Jan B.M.J. Jansen

Atrophic Gastritis and Helicobacter pylori Infection in Patients with Reflux Esophagitis Treated with Omeprazole or Fundoplication

BACKGROUND Helicobacter pylori infection plays an important part in the development of atrophic gastritis and intestinal metaplasia, conditions that predispose patients gastric cancer. Profound suppression of gastric acid is associated with increased severity of gastritis caused by H. pylori, but it is not known whether acid suppression increases the risk of atrophic gastritis. METHODS We studied patients from two separate cohorts who were being treated for reflux esophagitis: 72 patients treated with fundoplication in Sweden and 105 treated with omeprazole (20 to 40 mg once daily) in the Netherlands. In both cohorts, the patients were followed for an average of five years (range, three to eight). After fundoplication, the patients did not receive acid-suppressive therapy. The presence of H. pylori was assessed at the first visit by histologic evaluation in the fundoplication group and by histologic and serologic evaluation in the omeprazole group. The patients were not treated for H. pylori infection. Before treatment and during follow-up, the patients underwent repeated gastroscopy, with biopsy sampling for histologic evaluation. RESULTS Among the patients treated with fundoplication, atrophic gastritis did not develop in any of the 31 who were infected with H. pylori at base line or the 41 who were not infected; 1 patient infected with H. pylori had atrophic gastritis before treatment that persisted after treatment. Among the patients treated with omeprazole, none of whom had atrophic gastritis at base line, atrophic gastritis developed in 18 of the 59 infected with H. pylori(P<0.001) and 2 of the 46 who were not infected (P=0.62). CONCLUSIONS Patients with reflux esophagitis and H. pylori infection who are treated with omeprazole are at increased risk of atrophic gastritis.

Long-Term Treatment with Omeprazole for Refractory Reflux Esophagitis: Efficacy and Safety

Omeprazole, a substituted benzimidazole, diminishes gastric acid secretion profoundly and continuously by selectively inhibiting the proton pump (H+/KATPase) in the secretory membrane of the parietal cell [1]. In several studies, omeprazole, in doses ranging from 20 to 60 mg/d, was found to be superior to 150 to 300 mg of ranitidine twice daily [2-8] and to 400 mg of cimetidine once daily [9] in the short-term treatment of reflux esophagitis. However, after therapy was stopped, reflux esophagitis rapidly recurred in most cases [5, 6]. The primary advantage of proton pump inhibitors over all other antireflux therapies is their specific efficacy in patients with severe, refractory reflux disease, nonhealing Barrett ulcers, or peptic strictures [10-22]. Omeprazole is approved only for short-term use in the United States but is approved in other countries, such as the Netherlands, United Kingdom, Belgium, and Brasil, for long-term treatment of reflux esophagitis. Most clinical experience has been gained outside rigorously controlled clinical trials. In the Netherlands, a protocol of omeprazole to treat patients with refractory reflux disease was started in 1985. We report the results of omeprazole to treat patients for as long as 64 months. Methods Patients This open, compassionate-use study started in November 1985; our analysis includes all data collected to March 1991. It was conducted in 7 referral centers in the Netherlands. From November 1985 to January 1989, all patients with erosive reflux esophagitis diagnosed with endoscopy and no response to treatment with H2-receptor antagonists (cimetidine, 800 to 2000 mg/d; ranitidine, 600 to 900 mg/d; or famotidine, 80 to 120 mg/d) for at least 3 months before the start of the study were selected for the study. All eligible patients (n = 91) participated. Pre-entry severity of esophagitis was classified endoscopically as grade II (noncircumferential erosions), grade III (circumferential erosions or ulceration), or grade IV (erosions, ulceration plus deep ulcer or stricture) according to the classification of Savary and Miller [23]. We classified patients with Barrett esophagus according to the grade of esophagitis proximal to the Barrett epithelium. We defined healing of reflux esophagitis as absence of mucosal defects. Thirty-two patients had Barrett esophagus in combination with esophagitis. Twenty-five patients previously had antireflux surgery (Nissen fundoplication or hiatoplasty). Nine patients had been hospitalized for esophageal bleeding. Twenty-eight patients needed repeated dilatations before and during the initial healing phase. All patients were given 40 mg of omeprazole once daily for 4 to 16 weeks, until endoscopic examinations showed that the esophagitis was healed. In 5 patients, the healing dose of omeprazole was continued as a maintenance dose for reasons specified later. We did follow-up examinations every 3 months in the first year of maintenance therapy and thereafter at 6-month intervals. We interviewed patients to determine recurrence of symptoms (heartburn, regurgitation, and dysphagia) and adverse events. In addition, upper gastrointestinal endoscopy was done, including fundic biopsies, and a fasting blood sample was obtained for routine laboratory screening and serum gastrin tests. In patients with endoscopic relapse, we increased the dose of omeprazole by 20 mg. From 1990, patients received endoscopic examinations and laboratory tests annually. Serum gastrin was measured by a previously described sensitive and specific radioimmunoassay [24]. We considered 100 ng/L the upper limit of normal for fasting serum gastrin. At endoscopy, two or three biopsy specimens were obtained from the gastric corpus mucosa approximately 10 cm below the cardia along the greater curvature. The biopsy specimens were coded, fixed in neutral formalin, and embedded in paraffin. Deparaffinized 5-msections were stained with hematoxylin and eosin to assess the overall tissue structure. Adjacent sections were also stained with Sevier-Munger silver for argyrophil endocrine cells [25]. Of the six endocrine cell types in gastric corpus mucosa, 50% [26] or more [25] are composed of enterochromaffin-like cells, which are distinctly positive with Sevier-Munger silver stain. Serotonin-producing argentaffin enterochromaffin cells, composing a minor part (10% to 20%), and a minute number of somatostatin D1 cells are also argyrophilic, whereas the remaining endocrine cell types are negative [26]. We classified chronic gastritis as subatrophic or atrophic when at least 30% gland atrophy was evident, corresponding to both preatrophic and atrophic gastritis [27]. We classified the remaining cases of chronic gastritis as nonatrophic, thereby including superficial and interstitial gastritis and also mild subatrophic or atrophic changes. The endocrine cell changes were evaluated according to the classification of Solcia and associates [26]. The qualitative analysis of all corpus biopsy specimens was done blindly (by N. Havu, MD, Department of Pathology, Safety Assessment, AB Astra, Sodertalje, Sweden). Statistical Analysis We analyzed differences in serum gastrin level between the various time intervals for statistical significance using the Wilcoxon signed-rank test [28]. To compare percentages, we used Fisher exact tests. To compare the degree of enterochromaffin-like cell hyperplasia and gastritis at first and last biopsy, we used the McNemar test. This test considers all patients with changes but disregards those with unchanged classification of hyperplasia and gastritis, respectively. We estimated percentages of patients still in remission using the life-table method. Results are expressed as medians and ranges unless otherwise indicated. The protocol was approved by the ethics committee of the Free University Hospital. All eligible patients gave informed consent. Results Of the 91 patients entering the study, esophagitis healed in 58 (64%) after 4 weeks of treatment with 40 mg of omeprazole; it healed in 16 (18%) after 8 weeks and in 12 (13%) after 12 weeks. Four patients (4%) were healed only after acute treatment was extended to 16 weeks. One patient only healed after the dose of omeprazole was increased to 60 mg daily. These 5 patients continued to receive 40 mg of omeprazole as a maintenance dose. The time to healing for patients with Barrett esophagus and esophagitis was the same as for other patients, although prestudy endoscopic examination showed that patients with Barrett esophagus had more severe reflux esophagitis (63% grade IV esophagitis compared with 27% in the other patients). The median observation time during maintenance treatment was 48 months (range, 24 to 64 months). Drop-outs Four patients dropped out of the study. Three patients died: One died of postsurgical complications after a hip fracture 48 months after the start of maintenance treatment; one with known multiple myeloma died of related infectious complications after 36 months of maintenance therapy; and one died of pancreatic carcinoma that was diagnosed at autopsy after 42 months of therapy with omeprazole. One patient was lost to follow-up because of emigration. Clinical Evaluation All 91 patients were followed for at least 36 months: 67 patients for 48 months and 27 for 60 months or more. Symptomatic and endoscopic relapse of esophagitis occurred in 47% (95% CI, 36% to 58%) of the 86 patients receiving maintenance treatment with 20 mg of omeprazole daily (Figure 1). All patients with relapses healed within 3 months of increasing the daily dose of omeprazole by 20 mg daily (Figure 2). Seven of those 40 patients (18%; CI, 7% to 33%), who had already had a relapse, had another relapse after a mean follow-up period of 24 months (range, 9 to 36 months) and were successfully treated with a further dose increment to 60 mg daily for a mean duration of 36 months (range, 6 to 39 months). Attempts to decrease the dose after rehealing resulted in rapid relapse, as evidenced by symptoms and endoscopic examination. During the maintenance period, peptic strictures did not occur. We diagnosed Barrett esophagus by pre-entry endoscopic examination in 32 patients. During the follow-up period, we observed no regression or disappearance of Barrett epithelium. However, Barrett epithelium did not progress during the entire observation period. The relapse rate in patients with previous antireflux surgery was 40% (16 of 25 patients), which was similar to that for the whole group. Although most patients remained asymptomatic during maintenance treatment, 7 of the 91 (8%) patients reported occasional mild heartburn. Figure 1. Remission rates (%) in 86 patients with reflux esophagitis during maintenance treatment with 20 mg of omeprazole once daily during 60 months of follow-up (life-table method. Figure 2. Cumulative remission rates with dose adjustments required to maintain remission in 91 patients with reflux esophagitis during maintenance treatment with omeprazole. Effect on Fasting Serum Gastrin Levels In the initial healing phase, median fasting serum gastrin levels increased from 60 ng/L before study and during treatment with an H2-receptor antagonist to 162 ng/L during treatment with omeprazole (P<0.01). Thereafter, gastrin levels did not change significantly during maintenance treatment (Figure 3). For example, the mean of the paired differences in gastrin levels in 63 patients between 12 and 36 months of treatment was 109.73 ng/L, which was not significant (P = 0.1; CI, 247.31 to 27.85 ng/L). We detected no relation between the dose of omeprazole in the maintenance period and the serum gastrin level. Figure 3. Distribution of fasting serum gastrin levels (all measured individual values) during maintenance treatment with omeprazole. Ten of the 91 patients showed very high serum gastrin levels (at least two recordings of more than 500 ng/L during the follow-up period), with the highest recording being 3867 ng/L (Tabl

Clinical and genetic characteristics of hereditary pancreatitis in Europe.

BACKGROUND & AIMS Hereditary pancreatitis is an autosomal dominant disease that is mostly caused by cationic trypsinogen (PRSS1) gene mutations. The aim was to determine phenotype-genotype correlations of families in Europe. METHODS Analysis of data obtained by the European Registry of Hereditary Pancreatitis and Pancreatic Cancer was undertaken using multilevel proportional hazards modelling. RESULTS There were 112 families in 14 countries (418 affected individuals): 58 (52%) families carried the R122H, 24 (21%) the N29I, and 5 (4%) the A16V mutation, 2 had rare mutations, and 21 (19%) had no PRSS1 mutation. The median (95% confidence interval [CI]) time to first symptoms for R122H was 10 (8, 12) years of age, 14 (11, 18) years for N29I, and 14.5 (10, 21) years for mutation negative patients (P = 0.032). The cumulative risk (95% CI) at 50 years of age for exocrine failure was 37.2% (28.5%, 45.8%), 47.6% (37.1%, 58.1%) for endocrine failure, and 17.5% (12.2%, 22.7%) for pancreatic resection for pain. Time to resection was significantly reduced for females (P < 0.001) and those with the N29I mutation (P = 0.014). The cumulative risk (95% CI) of pancreatic cancer was 44.0% (8.0%, 80.0%) at 70 years from symptom onset with a standardized incidence ratio of 67% (50%, 82%). CONCLUSIONS Symptoms in hereditary pancreatitis start in younger patients and endpoints take longer to be reached compared with other forms of chronic pancreatitis but the cumulative levels of exocrine and endocrine failure are much higher. There is an increasingly high risk of pancreatic cancer after the age of 50 years unrelated to the genotype.

Radioimmunoassay of cholecystokinin in human tissue and plasma

A highly sensitive radioimmunoassay for cholecystokinin (CCK) without any cross-reactivity with gastrin is described. The antibody was raised in a rabbit by immunisation with 30% CCK and bound to all COOH-terminal CCK-peptides containing at least 14 amino acid residues. The affinity constant of the antibody was 59.4 X 10(10) l/mol. CCK 33 conjugated to [125I]hydroxyphenylpropionic acid-succinimide ester was used as label. The binding between label and antibody was inhibited by 50% (ID50) at a concentration of 2.8 pmol/l cholecystokinin 33. The detection limit of the assay was between 0.5 and 1.0 pmol/l plasma. Concentrations of CCK in aqueous acid extracts of human upper small intestine were 36.5 +/- 9.8 pmol/g and of human cerebral cortex 28.2 +/- 2.5 pmol/g tissue. Plasma samples were extracted in 96% ethanol prior to assay. No advantage was obtained by adding aprotinin to the tubes. When frozen at -20 degrees C plasma CCK was stable for at least 6 months. Basal plasma CCK concentrations in 30 normal subjects were very low, 0.9 +/- 0.1 pmol/l, range 0.5 to 3.1 pmol/l. Intraduodenal administration of fat induced significant increases in plasma CCK from 1.1 +/- 0.1 to 8.2 +/- 1.3 pmol/l (p = 0.01). Infusion of exogenous CCK, resulting in plasma CCK levels slightly lower than those measured during administration of fat, induced pancreatic enzyme secretion and gallbladder contraction. The reliability of this radioimmunoassay for measurements of CCK in human plasma was extensively evaluated.

The N34S mutation of SPINK1 (PSTI) is associated with a familial pattern of idiopathic chronic pancreatitis but does not cause the disease

Background: Mutations in the PRSS1 gene explain most occurrences of hereditary pancreatitis (HP) but many HP families have no PRSS1 mutation. Recently, an association between the mutation N34S in the pancreatic secretory trypsin inhibitor (SPINK1 or PSTI) gene and idiopathic chronic pancreatitis (ICP) was reported. It is unclear whether the N34S mutation is a cause of pancreatitis per se, whether it modifies the disease, or whether it is a marker of the disease. Patients and methods: A total of 327 individuals from 217 families affected by pancreatitis were tested: 152 from families with HP, 108 from families with ICP, and 67 with alcohol related CP (ACP). Seven patients with ICP had a family history of pancreatitis but no evidence of autosomal dominant disease (f-ICP) compared with 87 patients with true ICP (t-ICP). Two hundred controls were also tested for the N34S mutation. The findings were related to clinical outcome. Results: The N34S mutation was carried by five controls (2.5%; allele frequency 1.25%), 11/87 (13%) t-ICP patients (p=0.0013 v controls), and 6/7 (86%) affected (p<0.0001 v controls) and 1/9 (11%) unaffected f-ICP cases. N34S was found in 4/108 affected HP patients (p=0.724 v controls), in 3/27 (11%) with wild-type and in 1/81 (1%) with mutant PRSS1, and 4/67 ACP patients (all p>0.05 v controls). The presence of the N34S mutation was not associated with early disease onset or disease severity. Conclusions: The prevalence of the N34S mutation was increased in patients with ICP and was greatest in f-ICP cases. Segregation of the N34S mutation in families with pancreatitis is unexplained and points to a complex association between N34S and another putative pancreatitis related gene.

Germline mutations in PRKCSH are associated with autosomal dominant polycystic liver disease.

Polycystic liver disease (PCLD, OMIM 174050) is a dominantly inherited condition characterized by the presence of multiple liver cysts of biliary epithelial origin. Fine mapping established linkage to marker D19S581 (Zmax = 9.65; θ = 0.01) in four large Dutch families with PCLD. We identified a splice-acceptor site mutation (1138–2A→G) in PRKCSH in three families, and a splice-donor site mutation (292+1G→C) in PRKCSH segregated completely with PCLD in another family. The protein encoded by PRKCSH, here named hepatocystin, is predicted to localize to the endoplasmic reticulum. These findings establish germline mutations in PRKCSH as the probable cause of PCLD.

A degradation-sensitive anionic trypsinogen (PRSS2) variant protects against chronic pancreatitis

Chronic pancreatitis is a common inflammatory disease of the pancreas. Mutations in the genes encoding cationic trypsinogen (PRSS1) and the pancreatic secretory trypsin inhibitor (SPINK1) are associated with chronic pancreatitis. Because increased proteolytic activity owing to mutated PRSS1 enhances the risk for chronic pancreatitis, mutations in the gene encoding anionic trypsinogen (PRSS2) may also predispose to disease. Here we analyzed PRSS2 in individuals with chronic pancreatitis and controls and found, to our surprise, that a variant of codon 191 (G191R) is overrepresented in control subjects: G191R was present in 220/6,459 (3.4%) controls but in only 32/2,466 (1.3%) affected individuals (odds ratio 0.37; P = 1.1 × 10−8). Upon activation by enterokinase or trypsin, purified recombinant G191R protein showed a complete loss of trypsin activity owing to the introduction of a new tryptic cleavage site that renders the enzyme hypersensitive to autocatalytic proteolysis. In conclusion, the G191R variant of PRSS2 mitigates intrapancreatic trypsin activity and thereby protects against chronic pancreatitis.

Omeprazole in Zollinger-Ellison syndrome. Effects of a single dose and of long-term treatment in patients resistant to histamine H2-receptor antagonists.

We studied the effect of omeprazole, a benzimidazole inhibitor of gastric acid secretion, in patients with Zollinger-Ellison syndrome. In five patients ingestion of 80 mg of omeprazole inhibited gastric acid secretion by 26 to 100 per cent after 6 hours and by 76 to 100 per cent after 24 hours. Seven patients were continuously treated with omeprazole once or twice daily for 8 to 19 months (average, 14). Six of these seven had symptoms that were resistant to high doses of histamine H2-receptor antagonists, and the seventh could not take high doses of cimetidine because of a possible drug-related increase in the serum creatinine concentration. Symptoms resolved in all patients within two weeks, and peptic lesions were healed at endoscopy after four weeks. All patients remained free of symptoms, and gastric acid secretion continued to be markedly inhibited by omeprazole therapy. We conclude that omeprazole is a potent and long-acting antisecretory drug in patients with Zollinger-Ellison syndrome and that it is effective in patients whose peptic-ulcer disease is relatively resistant to treatment with histamine H2-receptor antagonists. Its safety and effectiveness in long-term therapy remain to be assessed.

Effect of a low dose of intraduodenal fat on satiety in humans: studies using the type A cholecystokinin receptor antagonist loxiglumide.

Satiation, the process that brings eating to an end, and satiety, the state of inhibition over further eating, may be influenced by cholecystokinin (CCK). In animal and human studies, it has been shown that infusion of exogenous CCK decreases food intake, but the doses given may well have led to supraphysiological plasma concentrations. This study was done to discover if a low dose of intraduodenal fat releasing physiological amounts of endogenous cholecystokinin exerts satiation or satiety effects, or both and if these effects could be inhibited by the CCK receptor antagonist loxiglumide. In 10 healthy lean volunteers (5 F, 5 M, mean age 26) three tests were performed in a randomised blind fashion. Intralipid 20% (6 g/h) (experiments A and C) or saline (experiment B) were given intraduodenally from 1030 until 1300. The subjects received saline (experiments A and B) or loxiglumide (experiment C) a specific CCK-receptor antagonist (10 mg/kg/h) intravenously from 0930 until 1300. At 1200 a meal was served. At regular time intervals hunger feelings were measured using visual analogue scales and food selection lists and plasma CCK was measured by radioimmunoassay. Food intake (mean (SEM)) during intraduodenal fat (206(35)g) was lower than in the control study (269(37)g, p = 0.09). Loxiglumide largely prevented the inhibitory effect of intraduodenal fat on food intake (245(30)g). From 1030 until the meal at 1200 there was a significant satiating effect of intraduodenal fat compared with the control and loxiglumide experiments according to the food selection lists, which was because of the satiating effect for the fat rich items (p<0.05). Also feelings of fullness were significantly higher during intraduodenal fat than in the control or loxiglumide experiments (p<0.05). During intraduodenal fat there was a significant increase of plasma CCK from 2.4(0.3) to 4.8(0.4) pM (p<0.001). Loxiglumide led to an exaggerated CCK release to a peak concentration of 16(2.4) pM before the meal. This study shows that in humans low dose intraduodenal fat increases satiety and satiation, mainly through the effect of CCK.

Feedback Regulation of Human Pancreatic Secretion: Effects of Protease Inhibition on Duodenal Delivery and Small Intestinal Transit of Pancreatic Enzymes

To determine the effects of luminal protease inhibition on duodenal delivery and the intraluminal fate of pancreatic enzymes, six healthy subjects were intubated with an oro-ileal multilumen tube assembly. By using nonabsorbable markers, cumulative trypsin, chymotrypsin, lipase, and amylase activities were measured as delivered to duodenum, midjejunum, and distal ileum, with or without simultaneous duodenal perfusion of the protease inhibitor camostat at graded doses. Compared with saline, camostat (a) inhibited trypsin activity in the entire small intestinal lumen by up to 99%, and significantly reduced chymotrypsin activity by up to 89%; (b) significantly increased duodenal deliveries of lipase activity, amylase activity and volume; (c) did not influence plasma cholecystokinin concentrations; and (d) significantly increased jejunal and ileal deliveries of lipase but not amylase activity. Small intestinal transit and motility were not affected by camostat. In additional in vitro studies, camostat significantly reduced the spontaneous decline in lipase activity in fresh human duodenal juice incubated at 37 degrees C. These findings demonstrate that duodenal deliveries of lipase and amylase activities increase when intraluminal protease activity is decreased; they suggest that this increase is not caused by slower proteolytic destruction of enzyme protein but by stimulation of pancreatic secretion. Thus, luminal protease-mediated feedback regulation of pancreatic secretion may be operative in humans. Because plasma cholecystokinin concentrations were not affected, these effects may in part be independent of cholecystokinin. The data further suggest that proteolytic digestion plays a major role in the rapid loss of luminal lipase activity on small intestinal transit.