Clinical aspects of gastrin physiology

Landmarks in the understanding and treatment of reflux disease

The last 50 years have seen a transformation in the understanding and treatment of reflux disease. The development and wide use of flexible endoscopy and progressively more sophisticated approaches to measurement of pathophysiological factors have been major drivers of advances. The recognition and progressive elucidation of the mechanical events that comprise the transient lower esophageal sphincter relaxation and how they lead to reflux provide a novel and firm foundation for tailoring therapies that act directly to reduce occurrence of reflux episodes, either surgically or pharmacologically. Novel GABA(B) agonist drugs have been shown to inhibit transient relaxations and are currently being evaluated in clinical trials on patients with reflux disease. Better understanding has extended to recognition of the extraordinarily high prevalence of reflux disease and of the ability of proton pump inhibitor drugs to deliver major benefits to a high proportion of patients with reflux disease. The life of the Gastroenterological Society of Australia has spanned the period of these major advances. A large number of the members of the Society and their associates have contributed substantially to these advances.

An improved radioimmunoassay for measurement of pepsinogen in porcine blood samples

The study was conducted to develop a sensitive and specific radioimmunoassay (RIA) for the measurement of pepsinogen in porcine serum, and to use this test for the determination of pepsinogen concentrations in serum samples from fetuses and pigs of different ages. Compared to a previously described RIA, major improvements were made concerning the use of specific polyclonal antibodies and the use of an appropriate buffer. The assay was able to detect pepsinogen concentrations of >/=0.2 ng/mL. The recovery of pepsinogen was close to 95%. The intra-assay coefficients of variations ranged between 3.9 and 7.5% whereas the interassay ranged between 8.8 and 11.9%. These percentages correspond to a satisfactory accuracy and reproducibility of the assay. No cross-reactions were observed with the main commercially available products of the aspartic proteases family except porcine pepsin cross-reacted over 62.5 microg/mL. Pepsinogen concentrations increased steadily with increasing age of the fetuses and the pigs (P<0.05). Pepsinogen concentrations (+/-SE) in fetuses of 90-100 (n=24) and 100-110 days of pregnancy (n=36) were 0.5+/-0.1 and 5.3+/-1.3 ng/mL, respectively. In pigs of 21, 98, and 213 days of age, the pepsinogen concentrations were 290.6+/-10.8, 343.1+/-17.9 and 383.5+/-15.3 ng/mL, respectively. The results demonstrate that RIA is accurate and can be used easily to assess pepsinogen concentrations in pig sera. The test may constitute a valuable tool in epidemiological surveys and in studies related to gastric diseases in pigs.

Evaluation of pepsinogen, gastrin and antibody response in diagnosing ostertagiasis

Ostertagia ostertagi is widely distributed and is one of the most important parasites affecting young bovine livestock. There is, therefore, a substantial need for sensitive and specific parameters in support of diagnosis of ostertagiasis, especially for subclinical disease related to production losses. In this review, the value and application of pepsinogen, gastrin and antibody response as diagnostic tools are discussed. These three parameters are useful and comparable for confirming clinical disease in calves during their first grazing season. However, their value for detecting subclinical parasitism is questionable. Differences in the course of gastrin and pepsinogen late in the grazing season can be correlated with larval inhibition and the possibility of ostertagiasis Type II. Relatively few serological methods have been developed for the immunodiagnosis of Ostertagia and until now the indirect antibody-detecting enzyme-linked immunosorbent assay (ELISA) has been the method of choice. Antibody measuring methods have several disadvantages, most notably a lack of sensitivity and specificity, which limits their use in longitudinal epidemiological studies. Considering the necessity of cost effectiveness and ease of use, it is anticipated that additional work will result in the enhancement and quality of current immunodiagnostic methods.

Is antral gastrin important in the resistance of duodenal ulcers to H2 receptor antagonists or in recurrent ulceration after highly selective vagotomy?

Basal serum gastrin, integrated gastrin response to a meal, and integrated gastrin response to insulin induced hypoglycaemia were measured in 60 patients with duodenal ulcer before and after elective highly selective vagotomy to determine whether antral gastrin has a role in resistance to H2 receptor antagonist treatment which the patients had received before surgery or in the development of recurrent ulceration after vagotomy. The basal gastrin, integrated gastrin response to a meal, and the integrated gastrin response to insulin were similar in patients whose ulcers healed after H2 receptor agonist treatment or were refractory to at least three months of this treatment. The same parameters measured before or after highly selective vagotomy were similar in patients who eventually developed recurrent ulceration compared with those who did not. As expected the basal and meal stimulated (but not insulin stimulated) serum gastrin values increased after highly selective vagotomy. Ulcer patients with particularly high gastrin values (whether basal or stimulated) were not more resistant to H2 receptor antagonist treatment or prone to develop ulcer recurrence after highly selective vagotomy. This study suggests that antral gastrin is not important in 'resistance' of duodenal ulceration either to H2 receptor antagonist treatment or to highly selective vagotomy.

Treatment of Zollinger-Ellison syndrome with exploratory laparotomy, proximal gastric vagotomy, and H2-receptor antagonists. A prospective study

Twenty-two patients with Zollinger-Ellison syndrome were managed by a combined medical and surgical approach. Patients were treated initially with cimetidine or ranitidine. A laparotomy was performed to remove easily resectable tumors and to carry out a proximal gastric vagotomy. Tumors were found in 9 patients (41%) and all visible tumors were removed from 6 of the 9 patients. Fasting serum gastrin concentrations and serum gastrin responses to intravenous secretin were normal 6 wk after surgery in each of the patients from whom all visible tumors were resected and are normal in 4 patients, 6 wk to 5 yr after surgery. Acid secretion was reduced after vagotomy in each patient, even when tumors were not found or completely resected. Thus, vagotomy decreased the acid secretory response to endogenous hypergastrinemia. In addition, vagotomy augmented the inhibitory effect of H2-receptor antagonists on acid secretion. Follow-up has ranged from 6 wk to 6 yr (median, 2 yr). Dosages of cimetidine or ranitidine have been reduced, compared with preoperative amounts, in all but 1 patient. Two patients are taking no antisecretory drugs. Only 3 patients have had occasional symptoms of ulcer disease. Complications such as bleeding, perforation, or obstruction have not occurred in any patient. Endoscopy was performed in all patients to estimate the point prevalence of active ulcers and an ulcer was found in 1 patient. Based on these results, it is our opinion that this combined medical and surgical approach is an effective treatment for patients with Zollinger-Ellison syndrome.

Effects of Ostertagia circumcincta infections on plasma gastrin in sheep

Radio-immunoassay of plasma gastrin showed that hypergastrinaemia developed in sheep during experimental infections with Ostertagia circumcincta. Elevations of plasma gastrin occurred within 8 days of the first dose of infective larvae, with the most marked increase being after 11-20 days when adult worms would be expected to be present in the abomasum. Increases of plasma gastrin levels from 69.0 +/- 7.6, 28.7 +/- 5.3, 48.7 +/- 5.9 and 60.6 +/- 9.4 pg/ml before infection to maxima of 650, 230, 900 and 750 pg/ml respectively were recorded in 4 sheep infected for the first time. In 2 others which had been previously infected and then treated with anthelmintic, plasma gastrin rose from 16.0 +/- 4.0 and 377 +/- 87 pg/ml to maxima of 260 and 900 pg/ml at 24 and 29 days after re-infection, respectively. The cause of hypergastrinaemia has not been established. The elevation of abomasal pH which occurs in ostertagiasis may result in increased gastrin levels but is thought not to be the only cause since plasma gastrin increased before the abomasal pH rose and developed in sheep infected for a second time although their abomasal contents remained at pH 4.0 or lower. The presence of the parasite is critical for development of hypergastrinaemia as shown by return of the gastrin level to normal following therapy with an anthelmintic. It was shown that the parasites do not depend on the hypergastrinaemia since O. circumcincta became established in antrectomized sheep in which hypergastrinaemia did not develop.

A case of multiple endocrine adenomatosis with primary amenorrhoea

A well documented sporadic case of multiple endocrine adenomatosis (MEA) type I, with the pituitary tumour presenting as a prolactinoma, is described in a 28-year-old female. Primary amenorrhoea, resulting from hyperprolactinaemia, was the first symptom of the polyglandular neoplasia. A gastrinoma was removed from the head of the pancreas and latent hyperparathyroidism appeared to be present. Treatment with bromocriptine was poorly tolerated; neurosurgical intervention was refused by the patient. The possibility that a serum prolactin determination may be useful in detecting pituitary involvement in MEA deserves consideration.

Do beta adrenergic agents directly stimulate gastrin secretion?

Isoproterenol if given during methacholine stimulation in dogs neither depresses gastric secretion nor elevates serum gastrin. Therefore, we conclude that beta adrenergics (isoproterenol) are unlikely to be direct liberators of gastrin, but raise serum gastrin indirectly only if they inhibit gastric secretion.