The effects of high-dose esomeprazole on gastric and oesophageal acid exposure and molecular markers in Barrett's oesophagus

Screening and Prevention of Barrett's Esophagus

Barrett's esophagus (BO) is a risk factor for esophageal adenocarcinoma. However, screening for BO is difficult since it is not yet clear who should be screened and which screening method is cost-effective. Screening methods could be upper endoscopy at the time of the first screening colonoscopy, transnasal endoscopy, esophageal capsule endoscopy, or cytosponge. In order to prevent the development of BO or its neoplastic progression, there are modifiable risk factors like obesity or smoking that can be influenced. In addition, several drugs like proton pump inhibitors, aspirin, nonsteroidal anti-inflammatory drugs and statins have shown promising effects in mostly observational studies. However, data from prospective randomized trials are scarce in order to draw final conclusions.

A comparative study on the possible protective effect of esomeprazole, spirulina, wheatgrass on indomethacin-induced gastric ulcer in male albino rats

Gastric ulcer is a common problem affecting the gastrointestinal tract. Spirulina and wheatgrass are natural substances that have anti-inflammatory and antioxidant effects. The aim of the Work was to elucidate the possible protective role of spirulina and wheatgrass versus standard treatment esomeprazole on indomethacin-induced gastric ulcer in adult male albino rats. Eighty adult male albino rats were divided into eight groups: group I (the control group), group II that received indomethacin (100 mg/kg orally), group III that received esomeprazole (20 mg/kg orally), group IV that received spirulina (1000 mg/kg orally), group V that received wheatgrass (1000 mg/kg orally), group VI that received indomethacin (100 mg/kg) + esomeprazole (20 mg/kg), group VII that received indomethacin (100 mg/kg) + spirulina (1000 mg/kg) and group VIII that received indomethacin (100 mg/kg) + wheatgrass (1000 mg/kg). Six hours after indomethacin treatment, all rats were anesthetized and their stomachs obtained for measures of gastric acidity, pepsin activity, mucin content, gastrin, ulcer index, total antioxidant capacity (TAC), tumor necrosis factor -α (TNF-α), interleukin-8 (IL8), proapoptotic protein (Bax). Histological (using H&E stain, PAS reaction) and immunohistochemical (using anti Ki67 immunostain) techniques were performed. Western immunoblot analysis for heat shock protein 70 (HSP70) was also done. Moreover, a morphometric study was done for area% of positive immunoreactive cells for Ki67 and optical density and area% of PAS reaction. All performed measurements were followed by statistical analysis. Indomethacin induced loss of normal architecture of gastric mucosa with sloughing of surface epithelium and inflammatory cellular infiltration. It also led to a significant increase in gastric acidity, inflammatory mediators (TNF-α, IL-8), pro-apoptotic protein Bax and a significant decrease in TAC levels and HSP-70 expression. There was also a significant decrease in area% of Ki67 immunoreactivity and area% and optical density of PAS reaction as compared with the control group and other pre-treated rats. These disturbed parameters were associated with increased ulcer index. In pre-treatment groups, the structure of the mucosa was similar to control with marked improvement in the biochemical assay. In conclusion, Spirulina and wheatgrass can partly protect the gastric mucosa against indomethacin-induced damage to a degree similar to that of the classical treatment esomeprazole.

Barrett oesophagus

Barrett oesophagus (BE), the only known histological precursor of oesophageal adenocarcinoma (EAC), is a condition in which the squamous epithelium of the oesophagus is replaced by columnar epithelium as an adaptive response to gastro-oesophageal reflux. EAC has one of the fastest rising incidences of cancers in Western countries and has a dismal prognosis. BE is usually detected during endoscopic examination, and diagnosis is confirmed by the histological presence of intestinal metaplasia. Advances in genomics and transcriptomics have improved our understanding of the pathogenesis and malignant progression of intestinal metaplasia. As the majority of EAC cases are diagnosed in individuals without a known history of BE, screening for BE could potentially decrease disease-related mortality. Owing to the pre-malignant nature of BE, endoscopic surveillance of patients with BE is imperative for early detection and treatment of dysplasia to prevent further progression to invasive EAC. Developments in endoscopic therapy have resulted in a major shift in the treatment of patients with BE who have dysplasia or early EAC, from surgical resection to endoscopic resection and ablation. In addition to symptom control by optimization of lifestyle and pharmacological therapy with proton pump inhibitors, chemopreventive strategies based on NSAIDs and statins are currently being investigated for BE management.

Impact of gastroesophageal reflux control through tailored proton pump inhibition therapy or fundoplication in patients with Barrett’s esophagus

AIM

To determine the impact of upwards titration of proton pump inhibition (PPI) on acid reflux, symptom scores and histology, compared to clinically successful fundoplication.

METHODS

Two cohorts of long-segment Barrett’s esophagus (BE) patients were studied. In group 1 (n = 24), increasing doses of PPI were administered in 8-wk intervals until acid reflux normalization. At each assessment, ambulatory 24 h pH recording, endoscopy with biopsies and symptom scoring (by a gastroesophageal reflux disease health related quality of life questionnaire, GERD/HRLQ) were performed. Group 2 (n = 30) consisted of patients with a previous fundoplication.

RESULTS

In group 1, acid reflux normalized in 23 of 24 patients, resulting in improved GERD/HRQL scores (P = 0.001), which were most pronounced after the starting dose of PPI (P < 0.001). PPI treatment reached the same level of GERD/HRQL scores as after a clinically successful fundoplication (P = 0.5). Normalization of acid reflux in both groups was associated with reduction in papillary length, basal cell layer thickness, intercellular space dilatation, and acute and chronic inflammation of squamous epithelium.

CONCLUSION

This study shows that acid reflux and symptom scores co-vary throughout PPI increments in long-segment BE patients, especially after the first dose of PPI, reaching the same level as after a successful fundoplication. Minor changes were found among GERD markers at the morphological level.

The Role of Acid Suppression in Barrett's Esophagus

In recent years, proton pump inhibitors (PPIs) have come under great scrutiny due to possible adverse, long-term side effects. At the same time, Barrett's esophagus, a premalignant condition in the esophagus, continues to be a disease whose course is thought to be improved by the use of PPIs. We review the impact of proton pump therapy on the esophagus and on Barrett's mucosa. In analyzing changes on a cellular level, we explore the effect of mixed gastric refluxate and the complex cascade that ensues with esophageal exposure of these contents. Because the incidence of esophageal adenocarcinoma is on the rise, we explore other factors that may contribute to the progression of Barrett's from non-dysplastic mucosa to esophageal adenocarcinoma. By revisiting the need for adequate acid suppression in Barrett's and increasing our understanding of other possible factors that may have an effect of Barrett's progression, we hope to support our multifaceted approach to acid suppression in patients with Barrett's esophagus.

Androgen Signaling in Esophageal Adenocarcinoma Cell Lines In Vitro

BACKGROUND

We showed previously that nuclear localization of the androgen receptor (AR) and expression of the androgen-responsive gene FK506-binding protein 5 (FKBP5) in esophageal adenocarcinoma (EAC) tissues were associated with decreased patient survival, suggesting a role for androgens in this cancer.

AIM

To investigate the effect of the AR ligand 5α-dihydrotestosterone (DHT) on AR-expressing EAC cell lines in vitro.

METHODS AND RESULTS

In tissue resection specimens from EAC patients, FKBP5 expression was positively associated with proliferation as measured by Ki-67 expression. We stably transduced AR into three AR-negative EAC cell lines, OE33, JH-EsoAd1, and OE19, to investigate androgen signaling in vitro. In the AR-expressing cell lines, 10 nM DHT, the concentration typically used to study AR signaling, induced changes in the expression of androgen-responsive genes and inhibited proliferation by inducing cell cycle arrest and senescence. At lower DHT concentrations near the half maximal inhibitory concentration (IC50), the AR-expressing cell lines proliferated and there were changes in the expression of androgen-responsive genes. In direct co-culture with cancer-associated fibroblast-like PShTert myofibroblasts, 10 nM DHT induced changes in the expression of androgen-responsive genes but did not inhibit proliferation.

CONCLUSIONS

This is the first study to show that EAC cell lines respond to androgen in vitro. Proliferation together with the expression of androgen-responsive genes was dependent on the concentration of DHT, or the presence of a permissive microenvironment, consistent with observations in the tissues. These findings are consistent with a role for androgen signaling in EAC.

[Barrett's esophagus]

Barrett's esophagus is an endoscopically visible metaplasia of the columnar epithelium in the esophagus with histological detection of a specialized intestinal metaplasia. The circumferential and longitudinal extent are described endoscopically using the Prague classification. Barrett's esophagus mostly occurs as the result of gastroesophageal reflux disease. The risk of developing esophageal adenocarcinoma is increased but the absolute risk is low with 0.10-0.15 % per year. According to guideline recommendations, screening for Barrett's esophagus as well as endoscopic and biopsy surveillance should be limited to high risk groups. On detection of intraepithelial neoplasia (IEN) endoscopic therapy is indicated, whereby a second opinion must be obtained from a specialized pathologist for low-grade IEN. The influence of proton pump inhibitors on the progression to carcinoma is controversially discussed and a preventive anti-reflux operation is not indicated.

Influence of Life Style Factors on Barrett's Oesophagus

Background. Since the incidence of adenocarcinoma of the oesophagus is rising, the prognosis is poor, and surveillance programs are expensive and mostly cost ineffective, there is a need to increase the knowledge of risk factors in Barrett's oesophagus and oesophageal cancer in order to be able to give attention to medical prevention and/or surveillance programs. Aim. To study if there is a correlation between the development of Barrett's oesophagus and GOR (gastro oesophageal reflux), family history of GOR, and life style factors, such as alcohol, smoking habits, and mental stress. Methods. Fifty-five consecutively selected patients with Barrett's oesophagus (BO) examined at Linköping University Hospital's Oesophageal Laboratory were matched by sex, age, and duration of reflux symptoms with 55 GOR patients without Barrett's oesophagus at the Oesophageal Laboratory. The medical charts in respective groups were examined for comparison of life style factors, mental stress, medication, duration of gastroesophageal acid reflux at 24 hr-pH-metry, and incidence of antireflux surgery and of adenocarcinoma of the oesophagus (ACO). Also, potential gender differences and diagnosis of ACO were studied. Results. Mean percentage reflux time on 24 hr-pH-metry was higher for the Barrett's oesophagus group, 18% for women and 17% for men compared to 4% for women and 4% for men in the control group (P < 0.05). Family history of GOR was more frequent in Barrett's oesophagus patients (62%) than in the control group (35%) (P < 0.05). Male patients with Barrett's oesophagus had medical therapy for their GOR symptoms to a higher extent (38%) than male controls (65%) (P < 0.05). No difference was found in the number of tobacco users or former tobacco users between Barrett's oesophagus patients and controls. Barrett's oesophagus patients had the same level of alcohol consumption and the same average BMI as the control subjects. Female patients with Barrett's oesophagus rated themselves as more mentally stressed (67%) than the female controls (38%) (P < 0.05). In the five-year medical chart follow-up, five of 55 patients developed adenocarcinoma among the Barrett's oesophagus patients, none in the control group. Conclusions. Long reflux time and family clustering of GOR seem to influence the development of Barrett's oesophagus. Smoking habits, alcohol consumption and BMI do not seem to have any impact on the development of Barrett's oesophagus.

Management strategies of Barrett's esophagus

Barrett’s esophagus is a condition resulting from chronic gastro-esophageal reflux disease with a documented risk of esophageal adenocarcinoma. Current strategies for improved survival in patients with Barrett's adenocarcinoma focus on detection of dysplasia. This can be obtained by screening programs in high-risk cohorts of patients and/or endoscopic biopsy surveillance of patients with known Barrett’s esophagus (BE). Several therapies have been developed in attempts to reverse BE and reduce cancer risk. Aggressive medical management of acid reflux, lifestyle modifications, antireflux surgery, and endoscopic treatments have been recommended for many patients with BE. Whether these interventions are cost-effective or reduce mortality from esophageal cancer remains controversial. Current treatment requires combinations of endoscopic mucosal resection techniques to eliminate visible lesions followed by ablation of residual metaplastic tissue. Esophagectomy is currently indicated in multifocal high-grade neoplasia or mucosal Barrett’s carcinoma which cannot be managed by endoscopic approach.

Systematic review: hypomagnesaemia induced by proton pump inhibition

BACKGROUND

Proton pump inhibitors (PPIs) are a mainstay therapy for all gastric acid-related diseases. Clinical concerns arise from a small but growing number of case reports presenting PPI-induced hypomagnesaemia (PPIH) as a consequence of long-term PPI use. Current opinion is that reduced intestinal magnesium absorption might be involved, but nothing is known on the molecular mechanism underlying PPIH.

AIM

To investigate whether or not PPIH is a true, long-term drug-class effect of all PPIs and to scrutinise a possible role of comorbidity in its aetiology. Therefore, the primary objective in particular was to investigate serum magnesium dynamics in trials drug withdrawal and re-challenge. The secondary objective was to profile the 'patient at risk'.

METHODS

We reviewed systematically all currently available case reports on the subject and performed a statistical analysis on extracted data.

RESULTS

Proton pump inhibitor-induced hypomagnesaemia PPIH is a drug-class effect and occurred after 5.5 years (median) of PPI use, onset was broad and ranged from 14 days to 13 years. Discontinuation of PPIs resulted in fast recovery from PPIH in 4 days and re-challenge led to reoccurrence within 4 days. Histamine-2-receptor antagonists were the preferable replacement therapy in PPIH and prevented reoccurrence of hypomagnesaemia. In PPIH no specific risk profile was identified that was linked to the hypomagnesaemia.

CONCLUSIONS

The cases of PPIH show severe symptoms of magnesium depletion and identification of its causation was only possible through withdrawal of the PPI. Clinical awareness of PPIH is key to avoid putting patients at risk.

Recent developments in gastroesophageal reflux disease and Barrett's esophagus: ANNO 2012

The incidence of gastroesophageal reflux disease (GERD) and esophageal columnar metaplasia is rising worldwide. Both mechanical and functional factors perturb the double sphincter barrier at the esophagogastric junction (EGJ). Discovery of the acid pocket is fundamental in understanding postprandial acid reflux. Adding impedencemetry to pH measurements allows detection of non-acid or weakly acidic reflux. Histologic and endoscopic injury of the squamous mucosa rises from dilation of the intercellular spaces, papillary extension, accentuated intrapapillary looping, red streaks, erosive tissue loss, etc., graded with the Los Angeles system. Seventy percent of patients have no recognizable abnormalities (non-erosive or neGERD). Treatment of GERD mainly relates to the control of acid secretion but a revival of alginate/antacid obliterating the acid pocket is to be expected. Weaker heartburn control in neGERD is a misnomer because most studies included patients with no evidence of reflux disease. Traditional (delayed-release) proton pump inhibitors (PPIs) are powerful suppressors of acid secretion but do have limitations such as gradual build up of acid control, weak control of nocturnal acid recovery, possibility of rebound, occasional need for dose escalation, etc. Barrett's esophagus (BE) is endoscopically diagnosed also in the absence of intestinal metaplasia. A prerequisite is the precise location of the EGJ (proximal end of gastric folds, esophageal sphincter pinch, distal extent of palisade vessels). BE is graded with the Prague C & M system. Barrett's cancer develops usually via low-grade and high-grade dysplasia. Endoscopic examination may indicate suspicious areas, amenable for targeted biopsy. Otherwise, four quadrant biopsies are obtained when searching for neoplasia. Low-grade dysplasia, especially when it is multifocal and p53 positive, high-grade dysplasia and mucosal cancer should be treated with endoscopic resection of the target area, followed by radiofrequency ablation of the adjacent non-neoplastic columnar mucosa, followed with powerful acid suppressant therapy. The long-term results of the combination of resection and ablation are exiting and at least comparable to surgical resection.

Barrett's esophagus: A historical perspective, an update on core practicalities and predictions on future evolutions of management

Interpretation of exploding knowledge about Barrett's esophagus is impaired by use of several conflicting definitions. Because any histological type of esophageal columnar metaplasia carries risk for esophageal adenocarcinoma, the diagnosis of Barrett's esophagus should no longer require demonstration of intestinal-type metaplasia. Endoscopic recognition and grading of Barrett's esophagus remains a significant source of ambiguity. Reflux disease is a key factor for development of Barrett's esophagus, but other factors must underlie its development, since it occurs in only a minority of reflux disease patients. Neither antireflux surgery nor proton pump inhibitor (PPI) therapy has major impacts on cancer risk. Within a year, a major trial should indicate whether low-dose aspirin usefully reduces cancer risk. The best referral centers have transformed the accuracy of screening and surveillance for early curable esophageal adenocarcinoma by use of enhanced and novel endoscopic imaging, visually-guided, rather than blind biopsies and by partnership with expert pathologists. General endoscopists now need to upgrade their skills and equipment so that they can rely mainly on visual targeting of biopsies on mucosal areas of concern in their surveillance practice. General pathologists need to greatly improve their interpretation of biopsies. Endoscopic therapy now achieves very high rates of cure of high-grade dysplasia and esophageal adenocarcinoma with minimal morbidity and risk. Such results will only be achieved by skilled interventional endoscopists. Esophagectomy should now be mainly restricted to patients whose cancer has extended into and beyond the submucosa. Weighing risks and benefits in the management of Barrett's esophagus is difficult, as is the process of adequately informing patients about their specific cancer risk.