Duodenal Contents Research Articles

Acute pancreatitis as an adverse event in patients with the duodenal-jejunal bypass liner.

Placement of the duodenal-jejunal bypass liner (DJBL) is a minimally invasive technique for the management of patients with type 2 diabetes mellitus and obesity. Acute pancreatitis was seen in 5 of 167 patients (3 %) in our series. It is suggested that acute pancreatitis in patients with the DJBL results from either direct blockage or edema of the major duodenal papilla, which may be caused by the following: migration of the anchor of the DJBL, accumulation of food debris between the liner and the duodenal wall, or reflux of duodenal contents into the pancreatic duct due to intraluminal hypertension caused by the liner. Early removal of the DJBL resulted in fast and complete recovery, whereas delayed diagnosis and removal led to severe, necrotizing acute pancreatitis.

Gastrointestinal behavior of nano- and microsized fenofibrate: In vivo evaluation in man and in vitro simulation by assessment of the permeation potential

IntroductionThe purpose of this study was (i) to evaluate the gastrointestinal behavior of micro- and nanosized fenofibrate in humans and (ii) to develop a simple yet qualitatively predictive in vitro setup that simulates the observed absorption-determining factors. Materials and methodsCommercially available micro- and nanoparticles of fenofibrate (Lipanthyl® and Lipanthylnano®, respectively) were administered orally to five healthy volunteers in fasting and postprandial conditions. Intraluminal and systemic drug concentrations were determined as reference data for the development of a predictive in vitro setup. To capture the observed solubility/permeability interplay, in vitro dissolution testing was performed in the presence of a permeation bag with sink conditions. ResultsIn fasting conditions, intake of nanosized fenofibrate generated increased duodenal concentrations compared to microsized fenofibrate, which was reflected in an improved systemic exposure. In postprandial conditions, duodenal concentrations were greatly enhanced for both formulations, however without an accompanying increase in systemic exposure. It appeared that micellar encapsulation of the highly lipohilic fenofibrate limited its potential to permeate from fed state intestinal fluids. To capture these in vivo observations in an in vitro setup, classic dissolution testing was combined with permeation assessment into a permeation bag with sink conditions. In case of fasting conditions, the dissolution/permeation approach allowed for an improved discriminative power between micro- and nanosized fenofibrate by better simulating the dynamic interplay of dissolution and absorption. In case of postprandial conditions, the observed solubility–permeability interplay could be simulated using the dissolution/permeation approach in combination with biorelevant media (FeSSGFFortimel and FeSSIF-V2) to mimic micellar entrapment and reduced permeation potential of fenofibrate. ConclusionFor the first time, reduced permeation of a lipophilic drug despite increased intraluminal concentrations, was demonstrated in humans. Dissolution testing using biorelevant media in combination with permeation assessment into a sink permeation bag appeared to be a simple yet pragmatic approach to capture this solubility–permeability interplay in early formulation evaluation.

Two distinct etiologies of gastric cardia adenocarcinoma: interactions among pH, Helicobacter pylori, and bile acids.

Gastric cancer can be classified as cardia and non-cardia subtypes according to the anatomic site. Although the gastric cancer incidence has decreased steadily in several countries over the past 50 years, the incidence of cardia cancers and esophageal adenocarcinoma (EAC) continue to increase. The etiological factors involved in the development of both cardia cancers and EACs are associated with high animal fat intake, which causes severe obesity. Central obesity plays roles in cardiac-type mucosa lengthening and partial hiatus hernia development. There are two distinct etiologies of cardia cancer subtypes: one associated with gastroesophageal reflux (GER), which predominantly occurs in patients without Helicobacter pylori (H. pylori) infection and resembles EAC, and the other associated with H. pylori atrophic gastritis, which resembles non-cardia cancer. The former can be developed in the environment of high volume duodenal content reflux, including bile acids and a higher acid production in H. pylori–negative patients. N-nitroso compounds, which are generated from the refluxate that includes a large volume of bile acids and are stabilized in the stomach (which has high levels of gastric acid), play a pivotal role in this carcinogenesis. The latter can be associated with the changing colonization of H. pylori from the distal to the proximal stomach with atrophic gastritis because a high concentration of soluble bile acids in an environment of low acid production is likely to act as a bactericide or chemorepellent for H. pylori in the distal stomach. The manuscript introduces new insights in causative factors of adenocarcinoma of the cardia about the role of bile acids in gastro-esophageal refluxate based upon robust evidences supporting interactions among pH, H. pylori, and bile acids.

Duodenal Contents Reflux can Induce Esophageal Squamous Cell Carcinoma as Well as Adenocarcinoma

Duodenal Contents Reflux can Induce Esophageal Squamous Cell Carcinoma as Well as Adenocarcinoma

Effect of Origanum chemotypes on broiler intestinal bacteria

Essential oils have been proposed as alternatives to antibiotic use in food animal production. This study evaluated 3 chemotypes of the Origanum genus, containing varying amounts of secondary metabolites carvacrol, thymol, and sabinene, in the broiler chicken diet. Aerial parts of Origanum vulgare L. (OL), O. vulgare L. ssp. hirtum (OH), and O. majorana (OM) were collected from a greenhouse located in the high altitude Sabana de Bogotá (Savanna of Bogotá) and O. vulgare L. ssp. hirtum (OG) produced and ground in Greece. Oregano essential oils (OEO) from these plants were obtained by steam distillation and analyzed by gas chromatography coupled to a mass spectrometer. Six treatments were evaluated: 200 mg/kg of OEO from OH, OL, and OM, 50 mg/kg of OEO from OG, 500 mg/kg of chlortetracycline, and without additives. Broiler chicks were maintained at 2,600 m above sea level, placed in brooder cages under a completely randomized design. Template DNA was isolated from duodenal, jejunal, ileal, and cecal contents in each group and bacterial 16S rDNA patterns were analyzed by denaturing gradient gel electrophoresis. Dendrograms of denaturing gradient gel electrophoresis band patterns revealed 2 main clusters, OEO-treated chicks and nontreated control chicks, in each intestinal segment. Band patterns from different gut compartments revealed major bacterial population shifts in the foregut (duodenum, jejunum, and ileum) compared with the hindgut (cecum and colon) at all ages evaluated (P < 0.05). The OEO groups showed less shift (62.7% similarity coefficient) between these 2 compartments versus the control groups (53.7% similarity coefficient). A reduction of 59% in mortality from ascites was seen in additive-supplemented groups compared with the control group. This study represents the first work to evaluate the effects of the 3 main chemotypes of Origanum genus in broilers.

The mycotoxin deoxynivalenol predisposes for the development of Clostridium perfringens-induced necrotic enteritis in broiler chickens.

Both mycotoxin contamination of feed and Clostridium perfringens-induced necrotic enteritis have an increasing global economic impact on poultry production. Especially the Fusarium mycotoxin deoxynivalenol (DON) is a common feed contaminant. This study aimed at examining the predisposing effect of DON on the development of necrotic enteritis in broiler chickens. An experimental Clostridium perfringens infection study revealed that DON, at a contamination level of 3,000 to 4,000 µg/kg feed, increased the percentage of birds with subclinical necrotic enteritis from 20±2.6% to 47±3.0% (P<0.001). DON significantly reduced the transepithelial electrical resistance in duodenal segments (P<0.001) and decreased duodenal villus height (P = 0.014) indicating intestinal barrier disruption and intestinal epithelial damage, respectively. This may lead to an increased permeability of the intestinal epithelium and decreased absorption of dietary proteins. Protein analysis of duodenal content indeed showed that DON contamination resulted in a significant increase in total protein concentration (P = 0.023). Furthermore, DON had no effect on in vitro growth, alpha toxin production and netB toxin transcription of Clostridium perfringens. In conclusion, feed contamination with DON at concentrations below the European maximum guidance level of 5,000 µg/kg feed, is a predisposing factor for the development of necrotic enteritis in broilers. These results are associated with a negative effect of DON on the intestinal barrier function and increased intestinal protein availability, which may stimulate growth and toxin production of Clostridium perfringens.

Gastrointestinal transfer: In vivo evaluation and implementation in in vitro and in silico predictive tools

IntroductionThe purpose of this study was to explore the transfer of drug solutions from stomach to small intestine and its impact on intraluminal drug concentrations in humans. The collected intraluminal data were used as reference to evaluate simulations of gastrointestinal transfer currently implemented in different in vitro and in silico absorption models. MethodsGastric and duodenal concentrations of the highly soluble and non-absorbable compound paromomycin were determined following oral administration to 5 healthy volunteers under the following conditions: fasted state, fed state and fed state in the presence of a transit-stimulating (domperidone) or transit-inhibiting (loperamide) agent. Based on the obtained intraluminal concentration–time profiles, gastrointestinal transfer (expressed as the half-life of gastric emptying) was analyzed using physiologically-based parameter estimation in Simcyp®. Subsequently, the observed transfer profiles were used to judge the implementation of gastrointestinal transfer in 2 in vitro simulation tools (the TNO Intestinal Model TIM-1 and a three-compartmental in vitro model) and the Simcyp® population-based PBPK modeling platform. ResultsThe observed duodenal concentration–time profile of paromomycin under fasting conditions, with a high average Cmax obtained after 15min, clearly indicated a fast transfer of drug solutions from stomach to duodenum (estimated gastric half-life between 4 and 13min). The three-compartmental in vitro model adequately reflected the in vivo fasted state gastrointestinal transfer of paromomycin. For both TIM-1 and Simcyp®, modifications in gastric emptying and dilutions were required to improve the simulation of the transfer of drug solutions. As expected, transfer from stomach to duodenum was delayed in the fed state, resulting in lower duodenal paromomycin concentrations and an estimated gastric half-life between 21 and 40min. Administration of domperidone or loperamide as transit-stimulating and transit-inhibiting agent, respectively, did not affect the fed state gastric half-life of emptying. ConclusionFor the first time, the impact of gastrointestinal transfer of solutions on intraluminal drug concentrations was directly assessed in humans. In vitro and in silico simulation tools have been validated and optimized using the in vivo data as reference.

Classification schema of symptomatic enterogastric reflux utilizing sincalide augmentation on hepatobiliary scintigraphy.

Enterogastric reflux (EGR) is the reflux of duodenal contents into the stomach. Hepatobiliary scintigraphy provides physiologic assessment of the biliary system and was used to test the hypothesis that presence and timing of EGR may be associated with infusion of sincalide, a surrogate of endogenous cholecystokinin. One hundred fifty-seven hepatobiliary scintigraphy studies were retrospectively reviewed. Data included EGR incidence on initial reports, incidence after masked second reads, and time of EGR onset in relation to sincalide infusion. EGR cases were then classified according to onset on pre-, post-, or both presincalide and postsincalide imaging. Time of EGR onset at 19-24 minutes after start of a 15-min sincalide infusion differed significantly from normal (p<0.0001). EGR was initially reported in 14 of 157 cases (8.9%) but found in 38 of 157 cases on masked second reads (24.2%), corresponding to a 15.3% discrepancy rate. The temporal association of EGR onset with sincalide infusion may identify patients with EGR mimicking chronic cholecystitis or biliary dyskinesia. A novel classification schema was therefore developed as a framework for future research, utilizing EGR onset in relation to pre-, post-, or both presincalide and postsincalide imaging as a hypothetical biomarker of clinically significant EGR.

Effect of surfactants, gastric emptying, and dosage form on supersaturation of dipyridamole in an in vitro model simulating the stomach and duodenum.

The purpose of this study was to investigate the influence of gastric emptying patterns, surfactants, and dosage form on the supersaturation of a poorly soluble weakly basic drug, dipyridamole, using an in vitro model mimicking the dynamic environment of the upper gastrointestinal tract, and, furthermore, to evaluate the usefulness of this model in establishing correlations to in vivo bioavailability for drugs with solubility/dissolution limited absorption. A simulated stomach duodenum model comprising four compartments was used to assess supersaturation and precipitation kinetics as a function of time. It integrates physiologically relevant fluid volumes, fluid transfer rates, and pH changes of the upper GI tract. Monoexponential gastric emptying patterns simulating the fasted state were compared to linear gastric emptying patterns simulating the fed state. The effect of different surfactants commonly used in oral preparations, specifically, sodium lauryl sulfate (SLS), poloxamer-188, and polysorbate-80, on dipyridamole supersaturation was investigated while maintaining surface tension of the simulated gastric fluids at physiological levels and without obtaining artificial micellar solubilization of the drug. The supersaturation behavior of different dose strengths of dipyridamole was explored. Significant levels of dipyridamole supersaturation were observed in the duodenal compartment under all the different in vivo relevant conditions explored. Dipyridamole supersaturation ratios of up to 11-fold have been observed, and supersaturation has been maintained for up to 120 min. Lower duodenal concentrations of dipyridamole were observed under linear gastric emptying patterns compared to mononexponential gastric emptying. The mean duodenal area under concentration-time curves (AUC60min) for the dipyridamole concentration profile in the duodenal compartment is significantly different for all the surfactants explored (P < 0.05). Our investigations with the different surfactants and comparison of dosage form (solution versus suspension) on the precipitation of dipyridamole revealed that crystal growth, rather than nucleation, is the rate-limiting step for the precipitation of dipyridamole. A linear dose-response relationship was found for the mean in vitro duodenal area under concentration-time curves (AUC∞) in the dose range of 25 mg to 100 mg (R(2) = 0.886). This is in agreement with the pharmacokinetic data of dipyridamole reported in the literature. The simulated stomach duodenum model can provide a reliable and discriminative screening tool for exploring the effect of different physiological variables or formulations on the supersaturation/precipitation kinetics of weakly basic drugs with solubility limited absorption. The amount of drug in solution in the duodenal compartment of the SSD correlates to bioavailability for the weakly basic drug, dipyridamole, which has solubility limited absorption and undergoes supersaturation/precipitation.

Impact of histone deacetylase 1 and metastasis-associated gene 1 expression in esophageal carcinogenesis.

Animal models are important for the development of novel therapies for esophageal cancer. Histone deacetylase 1 (HDAC1)/metastasis-associated gene (MTA1) complexes inhibit p53 acetylation and thus, inhibit p53-induced apoptosis. The aim of the present study was to evaluate HDAC1 and MTA1 expression in esophageal carcinogenesis in rats. The rats underwent a total gastrectomy followed by esophagojejunostomy to induce chronic duodenal content reflux esophagitis. The rats were sacrificed sequentially at 20, 30, 40 and 50 weeks post-surgery and the esophagi were examined. Immunohistochemical analysis was conducted to assess the expression and localization of HDAC1 and MTA1. At 20 weeks post-surgery, squamous proliferative hyperplasia and Barrett’s metaplasia (BM) were observed. While, adenocarcinoma-associated BM and squamous cell carcinoma were observed at 30–50 weeks post-surgery. The nuclear expression of HDAC1 and MTA1 was observed in all of the stages of squamous carcinogenesis and adenocarcinogenesis, although not in the normal esophageal epithelium. The expression of HDAC1 and MTA1 may be involved in duodenoesophageal reflux-induced neoplastic transformation of the esophageal mucosa into cancer cells with squamous and adeno differentiation.

Su2096 Gluten Degrading Enzyme Effectively Digests Gluten in the Stomach and Small Intestine of Healthy Volunteers

A significant proportion of the population does not tolerate gluten. Aspergillus niger prolyl endopeptidase (AN-PEP) enzyme efficiently degrades gluten molecules into non-immunogenic peptides in a dynamic, multi-compartmental gastrointestinal simulation model but its efficacy in vivo remains to be established. Aim of our study was to assess the efficacy of ANPEP on gastrointestinal breakdown of gluten in healthy subjects, as well as the effect of meal caloric density on AN-PEP efficiency. Methods: In this double-blind, randomized, placebo-controlled cross-over study 12 healthy subjects attended to four test days in random order. On each occasion they received a low (143 kCal) or high caloric (405 kCal) meal, containing 4g gluten, with AN-PEP or placebo via a triple-lumen nasoduodenal catheter. Acetaminophen was added to measure gastric emptying rate. One lumen, positioned in the stomach, was used for administration of the test meal and collection of gastric fluid. A second lumen was used for the continuous injection of the inert dilution marker polyethylene glycol 3350 (PEG3350) to enable the calculation of meal dilution by endogenous secretions, with the injection port positioned just distal to the pylorus. A third lumen, located at the tube tip 10 cm distal to the second port, was used for collection of duodenal content. Fluid samples were taken regularly during 4 hours after meal infusion. The presence of the DQ2.5glia-α3 epitopes was quantified using the Gluten-Tec® ELISA assay, which provides an accurate estimate of the actual α-gliadin content of the samples. Degradation of intact gluten proteins was measured by Western-Blot analysis. Duodenal PEG3350 concentrations and gastric acetaminophen concentrations were determined by high-performance liquid chromatography. The effect of AN-PEP on gluten degradation was measured by the difference in 240-minute Area Under the Curve (AUC) of relative and absolute gluten exposure between AN-PEP and placebo. Differences between combinations of treatment and meal were assessed using linear mixed models. Results: AN-PEP significantly reduced gliadin concentration and absolute output in the stomach and duodenum (as 240-min AUCs) in both low and high caloric meals, compared to placebo. Furthermore, in the high caloric meal with placebo the duodenal gliadin concentration was lower, compared to the low caloric meal with placebo. No differences were observed between gliadin concentrations of a low or high caloric meal containing AN-PEP (Table). The gastric emptying time of the high caloric meal was longer compared to the low caloric meal, both in the presence of placebo (p=0.014) and AN-PEP (p=0.100). Conclusion: AN-PEP addition to a gluten containing meal significantly enhances gluten digestion in healthy volunteers. Meal caloric density does not affect the efficacy of AN-PEP on gluten degradation. Gliadin concentration and absolute output in stomach and duodenum

LIM homeodomain transcription factor Isl1 directs normal pyloric development by targeting Gata3

BackgroundAbnormalities in pyloric development or in contractile function of the pylorus cause reflux of duodenal contents into the stomach and increase the risk of gastric metaplasia and cancer. Abnormalities of the pyloric region are also linked to congenital defects such as the relatively common neonatal hypertrophic pyloric stenosis, and primary duodenogastric reflux. Therefore, understanding pyloric development is of great clinical relevance. Here, we investigated the role of the LIM homeodomain transcription factor Isl1 in pyloric development.ResultsExamination of Isl1 expression in developing mouse stomach by immunohistochemistry, whole mount in situ hybridization and real-time quantitative PCR demonstrated that Isl1 is highly expressed in developing mouse stomach, principally in the smooth muscle layer of the pylorus. Isl1 expression was also examined by immunofluorescence in human hypertrophic pyloric stenosis where the majority of smooth muscle cells were found to express Isl1. Isl1 function in embryonic stomach development was investigated utilizing a tamoxifen-inducible Isl1 knockout mouse model. Isl1 deficiency led to nearly complete absence of the pyloric outer longitudinal muscle layer at embryonic day 18.5, which is consistent with Gata3 null mouse phenotype. Chromatin immunoprecipitation, luciferase assays, and electrophoretic mobility shift assays revealed that Isl1 ensures normal pyloric development by directly targeting Gata3.ConclusionsThis study demonstrates that the Isl1-Gata3 transcription regulatory axis is essential for normal pyloric development. These findings are highly clinically relevant and may help to better understand pathways leading to pyloric disease.

Accumulation of monepantel and its sulphone derivative in tissues of nematode location in sheep: Pharmacokinetic support to its excellent nematodicidal activity

The amino-acetonitrile derivatives (AADs) are a new class of anthelmintic molecules active against a wide range of sheep gastrointestinal (GI) nematodes including those that are resistant to other anthelmintic families. The plasma disposition of monepantel (MNP) has been previously characterized in sheep. However, information on drug concentration profiles attained at tissues of parasite location is necessary to fully understand the pharmacological action of this novel compound. The current work aimed to study the relationship between the concentrations of MNP parent drug and its main metabolite monepantel sulphone (MNPSO2), measured in the bloodstream and in different GI tissues of parasite location in sheep. Twenty two (22) uninfected healthy Romney Marsh lambs received MNP (Zolvix®, Novartis Animal Health) orally administered at 2.5mg/kg. Blood samples were collected from six animals between 0 and 14 days post-treatment to characterize the drug/metabolite plasma disposition kinetics. Additionally, 16 lambs were sacrificed at 8, 24, 48 and 96h post-administration to assess the drug concentrations in the GI fluid contents and tissues. MNP and MNPSO2 concentrations were determined by HPLC. MNP parent compound was rapidly oxidized into MNPSO2. MNP systemic availability was significantly lower than that observed for MNPSO2. The peak plasma concentrations were 15.1 (MNP) and 61.4ng/ml (MNPSO2). The MNPSO2 to MNP plasma concentration profile ratio (values expressed in AUC) reached a value of 12. Markedly higher concentrations of MNP and MNPSO2 were measured in both abomasal and duodenal fluid contents, and mucosal tissues compared to those recovered from the bloodstream. A great MNP availability was measured in the abomasal content with concentration values ranging between 2000 and 4000ng/g during the first 48h post-treatment. Interestingly, the metabolite MNPSO2 was also recovered in abomasal content but its concentrations were significantly lower compared to MNP. The parent drug and its sulphone metabolite were detected in the different segments of the sheep intestine. MNPSO2 concentrations in the different intestine sections sampled were significantly higher compared to those measured in the abomasum. Although MNP is metabolized to MNPSO2 in the liver, the large concentrations of both anthelmintically active molecules recovered during the first 48h post-treatment from the abomasum and small intestine may greatly contribute to the well-established pharmacological activity of MNP against GI nematodes.

The effects of aqueous extract of Aloe vera leaves on the gastric acid secretion and brain and intestinal water content following acetic acid- induced gastric ulcer in male rats.

Gut-brain axis (GBA) is very important in creation and modulation of gastrointestinal problems. Aloe vera gel has gastroprotective properties. The purpose of this study was to evaluate the effect of aqueous extract of Aloe vera leaves on the gastric acid secretion and brain and intestinal water content following acetic acid gastric ulcer induction. Gastric ulcer was induced by injection of 20% acetic acid into the subserosal layer in male rats. Rats were randomly assigned into three groups: intact group, gastric ulcer group and Aloe vera group (treatment with Aloe vera following gastric ulcer induction). The acid levels and brain and intestinal water content of each sample were measured eight days after the gastric ulcer induction. Gastric acid levels were significantly decreased in Aloe vera group when compared with gastric ulcer group (p<0.05). However, there were no differences in acid output between gastric ulcer and Aloe vera groups with intact group. After Aloe vera administration, the amount of brain water content had no difference with intact and gastric ulcer groups (p<0.05). The duodenal water content in Aloe vera group was significantly reduced compared with intact group (p<0.05) but gastric ulcer group had no significant difference with intact and Aloe vera group. The administration of Aloe vera has an inhibitory effect on the gastric acid output.

Impact of Inflammation–Metaplasia–Adenocarcinoma Sequence and Inflammatory Microenvironment in Esophageal Carcinogenesis Using Surgical Rat Models

Chronic inflammation has been demonstrated to correlate with tumor onset and progression. Tumor-associated macrophages (TAMs) play an important role in inflammatory tumor microenvironment. We hypothesized that an inflammatory microenvironment around TAMs may promote the development of esophageal carcinomas when induced by duodenal content reflux without carcinogens. A total gastrectomy followed by esophagojejunostomy was performed on rats in order to induce chronic duodenal content reflux esophagitis. The animals were sacrificed sequentially, at the 20th, 30th, 40th and 50th week after surgery, and their esophagi were examined. The primary antibodies against CD68, CD163, pStat3 and Foxp3 were used. Expression and localization of infiltrated cells was assessed by immunohistochemical analysis. At 20-weeks' post-surgery, squamous proliferative hyperplasia (PHP) and Barrett's metaplasia (BM) were observed. Adenocarcinoma (ADC) associated with BM, and squamous cell carcinoma (SCC) were observed 30-50weeks' post-surgery. Numerous CD68 and pStat3-positive cells were identified surrounding PHP and BM after 20weeks, and around ADC and SCC after 30weeks. Moderate infiltration of CD163-positive macrophages was seen with BM, ADC, and SCC after 30weeks. However, very few Foxp3-positive cells were observed around ADC and SCC. Macrophages infiltrate the esophagus and activate the pStat3 pathway in stromal cells and epithelium. M2 phenotype macrophages infiltrate following infiltration of M1 macrophage and contribute to tumor development through regulatory T cells (Tregs). The involvement of immune cells such as TAMs and Tregs in the inflammatory microenvironment promotes esophageal carcinogenesis.

Overexpression of gastric leptin precedes adipocyte leptin during high-fat diet and is linked to 5HT-containing enterochromaffin cells

In obesity, while hyperleptinemia highly correlates with excess fat mass, the status of gastric leptin remains unknown. Here, we investigated the expression of leptin in stomach biopsies of obese humans and analyzed the temporal changes of gastric leptin expression in response to diet-induced obesity and its impact on 5-hydroxytryptamine (5HT)-producing cells. Enterochromaffin (EC) cells and expression of leptin, PAX4 (critical factor for EC specification), tryptophane hydroxylase-1 (TPH1, the peripheral rate-limiting enzyme for 5HT) and 5HT were examined by immunofluorescence, quantitative real-time PCR, radioimmunoassay, respectively, in stomach and duodenum biopsies from 19 obese and 14 normo-weighed individuals, and in mucosa scrapings from C57Bl6/J diet-induced obese mice, leptin-deficient ob/ob mice and intestine-specific leptin receptor isoform B-deficient mice. Gastric mucosa of obese subjects displays an increased expression of leptin (LEP mRNA by fivefold and protein by twofold, P<0.01), TPH1 ((1.75-2.73, 95% confidence interval (CI)) vs (0.38-0.67, 95% CI); P<0.01) and PAX4 ((1.33-2.11, 95%CI) vs (0.62-0.81, 95% CI); P<0.01) as compared with normo-weighed individuals. In diet-induced obese mice, the overexpressions of gastric leptin, antral Pax4, Tph1 and increased EC cell number occurred before the onset of obesity and hyperleptinemia (reflect of adipocyte leptin production). In addition, leptin deficiency was associated with reduced Pax4 mRNA, whereas oral leptin treatment enhanced both Tph1 and Pax4 mRNA. Finally, mice with an intestine-specific deletion of leptin signaling exhibit significant decrease in duodenal mucosa 5HT content. These data demonstrate that gastric leptin is upregulated in obese individuals. RESULTS from high-fat diet mice showed that overexpression of gastric leptin that is linked to gut '5HT pathway' occurred before the onset of obesity and expansion of fat mass. This may be relevant in the pathophysiology of obesity.

Gastroesophageal Reflux Symptoms not Responding to Proton Pump Inhibitor: GERD, NERD, NARD, Esophageal Hypersensitivity or Dyspepsia?

Gastroesophageal reflux (GER) is a common gastrointestinal process that can generate symptoms of heartburn and chest pain. Proton pump inhibitors (PPIs) are the gold standard for the treatment of GER; however, a substantial group of GER patients fail to respond to PPIs. In the past, it was believed that acid reflux into the esophagus causes all, or at least the majority, of symptoms attributed to GER, with both erosive esophagitis and nonerosive outcomes. However, with modern testing techniques it has been shown that, in addition to acid reflux, the reflux of nonacid gastric and duodenal contents into the esophagus may also induce GER symptoms. It remains unknown how weakly acidic or alkaline refluxate with a pH similar to a normal diet induces GER symptoms. Esophageal hypersensitivity or functional dyspepsia with superimposed heartburn may be other mechanisms of symptom generation, often completely unrelated to GER. Detailed studies investigating the pathophysiology of esophageal hypersensitivity are not conclusive, and definitions of the various disease states may overlap and are often confusing. The authors aim to clarify the pathophysiology, definition, diagnostic techniques and medical treatment of patients with heartburn symptoms who fail PPI therapy.

Effects of bile acids on cyclooxygenase-2 expression in a rat model of duodenoesophageal anastomosis.

To examine the expression of cyclooxygenase-2 (COX-2) and prostaglandin E2 (PGE2) in rat esophageal lesions induced by reflux of duodenal contents. Thirty 8-week-old male Wistar rats were exposed to duodenal content esophageal reflux. All animals underwent an esophagoduodenal anastomosis (EDA) with total gastrectomy to elicit chronic esophagitis. In ten rats sham operations with only a midline laparotomy were performed (Control). The rats were sacrificed at the 40(th) week, their esophagi were taken for hematoxylin and eosin staining and for examination of expression of COX2, PGE2, and proliferating cell nuclear antigen (PCNA), and total bile acids in the esophageal lumen was measured. After 40 wk of reflux, columnar dysplasia, squamous cell carcinoma and adenocarcinoma were observed. Total bile acids in the esophageal lumen were significantly increased in the EDA group compared with the sham operated rats. PCNA labelling index and esophageal tissue PGE2 levels were higher in dysplastic and cancer tissues than in control tissues. Overexpression of COX2 was observed in dysplastic and cancer tissues. Reflux of duodenal contents induces COX2 expression and increases prostaglandin synthesis in dysplastic and cancer tissues. This result suggests a possible mechanism by which bile acids promote esophageal cancer.

Efficacy of combination therapy (metronidazole and/or artemether) in experimental giardiasis and its impact on nonenzymatic oxidative stress biomarkers

BackgroundGiardia lamblia trophozoites colonize in the upper small intestine resulting in diarrhea and various clinical manifestations, including abdominal pain, anorexia, and signs of malabsorption. A decrease in the level of trace elements might occur because of this absorption deficiency resulting from giardiasis. Experimentally, the excretory secretory product of G. lamblia trophozoites increased the level of reactive oxygen species in mice enterocytes. The levels of bilirubin, uric acid, and albumin are often used as major nonenzymatic oxidative biomarkers.ObjectiveThis study was designed to determine the effect of therapy by metronidazole (MTZ) and artemether (ART) on trophozoite and cyst forms in experimentally Giardia spp.-infected hamsters and to reveal the changes in iron (Fe), manganese (Mn), copper (Cu), and chromium (Cr) serum levels pretreatment and post-treatment. Another objective was to evaluate the impact of this therapy on serum levels of bilirubin, uric acid, and albumin as nonenzymatic oxidative stress biomarkers.Materials and methodsHamsters were divided into four groups: the control group I included two subgroups, Ia (noninfected, nontreated) and Ib (infected, nontreated); group II (infected and treated with MTZ); group III (infected and treated with ART); and group IV (infected and treated with combined therapy of MTZ+ART). Hamsters of all four groups were killed 5 weeks postinfection (PI) - that is, 2 weeks after treatment - to evaluate drug efficacy. Stool samples and duodenal contents were examined to count the number of G. lamblia cysts and trophozoites, respectively. Blood samples were also collected to estimate trace elements (Fe, Mn, Cu, and Cr) as well as nonenzymatic oxidative stress biomarkers (bilirubin, uric acid, and albumin).ResultsThere was a significant reduction in trophozoite and cyst counts following treatment with ART alone (88 and 82.5%, respectively) as compared with the infected control group Ib. Treatment with MTZ alone and in combination with ART also yielded a very high percentage of reduction in both trophozoites (94.2 and 98.3%, respectively) and cysts counts (93.9 and 95.5%, respectively). The trace elements in serum of infected controls (Ib) displayed nonsignificant decrease in Fe and significant decrease in Mn levels as compared with their levels in noninfected hamsters of group Ia. Cu levels increased in the infected group and were still increased after treatment with either MTZ or ART but decreased to normal with the combined therapy. Cr levels showed no significant change in all groups. Uric acid increased in infected controls as compared with normal controls. Treatment with MTZ or ART alone decreased uric acid levels lower than normal, and the combination of both drugs normalized its levels. Evaluation of serum bilirubin levels in the infected group and in those treated by MTZ and ART alone did not show any statistically significant differences compared with the normal noninfected group. Treatment with the combined therapy yielded even slightly lower insignificant level. Albumin level also did not differ significantly except in the combined regimen where it was lower than the normal range.ConclusionThe effect of giardiasis on the changes in the level of trace elements and nonenzymatic oxidative stress biomarkers is relevant in this study. The combined therapy produced significant parasite eradication and normalized the studied parameters with the exception of Mn and albumin levels, which were adversely affected and remained lower than normal. Further studies are needed to evaluate these data in undernourished and chronically infected hamsters.

Duodenogastric Reflux after Biliary Procedure

Duodenogastric reflux (DGR) is a poorly understood gastrointestinal process that is defined as reflux of duodenal contents into the stomach. Therapeutic biliary procedures disrupt the function of the sphincter of Oddi. Patients are potential “bile refluxers”. Methods: The present study was carried out to document the incidence and evaluate the clinical significance of DGR after cholecystectomy (n = 9) and choledochoduodenostomy (CDD) (n = 6). Duodenogastric reflux was quantified using continuous intravenous infusion of 99mTc-HIDA. They are studied by symptom evaluation and hepatobiliary scintigraphy. The scintigraphic findings were then compared with those of nine patients who had undergone cholecystectomy alone. Results: The incidence of DGR after CDD was 67% compared to 22% in the cholecystectomy alone group (P 99mTc-HIDA scanning of the hepatobiliary system is a reasonable and reliable method for the quantitative evaluation of DGR. CDD is frequently associated with mild to moderate DGR compared to cholecystectomy alone group. We need to understand these issues to adequately advise patients of the implications of cholecystectomy and CDD