Increased local synthesis of epidermal growth factors in infantile hypertrophic pyloric stenosis

New insights into the pathogenesis of infantile pyloric stenosis

Infantile hypertrophic pyloric stenosis (IHPS) is the most common surgical cause of vomiting in infants. Despite numerous hypotheses, the aetiopathogenesis of IHPS is not fully understood. Genetic, extrinsic and hormonal factors have been implicated in the pathogenesis of the disease. Furthermore, abnormalities of various components of the pyloric muscle such as smooth muscle cells, growth factors, extracellular matrix elements, nerve and ganglion cells, synapses, nerve supporting cells, neurotransmitters and interstitial cells of Cajal have been reported. Recently, genetic studies have identified susceptibility loci for IHPS and molecular studies have concluded that smooth muscle cells are not properly innervated in IHPS.

Pyloric stenosis in in vitro fertilized triplets--is it a coincidence?

Infantile hypertrophic pyloric stenosis was previously reported in multiple births, but there were only 3 triplets in the literature and all were naturally conceived. Assisted reproductive technologies, such as in vitro fertilization, are accused for increasing the risk for some anomalies in children. Triplets of in vitro fertilization, all of whom were operated on because of pyloric stenosis, are presented.

Estrous cycle specific immunolocalization of different domains of the epidermal growth factor receptor in the porcine oviduct

Although porcine uterus is known to contain active and inactive forms of epidermal growth factor receptor (EGF-R), the latter consist of the extracellular domain only; it is currently unknown whether different EGF-R isoforms are expressed in the porcine oviduct during estrous cycle. Therefore, we used two different monoclonal antibodies, one against the extracellular and the other against the cytoplasmic domain of the EGF-R, to investigate cycle-dependent and cell-type-specific expression of full-size and truncated receptor forms. At metestrus, the majority of epithelial cells of the oviduct were strongly immunopositive for both antibodies, indicating the presence of the full-size receptor. In diestrous and proestrous stages, we found a low level of cytoplasmic but no extracellular EGF-R staining in epithelial cells. While the staining intensity of cytoplasmic domain of the EGF-R was only faint or absent in muscular tissue and blood vessels throughout the estrous cycle, extracellular domain of the EGF-R exhibited a strong immunostaining of smooth muscle cells and vascular smooth muscle cells, especially in diestrous and proestrous stages. There was no significant difference between the oviductal ampulla and isthmus in either the intensity or the pattern of both cytoplasmic and extracellular EGF-R immunostaining. We conclude that the restricted presence of the functional full-size receptor to the epithelial layer indicates a specific role during early embryonic development, whereas truncated EGF-R forms may potentially regulate contractions and blood flow in the oviduct.

The pylorus

The pylorus controls the flow between a reservoir dedicated to mechanical and chemical digestion (the stomach) and a conduit dedicated to the absorption of nutrients (the intestines). The pylorus adjusts gastric outflow resistance to physiological needs. It allows the outflow of isotonic fluids yet selectively retains particles too large for delivery to the intestines and in concert with the antrum further processes them (gastric sieving). Unlike most gut sphincters, the pylorus, at least of man, maintains a patent lumen most of the time. It only intermittently becomes a tightly closed barrier that arrests all flow out of and into the stomach. The geometry of the pylorus changes dramatically from the relaxed open state to closure. Pyloric closure involves contraction of its proximal and distal muscle loops, and occlusion of its lumen by mucosal folds. Current studies that combine pressure recordings with imaging by magnetic resonance imaging or ultrasound and fluid-mechanical analysis shed new light on the role of the pylorus in gastric emptying and digestion. Much has been learned in recent years on the innervation of the normal pylorus particularly from studies on infantile hypertrophic stenosis, and attempts are being made to treat gastroparesis by interventions on the pylorus.

The association of erythromycin and infantile hypertrophic pyloric stenosis: causal or coincidental?

The safety profile of erythromycin is notable for the frequent occurrence of intolerable gastrointestinal effects. One of the more serious of these is infantile hypertrophic pyloric stenosis (IHPS). A recent cluster of IHPS cases prompted an epidemiological investigation which identified oral erythromycin chemoprophylaxis of pertussis as the major risk factor. Evidence suggests an association between early postnatal erythromycin exposure and IHPS. There is no substantive evidence of a risk associated with prenatal exposure, with the single published case-control study to date producing negative findings. The epidemiological investigations of the association with early postnatal exposure have reported significantly elevated odds ratios but have a variety of methodological limitations that prevent definitive conclusions being made. Nevertheless, the concordance of findings across studies increases the strength of evidence favouring an association. The prominent gastrokinetic properties of erythromycin have been postulated as the mechanism behind this phenomenon. A comprehensive assessment of this potential adverse effect should consider its biological plausibility in light of known gastrointestinal physiology, its modulation by erythromycin, and the known pathophysiology of IHPS. Gastrointestinal motor activity in the fasted mammal consists of three phases, phase III being large amplitude contractions called migrating motor complexes (MMC) that can be initiated by motilin and erythromycin. The gastrokinetic effects of erythromycin are variable and complex and include effects on the timing, duration, amplitude and distribution of MMCs. It has been speculated that the motilinomimetic effects of erythromycin on antral smooth muscle function, such as the MMC, may mediate the effect via work hypertrophy. Although intuitively plausible and consistent with hypertrophic obstructive changes similar to IHPS observed in hyperplastic rat ileum after artificially induced mechanical obstruction, there is no direct evidence of this phenomenon. Further complicating the association is the limitations of our knowledge about the pathophysiology of IHPS, including numerous genetic abnormalities, increased parietal cell mass, and gastric hyperacidity. The implications of the reported findings with erythromycin on the benefit-risk profiles of newer macrolides and azalides must be considered. The available data on the comparative gastrokinetic properties of macrolides are significant for the potent gastrokinetic properties and its acid degradation products, the marked variation in gastrokinetic properties associated with macrolide ring size, and the requirement for specific glycosidic linkages at the C-3 and C-5 carbons of the macrolide ring. The variation in gastrokinetic properties associated with variations in molecular structure suggests that if the association between erythromycin and IHPS is causal it may not be a class effect.

EGF family ligand-dependent phenotypic modulation of smooth muscle cells through EGF receptor

The phenotypic modulation of smooth muscle cells (SMCs) is closely associated with the development and progression of various SMC diseases. We investigated the molecular mechanism of phenotypic modulation triggered by EGF family ligands using a primary culture system of differentiated SMCs. Among four EGF-receptor (EGFR) family members, the EGFR was solely activated by EGF, heparin-binding EGF (HB-EGF), transforming growth factor alpha (TGF alpha), epiregulin (ER), and betacellulin (BTC), resulting in induction of phenotypic modulation of SMCs. This effect was mediated through the coordinated activation of the extracellular signal-regulated kinase (ERK) and p38 mitogen-activated protein kinase (p38MAPK) pathways. These results suggest that EGF family ligand- and EGFR-triggered signaling pathways are critically involved in the phenotypic modulation of SMCs.

Gastroduodenal disorders in children

Studies within the past year examining the mechanisms underlying infantile hypertrophic stenosis at the cellular and molecular level are reviewed. A number of new modalities, including electrogastrography, and the 13C octanoid acid breath test have been used in the study of normal and abnormal gastrointestinal motility, as well as for the characterization of patterns of development of gastric motility in early infancy. Several studies pertaining to the natural outcome, the mode of transmission, and the associated symptomatology of Helicobacter pylori were published, attesting that, despite the tremendous progress achieved in our understanding of H. pylori, important gaps remain in our knowledge of this microorganism. Newly described clinical presentations of eosinophilic gastroenteritis and food allergy will also be of interest to the reader.