Nonsteroidal anti-inflammatory drug gastrointestinal toxicity

Acetylsalicylic acid-induced changes in the chemical coding of extrinsic sensory neurons supplying the prepyloric area of the porcine stomach

Acetylsalicylic acid is a popular drug that is commonly used to treat fever and inflammation, but which can also negativity affect the mucosal layer of the stomach, although knowledge concerning its influence on gastric innervation is very scarce. Thus, the aim of the present study was to study the influence of prolonged acetylsalicylic acid supplementation on the extrinsic primary sensory neurons supplying the porcine stomach prepyloric region. Fast Blue (FB) was injected into the above-mentioned region of the stomach. Acetylsalicylic acid was then given orally to the experimental gilts from the seventh day after FB injection to the 27th day of the experiment. After euthanasia, the nodose ganglia (NG) and dorsal root ganglia (DRG) were collected. Sections of these ganglia were processed for routine double-labelling immunofluorescence technique for substance P (SP), calcitonine gene related peptide (CGRP), galanin (GAL), neuronal isoform of nitric oxide synthase (nNOS) and vasoactive intestinal polypeptide (VIP). Under physiological conditions within the nodose ganglia, the percentage of the FB-labeled neurons immunoreactive to particular substances ranged between 17.9 ± 2.7% (VIP-like immunoreactive (LI) neurons in the right NG) and 60.4 ± 1.7% (SP-LI cells within the left NG). Acetylsalicylic acid supplementation caused a considerable increase in the expression of all active substances studied within both left and right NG and the percentage of neurons positive to particular substances fluctuated from 47.2 ± 3.6% (GAL-LI neurons in the right NG) to 67.2 ± 2.0% (cells immunoreactive to SP in the left NG). All studied substances were also observed in DRG neurons supplying the prepyloric region of the stomach, but the number of immunoreactive neurons was too small to conduct a statistical analysis. The obtained results show that ASA may influence chemical coding of the sensory neurons supplying the porcine stomach, but the exact mechanisms of this action still remain unknown.

Operative management of acute diverticulitis in immunosuppressed compared to immunocompetent patients: A systematic review

AIM: To determine short and long-term outcomes following operative management of acute diverticulitis in immunosuppressed (IMS) compared to immunocompetent (IMC) patients.

METHODS: PRISMA guidelines were followed in conducting this systematic review. We searched PubMed (1946 to present), OVID MEDLINE(R) In-Process and Other Non-Indexed Citations, OVID MEDLINE(R) Daily and OVID MEDLINE(R) (1946 to present), EMBASE on OVID platform (1947 to present), CINAHL on EBSCO platform (1981 to present), and Cochrane Library using a systematic search strategy. There were no restrictions on publication date and language. We systematically reviewed all published cohort comparative studies, case-control studies, and randomized controlled trials that reported outcomes on operative management of acute episode of colonic diverticulitis in IMS in comparison to IMC patients.

RESULTS: Seven hundred and fifty-five thousand five hundred and eighty-three patients were included in this systematic review; of which 1478 were IMS and 754105 were IMC patients. Of the nine studies included there was one prospective cohort, seven retrospective cohorts, one retrospective case-control study, and no randomized controlled trials. With the exception of solid organ transplant patients, IMS patients appeared to be older than IMC when they presented with an acute episode of diverticulitis. IMS patients presented with more severe acute diverticulitis and more insidious onset of symptoms than IMC patients. In the emergency setting, peritonitis was the main indication for operative intervention in both IMS and IMC patients. IMS patients were more likely to undergo Hartmann’s procedure and less likely to undergo reconstructive procedures compared to IMC patients. Furthermore, IMS patients had higher morbidity and mortality rates in the emergency setting compared to IMC patients. In the elective settings, it appeared that reconstruction with primary anastomosis with or without a diverting loop stoma is the procedure of choice in the IMS patients and carried minimal morbidity and mortality equivalent to IMC patients.

CONCLUSION: Emergency operations for diverticulitis in IMS compared to IMC patients have higher morbidity and mortality, whereas, in the elective setting both groups have comparable outcomes.

Prolonged acetylsalicylic-acid-supplementation-induced gastritis affects the chemical coding of the stomach innervating vagal efferent neurons in the porcine dorsal motor vagal nucleus (DMX)

The main goal of our research was to study the possible alterations of the chemical coding of the dorsal motor vagal nucleus (DMX) neurons projecting to the porcine stomach prepyloric region following prolonged acetylsalicylic acid supplementation. Fast Blue (FB) was injected into the studied area of the stomach. Since the seventh day following the FB injection, acetylsalicylic acid (ASA) was given orally to the experimental gilts. All animals were euthanized on the 28th day after FB injection. Medulla oblongata sections were then processed for double-labeling immunofluorescence for choline acetyltransferase (ChAT), pituitary adenylate cyclase-activating peptide (PACAP), vasoactive intestinal polypeptide (VIP), nitric oxide synthase (NOS), galanin (GAL), substance P (SP), leu enkephalin (LENK), and cocaine- and amphetamine-regulated transcript (CART). In the control DMX, only PACAP was observed in 30.08 ± 1.97 % of the FB-positive neurons, while VIP, NOS, GAL, SP, LENK, and CART were found exclusively in neuronal processes running between FB-labeled perikarya. In the ASA DMX, PACAP was revealed in 49.53 ± 5.73 % of traced vagal perikarya. Moreover, we found de novo expression of VIP in 40.32 ± 7.84 %, NOS in 25.02 ± 6.08 %, and GAL in 3.37 ± 0.85 % of the FB-labeled neurons. Our results suggest that neuronal PACAP, VIP, NOS, and GAL are mediators of neural response to aspirin-induced stomach inflammatory state.

Allele variants of the cytochrome P450 2C9 genotype in white subjects from the netherlands with serious gastroduodenal ulcers attributable to the use of NSAIDs

BACKGROUND

The most common serious adverse effects (AEs) associated with NSAID therapy are bleeding and perforated gastroduodenal ulcers. These AEs are dose related, and reduced oral clearance of NSAIDs associated with polymorphisms of cytochrome P450 (CYP) would, theoretically, increase the risk for AEs.

OBJECTIVE

The purpose of this study was to determine whether polymorphisms of the CYP2C9 genotype are associated with the development of serious complications of NSAID-related ulcers.

METHODS

We examined the records of patients with complications of serious NSAID-related ulcers who were hospitalized from November 2001 to December 2003. Diagnosis was confirmed by endoscopy or abdominal surgery, and a group of consecutive subjects was identified for genetic analysis. CYP2C9 allele frequencies were determined and compared with those in a matched cohort of subjects receiving stable weekly maintenance doses of oral coumarin anticoagulants. Allele frequencies also were compared with those in matched cohorts from earlier studies.

RESULTS

All 26 subjects with serious NSAID-related ulcers were white, 15 (58%) were female, and the median age was 74.5 years (range, 32-96 years). All 87 subjects in the reference group were white, 24 (28%) were female, and the median age was 69 years (range, 48-81 years). CYP2C9 genotype frequencies did not differ significantly between subjects with serious complications of NSAID-related ulcers and subjects using oral coumarin anticoagulants. The genotype frequencies in both groups were similar to those reported in previous studies in white subjects.

CONCLUSION

The CYP2C9 genotype was not a significant or clinically relevant risk factor in the development of serious NSAID-related ulcers in this group of subjects.

Traitements curatif et préventif des ulcères gastro-duodénaux induits par les AINS

The use of treatments to heal or to prevent nonsteroidal anti-inflammatory drugs (NSAIDs) associated gastroduodenal lesions is based on replacement of mucosal prostaglandin deficiency or inhibition of acid secretion. Four-week acid suppression by proton pump inhibitors (PPI) with 7-day eradication triple therapy in Helicobacter pylori positive patients is effective in healing gastric and duodenal ulcer upon discontinuation of NSAIDs. In the event NSAIDs must be continued, PPIs (omeprazole 20 mg, lansoprazole 30 mg, pantoprazole 40 mg) are more effective than H2-blockers and cytoprotective agents (sucralfate, misoprostol) to heal mucosal lesions. In long-term prevention studies, omeprazole 20 mg, lansoprazole 15 mg, and pantoprazole 20 mg significantly reduce gastric and duodenal ulcer rates. Misoprostol 800 microg is as effective as PPIs for preventing symptomatic and complicated gastric ulcers, but less effective to prevent duodenal ulcer, with a high rate of adverse effects such as diarrhea. Helicobacter pylori eradication in infected patients decrease the risk of NSAIDs-associated lesions but is less effective than concomitant antisecretory treatment. Current data from comparative studies of PPIs vs ranitidine or misoprostol are in favor of the PPIs as well tolerated and effective drugs in the prophylaxis of NSAIDs-related gastroduodenal lesions in high-risk patients.