The histological and immunohistochemical aspects of bile reflux in patients with gastroesophageal reflux disease

Andreas Nakos, Georgios Kouklakis, Michail Pitiakoudis, Petros Zezos, Eleni Efraimidou, Alexandra Giatromanolaki, Alexandros Polychronidis, Nikolaos Liratzopoulos, Efthimios Sivridis, Konstantinos Simopoulos, Andreas Nakos, Georgios Kouklakis, Michail Pitiakoudis, Petros Zezos, Eleni Efraimidou, Alexandra Giatromanolaki, Alexandros Polychronidis, Nikolaos Liratzopoulos, Efthimios Sivridis, Konstantinos Simopoulos

Abstract

Introduction. The pathogenesis of GERD is strongly related with mixed acid and bile reflux. Benign and malignant esophageal and gastric lesions have been associated with synergetic activity between those parameters. Bile reflux causes reactive gastropathy evaluated with Bile Reflux Index (BRI). The aim was to investigate if the sequence: bile reflux-intestinal metaplasia-GERD-esophagitis, is associated with apoptotic/oncogenetic disturbances. Materials/Methods. Fifteen asymptomatic subjects and 53 GERD patients underwent gastroscopy with biopsies. The specimens examined histologically and immunohistochemically for p53, Ki-67, Bax, and Bcl-2. Results. Elevated BRI score detected in 47% (25/53) of patients with GERD and in 13% (2/15) of controls (P = 0.02). Severe esophageal lesions were significantly more common in BRI (+) patients (14/25) compared to BRI (-) ones (P = 0.0049). Immunohistochemical analysis did not show associations between BRI score and biomarker expression. Conclusions. Bile reflux gastropathy is associated with GERD severity, but not with oncogene expression or apoptotic discrepancies of the upper GI mucosa.

Figures

Figure 1
Figure 1
Bax expression in gastric mucosa in healthy controls (HCs) and GERD patients, in relation to BRI status. Grouped data are presented in 100% display stacked columns for each grade (n; %). According to the percentages of the stained epithelial cells, the immunohistological sections were scored and graded as follows: 0 = absence of staining, 1 = staining up to 5%, 2 = staining >5%–10%, 3 = staining >10%–25%, 4 = staining >25%–50%, and 5 = staining >51%.
Figure 2
Figure 2
Bcl-2 expression in gastric mucosa in healthy controls (HC) and GERD patients, in relation to BRI status. Grouped data are presented in 100% display stacked columns for each grade (n; %). According to the percentages of the stained epithelial cells, the immunohistological sections were scored and graded as follows: 0 = absence of staining, 1 = staining up to 5%, 2 = staining >5%–10%, 3 = staining >10%–25%, 4 = staining >25%–50%, and 5 = staining >51%.
Figure 3
Figure 3
Ki-67 expression in the gastric mucosa (magnification ×100). The immunoreactive cells (dark nuclei) are mainly located at the base of the epithelium.

References

    1. Spechler SJ. Epidemiology and natural history of gastro-oesophageal reflux disease. Digestion. 1992;51(1, supplement):24–29.
    1. Locke GR, III, Talley NJ, Fett SL, Zinsmeister AR, Melton LJ. Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmsted County, Minnesota. Gastroenterology. 1997;112(5):1448–1456.
    1. Holloway RH, Kocyan P, Dent J. Provocation of transient lower esophageal sphincter relaxations by meals in patients with symptomatic gastroesophageal reflux. Digestive Diseases and Sciences. 1991;36(8):1034–1039.
    1. Hirschowitz BI. Gastric secretion of acid and pepsin in patients with esophageal stricture and appropriate controls. Digestive Diseases and Sciences. 1996;41(11):2115–2122.
    1. Lirón R, Parrilla P, De Haro LFM, et al. Quantification of duodenogastric reflux in Barrett’s esophagus. American Journal of Gastroenterology. 1997;92(1):32–36.
    1. Avidan B, Sonnenberg A, Schnell TG, Sontag SJ. Acid reflux is a poor predictor for severity of erosive reflux esophagitis. Digestive Diseases and Sciences. 2002;47(11):2565–2573.
    1. Koek GH, Sifrim D, Lerut T, Janssens J, Tack J. Multivariate analysis of the association of acid and duodeno-gastro- oesophageal reflux exposure with the presence of oesophagitis, the severity of oesophagitis and Barrett’s oesophagus. Gut. 2008;57(8):1056–1064.
    1. Shi G, Bruley Des Varannes S, Scarpignato C, Le Rhun M, Galmiche JP. Reflux related symptoms in patients with normal oesophageal exposure to acid. Gut. 1995;37(4):457–464.
    1. Katzka DA, Paoletti V, Leite L, Castell DO. Prolonged ambulatory pH monitoring in patients with persistent gastroesophageal reflux disease symptoms: testing while on therapy identifies the need for more aggressive anti-reflux therapy. American Journal of Gastroenterology. 1996;91(10):2110–2113.
    1. Vaezi MF, Richter JE. Synergism of acid and duodenogastroesophageal reflux in complicated Barrett’s esophagus. Surgery. 1995;117(6):699–704.
    1. Vaezi MF, Richter JE. Role of acid and duodenogastroesophageal reflux in gastroesophageal reflux disease. Gastroenterology. 1996;111(5):1192–1199.
    1. Stein HJ, Kauer WKH, Feussner H, Siewert JR. Bile reflux in benign and malignant Barrett’s esophagus: effect of medical acid suppression and nissen fundoplication. Journal of Gastrointestinal Surgery. 1998;2(4):333–340.
    1. Kauer WKH, Peters JH, DeMeester TR, et al. Mixed reflux of gastric and duodenal juices is more harmful to the esophagus than gastric juice alone: the need for surgical therapy re- emphasized. Annals of Surgery. 1995;222(4):525–533.
    1. Marshall RE, Anggiansah A, Owen WA, Owen WJ. The temporal relationship between esophageal bile reflux and pH in gastro-esophageal reflux disease. European Journal of Gastroenterology & Hepatology. 1998;10:385–392.
    1. Wilmer A, Tack J, Frans E, et al. Duodenogastroesophageal reflux and esophageal mucosal injury in mechanically ventilated patients. Gastroenterology. 1999;116(6):1293–1299.
    1. Sobala GM, O’Connor HJ, Dewar EP, King RFG, Axon ATR, Dixon MF. Bile reflux and intestinal metaplasia in gastric mucosa. Journal of Clinical Pathology. 1993;46(3):235–240.
    1. Dvorakova K, Payne CM, Ramsey L, et al. Apoptosis resistance in Barrett’s esophagus: ex vivo bioassay of live stressed tissues. American Journal of Gastroenterology. 2005;100(2):424–431.
    1. Targa AC, César ACG, Cury PM, Silva AE. Apoptosis in different gastric lesions and gastric cancer: relationship with Helicobacter pylori, overexpression of p53 and aneuploidy. Genetics and Molecular Research. 2007;6(3):554–565.
    1. Nakos A, Zezos P, Liratzopoulos N, et al. The significance of histological evidence of bile reflux gastropathy in patients with gastro-esophageal reflux disease. Medical Science Monitor. 2009;15(6):CR313–CR318.
    1. Nehra D, Howell P, Williams CP, Pye JK, Beynon J. Toxic bile acids in gastro-oesophageal reflux disease: influence of gastric acidity. Gut. 1999;44(5):598–602.
    1. Vaezi MF, Richter JE. Importance of duodeno-gastro-esophageal reflux in the medical outpatient practice. Hepato-Gastroenterology. 1999;46(25):40–47.
    1. Menges M, Müller M, Zeitz M. Increased acid and bile reflux in Barrett's esophagus compared to reflux esophagitis, and effect of proton pump inhibitor therapy. American Journal of Gastroenterology. 2001;96(2):331–337.
    1. Lazarescu A, Sifrim D. Ambulatory Monitoring of GERD: current Technology. Gastroenterology Clinics of North America. 2008;37(4):793–805.
    1. Dixon MF, Neville PM, Mapstone NP, Moayyedi P, Axon ATR. Bile reflux gastritis and Barrett’s oesophagus: further evidence of a role for duodenogastro-oesophageal reflux? Gut. 2001;49(3):359–363.
    1. Nigro JM, Baker SJ, Preisinger AC, et al. Mutations in the p53 gene occur in diverse human tumour types. Nature. 1989;342(6250):705–708.
    1. Cherbonnel-Lasserre C, Dosanjh MK. Suppression of apoptosis by overexpression of Bcl-2 or Bcl-x(L) promotes survival and mutagenesis after oxidative damage. Biochimie. 1997;79(9-10):613–617.
    1. Gerdes J, Lemke H, Baisch H. Cell cycle analysis of a cell proliferation associated human nuclear antigen defined by the monoclonal antibody Ki-67. Journal of Immunology. 1984;133(4):1710–1715.
    1. Woodward TA, Klingler PD, Genko PV, Wolfe JT. Barrett’s esophagus, apoptosis and cell cycle regulation: correlation of p53 with Bax, Bcl-2 and p21 protein expression. Anticancer Research. 2000;20(4):2427–2432.
    1. Chatzopoulos D, Kyrgidis A, Kountouras J, Zavos C, Molyvas E, Venizelos I. Bax upregulation may provide a rationale for the low incidence of esophageal adenocarcinoma in a Greek cohort of patients with Barrett’s esophagus. Hepato-Gastroenterology. 2007;54(75):705–709.
    1. Raouf AA, Evoy DA, Carton E, Mulligan E, Griffin MM, Reynolds JV. Loss of Bcl-2 expression in Barrett’s dysplasia and adenocarcinoma is associated with tumor progression and worse survival but not with response to neoadjuvant chemoradiation. Diseases of the Esophagus. 2003;16(1):17–23.
    1. Bax DA, Haringsma J, Einerhand AWC, et al. MUC4 is increased in high grade intraepithelial neoplasia in Barrett’s oesophagus and is associated with a proapoptotic Bax to Bcl-2 ratio. Journal of Clinical Pathology. 2004;57(12):1267–1272.
    1. Shaheen N, Ransohoff DF. Gastroesophageal reflux, Barrett esophagus, and esophageal cancer: clinical applications. Journal of the American Medical Association. 2002;287(15):1982–1986.
    1. Bernstein H, Bernstein C, Payne CM, Dvorakova K, Garewal H. Bile acids as carcinogens in human gastrointestinal cancers. Mutation Research. 2005;589(1):47–65.
    1. Theisen J, Peters JH, Fein M, et al. The mutagenic potential of duodenoesophageal reflux. Annals of Surgery. 2005;241(1):63–68.
    1. Lassen A, Hallas J, De Muckadell OBS. Esophagitis: incidence and risk of esophageal adenocarcinoma—a population-based cohort study. American Journal of Gastroenterology. 2006;101(6):1193–1199.
    1. Binato M, Gurski RR, Fagundes RB, Meurer L, Edelweiss MI. P53 and Ki-67 overexpression in gastroesophageal reflux disease—Barrett’s esophagus and adenocarcinoma sequence. Diseases of the Esophagus. 2009;22(7):588–595.
    1. Hamelin R, Fléjou JF, Muzeau F, et al. TP53 gene mutations and p53 protein immunoreactivity in malignant and premalignant Barrett’s esophagus. Gastroenterology. 1994;107(4):1012–1018.
    1. Feith M, Stein HJ, Mueller J, Siewert JR. Malignant degeneration of Barrett’s esophagus: the role of the Ki-67 proliferation fraction, expression of E-cadherin and p53. Diseases of the Esophagus. 2004;17(4):322–327.
    1. Pilger DA, Da Costa Lopez PL, Segal F, Leistner-Segal S. Analysis of R213R and 13494 g→a polymorphisms of the p53 gene in individuals with esophagitis, intestinal metaplasia of the cardia and Barrett’s Esophagus compared with a control group. Genomic Medicine. 2007;1(1-2):57–63.
    1. Craanen ME, Blok P, Dekker W, Offerhaus GJA, Tytgat GNJ. Chronology of p53 protein accumulation in gastric carcinogenesis. Gut. 1995;36(6):848–852.
    1. Unger Z, Molnár B, Prónai L, Szaleczky E, Zágoni T, Tulassay Z. Mutant p53 expression and apoptotic activity of Helicobacter pylori positive and negative gastritis in correlation with the presence of intestinal metaplasia. European Journal of Gastroenterology and Hepatology. 2003;15, supplement 4:389–393.
    1. Jorge O, Cuello Carrión FD, Jorge A, Ciocca DR. Helicobacter pylori infection affects the expression of PCNA, p53, c-erbB-2 and Bcl-2 in the human gastric mucosa. Revista Espanola de Enfermedades Digestivas. 2003;95(2):97–104.
    1. Xia HHX, Zhang GS, Talley NJ, et al. Topographic association of gastric epithelial expression of Ki-67, Bax, and Bcl-2 with antralization in the gastric incisura, body, and fundus. American Journal of Gastroenterology. 2002;97(12):3023–3031.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera