Review article: the ageing bowel and intolerance to aspirin

Non-Steroidal Anti-Inflammatory Drugs: A Rare Cause of Colonic Mass

NSAIDs (non-steroidal anti-inflammatory drugs) are one of the most used medications worldwide. Every day they are used by more than 30 million Americans. Here, we report a rare and interesting case of a 63-year-old woman with a history of NSAID use who presented to our emergency room with lower abdominal pain. Computed tomography (CT) scan of the abdomen with intravenous contrast revealed focal mucosal thickening in the cecum which was highly suspicious for colonic malignancy. She had a colonoscopy which showed two masses and ulcers in the right colon, pathology was negative for malignancy and showed inflammation consistent with NSAID colopathy.

Aspirin and omeprazole for secondary prevention of cardiovascular disease in patients at risk for aspirin-associated gastric ulcers

INTRODUCTION

Cardiovascular disease is the most important cause of morbidity and mortality in the world and low-dose aspirin is considered the cornerstone of the cardiovascular disease prevention. However, low-dose aspirin use is associated with gastrointestinal adverse effects in the whole gastrointestinal tract. In this setting, co-therapy with a proton pump inhibitor is the most accepted strategy to reduce aspirin related upper gastrointestinal damage. In addition, some adverse effects have been described with proton pump inhibitors long term use. Areas covered: Low-dose aspirin related beneficial and adverse effects in cardiovascular system and gastrointestinal tract are reviewed. In addition, this manuscript summarizes current data on upper gastrointestinal damage prevention and adverse events with proton pump inhibition. Finally, we discuss the benefit/risk ratio of proton pump inhibitor use in patients at risk of gastrointestinal damage taking low-dose aspirin. Expert commentary: Nowadays, with the current available evidence, the combination of low-dose aspirin with proton pump inhibitor is the most effective therapy for cardiovascular prevention in patients at high gastrointestinal risk. However, further studies are needed to discover new effective strategies with less related adverse events.

Influence of ageing on the gastrointestinal environment of the rat and its implications for drug delivery

Age-mediated changes in gut physiology are considerations central to the elucidation of drug performance from oral formulations. Using rats of different age groups we measured the pH, buffer capacity, fluid volume, osmolality, and surface tension of gastrointestinal (GI) fluids, and therein explored the impact of these variables on prednisolone and mesalazine solubility in luminal fluids. We also studied the distribution of gut associated lymphoid tissue (GALT) and mucus layer thickness across the GI tract in rats of different age groups. At a mucosal level, there was an increase in GALT from young to adult rat. Gastrointestinal pH and buffer capacity remained mostly unchanged with age, except some pH differences in stomach and distal small intestine and a higher buffer capacity in the large intestinal fluids of young rats. Osmolality and surface tension also remained unaffected with the exception of a lower osmolality in elderly stomach and a lower surface tension in the small intestine of young rats. The difference in luminal environment on ageing influenced the solubility of studied drugs, for instance prednisolone solubility was shown to be higher in adult rats (mid small intestine and caecum) and solubility of mesalazine was significantly higher in the elderly distal small intestine.

Low-dose aspirin and upper gastrointestinal damage: epidemiology, prevention and treatment

BACKGROUND

Low-dose aspirin (75-325 mg/day) is widely used for the prevention of cardiovascular disease. However, due to its action on cyclo-oxygenase (COX), aspirin is associated with upper gastrointestinal (GI) side effects including ulcers and bleeding.

SCOPE

This was a comprehensive review of the literature available on the side effects associated with low-dose aspirin, together with the available treatment and prevention options, which was based on the authors' expertise in the field and a supplementary PubMed search limited to papers published in English during the last 10 years, up to November 2006.

FINDINGS

Although the risk of upper GI side effects is smaller with low-dose aspirin compared with non-selective, non-steroidal anti-inflammatory drugs (NSAIDs), it is nevertheless a substantial healthcare issue. Factors associated with an increased risk of upper GI complications during low-dose aspirin therapy include aspirin dose, history of ulcer or upper GI bleeding, age > 70 years, concomitant use of NSAIDs (including COX-2-selective NSAIDs), and Helicobacter pylori infection. Co-administration of a gastroprotective agent such as proton pump inhibitors (PPIs) may be useful for alleviating the upper GI side effects associated with use of low-dose aspirin. Eradication of H. pylori also appears to reduce the risk of these side effects, especially in those at high risk. The use of other antiplatelet agents such as clopidogrel does not seem to provide a safer alternative to low-dose aspirin in at-risk patients.

CONCLUSIONS

Prophylactic low-dose aspirin therapy is associated with an increased risk of developing upper GI side effects. Administration of a PPI seems the most effective therapy for the prevention and/or relief of such side effects in at-risk patients. H. pylori eradication therapy further reduces the risk of upper GI bleeding in these patients.

Human pancreatic polypeptide has a marked diurnal rhythm that is affected by ageing and is associated with the gastric TFF2 circadian rhythm

Normal circadian variations in vasoactive intestinal polypeptide, somatostatin, cholecystokinin and pancreatic polypeptide were measured to determine if these alter with aging and to identify gastrointestinal regulatory hormones that might control the dramatic diurnal variation in the gastric cytoprotective trefoil protein TFF2. Plasma pancreatic polypeptide concentrations showed a marked diurnal rhythm (p < 0.0001). Basal and postprandial pancreatic polypeptide concentrations increased with age (p < 0.01). The timing of the diurnal rhythm was consistent with pancreatic polypeptide inhibiting TFF2 secretion and there was a negative association between pancreatic polypeptide and TFF2 concentrations (p < 0.002). The much higher pancreatic polypeptide concentrations in older people will induce increased satiety that may contribute to 'anorexia of ageing'. These results identify potential therapies for treatment of gastric mucosal morbidity and age-associated loss of appetite.

The diurnal rhythm of the cytoprotective human trefoil protein TFF2 is reduced by factors associated with gastric mucosal damage: ageing, Helicobacter pylori infection, and sleep deprivation

OBJECTIVES

To determine if the normal TFF2 diurnal rhythm is disrupted in those with increased risk of gastric morbidity. Trefoil proteins protect the gastrointestinal mucosa from damage and aid its repair. TFF2 is considered the major cytoprotective gastric trefoil protein. There is a marked circadian variation in gastric luminal TFF2 in young healthy volunteers with peak levels present during the night.

METHODS

Gastric juice was aspirated at two hourly intervals over a 24-h period via a nasogastric tube. TFF2 was measured by quantitative western transfer analysis. Helicobacter pylori (H. pylori) status was measured by C13 urea breath test and by serology. The effects of H. pylori infection, sleep deprivation, and ageing, which cause increased gastric morbidity, on the TFF2 circadian rhythm were tested.

RESULTS

H. pylori infection attenuated the increase in TFF2 that occurs during the night. The TFF2 diurnal rhythm was reduced in older people and both the TFF2 level reached and the time at which the maximum TFF2 concentration occurs were associated inversely with age (p < 0.005). Sleep deprivation delayed the normal night time increase in gastric TFF2 and resulted in an overall reduction in TFF2 secretion.

CONCLUSIONS

H. pylori infection, ageing, and sleep deprivation cause a reduction in the TFF2 diurnal rhythm. The demonstration that the TFF2 rhythm is impaired in cohorts of individuals known to suffer gastric symptoms suggests that interventions to restore the normal TFF2 rhythm in those with poor mucosal protection could reduce morbidity.