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Fossmark R, Ness-Jensen E, Sørdal Ø. Is empiric proton pump inhibition in patients with symptoms of extraesophageal gastroesophageal reflux justified? BMC Gastroenterol 2023; 23:303. [PMID: 37674110 PMCID: PMC10483799 DOI: 10.1186/s12876-023-02945-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 09/04/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND The prevalence of gastroesophageal reflux disease (GERD) has had a marked increase in Western countries with a paralleling interest in extraesophageal (EE) manifestations of GERD, including laryngopharyngeal reflux (LPR). There are considerable differences in clinical practice between gastroenterologists, otolaryngologists and pulmonologists. METHODS In this narrative review we address some of these controversies concerning EE manifestations of GERD and LPR. RESULTS It is disputed whether there is causal relationship between reflux and the numerous symptoms and conditions suggested to be EE manifestations of GERD. Similarly, the pathophysiology is uncertain and there are disagreements concerning diagnostic criteria. Consequently, it is challenging to provide evidence-based treatment recommendations. A significant number of patients are given a trial course with a proton pump inhibitor (PPI) for several months before symptoms are evaluated. In randomized controlled trials (RCTs) and meta-analyses of RCTs PPI treatment does not seem to be advantageous over placebo, and the evidence supporting that patients without verified GERD have any benefit of PPI treatment is negligible. There is a large increase in both over the counter and prescribed PPI use in several countries and a significant proportion of this use is without any symptomatic benefit for the patients. Whereas short-term treatment has few side effects, there is concern about side-effects after long-term use. Although empiric PPI treatment for suspected EE manifestations of GERD instead of prior esophageal 24-hour pH and impedance monitoring is included in several guidelines by various societies, this practice contributes to overtreatment with PPI. CONCLUSION We argue that the current knowledge suggests that diagnostic testing with pH and impedance monitoring rather than empiric PPI treatment should be chosen in a higher proportion of patients presenting with symptoms possibly attributable to EE reflux.
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Affiliation(s)
- Reidar Fossmark
- Department of Clinical and Molecular Medicine, NTNU, Norwegian University of Science and Technology, Prinsesse Kristinas gate 1, Trondheim, 7030, Norway.
- Medicus Endoscopy, Trondheim, Norway.
| | - Eivind Ness-Jensen
- HUNT Research Center, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Levanger, Norway
- Department of Medicine, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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Abstract
Recently, two epidemiological studies showed that long-term treatment with proton pump inhibitors (PPIs) increased the risk of gastric cancer. It is well known that hypergastrinemia predisposes to gastric neoplasia in animals as well as man. Recently a study showed that hypergastrinemic patients had an increased risk of gastric cancer when followed for about 25 years. It is likely that hypergastrinemia is the pathogenic factor for gastric carcinogenesis due to PPI. PPI are the only group of drugs that causes long-term hypergastrinemia in the doses used in a clinical setting. Due to the likely carcinogenic effect, PPIs should be used carefully. Moreover, since the carcinogenic effect of Helicobacter pylori (Hp) infection also may be mediated by an increase in gastrin, Hp should be eradicated whenever treatment with PPI is initiated. In peptic ulcer disease Hp eradication is the treatment of choice. Gastro-oesophageal reflux disease (GERD) is the most prevalent condition leading to long-term use of inhibitors of gastric acid secretion. Only in severe oesophagitis should the treatment be initiated by PPIs, whereas histamine-2 (H-2) blockers ought to be the initial option in most cases of GERD particularly since PPI treatment induces tolerance to H-2 blockers. In the cases where long-term PPI treatment is necessary, the dose should be adjusted by the determination of chromogranin A, which in a way reflects 24-h gastrin exposure. Finally, due to latency of neoplasia, the use of PPI must be very restricted in children and young adults.
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Affiliation(s)
- Helge L Waldum
- a Department of Clinical and Molecular Medicine, Faculty of Medicine , Norwegian University of Science and Technology , Trondheim , Norway.,b Department of Gastroenterology and Hepatology , St. Olav´s University Hospital , Trondheim , Norway
| | - Øystein Sørdal
- b Department of Gastroenterology and Hepatology , St. Olav´s University Hospital , Trondheim , Norway
| | - Reidar Fossmark
- a Department of Clinical and Molecular Medicine, Faculty of Medicine , Norwegian University of Science and Technology , Trondheim , Norway.,b Department of Gastroenterology and Hepatology , St. Olav´s University Hospital , Trondheim , Norway
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Mjønes P, Nordrum IS, Sørdal Ø, Sagatun L, Fossmark R, Sandvik A, Waldum HL. Expression of the Cholecystokinin-B Receptor in Neoplastic Gastric Cells. Discov Oncol 2017; 9:40-54. [PMID: 28980157 PMCID: PMC5775387 DOI: 10.1007/s12672-017-0311-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 09/25/2017] [Indexed: 12/13/2022] Open
Abstract
Gastric cancer is an important disease due to its high mortality. Despite the decline in frequency, most cases are discovered late in its course, and most of the cancer patients die within a few years of diagnosis. In addition to Helicobacter pylori gastritis, gastrin is considered an important factor in the development of this disease, and thus, cholecystokinin-B receptor (CCKBR) becomes of interest. The aim of our study was to explore whether CCKBR is expressed in stomach cancers. Thirty-seven tumors from 19 men and 18 women diagnosed with either adenocarcinoma or neuroendocrine neoplasm (NENs) were included in this study. The tumors were classified into 29 adenocarcinomas and eight NENs. Immunohistochemistry with antibodies against chromogranin A (CgA), synaptophysin and CCKBR, and in situ hybridization with probes against CgA, CCKBR and histidine decarboxylase were used to further explore these tumors. Thirty-three (89%) of the tumors expressed CCKBR protein, whereas only 20 (54%) of all tumors expressed CCKBR mRNA. Of the 20 tumors expressing CCKBR mRNA, eight were NENs and 12 were adenocarcinoma. The highest amount of CCKBR was expressed in NEN. Interestingly, a high degree of co-expression of CCKBR and CgA was observed when the two markers were examined together with in situ hybridization. In conclusion, we found that all eight NENs expressed CCKBR and neuroendocrine markers in a majority of tumor cells. The same markers were also expressed in a proportion of adenocarcinomas supporting the view that gastrin is important in the development of gastric cancer.
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Affiliation(s)
- Patricia Mjønes
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway. .,Department of Pathology, St Olav's Hospital-Trondheim University Hospital, Trondheim, Norway. .,Department of Laboratory Medicine, Children's and Woman's Health, NTNU, Trondheim, Norway.
| | - Ivar S Nordrum
- Department of Pathology, St Olav's Hospital-Trondheim University Hospital, Trondheim, Norway.,Department of Laboratory Medicine, Children's and Woman's Health, NTNU, Trondheim, Norway
| | - Øystein Sørdal
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Gastroenterology and Hepatology, St Olav's Hospital-Trondheim University Hospital, Trondheim, Norway
| | - Liv Sagatun
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Gastroenterology and Hepatology, St Olav's Hospital-Trondheim University Hospital, Trondheim, Norway
| | - Reidar Fossmark
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Gastroenterology and Hepatology, St Olav's Hospital-Trondheim University Hospital, Trondheim, Norway
| | - Arne Sandvik
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Gastroenterology and Hepatology, St Olav's Hospital-Trondheim University Hospital, Trondheim, Norway
| | - Helge L Waldum
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Gastroenterology and Hepatology, St Olav's Hospital-Trondheim University Hospital, Trondheim, Norway
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Mjønes PG, Nordrum IS, Qvigstad G, Sørdal Ø, Rian LLM, Waldum HL. Expression of erythropoietin and neuroendocrine markers in clear cell renal cell carcinoma. APMIS 2017; 125:213-222. [PMID: 28233444 DOI: 10.1111/apm.12654] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 11/26/2016] [Indexed: 12/21/2022]
Abstract
The aim of the study was to investigate the expression of erythropoietin and neuroendocrine markers in clear cell renal cell carcinoma (CCRCC). We retrospectively reviewed the medical records and re-evaluated histopathological specimens of 33 patients with CCRCC and compared with those of 11 cases of non-CCRCC. All patients were treated with a partial or radical nephrectomy at St. Olavs Hospital, Trondheim University Hospital, between 2010 and 2016. Thirty-three patients who were diagnosed with CCRCC had a total of 35 tumours, where 34 of the tumours were CCRCC and one was papillary adenoma. Thirty-three (97%) of 34 CCRCCs were positive for erythropoietin, and the same 33 (97%) tumours demonstrated strong expression for neuron-specific enolase (NSE). Two (6%) of 34 CCRCCs had a positive reaction for synaptophysin, and three (9%) of 34 were positive for CD56. Erythropoietin and NSE were negative in non-CCRCCs, and chromogranin A was negative in all tumours. The above findings suggest that there is a strong association between CCRCC and the expression of erythropoietin and NSE.
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Affiliation(s)
- Patricia G Mjønes
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Department of Pathology and Medical Genetics, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Ivar S Nordrum
- Department of Pathology and Medical Genetics, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Laboratory Medicine, Children's and Woman's Health, NTNU, Trondheim, Norway
| | - Gunnar Qvigstad
- Department of Gastroenterology and Hepatology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Øystein Sørdal
- Department of Gastroenterology and Hepatology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | | | - Helge L Waldum
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Department of Gastroenterology and Hepatology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Abstract
OBJECTIVE E-cadherin plays a crucial role in the adhesion between epithelial cells and thus epithelial integrity. Moreover, germline mutations in the E-cadherin gene (CDH1) causing loss of E-cadherin function (adhesion) leads to hereditary gastric cancer of the diffuse type, according to Laurén. Even sporadic gastric carcinomas of the diffuse type often lose E-cadherin expression due to mutations. Lack of E-cadherin has been recorded at an early phase in such carcinomas. For 25 years, we have provided evidence for neuroendocrine (NE) cell origin of gastric carcinomas of diffuse type. The present study was, therefore, done to examine whether normal NE cells in the gastrointestinal tract express E-cadherin or not. METHODS During upper gastrointestinal endoscopy, biopsies were taken from normal oxyntic mucosa, gastric carcinoids, gastric carcinomas, and from normal duodenal mucosa. Tissues were examined by immunohistochemistry (IHC) using antibodies toward chromogranin A, synaptophysin, and E-cadherin. Isolated mucosal cells were prepared from biopsies of normal mucosa and examined by antibodies against the same markers by immunofluorescence. RESULTS Normal gastrointestinal NE cells did not express E-cadherin as assessed by IHC or immunocytochemistry. No expression of E-cadherin was found on tumor cells from gastric carcinoids or cancer of diffuse type examined by IHC. CONCLUSION Our findings, which are in contrast to some previous studies, may explain why there is a discrepancy between lack of atypia and malignant biological behavior of such tumors. Since they normally lack the adhesion molecule E-cadherin, reflected in their spread occurrence, only minor changes may result in malignant behavior.
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Affiliation(s)
- Helge L Waldum
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology , Trondheim , Norway
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Sørdal Ø, Waldum H, Nordrum IS, Boyce M, Bergh K, Munkvold B, Qvigstad G. The gastrin receptor antagonist netazepide (YF476) prevents oxyntic mucosal inflammation induced by Helicobacter pylori infection in Mongolian gerbils. Helicobacter 2013; 18:397-405. [PMID: 23865485 DOI: 10.1111/hel.12066] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Long-term Helicobacter pylori infection causes gastritis leading to hypergastrinemia and predisposes to gastric cancer. Our aim was to assess the role of gastrin in oxyntic mucosal inflammation in H. pylori-infected Mongolian gerbils by means of the gastrin receptor antagonist netazepide (YF476). DESIGN We studied 60 gerbils for 18 months and left five animals uninfected (control group), inoculated 55 with H. pylori, and treated 28 of the infected animals with netazepide (Hp+YF476 group). Twenty-seven infected animals were given no treatment (Hp group). We measured plasma gastrin and intraluminal pH. H. pylori detection and histologic evaluations of the stomach were carried out. RESULTS All 55 inoculated animals were H. pylori positive at termination. Eighteen animals in the Hp group had gastritis. There was a threefold increase in mucosal thickness in the Hp group compared to the Hp+YF476 group, and a threefold increase in oxyntic neuroendocrine cells in the Hp group compared to the Hp+YF476 group (p < .05). All animals in the Hp+YF476 group had macro- and microscopically normal findings in the stomach. Plasma gastrin was higher in the Hp group than in the control group (172 ± 16 pmol/L vs 124 ± 5 pmol/L, p < .05) and highest in the Hp+YF476 group (530 ± 36 pmol/L). Intraluminal pH was higher in the Hp group than in the Hp+YF476 group (2.51 vs 2.30, p < .05). CONCLUSION The gastrin antagonist netazepide prevents H. pylori-induced gastritis in Mongolian gerbils. Thus, gastrin has a key role in the inflammatory reaction of the gastric mucosa to H. pylori infection in this species.
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Affiliation(s)
- Øystein Sørdal
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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Fossmark R, Sørdal Ø, Jianu CS, Qvigstad G, Nordrum IS, Boyce M, Waldum HL. Treatment of gastric carcinoids type 1 with the gastrin receptor antagonist netazepide (YF476) results in regression of tumours and normalisation of serum chromogranin A. Aliment Pharmacol Ther 2012; 36:1067-75. [PMID: 23072686 DOI: 10.1111/apt.12090] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 09/23/2012] [Accepted: 09/27/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patients with chronic atrophic gastritis have long-term gastric hypoacidity, and secondary hypergastrinaemia. Some also develop gastric ECL cells carcinoids (type 1 GC). Most type 1 GC remain indolent, but some metastasise. Patients undergo surveillance, and some are treated with somatostatin analogues, endoscopic resection or surgery. Netazepide (YF476) is a highly selective, potent and orally active gastrin receptor antagonist, which has anti-tumour activity in various rodent models of gastric neoplasia driven by hypergastrinaemia. Netazepide has been studied in healthy volunteers. AIM To assess the effect of netazepide on type 1 GC. METHODS Eight patients with multiple type 1 GC received oral netazepide once daily for 12 weeks, with follow-up at 12 weeks in an open-label, pilot trial. Upper endoscopy was performed at 0, 6, 12 and 24 weeks, and carcinoids were counted and measured. Fasting serum gastrin and chromogranin A (CgA) and safety and tolerability were assessed at 0, 3, 6, 9, 12 and 24 weeks. RESULTS Netazepide was well tolerated. All patients had a reduction in the number and size of their largest carcinoid. CgA was reduced to normal levels at 3 weeks and remained so until 12 weeks, but had returned to pre-treatment levels at 24 weeks. Gastrin remained unchanged throughout treatment. CONCLUSIONS The gastrin receptor antagonist netazepide is a promising new medical treatment for type 1 gastric carcinoids, which appear to be gastrin-dependent. Controlled studies and long-term treatment are justified to find out whether netazepide treatment can eradicate type 1 gastric carcinoids.
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Affiliation(s)
- R Fossmark
- Department of Gastroenterology and Hepatology, St. Olavs Hospital, Trondheim, Norway.
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