Adenocarcinoma arising in multiple hyperplastic polyps in a patient with Helicobacter pylori infection and hypergastrinemia during long-term proton pump inhibitor therapy

How to treat gastrinomas in patients with multiple endocrine neoplasia type1: surgery or long-term proton pump inhibitors?

In patients with multiple endocrine neoplasia type 1 syndrome (MEN 1) and Zollinger-Ellison syndrome (ZES), gastrinomas arise from the duodenum, about 60% are multiple, and about 15% of patients have coexisting pancreatic gastrinomas, which can be localized by the selective arterial secretagogue injection test (SASI test). The guidelines (GLs) by the Japanese Neuroendocrine Tumor Society (JNETS) recommend surgical resection for functioning duodenopancreatic neuroendocrine tumors (NETs), including gastrinomas, in patients with MEN1 (Grade A, 100% agreement among members). Conversely, the GLs of the National Comprehensive Cancer Network (NCCN) in the USA recommend observation and treatment with proton pump inhibitors (PPIs) or exploratory surgery for occult gastrinomas. An international Consensus Statement (ICS) from the European Union (EU) also does not recommend resection of gastrinomas in patients with MEN1, despite some surgeons having reported surgery being curative for gastrinomas in MEN1 patients. In this review, we discuss the serious side effects and tumorigenic effects of the prolonged use of PPIs and the safety and curability of surgery, supported by our results of curative surgery for gastrinomas in 20 patients with MEN1 over 30 years. We conclude that surgery should be the first-line treatment for gastrinomas in MEN1 patients.

The central role of gastrin in gastric cancer

The prevalence of gastric cancer has markedly declined, but due to the high mortality rates associated with gastric cancer, it is still a serious disease. The preferred classification of gastric cancer is according to Lauren into either the intestinal type, which has a glandular growth pattern, or the diffuse type, which does not have glandular structures. Both types have been classified as adenocarcinomas, with the latter type based on periodic acid-Schiff (PAS) positivity presumed to reflect mucin. However, the presence of mucin in the diffuse type, in contrast to neuroendocrine/enterochromaffin-like (ECL) cell markers, has not been confirmed by immunohistochemistry and in situ hybridization. The ECL cells are probably prone to becoming cancerous because they do not express E-cadherin. Gastric cancer is unique in that a bacterium, Helicobacter pylori, is thought to be its main cause. H. pylori predisposes infected individuals to cancer only after having caused oxyntic atrophy leading to gastric hypoacidity and hypergastrinemia. No single H. pylori factor has been convincingly proved to be carcinogenic. It is probable that gastrin is the pathogenetic factor for gastric cancer due to H. pylori, autoimmune gastritis, and long-term prolonged inhibition of gastric acid secretion. Hypergastrinemia induces ECL cell hyperplasia, which develops into neuroendocrine tumors (NETs) and then into neuroendocrine carcinomas in rodents, a sequence that has also been described in humans. During carcinogenesis, the tumor cells lose specific traits, requiring that sensitive methods be used to recognize their origin. Gastric cancer occurrence may hopefully be prevented by H. pylori eradication at a young age, and by the reduced use of inhibitors of acid secretion and use of a gastrin antagonist in those with previous long-term H. pylori infection and those with autoimmune gastritis.

Autoimmune gastritis with a gastric hamartomatous inverted polyp and two hyperplastic polyps: a case report

We report an unusual case of autoimmune gastritis (AIG) complicated with a submucosal tumor (SMT) and two pedunculated polyps in a 60-year-old man. The patient was admitted for epigastric distention, heartburn, and anorexia. Endoscopy showed an SMT in the fundus, two pedunculated polyps in the body, and markedly atrophic mucosa of the body and fundus. The SMT, measuring 20 mm in diameter, was resected by endoscopic submucosal dissection and histologically diagnosed as a gastric hamartomatous inverted polyp (GHIP), which is characterized by submucosal glandular proliferation, cystic dilatation, and calcification. The gland structures consisted of foveolar cells and pseudopyloric or mucous-neck cell types. The two pedunculated polyps that were resected by endoscopic mucosal resection were histologically diagnosed as hyperplastic polyps, which are characterized by hyperplastic foveolar glands with pseudopyloric or mucous-neck glands in the inflamed stroma in the mucosa, which consisted of almost the same types of lining cells as the GHIP in the fundus. Findings may indicate the relationship between GHIP, hyperplastic polyp, and AIG. We highlight considering GHIP as a differential diagnosis for an SMT in patients with AIG.

Use of Proton Pump Inhibitors and the Risk for the Development of Gastric Cancers: A Nationwide Population-Based Cohort Study Using Balanced Operational Definitions

Simple Summary

Previous cohort studies using national claim data in Korea have shown conflicting results about the association between the use of proton pump inhibitors (PPIs) and the risk of gastric cancer. In this population-based cohort analysis using balanced operational definitions, proton pump inhibitor use was not associated with an increased risk of gastric cancer (Hazard ratio: 1.30, 95% confidence interval: 0.75–2.27). Previous cohort studies with an inappropriate operational definition for the inclusion criteria of the study subjects or index dates could be the reason of conflicting results.

Abstract

Objectives: Previous cohort studies using national claim data in Korea have shown conflicting results about the association between the use of proton pump inhibitors (PPIs) and the risk of gastric cancer. This may be due to differences in the inclusion criteria or index dates of each study. This study aims to evaluate the association between PPI use and the risk of gastric cancer using balanced operational definitions. Design: A population-based cohort analysis was conducted using the Korean National Health Insurance Service database. Subjects who used PPIs or histamine-2 receptor antagonist (H₂RA) for more than 60 days after Helicobacter pylori eradication were included. The study subjects were those who had never used H₂RAs (PPI users) and controls were those who had never used PPIs (H₂RA users). For comparison, the index dates of previous studies were adopted and analyzed. The subjects were followed until the development of gastric cancer, death, or study end. Results: A total of 10,012 subjects were included after propensity score matching. During a median follow-up of 6.56 years, PPI was not associated with an increased risk of gastric cancer (Hazard ratio: 1.30, 95% confidence interval: 0.75–2.27). This was consistent if the cumulative daily dose was adjusted (90/120/180 days), or if the index date was changed to the first day of PPI prescription or the last day of Helicobacter pylori eradication. There was no significant difference in mortality between both groups. Conclusion: PPI use was not associated with an increased risk of gastric cancer.

A Noninvasive Risk Stratification Tool Build Using an Artificial Intelligence Approach for Colorectal Polyps Based on Annual Checkup Data

Colorectal cancer is the leading cause of cancer-related deaths worldwide, and early detection has proven to be an effective method for reducing mortality. The machine learning method can be implemented to build a noninvasive stratifying tool that helps identify patients with potential colorectal precancerous lesions (polyps). This study aimed to develop a noninvasive risk-stratified tool for colorectal polyps in asymptomatic, healthy participants. A total of 20,129 consecutive asymptomatic patients who underwent a health checkup between January 2005 and August 2007 were recruited. Positive relationships between noninvasive risk factors, such as age, Helicobacter pylori infection, hypertension, gallbladder polyps/stone, and BMI and colorectal polyps were observed (p < 0.0001), regardless of sex, whereas significant findings were noted in men with tooth disease (p = 0.0053). A risk stratification tool was developed, for colorectal polyps, that considers annual checkup results from noninvasive examinations. For the noninvasive stratified tool, the area under the receiver operating characteristic curve (AUC) of obese females (males) aged <50 years was 91% (83%). In elderly patients (>50 years old), the AUCs of the stratifying tools were >85%. Our results indicate that the risk stratification tool can be built by using random forest and serve as an efficient noninvasive tool to identify patients requiring colonoscopy.

Relationship of delta over baseline with serum levels of gastrin 17, interleukin-32, and soluble interleukin 2 receptor and gastroscopic pathological changes in patients with chronic atrophic gastritis and Helicobacter pylori infection

BACKGROUND

Helicobacter pylori (H. pylori) is a recognized causative factor of gastric cancer. The diagnosis and treatment of chronic atrophic gastritis (CAG) and H. pylori infection have always been the focus of clinical research.

AIM

To investigate the relationship of the delta over baseline (DOB) and serum gastrin 17 (G-17), interleukin-32 (IL-32), soluble interleukin 2 receptor (sIL-2R) levels and gastroscopic pathological changes in patients with CAG and H. pylori infection.

METHODS

A total of 224 CAG patients at the Physical Examination Center of Wenzhou Central Hospital from January 2017 to December 2019 were selected as the research subjects, including 124 patients with H. pylori infection as an observation group, and 100 patients without H. pylori infection as a control group. The clinical data, DOB, and serum levels of G-17, IL-32, and sIL-2R in the two groups were compared. Logistic regression analysis was used to identify the influencing factors of CAG and H. pylori infection, and the correlation of DOB with serum G-17, IL-32, and sIL-2R was analyzed. The levels of DOB and serum G-17, IL-32, and sIL-2R in patients with different gastroscopic pathological changes were compared, and ROC curves were drawn to evaluate the value of DOB, G-17, IL-32, and sIL-2R in assessing CAG and H. pylori infection.

RESULTS

There were statistically significant differences in the course of disease and gastroscopic pathological changes (chronic inflammation, atrophy, intestinal metaplasia, and intraepithelial neoplasia) between the two groups (P < 0.05). The DOB and serum levels of IL-32 and sIL-2R were significantly higher and serum G-17 level was significantly lower in the observation group than in the control group (P < 0.05). Logistic regression analysis showed that the course of disease, chronic inflammation, atrophy, intestinal metaplasia, intraepithelial neoplasia, DOB, and serum G-17, IL-32, and sIL-2R levels were all influencing factors of CAG and H. pylori infection (P < 0.05). Pearson correlation analysis showed that the DOB of patients with CAG and H. pylori infection was negatively correlated with G-17, and positively correlated with IL-32 and sIL-2R (P < 0.05). Spearman correlation analysis showed that the DOB and serum levels of G-17, IL-32, and sIL-2R in patients with CAG and H. pylori infection were significantly related to chronic inflammation, atrophy, intestinal metaplasia, and intraepithelial neoplasia (P < 0.05). ROC curve analysis showed that the area under the curve of combined DOB, G-17, IL-32, and sIL-2R was the largest (0.975), and the best sensitivity and specificity were 85.48% and 98.00%, respectively.

CONCLUSION

Serum levels of G-17, IL-32, and sIL-2R in patients with CAG and H. pylori infection are related to DOB. H. pylori infection may be involved in the occurrence and progression of gastric mucosal pathological changes in CAG patients by affecting the expression of G-17, IL-32, and sIL-2R. Combined detection of all the above indicators can effectively predict H. pylori infection, which is of great significance for clinical diagnosis and treatment.

Gastritis, Gastric Polyps and Gastric Cancer

Gastric cancer is still an important disease causing many deaths worldwide, although there has been a marked reduction in prevalence during the last few decades. The decline in gastric cancer prevalence is due to a reduction in Helicobacter pylori infection which has occurred for at least 50 years. The most probable mechanism for the carcinogenic effect of H. pylori is hypergastrinemia since H. pylori infected individuals do not have increased risk of gastric cancer before the development of oxyntic atrophy. When atrophy has developed, the carcinogenic process continues independent of H. pylori. Autoimmune gastritis also induces oxyntic atrophy leading to marked hypergastrinemia and development of ECL cell neoplasia as well as adenocarcinoma. Similarly, long-term treatment with efficient inhibitors of acid secretion like the proton pump inhibitors (PPIs) predisposes to ECL cell neoplasia of a different degree of malignancy. Contrasting the colon where most cancers develop from polyps, most polyps in the stomach have a low malignant potential. Nevertheless, gastric polyps may also give rise to cancer and have some risk factors and mechanisms in common with gastric cancer. In this overview the most common gastric polyps, i.e., hyperplastic polyps, adenomatous polyps and fundic gland polyps will be discussed with respect to etiology and particularly use of PPIs and relation to gastric carcinogenesis.

Gastric Hyperplastic Polyps after Argon Plasma Coagulation for Gastric Antral Vascular Ectasia in Patients with Liver Cirrhosis: A Case Suggesting the "Gastrin Link Theory"

We herein report a case of gastric hyperplastic polyps after argon plasma coagulation (APC) for gastric antral vascular ectasia (GAVE) in the antrum of a 65-year-old man with liver cirrhosis and hypergastrinemia induced by long-term proton pump inhibitor (PPI) use. Two years after APC therapy, endoscopy demonstrated multiple gastric polyps in the antrum and angle. A gastric polyp biopsy indicated foveolar epithelium hyperplasia, which was diagnosed as gastric hyperplastic polyps. One year after switching to an H2 blocker antagonist, endoscopy revealed that the polyps and GAVE had disappeared, with normal gastrin levels suggesting that PPI-induced hypergastrinemia had caused gastric hyperplastic polyps after APC therapy, and the polyps had disappeared after discontinuing PPIs.

Disappearance of Gastric Hyperplastic Polyps after the Discontinuation of Proton Pump Inhibitor in a Patient with Liver Cirrhosis

Here, we report on a rare case of gastric hyperplastic polyps which disappeared after the discontinuation of proton pump inhibitor (PPI). The patient was an 83-year-old woman with liver cirrhosis and portal hypertension, along with gastroesophageal reflux disease treated by PPI. An initial upper gastrointestinal endoscopy showed unique polypoid lesions in the greater curvature of the stomach. Biopsy specimens of the lesions were diagnosed as hyperplastic polyps and she was followed. One year later, a second endoscopy showed that the lesions had increased in number and size, and an endoscopic mucosal resection (EMR) was performed for the main polyps. The resected specimens indicated a proliferation of foveolar epithelium cells with an increase of capillary ectasia and parietal cell hyperplasia, which was thought to be induced by hypergastrinemia from the PPI. Three months after the EMR, she was admitted because of bleeding from the remaining polyps along with an increase in new polyps. After conservative treatment, PPI was stopped and rebamipide was used. One year and 6 months later, an endoscopy showed the complete disappearance of all gastric polyps.

Randomised trial of acid inhibition by vonoprazan 10/20 mg once daily vs rabeprazole 10/20 mg twice daily in healthy Japanese volunteers (SAMURAI pH study)

BACKGROUND

Vonoprazan (V), a potassium-competitive acid blocker, has a more durable acid-inhibitory effect as compared with standard-dose proton pump inhibitors (PPIs) but has not been compared with 2-4 times higher daily PPI doses administered in two divided doses.

AIMS

To evaluate the acid-inhibitory effect of V 10/20 mg once-daily (OD; V10/V20) vs rabeprazole (R) 10/20 mg twice-daily (BID; R20/R40) in healthy Japanese volunteers.

METHODS

This multicentre, randomised, open-label, two-period, crossover study compared V10 or V20 vs R20, or V20 vs R40 using three cohorts of 10 healthy Japanese adults. Within each cohort, subjects were randomised to receive V or R for 7 days and, following a washout period ≥7 days, the other treatment for 7 days. On day 6 of each period, 24-hours multichannel gastric impedance-pH monitoring was performed. Percent times pH ≥ 3, ≥4 and ≥5 (pH 3, 4 and 5 holding time ratios [HTRs]) in 24 hours were evaluated as primary pharmacodynamic endpoints.

RESULTS

Acid-inhibitory effect (24-hours pH 3 HTR) of V20 was greater than those of R20 (91.0% vs 65.3%; P = .0049) and R40 (98.5% vs 85.9%; P = .0073). Similar results were obtained for 24-hours pH 4 and 5 HTRs. V20 also achieved greater nocturnal pH 4 (91.5% vs 73.2%; P = .0319) and 5 HTRs (78.8% vs 62.2%; P = .0325) as compared with R40. One subject (20%) developed diarrhoea while receiving R40 which was considered treatment-related.

CONCLUSIONS

Compared with 2-4 times the standard daily dose of R, V20 exerts a more potent and durable acid-inhibitory effect. Trial identifier: UMIN000022198 (www.umin.ac.jp/ctr/index.htm).

Barretts's carcinogenesis

Barrett's esophagus is considered a precancerous lesion of esophageal adenocarcinoma (EAC). Long‐segment Barrett's esophagus, which is generally associated with intestinal metaplasia, has a higher rate of carcinogenesis than short‐segment Barrett's esophagus, which is mainly composed of cardiac‐type mucosa. However, a large number of cases reportedly develop EAC from the cardiac‐type mucosa which has the potential to involve intestinal phenotypes. There is no consensus regarding whether the definition of Barrett's epithelium should include intestinal metaplasia. Basic researches using rodent models have provided information regarding the origins of Barrett's epithelium. Nevertheless, it remains unclear whether differentiated gastric columnar epithelium or stratified esophageal squamous epithelium undergo transdifferentiation into the intestinal‐type columnar epithelium, transcommittment into the columnar epithelium, or whether the other pathways exist. Reflux of duodenal fluid including bile acids into the stomach may occur when an individual lies down after eating, which could cause the digestive juices to collect in the fornix of the stomach. N‐nitroso‐bile acids are produced with nitrites that are secreted from the salivary glands, and bile acids can drive expression of pro‐inflammatory cytokines via EGFR or the NF‐κB pathway. These steps may contribute significantly to carcinogenesis.

Hyperplastic polyps arising in autoimmune metaplastic atrophic gastritis patients: is this a distinct clinicopathological entity?

OBJECTIVES

Gastric hyperplastic polyp (GHP) commonly arises in the abnormal surrounding mucosa, including autoimmune metaplastic atrophic gastritis (AMAG). We aimed to compare clinicopathological features in patients with GHPs associated with AMAG with those in patients with GHPs associated with non-AMAG.

PATIENTS AND METHODS

A total of 1170 patients with GHP(s) were enrolled, and their clinical and pathological data were analyzed, retrospectively.

RESULTS

The GHP patients were divided into 181 A-GHP (type A GHP, AMAG-associated GHP) participants, 312 B-GHP (type B GHP, Helicobacter pylori infection-associated GHP) participants, and 677 other GHP participants (non-A-GHP and non-B-GHP) based on pathological status of the surrounding non-polypoid mucosa. The A-GHP patients were older and predominantly female (p < .05). Gastroscopically, A-GHPs showed less distal and more multiple-region distribution in the stomach (p < .001). In addition, the A-GHPs were observed to be usually numerous (55.8%), larger (mean maximum diameter 12.3 mm), and more pedunculated or sub-pedunculated (45.3%) (p < .001). Histopathologically, the intestinal metaplasia, intraepithelial neoplasia, and carcinomatous transformation within GHPs were present in 24.3%, 9.9%, and 2.8% of AMAG patients, respectively, which were significantly higher than those in the B-GHPs and other GHPs (p < .05). However, the differences of intraepithelial neoplasia and adenocarcinoma in surrounding non-polypoid mucosa did not reach statistical significance (p > .05).

CONCLUSIONS

The GHP(s) arising in AMAG patients is a distinct subgroup of GHP(s) and was an important precancerous lesion. The biopsy from surrounding non-polypoid mucosa was essential to evaluate the underlying etiology of the GHPs, and endoscopists should pay attention to these.

[The Effect of Helicobacter pylori Infection on Recurrence of Gastric Hyperplastic Polyp after Endoscopic Removal]

Background/Aims

Several previous studies suggest that eradication of Helicobacter pylori (H. pylori) leads to the disappearance of gastric hyperplastic polyps. However, little is known about the effect of H. pylori status and eradication on the recurrence of gastric polyps after endoscopic removal. Here, we investigated the recurrence of gastric polyps according to the final H. pylori status in patients who underwent endoscopic removal of gastric hyperplastic polyps.

Methods

Between January 2011 and December 2016, patients who underwent endoscopic removal of gastric hyperplastic polyps and were followed-up for more than two months were enrolled. The success of H. pylori eradication was assessed by histology and rapid urease test or urea breath test, at least 4 weeks after the completion of eradication treatment. At follow-up, the recurrence of gastric polyp was evaluated via esophagogastroduodenoscopy.

Results

Seventy-nine patients were enrolled. During the mean follow-up period of 16.4 months, the recurrence rate of gastric polyp was 25.3%. Among those who received H. pylori eradication therapy, the H. pylori persistent group showed a higher recurrence of polyp than the H. pylori eradicated group; but there was no statistical significance (42.9% vs. 21.7%, p=0.269). Regarding the final H. pylori infection status, the recurrence rate of gastric polyps was significantly higher in the H. pylori positive group than in the H. pylori negative group (42.9% vs. 18.9%, p=0.031). In multivariate analysis, the final H. pylori infection status was a significant risk factor for gastric polyp recurrence after endoscopic removal.

Conclusions

The final positive H. pylori infection status is significantly associated with higher recurrence of gastric hyperplastic polyps after endoscopic removal.