Efficacy Of Hydrotalcite And Esomeprazole Combination On The Healing Quality Of Gastric Ulcer:a Clinical Study

BackgroundGastric ulcer (GU) is a common,frequently-occurring disease in the department of gastroenterology,and related to acid. The mucosal injury in Gastric ulcer is over the muscularis mucosa layer, which as characteristics of chronic ulcer formation.Clinical symptoms are mainly for repeatedly periodic rhythm of upper abdominal pain, accompanied by belching, bloating discomfort, easy bleeding, perforation, and even cancer. All of these can seriously harm the human health. The pathogenesis of gastric ulcer has not been fully elucidated at present.Now we almost think it is mainly caused by defensive and attack factors imbalance of gastric mucosa[1].The Helicobacter pylori (H. pylori) eradication therapy and wide application of proton pump inhibitors (PPI) have improved the clinical cure rate of gastric ulcer.The recent healing rate was amost 95%[2],however its high recurrence rate remains a clinical challenge. Gastric ulcer mainly recurs in situ or at adjacent areas of the healed ulcer in clinic.According to past research[4],the ulcer recurrence rate was 60%-80% in 1 years after discontinuation.Although the application of PPI and H.pylori eradication therapy,ulcer recurrence rate was up to 20%-30% in one year. A follow-up study on the treatment of peptic ulcer of the Si Jian min,[5]showed that the recurrence rate is as high as 80% within 11 years.Tarnawski[6].et al put forward the concept of quality of ulcer healing (QOUH) in 1991 for the first time, which considers the fact that tissue regeneration is often incomplete within the ulcer scars. QOUH suggests that evaluation of gastric ulcer healing should focus on whether the structures and function of mucosal and submucosal tissue have been completely regenerated in addition to endoscopic examination of the patient or the evaluation of ulcer size in experimental studies. It has been shown that ulcer recurrence is closely related to QOUH. They believe that compromised healing of histology and ultrastructure of gastric mucosa impairs the function of mucosal defense, accounting for the pathological basis of ulcer recurrence171.Therefore, the treatments for gastric ulcer are not only repairing ulcer mucosa damage, but also to pursue the quality of healing and promote healing of the mucosa and submucosa was completely healed from the organizational structure and function, so as to reduce the recurrence rate. The evaluation of ulcer healing quality should not be limited to white light endoscopy superficial observation of regenerative mucosa.We should observed regenerative mucosa minute structures by magnifying endoscopy,chromoendoscopy or endoscopic ultrasonography, such as gastric pits and micro vascular morphological changes.In addition,we should also pay great attention to the mucosa and submucosa tissue and functional maturity evaluation.Healing process of gastric ulcer includes clearance of necrotic debris, growth of granulation tissues, angiogenesis, collagen fiber deposition and scar tissue formation, epithelial reconstruction with the reconstruction of mucosal microvascular network at the same time[8,9]。The gastric ulcer treatments are mainly for treatment of disease causes and complications such as bleeding and perforation.The widely use of PPI and H.pylori eradication therapy can significantly improve the clinical cure rate, but not reduce ulcer recurrence rate.Recently,researches shows that ulcer recurrence rate is still high in recent years.Tarnawski think it is due to QOUH.Abnormal histological, ultrastructural are the pathological basis for ulcer recurrence.Esomeprazole[10,11],as a specific proton pump inhibitor in the cell wall, has been widely used in clinical.Esomeprazole,as H+-K+-ATP enzyme inhibitor,is the S-isomer of omeprazole.Through specific target mechanism to reduce gastric acid secretion, the metabolism is less affected by gene polymorphic, small individual difference.lt can more thoroughly within 24 hours, longer inhibition of gastric acid secretion, accelerate the ulcer repair, but excessive acid suppression would cause indigestion, gastrointestinal bacterial infection, atrophy gastritis, and gastric cancer.Single anti acid drugs for gastric ulcer would lead to recurrence.Hydrotalcite[12]is a defense enhanced gastric mucosal protective agent,with layered lattice structure in the network,which forms protective film at the wounded ulcer site, provides HCO3-reservoir and repairs mucous bicarbonate barrier. Moreover, it upregulates various protective and repairing factors of the gastric tissue such as promoting the formation of prostaglandins, improving mucosal blood flow and metabolism at the ulcer site, thereby enhancing mucosal repair function.However,previous studies[12]comparing the efficacy of hydrotalcite tablet combined with esomeprazole vs esomeprazole therapy alone for treatment of gastric ulcer were lacking clinical researches and objective evaluation index, as these studies merely drew conclusions based on endoscopic observation of gastric mucosa but the histologic and ultrastructural changes of the mucosal and submucosal layer were ignored, and most of the studies only used rat models.This study in view of the above background.Forty-eight patients diagnosed as gastric ulcer by endoscopic from June 2014 to February 2016 were received. Twenty-four healthy persons were chosen as normal control grpup.Clinical datas and gastroscope results of all of them were collected at the same time.Objective To explore the efficacy of hydrotalcite combined with esomeprazole on the healing quality of gastric ulcer.Methods This study is a prospective trial.Forty-eight patients,diagnosed as gastric ulcer between June 2014 and February 2016 in the Department of digestive disease, Zhujiang Hosiptal of Southern Medical University, were allocated into the combination therapy group and single therapy group. The former received hydrotalcite (1 g three times a day) combined with esomeprazole(20mg twice a day) treatment, and the latter received esomeprazole (20mg twice a day) alone, for a treatment course of eight weeks. All specimens were tested for H.pylori using rapid urease test (CLO test; Delta West Pty Ltd, Western Australia).H.pylori-positive patients also received esomeprazole combined with amoxicillin, clarithromycin and colloidal pectin bismuth for 14 days, and Twenty-four healthy volunteers were recruited into the healthy control group without treatments. Performed by the same experienced endoscopists,endoscopic ulcer healing was observed in white light endoscopy at first,and then gastric pits and microvascular morphology were observed using Narrow Band Imaging (NBI) magnifying endoscopy.After that gastric mucosal tissues were biopsied from the patients before and after treatment by combination therapy or single therapy at the same location. Tissues were similarly biopsied from the healthy volunteers. Part of the specimen were embedded in paraffin,sectioned and stained by Masson staining, immunofluorescent and immunohistochemical methods. Remaining specimen was preserved at-80℃ for determination of hydroxyproline content by Enzyme-linked immune sorbent assay (ELISA).When following normal distribution, measurement data were expressed as means ± SD. These data were compared by the Analysis of variance (ANOVA) followed by multiple comparison using LSD method or, Dunnett’sT3 method based on determination of homogeneity of variance. For data not following normal distribution, Kruskal-Wallis test was used followed by multiple comparisons using all pairwise method. Enumeration data were compared by the chi-square test. P values less than 0.05 were considered as statistically significant. All data were analyzed using SPSS20.0 (SPSS Inc. U.S.A.).ResultsThree groups gastric mucosa were performed by the same experienced endoscopists,and no adverse events happened between combined therapy groups and single drug groups in the whole process.(1) Basic clinical characteristics and H. pylori eradication rateThere were no significant differences in gender and age among three groups (P> 0.05). H.pylori positive rates were similar between the combination therapy and single therapy group before and after treatment (P> 0.05)(2) Endoscopic ulcer healingThe total effective rate was not statistically significant between the combination therapy and single therapy group after treatment, P>0.05 (P=0.551).Gastric pits and microvascular morphology were observed using NBI magnifying endoscopy.The gastric pits in normal gastric mucosa amost are classified as type A and B, surrounded by rich and irregular microvascular network. After trearment, the proportion of type A and B of gastric pits were not statistically significant in the gastric pits between the combination therapy and single therapy (P>0.05), but were significantly different in the proportion of the regular microvascular networks (P<0.05).Combination therapy were significantly higher than that in single group and healthy control group.(3) Tissue Maturity of regenerated mucosaUsing Masson staining for Collagen deposition area,and immunofluorescence staining for Composition of collagen fibers.Collagen fibers usually distribute at gastric mucosal and submucosal layer under normal circumstances. Deposition areas of collagen fibers were significantly different after the treatment (P< 0.05), deposition area of collagen fibers in combination therapy was significantly higher than that in the single group (P<0.05), but was not statistically significant compared with the healthy control group (P> 0.05).The ratio of collagen I and collagen III in healthy control group was significantly higher than that of the combination therapy and single therapy groups after treatment (P<0.05). The ratios of collagen I and collagen III of combination therapy and single therapy after treatment were statistically significant compared with the healthy control group (P<0.05). This ratio of the combination therapy was significantly higher than that of the single therapy group (P<0.05),but there was no statistically significant difference between the combination therapy and the healthy control group (P>0.05,P=0.512). Hydroxyproline content in gastric mucosa was analyzed by ELISA method. Hydroxyproline content in the combination therapy and single therapy groups after the treatment were statistically significant as compared with the healthy control group (P<0.05),and hydroxyproline content in combination therapy was significantly higher than that in the single group (P<0.05), but was not statistically significant as compared with the healthy control group (P>0.05, P=0.674).The number of Factor Ⅷ-positive cells were observed by immunohistochemical staining,for quantitative microvessel numbers.The number of Factor Ⅷ-positive cells in the combination therapy and single therapy groups after the treatment were statistically significant as compared with the healthy control group (P<0.05). while that in the combination therapy was significantly higher than that in the single therapy and healthy control group after the treatment (P<0.05).(4)Function Maturity of regenerated mucosaIntegrated optical density of Transforming growth factor betal(TGF-β1) was observed by immunohistochemical staining. Integrated optical density(IOD) of TGF-β1 in the combination therapy and single therapy groups after the treatment were statistically significant as compared with the healthy control group (P< 0.05).while that in the combination therapy was significantly higher than that in the single therapy (P<0.05), but there was no statistically significant difference when compared with the healthy control group (P<0.05).ConclusionsHydrotalcite combined with esomeprazole was superior to oral esomeprazole alone on the healing quality of gastric ulcer in aspects of maturity of regenerated mucosal tissue, which improve structure and function of the mucosa by improving the microvessel morphology networks and promoting collagen fiber formation, angiogenesis, and expression of TGF β1. It is worthy of wider clinical application.