Normal values in ambulatory oesophageal pH monitoring at two levels in Spain

AIM

Upper oesophageal pH monitoring may play a significant role in the study of extra-oesophageal GERD, but limited normal data are available to date. Our aim was to develop a large series of normal values of proximal oesophageal acidification.

METHODS

155 healthy volunteers (74 male) participated in a multi-centre national study including oesophageal manometry and 24 hours oesophageal pH monitoring using two electrodes individually located 5 cm above the LOS and 3 cm below the UOS.

RESULTS

130 participants with normal manometry completed all the study. Twelve of them were excluded for inadequate pH tests. Twenty-seven subjects had abnormal conventional pH. The remaining 91 subjects (37 M; 18-72 yrs age range) formed the reference group for normality. At the level of the upper oesophagus, the 95th percentile of the total number of reflux events was 30, after eliminating the meal periods 22, and after eliminating also the pseudo-reflux events 18. Duration of the longest episodes was 5, 4 and 4 min, respectively (3.5 min in upright and 0.5 min in supine). The upper limit for the percentage of acid exposure time was 1.35, 1.05 and 0.95%, respectively. No reflux events were recorded in the upper oesophagus in 8 cases.

CONCLUSION

This is the largest series of normal values of proximal oesophageal reflux that confirm the existence of acid reflux at that level in healthy subjects, in small quantity and unrelated to age or gender. Our data support the convenience of excluding pseudo-reflux events and meal periods from analysis.

Effects of long-term cyclo-oxygenase 2 selective and acid inhibition on Barrett's oesophagus

BACKGROUND

There is an overexpression of cyclo-oxygenase 2 (COX-2) in Barrett's oesophagus (BO).

AIM

To determine the long-term effect of a COX-2 inhibitor on cellular mechanisms involved in BO.

METHODS

A randomized controlled trial was conducted in BO patients allocated to continue the usual proton pump inhibitor (PPI) alone treatment, or PPI combined with rofecoxib (25 mg/day) for 6 months. Cell proliferation index and COX-2 expression in BO glands was determined in biopsy specimens at baseline and after treatment. Cell apoptosis, cyclin D1, p53 and vascular endothelial growth factor (VEGF) expression was also explored in a subset of patients. Student-t test and the U-Mann-Whitney test were used for quantitative and ordinal variables.

RESULTS

Of 62 patients, 58 completed the study. A higher proportion of patients on rofecoxib + PPI exhibited a decrease in COX-2 expression compared to those treated with PPI alone, but cell proliferation index was not affected. Unlike PPI alone, rofecoxib + PPI was associated with an increase in the apoptotic cell index, a decrease in p53 cell staining and VEGF expression in mucosal vessels. No effect on low-grade dysplasia or cyclin D1 was observed.

CONCLUSIONS

The addition of rofecoxib to PPI therapy does not affect cell proliferation index in BO cells after 6 months of therapy, but does reduce COX-2 and VEGF expression and increases cell apoptosis.

TGFB1 gene polymorphisms: their relevance in the susceptibility to Helicobacter pylori-related diseases

Recent studies have revealed elevated expression of transforming growth factor beta1 (TGF-beta1) in gastric mucosa of patients with gastric cancer (GC) and those undergoing ulcer repair. As production of TGF-beta1 is genetically regulated, we aimed to assess whether functional polymorphisms of the TGFB1 gene are involved in susceptibility to and clinical characteristics of Helicobacter pylori-related diseases. DNA from 142 unrelated Spanish patients with GC, 200 with peptic ulcer and 342 healthy controls was typed for the MspA1I T+869C, and the Sau96I G+915C polymorphisms of the TGFB1 gene using polymerase chain reaction and RFLP analysis. H. pylori infection and CagA/VacA antibody status were determined by Western blot in patients and controls. H. pylori infection (odds ratio (OR): 11.44; 95% confidence interval (CI): 4.45-29.42; P<0.001) and non-steroidal anti-inflammatory drugs (OR: 5.07; 95% CI: 2.53-10.16; P<0.001) were identified as independent risks factors for duodenal ulcer (DU), whereas the TGFB1+869(*)C/C genotype was associated with reduced risk of developing the disease (OR: 0.32; 95% CI=0.15-0.68; P=0.003). Our results show that the TGFB1 T+869C gene polymorphism is involved in the susceptibility to DU and provide further evidence that host genetic factors play a key role in the pathogenesis of H. pylori-related diseases.

Effect of exogenous administration of transforming growth factor-beta and famotidine on the healing of duodenal ulcer under the impact of indomethacin

BACKGROUND

Non-steroidal anti-inflammatory drugs delay ulcer healing and cause refractory peptic ulcers in humans.

OBJECTIVE

To study the effects of growth factors on experimental duodenal ulcer healing in indomethacin-treated rats.

METHODS

Duodenal ulcers were induced in male Wistar rats by the serosal application of 75% acetic acid for 10 s. Rats were then treated with indomethacin (2 mg/kg/day; s.c.), transforming growth factor beta (15 ng locally injected subserosally at the ulcer site) or famotidine (5 mg/kg/day; p.o.), vehicle or combinations of treatments. On day 5, 8 or 12, rats were sacrificed and the ulcer area planimetrically measured under a dissecting microscope. Macroscopic area, microscopic diameter, collagen content and mucosal regeneration were assessed in histological preparations. Gastric secretion was assessed also in the pylorus-ligated rat-model. Data expressed as median and ranges were analyzed by non-parametric test.

RESULTS

Indomethacin delayed ulcer healing but transforming growth factor-beta and famotidine improved ulcer healing and reversed the effects of indomethacin. Maximal differences were observed on day 8. Transforming growth factor-beta was associated with an increase in epithelial and granulation tissue cell proliferation. Famotidine induced a profound inhibition of gastric secretion and increased collagen secretion but it did not affect cell proliferation.

CONCLUSIONS

Transforming growth factor-beta and famotidine accelerate ulcer healing delayed by indomethacin.

[Peripheral neuropathy associated with intestinal inflammatory disease]

The association of outlying peripheral neuropathy and inflammatory bowel disease is a rare fact leaving aside factors like the deficit of intestinal absorption of vitamins or the neurotoxicity of drugs employed for the treatment of the inflammatory bowel disease. We presented a series of four patients with this association, to whom a retrospective study was carried out. In all cases polineuropathy followed a course parallel to the inflammatory bowel disease, being acute and reversible in two cases. The polyneuropathy could be attributed to a deficit of vitamin B12 in one case and to metronidazole neurotoxicity in the other; in the remaining two cases the polineuropathy was chronic and no etiological factor could be found except for the own activity of the inflammatory bowel disease. We think that the neuropathy can represent a rare extraintestinal manifestation of the illness with a common autoimmune pathogenic mechanism. In one of our cases, the nerve biopsy demonstrated an axonal neuropathy with an alteration of the epineural vessels which showed a healed aspect.

Esophageal motility and intraesophageal pH patterns in patients with esophagitis and chronic nonsteroidal anti-inflammatory drug use

Clinical reports suggest that nonsteroidal anti-inflammatory drugs (NSAIDs) use might induce esophageal symptoms and damage, including esophagitis, but experimental data are conflicting, and some indicate that NSAIDs improve mucosal damage. It is not known whether patients with endoscopically diagnosed esophagitis during NSAID use have different baseline reflux patterns from patients with reflux esophagitis and no NSAID use. Two groups of patients with and without chronic NSAID use and esophagitis were prospectively studied. Twenty-four-hour pH monitoring and esophageal manometry were performed in all patients who were free of NSAID and any other drug use during tests. Esophageal motility and reflux patterns did not differ in patients with esophagitis regardless of the presence or absence of NSAID use. However, the subgroup of patients with grades II and III esophagitis and chronic NSAID use had a significantly greater lower esophageal sphincter (LES) pressure and a less severe intraesophageal pH profile than patients without NSAID use. In agreement with clinical reports, these results suggest that NSAID use may aggravate an otherwise milder acid-related esophageal disease in a subgroup of patients.

[Deficiency polyneuropathy secondary to immunoproliferative disease of the small intestine]

We report a new case of immunoproliferative small intestinal disease with neurological involvement expressed as deficiency polyneuropathy. In spite of non identifiable plasmatic paraprotein, the use of immunohistochemical techniques showed the characteristic proliferation in the intestinal mucosa of plasma cells with a prevalence of IgA cells, which define this disease.

[Gastric emptying of solids, acid secretion and tobacco in duodenal ulcer]

We study in a group of patients with endoscopically diagnosed duodenal ulcer (19; 17 males) and controls (11; 7 males) the gastric emptying of solids through scintigraphy and gastric acid secretion by standard tests. In the same way we investigated prospectively some clinical data, specially smoking habits. As a whole, patients with duodenal ulcer showed an emptying of solids slightly faster than controls (T 1/2-minutes-: 85.4 +/- 28.6 in patients with duodenal ulcer versus 116.9 +/- 46.5 in controls, p less than 0.03). However, most of our patients (15 of 19 or 79%) were found to have a normal emptying rate. No correlation was found between secretory outputs and gastric emptying. Smokers with duodenal ulcer had a faster emptying that non-smokers with duodenal ulcer (T 1/2 74.8 +/- 30.05 vs. 99.91 +/- 19.86; p = 0.05).

[Gammagraphy with labeled leukocytes as an activity and extension index of Crohn disease]

The knowledge of the location and extent of bowel involment and disease activity can be an important aspect on the evaluation of inflammatory bowel disease. Thirty five patients of Crohn's disease (CD) have been studied in this sense. We performed a total of 44 scintigraphic examinations using 99mTc-HMPAO labeled leukocytes and the results were compared with several clinical-biological indexes and with radiology and endoscopy. The Tc scan was the most sensitive (84.3%) and specific (100%) activity index and showed an excellent correlation with radiology and/or endoscopy in the assessment of extent of disease. Leukocyte scanning brought useful information for the management of stenosis in CD.

[The epidemiological aspects of Crohn's disease in Zaragoza]

Crohn's disease (CD) incidence is characterized by a wide variability in different countries. In our area it hasn't developed yet any epidemiologic study about this disease. We have reviewed fifty-four new cases diagnosed in Zaragoza University Clinical Hospital (Spain) during the period 1974-1988. The most striking facts were that the incidence of Crohn's Disease increased steadily during the 15-year period studied and the existence of a statistical association between smoking and CD. Other features were similar those previously described in the literature.