Gut, 1975, 16, 590-597 Gut: first published as 10.1136/gut.16.8.590 on 1 August 1975. Downloaded from Mucosal changes in gastric ulceration and their response to carbenoxolone sodium H. W. STEER' AND D. G. COLIN-JONES2 From Southampton University Medical School SUMMARY The epithelial differences between the normal stomach (six subjects) and 47 patients with gastric ulcers were compared. The concentrations of intraepithelial lymphocytes and polymorpho- nuclear leucocytes in lesser curve and prepyloric gastric ulcers were compared, and the effect of treatment with carbenoxolone sodium was studied. There is a statistically significant reduction in the total number of intraepithelial polymorphonuclear leucocytes before and after successful treat- ment with carbenoxolone sodium. There is also a statistically significant decrease in the quantity of intraepithelial lymphocytes in those patients with lesser curve gastric ulcers successfully treated with carbenoxolone sodium, whereas there is a significant increase in those patients with prepyloric gastric ulcers successfully treated and those patients in whom treatment failed. The value of counts of migrating white blood cells as a method of objectively assessing the effect of healing drugs upon the gastric mucosa is discussed. Pseudomonas aeruginosa was found in many specimens obtained, and evidence is presented that this was not a contaminant. Carbenoxolone appeared to increase the amount of mucus but had little effect upon the number of bacteria found. The possible contribution ofPseudomonas aeruginosa to gastric ulceration is discussed. The gastric mucosal barrier may be damaged inmany of epithelial cells of the gastric mucosa (Lipkin, http://gut.bmj.com/ ways. Amongst the causes of damage to the mucosa 1970). are the regurgitation of duodenal contents, includ- Gear, Truelove, and Whitehead (1971) failed to ing biliary reflux (Capper, 1967; Rhodes, 1972), and demonstrate any change in the gastritis present in the the ingestion of aspirin (Rhodes, 1972). Bacterial gastric biopsies from patients whose medical treat- contamination of the gastric aspirate has been ment included carbenoxolone sodium. Similarly, reported by Giannella, Broitman, and Zamcheck Thomas, Hall, and Hislop (1972) found that (1972), particularly where there is hypochlorhydria. carbenoxolone sodium did not produce any change on September 26, 2021 by guest. Protected copyright. It has been shown that patients with gastric ulcers in either the cellular infiltration or the type of tend to have a lower gastric acid output than normal gastritis noted before its administration. (Baron, 1963). The first part of this investigation examines the Doll, Hill, Hutton, and Underwood (1962) relationship between the activity of the gastritis, demonstrated the beneficial effect of carbenoxolone bacteria and gastric ulceration. The second part sodium upon the healing of gastric ulcers, and evaluates the effect of carbenoxolone sodium upon numerous attempts have been made to determine the gastric mucosa in gastric ulceration. how this effect is mediated. There is said to be an increased quantity of gastric mucus in the gastric Patients and Methods mucosa after treatment with carbenoxolone sodium (Goodier, Horwich, and Galloway, 1967). As- Forty-seven patients with benign gastric ulceration sociated with this increased mucus production, there and six normal patients are included in our study. is an alteration in the molecular constitution of the The six controls were patients who had had a mucus (Gheorghiu, Frotz, and Klein, 1971). gastroscopy during the investigation of abdominal Carbenoxolone sodium also increases the life span pain. In all cases the gastric appearances were "Present address: Nuffield Department of Surgery, Radcliffe Infirmary, normal and the final diagnosis in no way involved Oxford. 2Present address: Queen Alexandra Hospital, Portsmouth. the stomach. Biopsies were obtained at gastro- Received for publication 5 June 1975. scopy from 26 patients with ulceration of the lesser 590 Mucosal changes in gastric ulceration and their response to carbenoxolone sodium 591 Gut: first published as 10.1136/gut.16.8.590 on 1 August 1975. Downloaded from curvature of the stomach and from 13 patients with 4°C. Postfixation was carried out in veronal acetate- prepyloric ulceration. Specimens were taken from buffered 1 % osmium tetroxide (pH 7 3) for two five regions of the stomach-prepylorus, incisura hours at 4°C after which the specimens were rinsed angularis, high on the lesser curve, high on the in chilled tap water (4°C), dehydrated in a graded greater curve, and at the edge of the gastric ulcer. series of ethyl alcohol solutions, cleared in propylene In addition, material was obtained from eight oxide, and embedded in Araldite. Following this patients with lesser curve gastric ulceration at the initial embedding, the blocks were trimmed, time of partial gastrectomy. This tissue was pro- orientated and re-embedded in previously pre- cessed for light microscopic as well as electron micro- pared moulds so that sectioning was at right angles scopic studies. to the luminal surface of the biopsy. Sixteen patients were studied before and after Sections 1 p,m thick were cut with a glass knife on treatment with carbenoxolone sodium. These were 12 an ultramicrotome and stained by the method of patients (eight lesser curve gastric ulcers and four Richardson, Jarett, and Finke (1960). These prepyloric gastric ulcers) successfully treated with sections were examined with a light microscope and carbenoxolone sodium and four patients in whom cell counts were made with the aid of a calibrated the treatment failed. The biopsies were taken from grid square so that the number of polymorpho- the five regions of the stomach previously described nuclear leucocytes and lymphocytes in 0 0001 mm2 and in five patients duplicate biopsies were taken so of the gastric epithelium could be determined. All that one could be processed for electron micro- sections were coded so that the specimens were scopic study and the other for histological and histo- examined blind. In addition, the number of bacteria chemical examination. related to 0 625 mm2 of gastric epithelium was The specimens used for the histological and histo- calculated. The mucus content was assessed qualita- chemical examination were fixed in phosphate- tively from sections stained with methylene blue. buffered 10% neutral formalin at 4°C for 24 hours. Certain limited areas were selected from which The tissues were dehydrated in a graded series of sections approximately 25 nm thick were cut, ethyl alcohol solutions, cleared in benzene and stained with 1 % uranyl acetate and Reynold's lead embedded in paraffin wax. Sections 6 ,um thick were citrate, and examined with a Philips 300 electron cut and stained with haematoxylin and eosin, by microscope. Statistical analyses, using Student's the periodic acid-Schiff reaction (McManus, 1948), t test for paired and unpaired samples, were done on or by the Gram stain. The sections were then these calculations. examined with the light microscope. http://gut.bmj.com/ The material used for both light and electron Results microscopic studies was immediately fixed in 5% cacodylate-buffered glutaraldehyde (pH 7 3) for The histological appearances of the gastric mucosa four to 24 hours at 4°C and then rinsed in cacodyl- in normal people and those with gastric ulceration ate-buffered 10% sucrose (pH 7 3) for 24 hours at differ. The differences associated with the gastric on September 26, 2021 by guest. Protected copyright. Fig 1 Mucosa from high on the lesser curve ofa patient with a lesser curve gastric ulcer. Numerous bacteria (B) are related to the gastric epithelium (E). Polymorphonuclear leucocytes (PNL) are migrating through the gastric epithelium. Section stained with methylene blue Azur 11. 592 H. W. Steer and D. G. Colin-Jones Gut: first published as 10.1136/gut.16.8.590 on 1 August 1975. Downloaded from epithelium include the occurrence ofbacteria in those 3 ,um long and about 05 ,um wide, are related to the patients with gastric ulceration and the migration gastric mucus-secreting cells in patients with gastric of cells through the gastric epithelium. ulceration. The bacteria frequently occur in clusters and are found over extensive areas of the gastric BACTERIA mucosa but are not universally distributed over the Gram-negative bacteria (figs 1 and 2), up to about surface of the stomach. These bacteria have not been 92 :sr ; http://gut.bmj.com/ on September 26, 2021 by guest. Protected copyright. Fig 2 Bacterium (B) related to the surface ofa gastric mucus-secreting cell (E). The bacterium has been sectioned transversely. Mucus (M) can be seen in the gastric lumen. Mucosal changes in gastric ulceration and their response to carbenoxolone sodiunm 593 Gut: first published as 10.1136/gut.16.8.590 on 1 August 1975. Downloaded from seen in the biopsies from normal stomachs. In Further identification of these bacteria was under- patients with gastric ulceration the bacteria are taken. The microorganisms were cultured on blood situated on the luminal surface of the epithelial cells agar, McConkey's medium and cetrimide agar. The and are normally related to the surface epithelium microorganisms are Gram-negative bacilli, motile, but are also seen in the necks of the gastric glands. oxidase-positive, produce acid in glucose peptone They are found deep to the mucous layer covering water and produce ammonia from arginine. These the gastric mucosa. The gastric mucus-secreting cells results indicate that the bacterium is Pseudomonas related to these bacteria appeared to have a decreased aeruginosa. The presence of bacteria in relation to mucus content compared with the gastric mucus- the gastric epithelium was confirmed when these secreting cells of the normal stomach. We have specimens were examined with the electron micro- found that bacteria are not related to the goblet cells scope (fig 2). and are absent from areas of intestinal metaplasia. The distribution of the bacteria in the stomach is Bacteria have been observed in specimens ob- variable and differs with the type of gastric ulcera- tained at operation for gastric ulceration as well as tion.