Epidemiology and genetics of peptic ulcer

Autonomic dysfunction and inflammatory bowel disease

Inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, is a chronic immune-mediated intestinal disorder, and its etiology and pathogenesis are not well clarified. The pathogenesis of IBD is multifactorial, and the nerve system may participate in the development of IBD by modulating immune responses. Recently, autonomic dysfunction in IBD patients has been intensively studied. It has been reported that IBD patients suffer from autonomic dysfunction, and the severity of autonomic dysfunction correlates with disease activity of IBD, suggesting that autonomic dysfunction is a potential marker for IBD disease activity and also a potential target for IBD treatment. In this paper, we review the recent advances in understanding the relationship between autonomic dysfunction and IBD.

Time trends in epidemiology of peptic ulcer disease in India over two decades

BACKGROUND

Epidemiology of peptic ulcer disease (PUD) in India differs from that in the West. It may have undergone a change with recent improvement in hygiene and availability of potent antisecretory and ulcerogenic drugs. We therefore tried to assess time-trends in the frequency of PUD over the past two decades.

METHODS

Records of patients with uninvestigated dyspepsia and no alarm symptoms who had undergone upper gastrointestinal endoscopy at our institution during the years 1988 (n = 2,358), 1992 (n = 2,240), 1996 (n = 5,261), 2000 (n = 7,051), 2004 (n = 5,767) and 2008 (n = 7,539) were retrospectively reviewed. The frequencies of duodenal and gastric ulcer disease in these groups were compared.

RESULTS

Of the 30,216 patients (age:41.7±12.7 years, 34 % females) during the six study periods, 2,360 (7.8 %) had PUD. The frequencies of both duodenal ulcer and gastric ulcer showed a decline from 1988 to 2008, i.e. from 12 % to 2.9 % and 4.5 % to 2.7 %, respectively (p-value <0.001 for trend for each). The decline was more marked for duodenal ulcer, and the ratio of duodenal to gastric ulcer declined from 2.7 in 1988 to 1.1 in 2008.

CONCLUSIONS

The epidemiology of PUD in India may have changed in the past two decades with the incidence of duodenal ulcer declining more rapidly than that of gastric ulcer.

The natural course of Helicobacter pylori infection on endoscopic findings in a population during 17 years of follow-up: the Sørreisa gastrointestinal disorder study

The natural course of Helicobacter pylori (H. pylori) is poorly understood, as most research in the field has been on patient populations. We studied the natural course of H. pylori and its associations to morphological changes of the gastric mucosa, peptic ulcer, and reflux oesophagitis in a prospective cohort study of subjects with and without dyspepsia. A total of 361 adults (201 men/160 women, mean age 41/42 years) in Sørreisa municipality, Norway who in 1987 were subjected to upper endoscopy and assessed for gastrointestinal symptoms and H. pylori status were followed up in 2004. H. pylori was strongly associated with neutrophilic (odds ratio [OR] 23.79; 95% confidence interval [CI] 11.64:48.61) and mononuclear infiltration (OR 9.43; CI 5.12:17.36), moderately with atrophy of the antrum (OR 1.98; CI 1.17:3.34), but not with atrophy of the gastric body or intestinal metaplasia. Elimination of H. pylori was associated with regression of gastric inflammation and atrophy, whereas intestinal metaplasia progressed. H. pylori was positively associated with peptic ulcer (OR 2.69; CI 1.2:6.02) but not significantly negatively associated with oesophagitis (OR 0.62; CI 0.35:1.09). This is the first prospective study including endoscopic findings of subjects without dyspepsia, to show that the impact of H. pylori on gastric atrophy is only modest, and that eliminating H. pylori does not cause regression of intestinal metaplasia. However, inflammation of the gastric mucosa regresses after H. pylori elimination. H. pylori is only a moderate risk factor for peptic ulcer, and other explanatory factors deserve more attention.

Analysis of common transforming growth factor beta-1 gene polymorphisms in gastric and duodenal ulcer disease: pilot study

BACKGROUND AND AIM

Transforming growth factor-beta1 (TGF-beta1) has been shown to be an important cytokine that plays a role in cell proliferation, differentiation, tissue injury repair and ulcer healing. The purpose of this pilot study was to investigate if common polymorphisms Leu10Pro, Arg25Pro and C-509T within the TGF-beta1 gene are associated with susceptibility to gastric and duodenal ulcer disease in Russians.

METHOD

Blood samples from 377 unrelated patients with gastric and duodenal ulcer disease and 226 sex- and age-matched healthy controls were used to determine TGF-beta1 gene polymorphisms by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP).

RESULTS

Leu10Pro substitution in the signal peptide of TGF-beta1 has been found to be associated with susceptibility to gastric ulcer (odds ratio [OR] 1.76, 95% confidence interval [CI] 1.12-2.77). A genotype combination of 10Leu/Leu x 25Arg/Arg x -509C/C was also associated with susceptibility to gastric ulcer disease (OR 1.81, P = 0.01). In addition, the frequency of a combination of genotypes 10Pro/Pro x 25Arg/Pro x -509C/T was statistically lower in patients with duodenal ulcer than in controls (OR 0.42, P = 0.05). A significant difference (P = 0.04) in the distribution of rare haplotypes of the TGF-beta1 gene between patients with duodenal ulcer and healthy controls has been found. Polymorphism Leu10Pro was in positive linkage disequilibrium with C-509T polymorphism (coefficient D = 0.191; P < 0.0001).

CONCLUSIONS

These findings indicate that the Leu10Pro and C-509T polymorphisms may be involved in the modulation of expression of the TGF-beta1 gene, and therefore a predisposition to peptic ulcer disease could be linked to particular alleles of this gene. In particular, a possible role of TGF-beta1 in the pathogenesis of gastric ulcer disease is discussed.

Rare Helicobacter pylori infection as a factor for the very low stomach cancer incidence in Yogyakarta, Indonesia

To elucidate factors associated with the very low risk of gastric neoplasia in Yogyakarta, Indonesia, approximately 1/50 of the level in Japan, we recruited 52 male and 39 female participants from the general populace in the city of Yogyakarta in October 2003. Helicobacter pylori IgG antibodies were found in only 5% (0-13) (95% confidence interval) and 4% (0-9) for Javanese males and females, respectively, and were statistically lower than the 62% (58-65) and 57% (53-60), respectively, in Japanese. Furthermore, positive findings of pepsinogen test were only 0 and 2% (0-6) for males and females, in Yogyakarta, and were again significantly lower than the 23% (22-25) and 22% (20-23), in Japan. The very low incidence of stomach cancer in Yogyakarta may be due to a low prevalence of H. pylori infection and chronic atrophic gastritis.

Do Japanese and Swedish peptic ulcer patients respond differently to Helicobacter pylori eradication therapies and what are their histological features?

BACKGROUND

As a consequence of gastric histological differences, Japanese and Swedish peptic ulcer (PU) patients may respond differently to Helicobacter pylori eradication therapies.

METHODS

The study was single-blind and compared four eradication therapies in Japanese and Swedish patients with healed gastric (GU) or duodenal (DU) ulcer. Swedish patients received either (a) omeprazole+clarithromycin (OC, where O = 20 mg, C = 500 mg) for 2 weeks, or triple therapy with (b) omeprazole + amoxicillin + clarithromycin (OAC-L where O = 20mg, A = 1 g, C = 250 mg); (c) OAC-H (where O = 20 mg, A-1 g, C-500 mg); or (d) omeprazole + metronidazole + clarithromycin (OMC, where O = 20 mg, M = 400 mg, C = 250 mg) for 1 week. Antibiotic doses were weight-adjusted downwards in Japanese patients. H. pylori was assessed using the urea breath test (UBT), histology and culture pre-entry, with UBT being repeated 4 and 8 weeks after stopping treatment. Histology and culture were repeated if the UBT was positive post-therapy.

RESULTS

Recruitment included 120 patients from Japan (43 GU, 61 DU, 16 GU+DU) and 120 from Sweden (119 DU, 1 GU+DU). There were 26 exclusions from a FAS analysis due to H. pylori negativity (14), no drug administration (7) or no data after visit 1 (5). Eradication rates (FAS) from Japan were (a) 63%, (b) 93%, (c) 96% or (d) 96%, and for Sweden (a) 92%, (b) 86%, (c) 93% or (d) 96%. Dual therapy was less effective in patients with gastric atrophy associated with GU disease. Tolerability was good in all treatment groups, with no serious adverse events.

CONCLUSION

Triple therapies were safe and effective for H. pylori eradication in Japanese and Swedish peptic ulcer patients. Dual therapy was significantly less effective in the Japanese patients, half of whom had a history of GU and more abnormal histology than in the Swedish patients, all of whom had DU.

Comparison of Gastric Histology Among Swedish and Japanese Patients with Peptic Ulcer and &lt;emph type="2"&gt;Helicobacter pylori&lt;/emph&gt; Infection

BACKGROUND

The natural course of Helicobacter pylori gastritis may vary between different ethnic groups. Gastric histopathology and the occurrence of H. pylori organisms in the stomach were investigated in healed duodenal (DU) and gastric (GU) ulcer patients recruited in Sweden (S) and Japan (J) in an identical trial.

METHODS

In 203 patients (JGU = 39, JDU = 55, SDU = 109), various morphological gastritis variables and H. pylori were assessed from biopsy specimens obtained using a specific sampling protocol and interpreted according to guidelines of the updated Sydney grading system.

RESULTS

The ratio of GU:DU was observed to be very different between the recruited Japanese (39:55) and Swedish (0:109) patients. A comparison of data from SDU and JDU showed that the prevalence of H. pylori infection and the antral predominant gastritis demonstrated by both SDU and JDU were essentially identical. A comparison of data from JDU and JGU demonstrated a greater prevalence of H. pylori infection in the antrum, but not corpus, of JDU compared to JGU patients. The prevalence of atrophy and intestinal metaplasia was higher in both the antrum and corpus of JGU compared to JDU in all patients.

CONCLUSIONS

The site specified biopsy methodology and standardized interpretation criteria utilized in this study clearly show that the histotopographic profile of Swedish and Japanese DU patients is essentially the same.

Genetic and life-style determinants of peptic ulcer. A study of 3387 men aged 54 to 74 years: The Copenhagen Male Study

BACKGROUND

In the Copenhagen Male Study men with the Lewis blood group phenotype Le(a+b-), non-secretors of ABH antigen, and men with the O or the A phenotype in the ABO blood group have been found to have a significantly higher lifetime prevalence of peptic ulcer than others. We investigated the importance of the association of these genetic markers, life-style factors, and social class with lifetime risk of peptic ulcer, testing specifically the hypothesis that the strength of the association of risk factors with peptic ulcer depends on genetic susceptibility.

METHODS

Three thousand three hundred and forty-six white men 55-74 years old were included for study. From a questionnaire validated during an interview information was obtained about life-style factors and peptic ulcer history (gastric or duodenal). Potential non-genetic risk factors examined were smoking history, alcohol consumption, physical activity level, consumption of tea and coffee, and use of sugar in tea or coffee.

RESULTS

Three hundred and eighty-four men (11.5%) had a history of peptic ulcer; 120 (3.6%) had had an operation due to peptic ulcer. Non-genetic peptic ulcer risk factors identified were ever having been a smoker, use of sugar in tea or coffee, abstention from tea consumption, and low social class. On the basis of these and the genetic factors, it was possible to identify a low-risk group (n = 142) with a lifetime prevalence of 4.2%, several intermediate-risk groups, and a high-risk group (n = 55) with a prevalence of 29%; the odds ratio with 95% confidence limits (OR) was 9.3 (3.4-25.3). Corresponding values with regard to operation were 1.4% and 20.0%; OR = 17.5 (3.7-82.0). Several significant interactions were found; for example, the use of sugar was associated with peptic ulcer risk only when interacting with genetic risk groups.

CONCLUSIONS

Considering the role of Helicobacter pylori, it is interesting that the factors identified in this study were able to identify groups with extremely different lifetime risks. This finding and also the finding of strong interactions between genetic and life-style factors and between genetic factors and social class for the risk of peptic ulcer may have both public-health and clinical implications.

Effect of H. pylori infection and CagA status on leukocyte counts and liver function tests: extra-gastric manifestations of H. pylori infection

BACKGROUND

It has been suggested that H. pylori infection is associated with abnormalities in total leukocyte count as well as the number of basophils and lymphocytes. In addition, CagA seropositivity has been associated with an increase in serum transaminase (SGOT) values. The aim of this study was to confirm the findings of previous subgroup analyses in patients before and after treatment for H. pylori infection and to ascertain whether the abnormalities reversed following successful treatment.

METHODS

Blood counts and serum transaminase levels were obtained prior to and following treatment of H. pylori infection of H. pylori-infected duodenal ulcer patients. CagA status was assessed by Western blot of the H. pylori isolates obtained from the patients.

RESULTS

Ninety-four ulcer patients were studied, including 77 with CagA-positive H. pylori isolates (82%) and 17 with CagA-negative H. pylori isolates. All study parameters remained within normal limits both before and after therapy. There were no significant changes in any study parameter in those who failed therapy. Successful therapy resulted in a significant fall in total white cell count (7413 +/- 520 cmm to 6738 +/- 410 cmm, for pretreatment vs. cured, respectively, p = 0.04) and was almost entirely accounted for by a reduction in the number of circulating polymorphonuclear leukocytes (4595 +/- 370 cmm to 3855 +/- 270 cmm for pretreatment vs. cured, respectively, p = 0.015). The pretreatment SGOT and basophil count were significantly higher in those with CagA-positive H. pylori (SGOT = 23 +/- 1 vs. 18.5 +/- 1 U). Successful or failed therapy with follow-up for 3 months post therapy did not result in a significant change of SGOT levels.

CONCLUSIONS

We confirmed an increase in total leukocyte count and number of polymorphonuclear leukocytes in those with H. pylori infection. We also confirmed higher SGOT levels with CagA-positive H. pylori infection, but the failure to resolve within 3 months of cure of the infection makes it unlikely to be a direct result of the H. pylori infection.

Modification of Christensen urease test as an inexpensive tool for detection of Helicobacter pylori

About half the world population is infected with Helicobacter pylori. Most live in developing countries where clinical studies face the constraints of high costs of imported rapid diagnostic tests. In this work, we describe and validate a simple local urease test (LUT) to determine the presence of the bacterium in gastric biopsies, and report the incidence of infection among symptomatic patients in Caracas, Venezuela. Statistical comparison of LUT and CLOtest (Delta West, Bentley, Australia) (N = 216 patients) showed that the probability of 95% agreement between the two test was 0.936. Overall incidence of infection determined by the LUT was 65% (N = 229), and it was higher in patients from public (72%; N = 153) than from private (50%; N = 76) hospitals (p = .001). Therefore, the incidence of infection differs in two socioeconomic groups that coexist in the same city. LUT may represent an affordable tool in clinical studies needed to identify social factors that increase the risk of infection by H. pylori.

Genetic markers for peptic ulcer. A study of 3387 men aged 54 to 74 years: the Copenhagen Male Study

BACKGROUND

Knowledge on the genetic risk of peptic ulcer has predominantly been based on hospital materials. To minimize selection bias, we tested the association between some genetic markers and the risk of peptic ulcer in a large-scale epidemiologic design.

METHODS

Some 3387 white men aged 55-74 years were investigated and reported their history of peptic ulcer. Information about hospitalization and operation was collected from registers.

RESULTS

The lifetime prevalence of peptic ulcer in men with the Lewis phenotype Le(a + b-) and non-secretors of ABH antigen was 15%, significantly higher than others, 11% (P < 0.01); the risk in phenotypes O and A were equally high, 12%, and among other ABO groups, 7% (P < 0.05). Men with phenotype O had significantly higher risk of hospitalization than others (P < 0.01). Compared with others, the attributable risk of peptic ulcer in men who were Le(a + b-) or non-secretors, with O or A phenotypes, was 37%. No association was found with complement C3, MNS, or Rhesus blood groups.

CONCLUSIONS

1) The Le(a + b-) phenotype and the ABH non-secretor trait are relevant genetic markers of peptic ulcer. We suggest that these men have increased susceptibility to Helicobacter pylori infection. 2) This study challenges the importance of the ABO blood group: lifetime prevalence was equally high among men with O and A phenotypes, with more severe cases in men with phenotype O.