pump inhibitors in up to 2-3-fold increased standard doses to inhibit gastric acid hypersecretion. Elevation of gastric pH > 4 will be the therapeutic target to protect the mucosa of the upper gastrointestinal tract. Basal acid output should be reduced to less than 10 mEq H(+) per hour which requires administration of highly potent proton pump inhibitors with a recommended starting dose of 60 mg omeprazole equivalents per day.

Therapy insight: Prophylaxis of stress-induced gastrointestinal bleeding in critically ill patients

Stress-induced gastrointestinal bleeding is associated with increased morbidity and mortality in critically ill patients. Within the past few decades, the incidence of stress-induced gastrointestinal bleeding has decreased. Prophylaxis of stress-induced gastrointestinal bleeding, which is aimed at preventing morbidity and mortality, has to be achieved with as few adverse effects as possible. Data indicate that not all critically ill patients need prophylaxis for stress-induced gastrointestinal bleeding. The main risk factors associated with clinically important hemorrhage are mechanical ventilation for >48 h, and coagulopathy (thrombocyte count <50/nl, partial thromboplastin time (PTT) >2 times the upper limit of the normal range, international normalized ratio (INR) >1.5). Ranitidine is more effective than sucralfate for the prevention of clinically important bleeding. Immediate-release omeprazole is as effective as cimetidine, and is more efficient at increasing the intragastric pH. As yet, however, there is no firm evidence that any of the drugs used for prophylaxis of stress-induced gastrointestinal bleeding in critically ill patients decrease mortality or the length of hospital stay. When to stop prophylaxis is decided on clinical grounds rather than on the basis of data from clinical studies.

Ulcer protective effect of Terminalia arjuna on gastric mucosal defensive mechanism in experimental rats

The methanol extract of the bark of Terminalia arjuna (Combretaceae) (TAE) showed marked antiulcer and ulcer healing activity against 80% ethanol (ETH), diclofenac sodium (DIC) and dexamethasone (DEX) induced ulcer models dose dependently at doses of 100, 400 and 200 mg/kg body weight respectively. Pre-, post and co-administration of TAE offered 100% protection to the gastric mucosa against ETH, DIC and DEX induced ulcers as observed from the ulcer score. Gastric mucosal analysis of DEX induced rats were associated with changes in the levels of protein, protein bound carbohydrate complexes, lipid peroxides (LPO), glutathione (GSH) and activities of superoxide dismutase (SOD), catalase (CAT) and glutathione peroxidase (GPx) compared with control rats. Co-administration with TAE in DEX rats (DEX + TAE) favorably altered the levels of LPO, GSH and also the activities of SOD and CAT in gastric mucosa, whereas the activities of GPx remained unaltered in all groups. In DEX + TAE rats, the levels of protein and protein bound carbohydrate complexes were increased when compared with DEX rats. The results indicate that the gastroprotective effect of TAE is probably related to its ability to maintain the membrane integrity by its antilipid peroxidative activity that protects the gastric mucosa against oxidative damage and its ability to strengthen the mucosal barrier, the first line of defense against exogenous and endogenous ulcerogenic agents.

Proton pump inhibitor use and risk of colorectal cancer: a population-based, case-control study

BACKGROUND & AIMS

Use of proton pump inhibitors (PPIs) has been associated with elevated levels of serum gastrin. Because hypergastrinemia increases colorectal mucosa proliferation and has been associated with risk of colorectal cancer (CRC) in human beings, we conducted a large population-based study in Denmark to assess whether PPI use is associated with CRC risk.

METHODS

We conducted the study in North Jutland County, Denmark. From the County Hospital Discharge Registry we identified incident cases of CRC during the period 1989-2005. Using risk set sampling we selected approximately 10 controls from the Danish Civil Registration System, with matching for sex and birth year. PPI use was ascertained in the Prescription Database of North Jutland (and so recorded before CRC diagnosis) and analyzed with conditional logistic regression adjusted for multiple covariates.

RESULTS

We identified 5589 cases of CRC which were compared with 55,890 controls. In a comparison of ever to never or rare users (< or =30 pills during observation period), no evidence was observed of increased risk (adjusted odds ratio [OR], 1.11; 95% confidence interval [CI], 0.97-1.27). When we compared the most intense users of PPI (more than every other day) with never or rare users, we found that no increased cancer risk was shown in either short-term users (adjusted OR, 1.07; 95% CI, 0.86-1.34) or long-term users (>7 years; adjusted OR = 1.09; 95% CI, 0.58-2.06).

CONCLUSIONS

The use of PPIs in clinical practice does not measurably increase the risk of CRC.

The prevalence of pantoprazole associated thrombocytopenia in a community hospital

OBJECTIVE

Proton pump inhibitors (PPIs) are widely used in the treatment of gastritis, gastroesophageal reflux disease and peptic ulcer disease. Thrombocytopenia is not listed as one of the main side effects of PPI therapy. However, there have been documented cases of thrombocytopenia with the use of PPIs in the literature. Our objective was to determine whether exposure to PPIs leads to an increased incidence of thrombocytopenia in hospitalized patients.

METHODS

This retrospective cohort study examined the platelet counts of 468 hospitalized patients who were 18 - 80 years of age, were prescribed pantoprazole for a minimum of 3 days and were matched to 468 non-medicated controls. The primary outcome was defined as either a drop in the platelet count by >/= 50% relative to baseline, or a drop to < 150,000/ml. Exclusion criteria were baseline thrombocytopenia and hospitalization for < 3 days.

RESULTS

No difference was found in the occurrence of thrombocytopenia between the two groups (6.2%; 95% CI = 4.1 - 8.7%) in the study group versus (6.6%; 95% CI = 4.5 - 9.2%) in the control group (p = 0.90). Post-hoc analysis revealed a higher incidence of > 20% drop in platelet count in the study group compared with the controls (23%; 95% CI = 19 - 27% versus 11%; 95% CI = 8 - 14%, respectively; p < 0.001).

CONCLUSION

This study failed to demonstrate an increased incidence of thrombocytopenia for patients treated with pantoprazole. Our study adds support to the favorable safety profile of PPI therapy in hospitalized patients. Further investigation is needed to evaluate the effects of PPI use in the outpatient setting.

Laryngopharyngeal reflux and chronic sinusitis

In patients with chronic and recurrent sinusitis, laryngopharyngeal reflux disease may play a significant role. Laryngopharyngeal reflux disease differs from gastroesophageal reflux disease in the extent of reflux (into the hypopharynx and above) as well as timing (occurring more often when the patient is upright). Most patients are unaware of the extent of their symptoms, and diagnostic tools such as pH probe, multichannel intraluminal impedance, and manometry are required for adequate diagnosis. Although therapy with lifestyle modification and acid-suppressive agents may improve reflux in the majority of patients, for many with persistent symptoms, endoscopic or surgical intervention is required to reduce reflux successfully.

Aqueous suspension of anise “Pimpinella anisum” protects rats against chemically induced gastric ulcers

AIM: To substantiate the claims of Unani and Arabian traditional medicine practitioners on the gastroprotective potential effect of a popular spice anise, “Pimpinella anisum L.” on experimentally-induced gastric ulceration and secretion in rats.

METHODS: Acute gastric ulceration in rats was produced by various noxious chemicals including 80% ethanol, 0.2 mol/L NaOH, 25% NaCl and indomethacin. Anti-secretory studies were undertaken using pylorus-ligated Shay rat technique. Levels of gastric non-protein sulfhydryls (NP-SH) and wall mucus were estimated and gastric tissue was also examined histologically. Anise aqueous suspension was used in two doses (250 and 500 mg/kg body weight) in all experiments.

RESULTS: Anise significantly inhibited gastric mu-cosal damage induced by necrotizing agents and indomethacin. The anti-ulcer effect was further confirmed histologically. In pylorus-ligated Shay rats, anise suspension significantly reduced the basal gastric acid secretion, acidity and completely inhibited the rumenal ulceration. On the other hand, the suspension significantly replenished ethanol-induced depleted levels of gastric mucosal NP-SH and gastric wall mucus concentration.

CONCLUSION: Anise aqueous suspension possesses significant cytoprotective and anti-ulcer activities against experimentally-induced gastric lesions. The anti-ulcer effect of anise is possibly prostaglandin-mediated and/or through its anti-secretory and antioxidative properties.

Gastrointestinal regulatory peptides: an overview

PURPOSE OF REVIEW

This review is intended to provide an overview of this section on 'Gastrointestinal regulatory peptides' and to emphasize both similarities and differences between 'classic' hormones and those peptides synthesized within, and released from, the gastrointestinal tract. It will also discuss recent investigation involving these peptides and their physiological properties and pathologic potential.

RECENT FINDINGS

More recent investigation, much of which is discussed in this section, has looked at the central role of the gastrointestinal tract, and specifically gastrointestinal regulatory peptides, in nutrient homeostasis and in the pathogenesis of obesity and other nutritional disorders.

SUMMARY

Regulatory peptides are chemical messengers that provide a means of communication between two cells which are commonly located in different organ systems. The peptides interact via a shared aqueous environment; whereas this environment is endocrine in nature for classic hormones and gastrointestinal peptides, the latter also include those peptides that communicate more directly with their target via paracrine, neurocrine, and autocrine routes. The field of gastrointestinal regulatory peptides is in its infancy, and the coming decades will witness the development of these peptides, as well as analogues and antagonists, as potential new forms of therapy of obesity and other nutrition-related disorders, as well as other maladies.

A comparative study of intragastric acidity during post-breakfast and pre-dinner administration of low-dose proton pump inhibitors: a randomized three-way crossover study

BACKGROUND

The absorption and bioavailability of proton pump inhibitors is influenced by food intake. Proton pump inhibitors bind to the parietal cell active proton pump, which is maximally stimulated after dinner: usually the largest meal of the day. However, it has not been fully clarified whether the efficacy of proton pump inhibitors differs between post-breakfast and pre-dinner dosing.

AIM

To perform a pH-monitoring study to clarify this issue for two low-dose proton pump inhibitors.

SUBJECTS AND METHODS

The subjects were 20 healthy male volunteers (seven Helicobacter pylori-positive and 13 H. pylori-negative), who were divided into two groups of 10 and administered 15 mg lansoprazole or 10 mg rabeprazole, respectively. All subjects underwent ambulatory intragastric 24-h pH- monitoring under three conditions allocated randomly: (i) without medication, (ii) seventh day of post-breakfast administration and (iii) eighth day of pre-dinner administration of each drug.

RESULTS

There was no significant difference in the percentage time during which pH > or =4.0 in the 24-h period between post-breakfast and pre-dinner administration of both drugs (56.6% vs. 55.8%; P = 0.557), although intragastric acidity during administration of both drugs was significantly lower than that without medication.

CONCLUSIONS

The timing of drug administration does not significantly influence the efficacy of low-dose proton pump inhibitors.

Review article: the opportunities and benefits of extended acid suppression

Acid suppression therapy with proton pump inhibitors is associated with well-established benefits in the management of gastro-oesophageal reflux (GERD) and other acid-related disorders. However, a number of issues still remain unsettled. Despite their clinical efficacy, when given once daily, currently available proton pump inhibitors may not adequately control intragastric acidity during the night in a significant proportion of both healthy subjects and GERD patients, in whom symptom relief remains suboptimal. Although some novel proton pump inhibitors have been synthesized, only few reached clinical testing. Amongst them, tenatoprazole represents a true advance displaying a long half-life (five to seven times longer than that of currently available drugs) and extended acid suppression covering both day and night. All the available clinical studies suggest both pharmacokinetic and pharmacodynamic advantages of tenatoprazole over esomeprazole. As this last compound provides - amongst the members of the class - the most effective control of intragastric pH whatever the parameter considered, it is conceivable that tenatoprazole could similarly be better than the other existing proton pump inhibitors. Tenatoprazole appears to be a promising proton pump inhibitor for the treatment of acid-related diseases, where it has the potential to address unmet clinical needs.

Sub-optimal proton pump inhibitor dosing is prevalent in patients with poorly controlled gastro-oesophageal reflux disease

BACKGROUND

Proton pump inhibitors are the most potent drug treatment for gastro-oesophageal reflux disease. Pre-meal dosing maximizes efficacy while sub-optimal dose timing may limit efficacy.

AIM

To determine the prevalence of sub-optimal proton pump inhibitor dosing in a community-based gastro-oesophageal reflux disease population.

MATERIALS AND METHODS

One hundred patients on proton pump inhibitors referred for persistent gastro-oesophageal reflux disease symptoms were questioned about their proton pump inhibitor dosing habits and classified as optimal or sub-optimal dosers. Optimal dosers took proton pump inhibitors with or up to 60 min before meals. Sub-optimal dosers took proton pump inhibitors >60 min before meals, after meals, as needed, or at bedtime.

RESULTS

Forty-six percent dosed optimally. Fifty-four percent dosed sub-optimally with 21 of 54 (39%) dosing >60 min before meals, 16 (30%) after meals, 15 (28%) at bedtime and two (4%) as needed. Only 6% of the subjects on once-daily proton pump inhibitor regimens and 33% of subjects taking proton pump inhibitors two- to three times daily dosed in a manner that maximized acid suppression (15-30 min before a meal).

CONCLUSIONS

In this study, 54% of patients dosed proton pump inhibitors sub-optimally and only 12% dosed in a manner that maximized acid suppression. As sub-optimal proton pump inhibitor dose timing can limit efficacy, patients with refractory symptoms should be asked about dose timing to avoid inappropriate and costly dose escalations.

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.

Antiulcerogenic and ulcer healing effects of Solanum nigrum (L.) on experimental ulcer models: possible mechanism for the inhibition of acid formation

Solanum nigrum, an herbal plant which is recommended in ayurveda for the management of gastric ulcers. Therefore, the purpose of the study was to investigate the antiulcer effect of Solanum nigrum fruits extract (SNE) on cold restraint stress (CRU), indomethacin (IND), pyloric ligation (PL) and ethanol (EtOH) induced gastric ulcer models and ulcer healing activity on acetic acid induced ulcer model in rats. The treatment with SNE at higher dose significantly inhibited the gastric lesions induced by CRU (76.6%), IND (73.8%), PL (80.1%) and EtOH (70.6%), respectively, with equal or higher potency than omeprazole. SNE showed concomitant attenuation of gastric secretory volume, acidity and pepsin secretion in ulcerated rats. In addition, SNE (200 and 400mg/kgb.w.) accelerated the healing of acetic acid induced ulcers after the treatment for 7 days. Further, to ascertain the antisecretory action, the effects of SNE on H(+)K(+)ATPase activity and plasma concentration of gastrin hormone in ulcerated rats were determined. SNE significantly inhibits H(+)K(+)ATPase activity and decreases the gastrin secretion in EtOH-induced ulcer model. The severity of the reaction of ulcerogen and the reduction of ulcer size by SNE was evident by histological findings. Toxicity studies of SNE have also been carried out for its safety evaluation. SNE, thus, offers antiulcer activity by blocking acid secretion through inhibition of H(+)K(+)ATPase and decrease of gastrin secretion. These results further suggest that SNE was found to possess antiulcerogenic as well as ulcer healing properties, which might also be due to its antisecretory activity.

[A case of postoperative pulmonary metastasis of breast cancer treated with docetaxel and cyclophosphamide therapy]

A 55-year-old woman underwent a partial breast resection in our hospital for breast cancer in May 2002. For adjuvant therapy, she received cyclophosphamide, pirarubicin and 5-FU infusion a total of 6 times, and anastrozole. Then, in May of 2004, an abnormal shadow was detected on her of chest X-ray. After CT scan we diagnosed multiple pulmonary metastasis of breast cancer. We used combination therapy of docetaxel 60 mg/m(2) and cyclophosphamide 500 mg/m(2). After 9 months, pulmonary metastasis disappeared on her CT scan. During chemotherapy, she showed no major side effect.