Increased serum pepsinogen I and recurrence of duodenal ulcer

The pepsinogen releasing effect of Helicobacter pylori lipopolysaccharide

BACKGROUND

Helicobacter pylori lipopolysaccharide (LPS) affects pepsinogen release by a nontoxic mechanism. We hypothesized that this effect was characteristic of the organism and related to the clinical status of the strain.

MATERIALS AND METHODS

LPS was isolated from 11 H. pylori strains whose pathogenic profile was known and four other nongastric bacteria. The effects of luminal LPS on guinea pig gastric mucosal pepsinogen release was evaluated using the Ussing chamber technique. CCK-8 (10(-9)M) was used as a positive control.

RESULTS

H. pylori LPS dose-dependently stimulated pepsinogen release with a maximal stimulation at 250 microg/ml (approximately 4500; p < .001 vs. control). LPS from other Helicobacter or Campylobacter species had no effect on pepsinogen release. ANOVA demonstrated significant differences in the efficacies of pepsinogen release between the 11 clinical H. pylori strains (p < .0001) despite the fact that they were all cagA+ and 90 had the cytotoxic vacA subtype s1. Physical and chemical disruption of the LPS suggested that both the structure and the carbohydrate composition of this molecule may play a critical role in pepsinogen release. Polymyxin B partly (p < .03) inhibited and dephosphorylation completely inhibited (p = .0002) LPS-stimulated pepsinogen release.

CONCLUSION

Pepsinogen release is an innate property of all cagA+H. pylori LPS. The structure of the molecule and composition of side-chains are important in this response which appears to be partially lipid A driven.

Comparison of meal-stimulated serum gastrin response in Helicobacter pylori-positive duodenal ulcer and asymptomatic volunteers with and without H. pylori infection

BACKGROUND

Duodenal ulcer (DU) patients exhibit raised postprandial gastrin release as compared to that in healthy controls. It is believed that serum pepsinogen I (PG I) concentration reflects the chief cell mass and that hyperpepsinogenemia I plays an important role in the pathogenesis of DU. Currently, strong evidence suggests that Helicobacter pylori (H. pylori) infection plays an important role in the pathogenesis of DU.

MATERIALS AND METHODS

Subjects consisted of 15 patients with H. pylori-positive DU, 10 H. pylori-positive volunteers, and 35 H. pylori-negative volunteers. Blood samples were taken before and at 15, 30, and 60 minutes after eating the test meal, which consisted of 100 gm rice, 130 gm chicken, and 1 egg. The 1-hour integrated gastrin response (IGR) was taken as the area under the serum gastrin time curve, calculated by the trapezoid method. Serum gastrin (SG) and fasting serum PG I concentrations were measured by radioimmunoassay.

RESULTS

Meal-stimulated SG response and fasting PG I concentration were significantly higher in DU patients than in H. pylori-positive and -negative volunteers. The DU patients were divided into two groups in accordance with their IGR levels as follows: hyper-IGR and normo-IGR. Serum PG I concentration was significantly higher in the hyper-IGR than in the normo-IGR group.

CONCLUSIONS

The DU patients differed in some way (other than H. pylori infection) from the H. pylori-positive healthy volunteers. The fact that hyper-IGR DU patients had higher serum PG I concentrations suggests that patients in this group may be acid hypersecretors.

Long-term symptom patterns in duodenal ulcer: psychosocial factors

Seventy-five patients with recent-onset dyspepsia and endoscopically visible duodenal ulcer underwent psychological evaluation. Following ranitidine treatment, they were reinterviewed periodically for 12 to 76 months (mean 38.6). Ulcer symptoms were present during a mean of 14.9% of follow-up months. Patients did significantly worse if they had a low-status occupation, low education, depression, stressful life events, or abnormal Minnesota Multiphasic Personality Inventory at baseline. Of patients recalling premorbid life stress, those with a normal MMPI had a particularly benign course, whereas those with an abnormal MMPI did particularly poorly (6% versus 29% of months symptomatic: p < 0.04). Age, gender, smoking, drinking, antiinflammatory drugs, pepsinogen, Helicobacter pylori titers, and initial healing had no prognostic effect. Low socioeconomic status, life stress, depression, and psychopathology each predict a relatively poor symptom outcome for duodenal ulcer treated with antisecretory therapy, but psychologically stable individuals who develop an ulcer under stress have an excellent long-term prognosis.

Psychologic predictors of duodenal ulcer healing

We investigated psychologic influences on duodenal ulcer by examining the effect of personality, stress, and mood, measured at diagnosis, on subsequent ulcer healing. Stressful life events, psychopathology (assessed using the Minnesota Multiphasic Personality Inventory), anxiety, depression, smoking, alcohol consumption, nonsteroidal antiinflammatory drug use, and serum pepsinogen I levels were determined immediately after endoscopy showed duodenal ulcer craters in 70 patients with recent onset of symptoms. Endoscopy was repeated following 6 weeks of ranitidine therapy. Six ulcers (8.6%) persisted, and the duodenum remained inflamed in an additional five cases, for a total of 16% with incomplete healing. The only baseline characteristic significantly associated with poor healing was anxiety (p = 0.03 for ulcer persistence, p = 0.02 for incomplete healing). Being in the highest anxiety tertile was associated with a more than fourfold elevation in the risk of incomplete healing (p = 0.02). The association between anxiety and poor healing was not changed by modification of the anxiety score to eliminate gastrointestinal symptom items or by adjustment for serum pepsinogen, sex, or cigarette smoking. Anxiety inhibits the healing of duodenal ulcers treated with adequate antisecretory therapy.

Helicobacter pylori infection and serum pepsinogen I concentration in peptic ulcer patients: effect of bacterial eradication

OBJECTIVES

In order to test the hypothesis that H. pylori infections in the gastric antrum increase pepsinogen I release, fasting serum pepsinogen I concentrations were compared in peptic ulcer patients with and without H. pylori infection. A randomized prospective study was performed to determine whether the increased serum pepsinogen I concentrations associated with H. pylori infection respond to treatment that eradicates H. pylori.

METHODS

Fasting serum pepsinogen I concentrations were measured by RIA in 736 patients with endoscopically and histologically confirmed benign peptic ulcer with and without H. pylori infection. Out of 511 patients with H. pylori infection, 110 patients (group 1) were randomly selected and were treated with metronidazole and tripotassium dicitrato bismuthate combined with ranitidine and antacid, and 97 patients (group 2) were treated only with ranitidine and antacid. The third group, 54 patients free of H. pylori infection, was designed to evaluate the influence of H2-receptor antagonist and antacid on the change of pepsinogen I. Fasting pepsinogen I concentration and H. pylori status were compared before and after the treatment.

RESULTS

Patients infected by H. pylori (gastric ulcer 208, duodenal ulcer 303; total 511) had significantly higher fasting serum pepsinogen I concentrations than H. pylori negative patients (gastric ulcer 110, duodenal ulcer 115; total 225). Mean pepsinogen I level of the former was 124.3 +/- 46.9 and that of the latter was 77.9 +/- 25.8 ng/ml. (p < 0.0001). The difference in serum pepsinogen I concentrations according to the location of ulcer crater was significant only in non-infected subjects e.g., mean pepsinogen I level H. pylori-negative gastric ulcer was significantly lower than that of H. pylori-negative duodenal ulcer patients. H. pylori was eradicated in all the patients who had received antibacterial therapy for 4 weeks and serum pepsinogen I concentrations were significantly decreased from 129.8 +/- 43.0 to 82.4 +/- 24.0 ng/ml after eradication of the organism. (p < 0.0001) In contrast, H. pylori-positive patients who had not received antibacterial therapy were still infected at the completion of the study and there was no significant change in the serum pepsinogen I concentrations after the treatment (120.8 +/- 40.9 vs 126.3 +/- 40.4 ng/ml). (p > 0.57) None of the patients who were initially H. pylori-negative has been reinfected during the period of the study and their serum pepsinogen I concentrations were not changed. (pre-treatment value 75.1 +/- 8.0; post-treatment value 77.3 +/- 24.5 mg/ml) (p < 0.75) Four-to six-week therapy of H2-receptor antagonist and antacid did not exert any influence on serum pepsinogen I concentrations.

CONCLUSIONS

On the basis of our results, we have confirmed that the chronic infection of H. pylori of gastric antrum in peptic ulcer patients causes increased pepsinogen I release into the circulation, and eradication of the organism results in significant fall in serum pepsinogen I concentrations.

Gastric acid secretion, serum pepsinogen I, and serum gastrin in Japanese with gastric hyperplastic polyps or polypoid-type early gastric carcinoma

We determined the maximum secretion of gastric acid and the fasting serum levels of pepsinogen I and gastrin in Japanese patients with gastric hyperplastic polyps or polypoid-type early gastric carcinoma, comparing those findings with observations in control subjects. Both the maximum acid secretion and fasting levels of serum pepsinogen I were significantly lower in the patients with gastric hyperplastic polyps or polypoid-type early gastric carcinoma than in the controls. Fasting serum gastrin levels were significantly higher in the patients with gastric hyperplastic polyps than in the other two groups of subjects. These data demonstrated that the combination of hypochlorhydria, a low level of pepsinogen I, and hypergastrinemia (type-A gastritis) was common in the patients with gastric hyperplastic polyps, whereas hypochlorhydria and a low pepsinogen I without hypergastrinemia (type-B gastritis) were common in those with polypoid-type early gastric carcinoma.

Pepsinogens in health and disease

Pepsinogens, precursors of pepsins (potent and abundant digestive enzymes that are the primary products of the gastric chief cells), are members of the family of aspartic proteases. Because of the heterogeneity of pepsinogens, several classifications have appeared in the literature. I describe the recommended classification and nomenclature of the aspartic proteases and discuss their genetics, biochemistry (structure, activation of zymogens, mechanism of proteolytic activity and inhibitors), and physiology. The focus will be on the zymogens of pepsin, the so-called pepsinogens. The measurement of these enzymes in serum is a reliable noninvasive biochemical method for evaluating peptic secretion and obtaining information on the gastric mucosal status. A detailed review of the methods for the measurement of pepsinogens in serum, urine, and gastric mucosa is also provided. Data on pepsinogen levels in healthy subjects are discussed with respect to sex, age, smoking habit, and the presence of a circadian rhythm. The value of pepsinogen measurements in peptic ulcer to determine ulcer outcome and recurrence, in gastric cancer, and in Helicobacter pylori infection is reviewed. Finally, the effects of drugs on peptic secretion are discussed. In light of these data, the measurement of aspartic proteases, and in particular that of pepsinogen A and C, may be regarded as an effective biochemical approach to the evaluation and monitoring of patients with upper gastrointestinal diseases.

Helicobacter pylori lipopolysaccharide stimulates gastric mucosal pepsinogen secretion

The effect of Helicobacter pylori lipopolysaccharide on guinea pig gastric mucosal pepsinogen secretion has been examined using an Ussing chamber technique. Luminal addition of H. pylori lipopolysaccharide resulted in a fifty-fold stimulation of pepsinogen secretion compared to a twelve-fold increase with E. coli lipopolysaccharide. Electron microscopy showed marked degranulation of zymogen granules but no evidence of chief cell disruption.

Effect of Helicobacter pylori on serum pepsinogen I and plasma gastrin in duodenal ulcer patients

Duodenal ulcer patients have increased serum pepsinogen I (PGI) concentrations and an increased prevalence of Helicobacter pylori infection. We have examined the effect of eradicating the infection on PGI. In 12 duodenal ulcer patients in whom H. pylori was successfully eradicated, the median basal PGI was 90 ng/ml (range, 37-252) before treatment and fell to 74 ng/ml (28-197) 1 month after treatment (p less than 0.01). In 12 patients in whom therapy failed to eradicate the infection, the PGI was 87 ng/ml (35-128) before treatment and remained unchanged at 83 ng/ml (36-119) 1 month after treatment. In the group with successful eradication the median basal plasma gastrin was 43 ng/l (15-95) before treatment and fell to 30 ng/l (17-75) 1 month after treatment (p less than 0.003), but there was no change in the corresponding values in the group without eradication (55 ng/l; range, 25-120, and 45 ng/l; range, 5-175; p = 0.9). In conclusion, eradication of H. pylori results in a fall in PGI and plasma gastrin, and these changes are not due merely to the anti-H. pylori drugs themselves or to discontinuation of previous ulcer therapy.

Functional characteristics of duodenal ulcer patients and their first-degree relatives

The behaviour of acid secretion, serum pepsinogen I and II (PG I and PG II) and morphology of the gastric mucosa were analyzed in 59 duodenal ulcer probands (DU probands), their 199 first-degree relatives and 228 control subjects. DU probands had as a rule antral gastritis with normal or slightly altered corpus mucosa, and higher mean peak acid output (PAO), PG I and II levels than their relatives and controls. Sibs of DU probands differed from their controls mainly with regard to morphology which showed features characteristic of DU probands, i.e. antral gastritis with normal or slightly altered corpus mucosa. Moreover, high PAO levels were found highly significantly more often in sibs of DU probands (13%) than in controls (6%). Likewise, the prevalence of endoscopic signs of active or past duodenal ulcer were present in sibs highly significantly more often than in controls and they accumulated in the subgroup of sibs with high PAO or PG I levels. It seems probable that the occurrence of high PAO and PG I levels in sibs of DU probands can be considered as signs of increased liability to duodenal ulcer. PAO and PG I were as expected significantly higher in male than in female probands, relatives and controls. Exclusion of cases of corpus gastritis decreased the levels but the sex difference persisted. PAO, PG I and II revealed a significant increase of the levels in middle age followed in older age in case of PAO and PG I by a significant decrease. The decrease was abolished when the cases of corpus gastritis were excluded suggesting an effect of gastritis. However, the earlier increase of the levels remained virtually unaffected although there was a uniform decrease of the mean values. This suggests the participation of factors unrelated to gastritis. The nature of the factors remains unknown, but literature data and data derived from our recent study suggest involvement of anatomical factors such as an increase in the size of acid and PG I secreting area.