Gastritis in patients on non-steroidal anti-inflammatory drugs

Endoscopic Follow-Up Between 3 and 7 Years After Sleeve Gastrectomy Reveals Antral Reactive Gastropathy but no Barrett's Esophagus

BACKGROUND

The main concerns following sleeve gastrectomy (SG) include the risk of gastroesophageal reflux disease (GERD) and its complications, such as Barrett's esophagus (BE). However, there is conflicting data on esophageal conditions, and studies on alterations of gastric mucosa after SG are lacking, despite reported cases of gastric cancer. Our aim was to assess esophageal and gastric lesions after SG.

METHODS

From November 2017, an upper gastrointestinal endoscopy (UGE) was proposed at least 3 years after SG to all patients operated on in our institution. Endoscopic results and gastric histological findings were analyzed. BE was defined as endoscopically suspected esophageal metaplasia with histological intestinal metaplasia.

RESULTS

Between September 2008 and August 2018, 375 patients underwent SG at our institution, of which 162 (43%) underwent at least one UGE 3 years or more after SG (91% women, mean preoperative age: 43.3±10.3 years). Despite a significant increase in the prevalence of symptomatic GERD, hiatal hernia, and esophagitis after SG (p<0.001 vs. preoperatively), no cases of BE were detected. Gastric dysplasia was not found and the prevalence of gastric atrophy tended to decrease after SG. However, 27% of patients with gastric biopsies developed antral reactive gastropathy.

CONCLUSIONS

At a mean follow-up of 54 months after SG, no BE or gastric dysplasia was identified. However, reactive gastric lesions appeared, and their long-term consequences need to be further clarified. Thus, the timing of endoscopic follow-up, starting as early as 3 years after SG should be reevaluated to improve patient adherence with long-term endoscopies.

Efficiency evaluation of Amlodipine combined with N-acetylcysteine on Indomethacin-induced gastritis in rats

Introduction: It is a well-known phenomenon that nonsteroidal anti-inflammatory drugs cause gastric mucosal damage. Amlodipine is a third generation dihydropyridine-type calcium channel blocker; it can inhibit inflammatory cytokines and enhance antioxidant defenses. N-acetylcysteine can act both as a precursor of reduced glutathione and as a direct ROS scavenger. Moreover, N-acetylcysteine has been purported to have anti-inflammatory properties.

Materials and methods: 34 albino Wistar rats were used. The model of gastritis was induced by subcutaneous Indomethacin prepared in 5% sodium bicarbonate administered at a dose rate of 9 mg/kg for two days at 24h intervals. N-acetylcysteine (500 mg/kg), Amlodipine (10 mg/kg) and N-acetylcysteine (500 mg/kg) combined with Amlodipine (5 mg/kg) were administrated for seven consecutive days beginning 24 h after the first Indomethacin injection. Rats were sacrificed under ether anesthesia on the 8th day. The stomach injury was assessed by macroscopic damage and histological study.

Results and discussion: The results showed that macroscopic stomach damage scores caused by administration of Indomethacin did not significantly decrease by administration of N-acetylcysteine alone (p&gt;0.05), but it decreased significantly by administration of Amlodipine alone or by its combination with N-acetylcysteine (p&lt;0.05). Microscopic stomach damage scores did not significantly decrease by administration of Amlodipine or N-acetylcysteine alone (p&gt;0.05), but they decreased significantly by administering the combination of Amlodipine with N-acetylcysteine (p&lt;0.05). Administration of Amlodipine with N-acetylcysteine showed significant reduction in the severity of the gastric inflammation induced by Indomethacin, which was evidenced macroscopically and microscopically.

Conclusion: This study concluded that administration of Amlodipine with N-acetylcysteine produce obvious enhancement in gastritis induced by Indomethacin.

Graphical abstract:

Etiological Analysis of Reactive Gastropathy in an Urban Population

Background

Reactive gastropathy (RG) is an adaptive response to assaults of the gastric mucosa. Demographic information regarding RG as well as the coincidence of RG and gastrointestinal cancer are poorly characterized entities.

Objective

Herein, we aim to investigate relationships of RG to both modifiable and nonmodifiable risk factors, as well as conduct a stratified analysis by race in an ethnically diverse, urban population.

Methods

In this retrospective study, we queried an urban hospital inpatient pathology database searching for patients with surgical gastric biopsies positive for RG between March 25, 2015, and March 25, 2016. Of the 728 patients with a final diagnosis of RG, 292 were selected based on strict inclusion and exclusion criteria. We explored risk factors and conducted a stratified analysis for associations based on patient demographics.

Results

In this urban minority population, nonsteroidal anti-inflammatory drugs (NSAIDs) were the most common medication associated with RG (Fig. 1), as well as the most common cause of RG, followed by chronic bile reflux. In addition, significant differences in demographics and gastropathic characteristics associated with RG, stratified by ethnicity, were found (Fig. 2). Notably, Hispanics, African Americans, and Caucasians had the highest rate of concomitant RG and diabetes, hypertension, and tobacco/alcohol use, respectively.

Conclusion

Our study indicated that NSAID usage is the most common cause of RG, followed by bile reflux-mediated mucosal injury, in an ethnically diverse urban US-based population. Of note, few patients had intestinal metaplasia, suggesting it to be a slow or negligent sequela of RG.

Effect of frequently prescribed drugs on gastric cancer risk

Gastric cancer is the fifth leading cancer worldwide. Infection with Helicobacter pylori represents the major risk factor, but only a small fraction of infected individuals will develop neoplasia. The progression of advanced gastric lesions to cancer is influenced by characteristics of the bacterial strain, host genetic and environmental factors. Recently, the effect of medications on gastric cancer risk has gained interest, because many commonly prescribed drugs affect gastric homeostasis. While non-steroidal anti-inflammatory drugs (NSAIDs) are a frequent cause of gastric ulcer disease, low-dose aspirin has been propagated for chemoprevention of various tumour entities. Beneficial effects of cyclooxygenase-inhibition for gastric cancer prevention is plausible, but its clinical relevance remains unclear. Furthermore, anti-tumorous effects have been postulated for statins and metformin. On the contrary, proton pump inhibitors (PPIs), which are commonly used for prevention of gastric ulcers and bleeding, have been associated with an increased gastric cancer risk in large observational studies. Most of these observations still require confirmation in prospective controlled trials. NSAIDs, statins and metformin have also been investigated as concomitant cancer treatment, but studies did not show convincing results to date. Here, we review the available evidence and possible mechanisms for the role of PPIs, NSAIDs, statins and metformin in gastric carcinogenesis, and discuss possible implications for clinical practice.

Determination of Peptide Profile Consistency and Safety of Collagen Hydrolysates as Quality Attributes

Abstract

Collagen hydrolysates are dietary supplements used for nutritional and medical purposes. They are complex mixtures of low‐molecular‐weight peptides obtained from the enzymatic hydrolysis of collagen, which provide intrinsic batch‐to‐batch heterogeneity. In consequence, the quality of these products, which is related to the reproducibility of their mass distribution pattern, should be addressed. Here, we propose an analytical approach to determine the peptide pattern as a quality attribute of Colagenart®, a product containing collagen hydrolysate. In addition, we evaluated the safety by measuring the viability of two cell lines exposed to the product. The consistency of peptide distribution was determined using Size Exclusion Chromatography (SEC), Mass Spectrometry coupled to a reversed phase UPLC system (MS‐RP‐UPLC), and Shaped‐pulse off‐resonance water‐presaturation proton nuclear magnetic resonance spectrometry [¹Hwater_presat NMR]. The mass distribution pattern determined by SEC was in a range from 1.35 to 17 kDa, and from 2 to 14 kDa by MS‐RP‐UPLC. [¹Hwater_presat NMR] showed the detailed spin‐systems of the collagen hydrolysates components by global assignment of backbone Hα and NH, as well as side‐chain proton resonances. Additionally, short‐range intraresidue connectivity pathways of identified spin‐regions were obtained by a 2D homonuclear shift correlation Shaped‐pulse solvent suppression COSY scheme. Safety analysis of Colagenart® was evaluated in CaCo‐2 and HepG2 cells at 2.5 and 25 μg/mL and no negative effects were observed. The results demonstrated batch‐to‐batch reproducibility, which evinces the utility of this approach to establish the consistency of the quality attributes of collagen hydrolysates.

Practical Application

We propose state‐of‐the art analytical methodologies (SEC, MS, and NMR) to evaluate peptide profile and composition of collagen hydrolysates as quality attributes. These methodologies are suitable to be implemented for quality control purposes.

Mechanisms of Damage to the Gastrointestinal Tract From Nonsteroidal Anti-Inflammatory Drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs) can damage the gastrointestinal tract, causing widespread morbidity and mortality. Although mechanisms of damage involve the activities of prostaglandin-endoperoxide synthase 1 (PTGS1 or cyclooxygenase [COX] 1) and PTGS1 (COX2), other factors are involved. We review the mechanisms of gastrointestinal damage induction by NSAIDs via COX-mediated and COX-independent processes. NSAIDs interact with phospholipids and uncouple mitochondrial oxidative phosphorylation, which initiates biochemical changes that impair function of the gastrointestinal barrier. The resulting increase in intestinal permeability leads to low-grade inflammation. NSAID inhibition of COX enzymes, along with luminal aggressors, results in erosions and ulcers, with potential complications of bleeding, protein loss, stricture formation, and perforation. We propose a model for NSAID-induced damage to the gastrointestinal tract that includes these complex, interacting, and inter-dependent factors. This model highlights the obstacles for the development of safer NSAIDs.

Diclofenac toxicity in human intestine ex vivo is not related to the formation of intestinal metabolites

The use of diclofenac (DCF), a nonsteroidal anti-inflammatory drug, is associated with a high prevalence of gastrointestinal side effects. In vivo studies in rodents suggested that reactive metabolites of DCF produced by the liver or the intestine might be responsible for this toxicity. In the present study, precision-cut intestinal slices (PCIS) prepared from the jejunum of 18 human donors were used as an ex vivo model to investigate whether DCF intestinal metabolites are responsible for its intestinal toxicity in man. PCIS were incubated with a concentration range of DCF (0-600 µM) up to 24 h. DCF (≥400 µM) caused direct toxicity to the intestine as demonstrated by ATP depletion, morphological damage, caspase 3 activation, and lactate dehydrogenase leakage. Three main metabolites produced by PCIS (4'-hydroxy DCF, 5-hydroxy DCF, and DCF acyl glucuronide) were detected by HPLC. Protein adducts were detected by immunohistochemical staining and showed correlation with the intestinal metabolites. DCF induced similar toxicity to each of the samples regardless of the variation in metabolism among them. Less metabolites were produced by slices incubated with 400 µM DCF than with 100 µM DCF. The addition of the metabolic inhibitors such as ketoconazole, cimetidine, or borneol decreased the metabolite formation but increased the toxicity. The results suggest that DCF can induce intestinal toxicity in human PCIS directly at therapeutically relevant concentrations, independent of the reactive metabolites 4'-OH DCF, 5-OH DCF, or diclofenac acylglucuronide produced by the liver or formed in the intestine.

Loss of cell polarity protein Lgl2 in foveolar-type gastric dysplasia: correlation with expression of the apical marker aPKC-zeta

Recognition of gastric epithelial dysplasia, although a key to cancer prevention, can be challenging. In this study, we evaluated whether Lgl2 can serve as a marker of gastric foveolar-type dysplasia. Since atypical protein kinase C (aPKC) is a partner of Lgl2 in the control of apical-basal polarity we also investigated whether aPKC-zeta can compliment Lgl2 as a marker of dysplasia. Routinely processed specimens included 64 normal mucosa, 35 reactive gastropathies, 31 chronic gastritides, 65 gastric dysplasias (25 foveolar; 40 adenomatous), and 34 gastric adenocarcinomas. Twenty (80%) foveolar-type dysplasias showed absence of Lgl2 immunoreactivity, while normal basolateral expression of Lgl2 was consistently seen in normal gastric epithelium (n=20) and chronic gastritis (n=22; p<0.00001). Loss of Lgl2 was similar in the groups with low-grade and high-grade foveolar-type dysplasia, 79% and 83%, respectively. Linear apical anti-aPKC-zeta immunoreactivity was consistently present in the normal epithelium and was preserved in 91% of reactive gastropathies and 87% of chronic gastritides. In contrast, loss of apical aPKC-zeta staining was observed in 47% and 65% of low-grade dysplasias of foveolar and adenomatous types, respectively (p<0.005) and in nonsignificantly higher percentage of high-grade dysplasias. Apical aPKC-zeta staining was lost in 97% of gastric adenocarcinomas. Our data suggest a role of Lgl2 immunohistochemistry as an adjunct in the diagnosis of foveolar-type gastric dysplasia. aPKC-zeta had moderate sensitivity as a marker of gastric dysplasia and additional studies are needed to establish its role in the diagnosis of dysplasia.

Pathology of non-Helicobacter pylori gastritis: extending the histopathologic horizons

The development of modern endoscopic techniques, easier and greater access to healthcare, and interest in Helicobacter pylori infection and its implications have all led to a significant increase in upper endoscopies. In turn, gastroenterologists and pathologists have been recognizing an ever-increasing number of patterns of mucosal injury. Consequently, there is now an interest in a wider aspect of non-neoplastic gastric pathology, namely, non-HP (H. pylori) gastritis. In this review, we present major clinico-pathological entities, based on either the salient morphological features or the underlying etiologies.

Cell polarity protein Lgl2 is lost or aberrantly localized in gastric dysplasia and adenocarcinoma: an immunohistochemical study

The diagnosis of gastric epithelial dysplasia, a precursor lesion of gastric adenocarcinoma, is hindered by interobserver variability and by its resemblance to regenerative changes. Loss of cell polarity, a histological feature of gastric epithelial dysplasia, may be difficult to ascertain, especially in the setting of inflammation or injury. A biomarker of cell polarity could be useful in diagnosis of dysplasia, but has not been reported. The Lethal giant larvae (lgl) gene controls apical-basal polarity of epithelial cells in Drosophila, and has properties of a tumor-suppressor gene. Two homologs, lgl1 and lgl2, are present in mammals and lgl2 mRNA is highly expressed in the stomach. The goal of our study was to test the hypothesis that Lgl2 protein expression and/or localization are disrupted in gastric epithelial dysplasia and adenocarcinoma. Routinely processed pathology specimens including 94 benign mucosae of digestive organs, in addition to 36 reactive gastropathy, 57 gastric epithelial dysplasia, and 77 gastric adenocarcinomas, were immunostained for Lgl2 protein. All normal, reactive, and chronically inflamed gastric epithelia showed basolateral Lgl2 staining. Normal esophageal, duodenal, colonic, biliary, and pancreatic duct mucosae, as well as gastric intestinal metaplasia, did not express Lgl2. All but one case each of gastric epithelial dysplasia and adenocarcinoma showed either complete loss of anti-Lgl2 immunoreactivity or diffuse, mostly weak, cytoplasmic staining. Complete loss of immunoreactivity was significantly more often observed in diffuse-type than in intestinal-type adenocarcinomas (79 vs 48%, respectively). Our data suggest that Lgl2 expression is either aberrantly localized or lost in gastric epithelial dysplasia and adenocarcinoma, whereas it is maintained in reactive gastric mucosa. We propose that Lgl2 may be a potential marker to rule out gastric epithelial dysplasia and adenocarcinoma in diagnostic specimens. However, the consistently negative anti-Lgl2 immunoreactivity seen in intestinal metaplasia does not allow differentiation of dysplasia from intestinal metaplasia with reactive change.

Intestinal permeability in the pathogenesis of NSAID-induced enteropathy

BACKGROUND

The pathogenesis of nonsteroidal antiinflammatory drug (NSAID)-induced small bowel disease suggests that increased intestinal permeability is the central mechanism that translates biochemical damage to tissue damage. The purpose of this review is to summarize studies on the effect of NSAIDs to increase intestinal permeability in humans and methods for limiting this effect.

METHODS

A Medline search was made for papers that described measurements of increased intestinal permeability in humans.

RESULTS

Virtually all studies agree that all conventional NSAIDs increase intestinal permeability in the human within 24 h of ingestion and that this is equally evident when they are taken long term. Various methods have been tried to limit the damage. The most promising agents are coadministration of synthetic prostaglandins, micronutrients, pre-NSAIDs, and COX-2 selective agents. However, their efficacy in preventing the development of NSAID enteropathy in the long term has not been studied in detail, and, in the case of COX-2 selective agents, small bowel damage is comparable to that which is seen with conventional NSAIDs.

CONCLUSIONS

NSAID enteropathy is associated with significant morbidity and occasionally mortality. There are no proven effective ways of preventing this damage. Because increased intestinal permeability appears to be a central mechanism in the pathogenesis of NSAID enteropathy, it becomes a potential therapeutic target for prevention. At present there are a number of ways to limit the increased permeability, but additional studies are required to assess if this approach reduces the prevalence and severity of NSAID enteropathy.

Drug-induced injury in the gastrointestinal tract: clinical and pathologic considerations

Drug toxicity in the gastrointestinal tract is a common and serious medical problem; the number of drugs that can harm the gastrointestinal tract is impressive. The morbidity, mortality, and medical costs associated with drug toxicity, even when restricted to the gastrointestinal tract, are probably underestimated. Drug-induced gastrointestinal tract pathology is very diverse and can mimic many non-drug-related conditions. Drug toxicity, whether direct or indirect, can be restricted to a segment of the gastrointestinal tract or affect the entire gastrointestinal tract. The consequences of drug toxicity are also quite variable and can range from unimportant pathology (e.g. the relatively common and usually benign drug-induced diarrhea) at one end of the spectrum, to fatal gastrointestinal tract hemorrhage or perforation at the other end of the spectrum. Better awareness of the possibility of drug-induced gastrointestinal tract pathology, by both gastroenterologists and pathologists, and better communication between gastroenterologists, pathologists and other specialists will improve the recognition of drug-induced gastrointestinal tract pathology, and, ultimately, improve patient care. This Review focuses on the most common and well-described drug-related clinicopathologic conditions of the gastrointestinal tract. Much discussion is, therefore, dedicated to NSAIDs--the most commonly prescribed drugs and consequently the drugs most commonly associated with gastrointestinal tract toxicity.

Mucin expression in reactive gastropathy: an immunohistochemical analysis

CONTEXT

Reactive gastropathy is the second most common diagnosis made on gastric biopsies. Increased epithelial proliferation and modifications of epithelial cytokeratin profile, distinct from those of Helicobacter pylori gastritis, have been previously reported. However, the evaluation of mucins, important components of the protective mucosal mucous layer, has not been reported.

OBJECTIVE

To investigate alterations of membrane and secreted mucins in reactive gastropathy of various etiologies using antibodies against mucin glycoproteins.

DESIGN

Thirty-eight gastric biopsies diagnosed as reactive gastropathy, related to nonsteroidal anti-inflammatory drugs (n = 18) or bile reflux (n = 6) or of indeterminate etiology (n = 14), were evaluated using antibodies to MUC1, MUC5AC, MUC6, and MUC2. All cases were confirmed to be negative for H. pylori. The biopsies were classified in 3 groups based on the severity of cytoarchitectural changes (mild, moderate, and severe). Mucin expression and its distribution were recorded and the results correlated with the cytoarchitectural alterations and etiologies.

RESULTS

Loss of MUC1, either patchy or complete, was noted in 67% of the cases. Aberrant expression of MUC5AC in pyloric glands was observed in 81% of the cases, and aberrant expression of MUC6 in the upper foveolar epithelium was diffusely seen in 14% of the cases. Aberrant expression of MUC2 in non-goblet cells was observed in a single case. Aberrant expression of MUC6 was less extensive in the nonsteroidal anti-inflammatory drugs group than in other 2 groups (P = .03). Concurrently, the diffuse distribution of aberrant MUC6 expression was seen only in the cases of severe gastropathy (P = .09). There was no correlation between modifications in expression of other mucins and either the etiologies or the severity of cytoarchitectural changes.

CONCLUSIONS

Expressions of membrane (MUC1) and secreted (MUC5AC, MUC6) mucins are frequently modified in reactive gastropathy. The alteration of MUC1, which is involved in cell adhesion and polarity, may play a role in the development of the serrated profile of reactive gastropathy. Milder modifications of the secreted mucins may be explained by the reactive/regenerative nature of the process. Importantly, theses changes are different from the increase in MUC6 and reduction of MUC5AC expression reported in H. pylori gastritis, underlying their mechanistic differences. It is worth noting that similar alterations of mucin expression are shared by various etiologies, that is, nonsteroidal anti-inflammatory drugs and bile reflux, consistent with the nonspecific nature of reactive gastropathy.

Pathology of non-infective gastritis

The discovery of Helicobacter pylori and its intimate role in the development of the most common form of chronic gastritis has elicited a much-needed interest in non-neoplastic gastric pathology. This has been paralleled by an increase in upper endoscopic examinations, which allow recognition of novel patterns and distribution of mucosal injury. Numerous attempts at classification have been made, most based on the acuteness or chronicity of gastric mucosal injury. In this review, we will not offer a new classification but present a detailed description of the major clinicopathological entities, based either on the salient morphological features or the underlying aetiologies, i.e. iatrogenic, autoimmune, vascular or idiopathic.

Differential diagnosis of reactive gastropathy

Reactive or chemical gastropathy is the constellation of endoscopic and histological changes caused by chemical injury to the gastric mucosa. Its diagnosis rests on the histopathological demonstration of nonspecific elementary lesions that may occur simultaneously or separately in different degrees and various proportions. These lesions include foveolar hyperplasia, interfoveolar smooth muscle fibers, erosions, edema, and hyperemia, in the absence of significant inflammation. Their respective occurrence in a set of gastric biopsies can be placed on a spectrum of diagnostic certainty that is never absolute because each of such changes can and does occur in other conditions. Although a correlation between histological evidence of chemical gastropathy and clinical manifestations, particularly risk of bleeding, is yet to be documented, reporting the suspicion of drug-induced gastric damage may help clinicians to identify patients that might benefit from change, reduction, or discontinuation of certain medications.

Pathology of drug-associated gastrointestinal disease

A large number of drugs have gastrointestinal side-effects of which diarrhoea or constipation, nausea and vomiting are amongst the commonest. In relatively few are there diagnostic pathological changes and this review draws attention to the most common. Incriminating a drug as a cause of specific pathological changes requires the drug to be associated with the changes, for the latter to resolve when the drug is withdrawn and for them to re-appear when a patient is rechallenged with the drug. Individual histological features such as apoptosis, tissue infiltration by eosinophils and increased intra-epithelial lymphocytes within the gut mucosa can be clues to an iatrogenic aetiology but these are by no means specific. Amongst the few pathognomonic patterns of drug reactions is pseudomembranous colitis and diaphragm disease. These, along with others such as reactive gastritis and the collagenous and lymphocytic forms of microscopic colitis, in which drugs have also been implicated, are described here.

Novel diagnostic method of testing for Helicobacter pylori infection using the rapid leukocyte strip test, Leukostix

BACKGROUND AND AIM

A characteristic of gastric mucosa infected with Helicobacter pylori is infiltration of inflammatory cells, mainly consisting of neutrophils. The present study aimed to detect neutrophils in homogenates of biopsied gastric mucosa semiquantitatively using the rapid leukocyte strip test, Leukostix. The authors then investigated the association of these results with H. pylori status.

METHODS

The authors studied 342 patients undergoing endoscopy. Of these, 160 were treated for eradication of H. pylori infection and were reassessed after treatment. For the definitive diagnosis of H. pylori infection, quantitative culture, the rapid urease test and immunohistostaining were performed. Additionally, serum antibody against H. pylori was determined at the initial examination, and the 13C-urea breath test was performed after treatment. With the use of Leukostix, homogenates of biopsied gastric mucosa were spotted onto strips and judged 2 min later.

RESULTS

There was a significant correlation between the positive reaction of Leukostix and the number of neutrophils in gastric tissues determined by microscopic observation. The sensitivity and specificity of Leukostix at the initial examination were 97.9% and 76.9%, respectively, while those after eradication treatment were 100% and 97.2%, respectively. There was a significant positive correlation between the degree of reaction of Leukostix and the amount of H. pylori determined by quantitative culture.

CONCLUSIONS

The Leukostix test, using biopsied samples of gastric mucosa, was excellent for quantitative determination of neutrophils and useful for diagnosis of H. pylori infection and early assessment of treatment efficacy. Positive gradations of Leukostix results corresponded closely with the amount of H. pylori in gastric tissues.

Atypical histiocytic infiltration simulating diffuse-type carcinoma in a gastric ulcer due to non-steroidal anti-inflammatory drugs

A 83-year old man treated with naproxen during two years was admitted because of hypovolemia and peritoneal irritation. A panendoscopic study was performed and an ulcer localized at the large curvature of the stomach was disclosed. In the gastrectomy specimen the ulcer showed necrosis, edema, fibrosis, chronic inflammatory infiltrate with lymphocytes and plasma cells. Additionally, atypical cells with irregular and hyperchromatic nuclei or vacuolated cytoplasm were seen in the lamina propia and infiltrating the muscular layers; isolated signet-ring-like cells were also seen. Histochemical study with periodic acid-Schiff, mucicarmin, and colloidal stains revealed mucosubstances in these cells. A poorly differentiated carcinoma was initially diagnosed. However, the immunohistochemical study were positive for histiocytic markers (CD-68, S-100 protein) and negative for epithelial markers (cytokeratin; and epithelial membrane antigen). The positivity of mucus stains in the histiocytes could be explained in this case by phagocytosis of mucous substances released from broken hyperplastic glands in the vicinity of the ulcer. To our knowledge, atypical histiocytic infiltration in gastric ulcers has not been previously described; thus, it should be included in the group of gastric carcinoma mimicks.

Gastritis and carditis

Dyspepsia is a common clinical problem. Its causes include peptic ulcer disease, gastroesophageal reflux, and functional (nonulcer) dyspepsia. A detailed clinical description of pain does not reliably differentiate the cause. Approximately 80% of gastroscopies are performed for the investigation of dyspepsia. "Gastritis" is diagnosed endoscopically in 59% of all stomachs, although in only 3% are the changes severe. Pathologic examination of unselected gastric biopsy specimens reveals that abnormalities are present in 62-73%, but there is only a weak correlation between endoscopic and histologic findings. For these reasons, it is recommended that endoscopic examination should always be accompanied by biopsy. Ideally, biopsies should be taken in a systematic fashion to include sampling of antrum and corpus. Recent evidence suggests that gastric infection by Helicobacter pylori initially presents as a superficial gastritis. Later it may become atrophic with development of intestinal metaplasia. The onset of atrophic changes may be related to the duration of infection, the strain of the infecting organism, associated dietary factors, or as-yet undefined host factors related to immunity. Persistent superficial gastritis predisposes to duodenal ulcer and gastric mucosa-associated lymphoid tissue lymphoma. Atrophic gastritis predisposes to gastric ulcer and adenocarcinoma. Evidence is accumulating that in some patients, pernicious anemia may be an end result of H. pylori-induced atrophic gastritis. Reactive gastropathy is a relatively common finding in gastric biopsies; in most instances it is associated with either reflux of duodenal contents or therapy with nonsteroidal anti-inflammatory drugs. Lymphocytic gastritis, eosinophilic gastritis, and the gastritis associated with Crohn's disease are distinct morphologic entities. Lymphocytic gastritis and eosinophilic gastritis have a variety of clinical associations. Carditis is a controversial topic: currently opinions are divided as to whether it is the result of gastroesophageal reflux or a proximal extension of H. pylori infection from the remainder of the stomach.

Chemical gastropathy: a distinct histopathologic entity in children

BACKGROUND

Chemical gastropathy, also known as chemical or reactive gastritis, is a well-described histopathologic entity in adults. It is characterized by presence of foveolar hyperplasia, vascular congestion, lamina propria edema, and prominent smooth muscle fibers in the absence of inflammatory cells in the gastric antral mucosa. There are no data in children on this condition.

METHODS

All children showing features of chemical gastropathy in antral biopsy specimens were identified from pathology database from 1997 to 2000. Antral biopsy specimens were reviewed to assess the diagnosis of chemical gastropathy using standard diagnostic criteria. Charts of the children diagnosed with chemical gastropathy were reviewed for clinical course, endoscopic findings, and risk factors.

RESULTS

Twenty-one children (12 male, 9 female) with chemical gastropathy were identified. Common presenting symptoms were epigastric pain and vomiting. Eleven children were taking multiple medications, including nonsteroidal anti-inflammatory drugs. Endoscopy revealed esophagitis in 12, antral erythema in 7, and thick bile in the stomach in 7 children. Antral histology revealed foveolar hyperplasia in 19, congestion in 20, lamina propria edema and smooth muscle fibers in 16, and absence of inflammation in 19 patients. Acid suppression was the treatment in all patients. Mean follow-up duration was 11 months in 17 children. Symptoms resolved completely in 11 and partially in 6 patients.

CONCLUSIONS

As in adults, chemical gastropathy occurs in children. The factors associated with chemical gastropathy in this survey were gastroesophageal reflux disease and intake of multiple medications, including nonsteroidal anti-inflammatory drugs.

Foveolar hyperplasia at the gastric cardia: prevalence and associations

AIMS

In the gastric antrum and body, foveolar hyperplasia is a feature of reactive gastritis resulting from--for example, duodenogastric bile reflux and the use of non-steroidal anti-inflammatory drugs (NSAIDs). The aim of this study was to examine the occurrence and clinical relevance of gastric cardiac foveolar hyperplasia.

METHODS

The study population was drawn from a consecutive series of 1698 patients sent for upper gastrointestinal endoscopy. Only cases without chronic gastritis or Barrett's oesophagus were included. The final study population consisted of 307 patients.

RESULTS

Foveolar hyperplasia was seen in the gastric cardiac mucosa in 31 (10%) patients with histologically normal stomach mucosa, but none had endoscopically noticeable hyperplastic polyps. Compared with patients without gastric cardiac hyperplasia, those with hyperplasia more often had chronic inflammation and complete intestinal metaplasia in the junctional biopsies (48% v 77% and 9% v 26%, respectively). Logistic regression analysis revealed that chronic cardiac inflammation (odds ratio (OR), 3.2; 95% confidence interval (CI), 1.3 to 7.8) and intestinal metaplasia of the complete type (OR, 2.8; 95% CI, 1.1 to 7.1) were independent risk factors for cardiac foveolar hyperplasia. In univariate analysis, endoscopic erosive oesophagitis (endoscopy positive gastro-oesophageal reflux disease) and the use of NSAIDs were not related to the presence of foveolar hyperplasia.

CONCLUSIONS

Foveolar hyperplasia in the gastric cardiac mucosa occurs in patients with histologically normal non-gastritic stomachs and may develop as a consequence of chronic inflammation limited to the gastro-oesophageal junction ("junctitis"). It is not associated directly with endoscopy positive gastro-oesophageal reflux disease or the use of NSAIDs.

Cytoskeletal and kinetic epithelial differences between NSAID gastropathy and Helicobacter pylori gastritis: an immunohistochemical determination

AIMS

Distinguishing histological features between non-steroidal anti-inflammatory drug (NSAID) gastropathy and Helicobacter pylori gastritis have been accepted. However, the molecular basis explaining these dissimilar histologies has not been elucidated. In an attempt to clarify this question we investigated the differences in the structural cytoskeleton and proliferative activity of these two gastropathies.

METHODS AND RESULTS

We assessed the distribution of five cytokeratins (CK) (CK7, 8, 18, 19 and 20) and Ki67 for the ability to distinguish NSAID from H. pylori gastropathies. In H. pylori gastritis, CK7, 8, 18 and 19 were expressed comparably to normal mucosa from the deep foveolae up to the tips of the glands. The detection of CK20, normally expressed in the upper foveolar region and surface, was decreased with only an epithelial surface reaction. In NSAID gastropathy, CK expression was increased in intensity, with normal distribution for CK8, 18 and 19. Modification of localization was noted for CK7 and 20, with labelling extending toward the deep foveolar region. Unlike H. pylori gastritis, no surface epithelial labelling with Ki67 was noted with NSAID gastropathy but downward elongation of the proliferative zone occurred instead.

CONCLUSIONS

Contrasting cytostructural alterations and distinct proliferative patterns distinguish NSAID gastropathy from H. pylori gastritis, possibly reflecting different injury pathways.

Helicobacter pylori genotypes, host factors, and gastric mucosal histopathology in peptic ulcer disease

From 183 patients undergoing upper gastrointestinal endoscopy, we used antral and corpus gastric biopsies for bacterial culture and histopathologic examination, blood samples to detect immunoglobulin G antibodies against Helicobacter pylori, and H pylori genomic DNA to analyze cytotoxin-associated gene A (cagA) and vacuolating cytotoxin (vacA) genotypes. As expected, among H pylori biopsy-positive patients, those with duodenal ulcer (DU) (n = 34) had significantly more severe chronic and acute inflammation (P <.001) and epithelial degeneration (P =.004) in the gastric antrum than in the gastric corpus. Each of those 3 parameters and H pylori density were significantly higher in the antrum of patients with DU than in patients with gastric ulcer (GU) or no ulcer. Colonization with vacA s1/cagA-positive strains of H pylori was associated with inflammation and epithelial degeneration in gastric mucosa and increased risk for peptic ulcer disease (PUD), whereas colonization with vacA s2m2/cagA-negative strains was associated with mild gastric histopathology and was not associated with any significant risk for PUD. The predominant H pylori strains in African Americans were vacA s1bm1/cagA-positive, whereas all genotypes were well represented in non-Hispanic-Caucasians. By multivariate analysis, H pylori colonization was significantly associated with DU (Adjusted odds ratio [AdjOR] = 3.2 [1.4-7.2]) and nonsteroidal anti-inflammatory drugs (NSAID) use was inversely associated (AdjOR = 0.3 [0.2-0.7]). NSAID use (AdjOR = 4.3 [1.02-18.5]) and African-American ethnicity (AdjOR = 10.9 [2.6-50]) were significantly associated with GU. Smoking and age were not significantly associated with either DU or GU. These data indicate that DU is associated with an antral-dominant gastritis, and H pylori genotype and NSAID use independently contribute to the pathogenesis of PUD. HUM PATHOL 32:264-273. This is a US Government work. There are no restrictions on its use.

Increased prevalence of Helicobacter pylori in patients with diabetes mellitus

BACKGROUND

Whilst upper gastrointestinal disturbances are frequently observed in patients with diabetes mellitus, little is known about the prevalence of Helicobacter pylori infection and peptic disease in these patients.

AIM

To evaluate prevalence of Helicobacter pylori infection and peptic disease lesions in diabetics with dyspeptic symptoms.

PATIENTS AND METHODS

Study population comprises 74 consecutive diabetes mellitus patients with dyspepsia and 117 consecutive non diabetic dyspeptic patients. Upon enrolment, each patient completed an interview screening questionnaire to obtain information concerning presence and severity of dyspepsia. All patients underwent upper gastrointestinal endoscopy with biopsy specimens being collected from gastric antrum and body Helicobacter pylori was evaluated in each patient by rapid urease test and histology (Giemsa). Gastritis was classified according to the Sydney System. Statistical analysis was performed by chi-square, Fisher exact or t test and logistic regression analysis. A p value <0.05 was considered significant.

RESULTS

Prevalence of Helicobacter pylori infection was found to be significantly higher in diabetics than in controls. The prevalence rate of endoscopic lesions was comparable in the two groups, but the association between endoscopic lesions and Helicobacter pylori infection was significantly higher in diabetics. Overall, the presence of chronic gastritis, both non atrophic and atrophic, as well as intestinal metaplasia were comparable in the two groups of patients, whilst the association between chronic gastritis and Helicobacter pylori infection or gastritis activity were significantly higher in diabetics. In neither group, was any correlation found between severity of dyspepsia and presence of endoscopic lesions, chronic gastritis or Helicobacter pylori infection.

CONCLUSIONS

These data show a higher prevalence of Helicobacter pylori infection in diabetes mellitus patients with dyspepsia. Helicobacter pylori infection was significantly associated both with the presence of endoscopic lesions and chronic gastritis in diabetic patients, but not in the controls.

The nonsteroidal anti-inflammatory drugs controversy

The relationship between NSAIDs and H. pylori as risk factors for the development of peptic ulcer is complex and controversial. In the case of duodenal ulcers in NSAID users, there now is enough information to suggest that eradication of H. pylori usually is worthwhile. In the stomach, however, there is some evidence that ulcers heal faster and are no more likely to reappear if the infection is left alone, provided that patients continue to take an NSAID. Why this situation should be so is unclear. Possibilities include greater efficacy of antisecretory agents, a smaller inhibition of prostaglandin production, and a blunted apoptotic response in patients who are infected with H. pylori and take NSAIDs.

The effects of omeprazole on healing and appearance of small gastric and duodenal lesions during dosing with diclofenac in healthy subjects

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are associated with gastrointestinal mucosal damage. Omeprazole prevents the formation, and accelerates the healing, of NSAID-induced ulcers.

AIM

To test whether omeprazole accelerates healing of standardized gastroduodenal lesions in the presence of diclofenac.

METHODS

In a double-blind, double-dummy, placebo-controlled, crossover study, 12 healthy volunteers received consecutive, 2-week courses of omeprazole (40 mg o.d.) and placebo, in random order, with an intervening, 4-week washout period; diclofenac (50 mg t.d.s.), was given for the second week of each course. Five endoscopies were performed, one at the outset and the others before and after each course of diclofenac. Biopsies were taken from the endoscopically normal mucosa of the corpus, antrum and duodenum and also from any new mucosal lesion that developed after diclofenac. The sites of biopsies taken before each course of diclofenac were evaluated endoscopically after each course to assess the extent of healing according to a predetermined healing score scale.

RESULTS

The healing scores observed after administration of placebo/diclofenac (median=0; range 0-6) and after omeprazole/diclofenac (median=0; range 0-6; P=0.17) did not differ. Small gastroduodenal lesions developed de novo in six subjects during placebo/diclofenac and in seven during omeprazole/diclofenac. Focal chemical gastropathy was observed only in close proximity to macroscopic lesions.

CONCLUSIONS

In healthy subjects, omeprazole does not accelerate the healing of pre-existing mucosal lesions or prevent the development of small diclofenac-induced mucosal lesions.

The relation between Helicobacter pylori and nonsteroidal anti-inflammatory drugs

Both infection with Helicobacter pylori and use of nonsteroidal anti-inflammatory drugs (NSAIDs) can result in gastritis and ulcers. H. pylori has been identified as a major etiologic factor in the development of peptic ulcer disease; however, its relationship to NSAID-associated toxicity is less well characterized. Several studies have suggested that NSAID use does not increase susceptibility to H. pylori, and the converse has also been suggested, namely, that H. pylori does not exacerbate NSAID-associated injury. H. pylori itself may stimulate production of gastric prostaglandins, which may have a role in ulcer healing. More carefully controlled studies may be better able to elucidate the individual and synergistic mechanisms involved in ulceration induced by H. pylori and NSAIDs. Recent studies have suggested that elimination of H. pylori before NSAID treatment decreases ulcer occurrence. Therefore, at this time, eradication of H. pylori should be considered only in certain high-risk patients, i.e., those with a history of gastroduodenal ulcers.

Histology of the stomach and duodenum in Crohn's disease

Crohn's disease (CD) not uncommonly affects the stomach and duodenum, but its histologic appearance is not well described beyond the identification of granulomas. We retrospectively identified 209 upper gastrointestinal biopsy samples from 80 sets of biopsies from 49 patients with CD. Age- and sex-matched control biopsies were selected from recent cases of Helicobacter pylori gastritis (73 biopsy samples from 34 patients), from patients with a known history of nonsteroidal antiinflammatory drug use (18 biopsy samples from 12 patients), and from three patients with ulcerative colitis. Architectural and inflammatory changes were evaluated and compared. Over three fourths of the patients with CD had abnormal biopsy results. Fifty-six percent of patients with CD had acute inflammation, but only 10% of the patients were infected with H pylori. Focal acute inflammation was a characteristic of H pylori-negative CD (stomach, 31%; duodenum, 40%), which was much less common in the non-CD group (stomach, 2%; duodenum, 8%). Surface intraepithelial neutrophils of the duodenum were more common in H pylori-negative patients with CD (25%) than in those who did not have CD (4%), and deep acute inflammation of the duodenum was more likely in H pylori-negative patients with CD (19% vs. 0%). Granulomas were found in only 9% of the CD group. Focal acute inflammation of the gastroduodenum, especially in a background of noninflamed mucosa, is strong evidence for CD in the appropriate clinical context, but the stomach and duodenum must be properly sampled and carefully examined for any evidence of H pylori.

Relationship between nonsteroidal anti-inflammatory drug use, Helicobacter pylori, and gastroduodenal mucosal injury

With the realization that Helicobacter pylori is the main etiologic factor for peptic ulcer disease, recent studies have explored a potential relationship between H. pylori and nonsteroidal anti-inflammatory drug (NSAID)-related gastroduodenal mucosal injury. Using serology and/or histology to detect H. pylori, case-control studies have shown no meaningful differences in H. pylori prevalence in both arthritis and nonarthritis NSAID users and controls. Placebo-controlled short-term trials of NSAIDs have also shown no change in the frequency of detection of H. pylori by gastric mucosal biopsy specimens after 7-30 days of NSAID ingestion. A number of studies have shown that the histological gastritis identified in NSAID users is caused by H. pylori infection, whereas the reactive (chemical) gastritis can be caused by NSAID use. Although the overall relationship between H. pylori gastritis and dyspepsia remains controversial, there is no evidence from well-controlled studies using either serology or histology that this gastritis predisposes to NSAID-related dyspepsia. The effect of H. pylori on NSAID-related gastroduodenal mucosal injury may be best established by evaluating the ulcer recurrence rate after H. pylori eradication and rechallenge with NSAIDs. To date, only one such study has examined this question, and in this small study, the ulcer recurrence rate at 6 months was not reduced by H. pylori eradication.

Histological features do not define NSAID-induced gastritis

Nonsteroidal anti-inflammatory drug (NSAID) use is a common cause of peptic ulcer. This study investigated the nature, frequency, and topographic distribution of histological abnormalities of the gastric mucosa associated with chronic NSAID use. A set of 3 to 11 mapped gastric biopsy specimens were obtained from 108 chronic users of NSAIDs and 61 controls. Each specimen was graded from 0 to 3 for each of the following features: foveolar hyperplasia, smooth muscle fibers, edema, neutrophils, intestinal metaplasia, eosinophils, mononuclear cells, mucosal hemorrhage, atrophy, and Helicobacter pylori. We found that foveolar hyperplasia, considered one of the characteristic features of chemical gastropathy, was absent in 66% of NSAID users. Foveolar hyperplasia was present in 37 NSAID users (34%) and in 10 controls (18%); prominent smooth muscle fibers were found in 51 NSAID users (47%) and 10 of the controls (16%). Concurrent H pylori gastritis obscured the histopathologic changes of NSAID use. All other parameters, including H pylori infection rate (57% v 51%) were similar in NSAID users and controls. We conclude that the histological features characteristic of NSAID users were present only in a subset of patients. No single histological feature can be used to characterize or diagnose chemical gastropathy and no simple set of diagnostic criteria can be applied for this purpose.

Classification and grading of gastritis. The updated Sydney System. International Workshop on the Histopathology of Gastritis, Houston 1994

The Sydney System for the classification of gastritis emphasized the importance of combining topographical, morphological, and etiological information into a schema that would help to generate reproducible and clinically useful diagnoses. To reappraise the Sydney System 4 years after its introduction, a group of gastrointestinal pathologists from various parts of the world met in Houston, Texas, in September 1994. The aims of the workshop were (a) to establish an agreed terminology of gastritis; (b) to identify, define, and attempt to resolve some of the problems associated with the Sydney System. This article introduces the Sydney System as it was revised at the Houston Gastritis Workshop and represents the consensus of the participants. Overall, the principles and grading of the Sydney System were only slightly modified, the grading being aided by the provision of a visual analogue scale. The terminology of the final classification has been improved to emphasize the distinction between the atrophic and nonatrophic stomach; the names used for each entity were selected because they are generally acceptable to both pathologists and gastroenterologists. In addition to the main categories and atrophic and nonatrophic gastritis, the special or distinctive forms are described and their respective diagnostic criteria are provided. The article includes practical guidelines for optimal biopsy sampling of the stomach, for the use of the visual analogue scales for grading the histopathologic features, and for the formulation of a comprehensive standardized diagnosis. A glossary of gastritis-related terms as used in this article is provided.

Growth markers in the human gastric mucosa during adaptation to continued aspirin administration

The mechanism of gastric mucosal adaptation to continued aspirin (ASA) administration is unknown. We have investigated growth and proliferation markers in healthy subjects under prolonged ASA treatment. In eight healthy volunteers, ASA treatment (2 g/day) was continued for 14 days. Endoscopy was performed before medication; at days 3, 7, and 14 of ASA treatment; and at days 16 and 18 (2 and 4 days, respectively, after medication was ceased). Gastric biopsies from oxyntic and antral mucosa were studied by histology and by histochemistry for proliferating cell nuclear antigen (PCNA), epidermal growth factor (EGF), transforming growth factor-alpha (TGF-alpha), and epidermal growth factor receptor (EGFr). ASA treatment did not change the expression of EGF and EGFr significantly. The PCNA index showed local inconsistent variations. However, increased TGF-alpha expression after ASA was noted, particularly in hyperplastic surface epithelium. Edema and teleangiectases were common in gastric mucosa after ASA. An increasing incidence of foveolar hyperplasia was also noted in the antral mucosa. Healthy subjects on prolonged ASA treatment gradually develop parameters of chronic reactive gastritis accompanied by increased TGF-alpha expression in gastric surface epithelial cells, especially in hyperplastic areas.

Effect of longterm misoprostol coadministration with non-steroidal anti-inflammatory drugs: a histological study

Prostaglandins are widely used in the prevention and healing of non-steroidal anti-inflammatory drug (NSAID) induced gastric and duodenal ulcers, but their longterm effect on the human gastric mucosa is unknown. This study assessed the effect of coadministration of prostaglandins with NSAIDs on the histology of the gastroduodenal mucosa. Histological appearances (using the Sydney system) of gastric biopsy specimens from 180 patients receiving longterm NSAID treatment of whom 90 had been receiving misoprostol (400-800 micrograms/day) for one to two years were studied. Both groups of patients were comparable with regard to clinical and demographic details. There was no significant difference (p > 0.1) in the prevalence of chronic gastritis (total, corpus or antrum only) between patients receiving (36 of 90 (40%)) or not receiving misoprostol (35 of 90 (39%)). Chronic gastritis was equally associated with the presence of Helicobacter pylori, 86% and 73% (p > 0.1), respectively, in the two groups. Significantly fewer patients receiving misoprostol had reactive gastritis than those receiving only NSAIDs (8 (9%) versus 27 (30%), p < 0.01). Reactive gastritis was not associated with H pylori. Thirty nine (43%) of the misoprostol treated patients had normal histology compared with 16 (18%) receiving only NSAIDs (p < 0.01). These results show two different patterns of gastric damage in patients receiving NSAIDs, namely chronic and reactive gastritis. Misoprostol treatment was associated with a significantly reduced prevalence of reactive gastritis and it is suggested that this, along with its antisecretory action, may explain the reduced prevalence of gastroduodenal lesions when coadministered with NSAIDs.

Histological findings in gastric mucosa in patients treated with non-steroidal anti-inflammatory drugs

AIMS

To identify distinguishing and general histological features related to the use of non-steroidal anti-inflammatory drugs (NSAID).

METHODS

Slides from gastric antral biopsies of 50 patients with osteoarthritis taking NSAID were compared with slides from antral biopsies of 50 control cases matched for age, sex, and race. Semithin sections stained with toluidine blue were used.

RESULTS

Chronic gastritis was seen in 76% of the patients taking NSAID and in 58% of the control cases; active inflammation was detected in 10% of the NSAID treated patients and in 24% of the control cases, and it appeared closely related with Helicobacter pylori infection. Some histological features common to all slides of patients taking NSAID were recognised. These consisted of focal erosions of the gastric epithelium and macroerosions, and they seemed to represent successive steps of a process of "desquamation".

CONCLUSIONS

Some distinguishing morphological aspects appeared prominent; it is suggested that these may be related to the pathogenesis of NSAID linked peptic ulceration. On the other hand, epithelial damage due to NSAID appears very different from that due to Helicobacter pylori, another important factor involved in the aetiopathogenesis of peptic disease.

Histopathology of gastroduodenal inflammation: the impact of Helicobacter pylori

In this article the histological features of acute and chronic gastritis are reviewed. The histopathological gastric biopsy report can now encompass an aetiological, topographical (when antrum and corpus are sampled) and morphological comment on the gastric mucosa. The degree of detail included in the report (e.g. grading of the severity of inflammation, atrophy, density of Helicobacter pylori) will vary according to local requirement. However, the distinct recognisable patterns of inflammation categorised in the Sydney system provide a common terminology for a succinct diagnosis. The overall condition of the patient's gastric mucosa assigns him/her to one of the H. pylori-positive or negative categories of chronic gastritis. This may not only have relevance to current clinical management, but may be a valuable record if the patient returns with dyspeptic symptoms in the future. For example, duodenal ulcers are unlikely to develop except in patients with antrum predominant H. pylori-associated gastritis. Knowledge of the natural history of different types of gastritis is rapidly evolving, and the biopsy provides a permanent 'snapshot' of the state of the gastric mucosa at the time of the endoscopy.

Chemical gastritis induced by naproxen in the absence of Helicobacter pylori infection

AIM

To evaluate the histological changes that occur in the antral mucosa of healthy male subjects before and after one week of naproxen administration, using a chemical gastritis score according to the Helicobacter pylori status.

METHODS

Nineteen male subjects (mean age 31 years) underwent two endoscopies: one before and the other after one week of naproxen treatment (1 g daily). Antral biopsy specimens were assessed for the presence of H pylori infection and for chemical gastritis, defined as the presence of foveolar hyperplasia, muscle fibres in the lamina propria, oedema, and vasodilatation, in the absence of acute or chronic inflammatory cell infiltrate.

RESULTS

Of the 19 subjects, eight had H pylori infection. After one week of naproxen treatment, none of those with H pylori infection developed chemical gastritis, while five of 11 (45%) of those without H pylori infection did. In the absence of H pylori infection there was no evidence of inflammation, either before or after naproxen administration.

CONCLUSIONS

A different pattern of antral histological change occurs following naproxen administration. This pattern is related to the presence or absence of H pylori infection, suggesting that H pylori status should be determined in histological studies of subjects taking non-steroidal anti-inflammatory drugs.

Helicobacter pylori infection increases following cholecystectomy

Cholecystectomy is frequently linked with duodenogastric reflux and gastritis but its effect on Helicobacter Pylori (H pylori) infection has not been examined. In a prospective study, twenty two patients with documented cholelithiasis underwent upper gastrointestinal endoscopy and biopsy and 24hr dual channel pH monitoring prior to cholecystectomy and again at 3-6 months post-operatively. The antral biopsies were histologically assessed for H pylori and gastritis and awarded an alkaline reflux score. The number of patients with H pylori infection increased from 7 (32%) preoperatively to 15 (68%) post-cholecystectomy (p < 0.05). Cholecystectomy was also associated with an increase in the incidence of gastritis from 7 to 15 (p < 0.05). The increase in H pylori infection rate occurred in association with an increase in the percentage time gastric pH > 4 in the supine position, from 9.6 (2.2) to 22.2 (4.8) percent, (p < 0.01). The median chemical gastritis score, however, did not change significantly following surgery [8(3-11) vs 7(3-11)]. Seven patients remained symptomatic following cholecystectomy all of whom were H pylori positive and had gastritis. H pylori can survive in the alkaline environment which follows cholecystectomy and may contribute to the post-cholecystectomy syndrome.