Changes in gastric acid secretion assayed by

endoscopic gastrin test before and after

Helicobacter pylori eradication
K Iijima, S Ohara, H Sekine, T Koike, K Kato, S Asaki, T Shimosegawa, T Toyota
Abstract
BackgroundIt remains controversial
whether or not Helicobacter pylori infec-
tion causes altered gastric acid secretion.
A novel test for evaluating gastric acid
secretion (endoscopic gastrin test; EGT)
has recently been developed.
AimTo investigate by EGT the eVects of
H pylori eradication on the state of gastric
acid secretion in patients with peptic ulcer.
MethodsTwenty six patients with duode-
nal ulcer and 33 with gastric ulcer, for all
of whom H pylori infection had been
documented, were studied by EGT, histo-
logical examination of gastric mucosa,
and measurement of plasma gastrin levels
before and one and seven months after H
pylori eradication.
ResultsIn patients with duodenal ulcer,
the mean EGT value before H pylori
eradication was higher than that in H pylori
negative controls, but it had decreased
signicantly seven months after the treat-
ment. In contrast, the mean EGT value of
patients with gastric ulcer before H pylori
eradication was lower than that in H pylori
negative controls, but it had increased one
month after the treatment; this was followed
by a slight decrease at seven months. In both
groups, mean EGT values seven months
after the treatment were not signicantly
diVerent from the mean control value.
ConclusionsThe reduced acid secretion
in gastric ulcer patients and gastric acid
hypersecretion in duodenal ulcer patients
were both normalised after the clearance
of H pylori.
(Gut 2000;46:2026)
Keywords: acid secretion; duodenal ulcer; endoscopic
gastrin test (EGT); gastric ulcer; Helicobacter pylori
Since the discovery of Helicobacter pylori, many
studies have shown that its eradication markedly
decreases the rate of duodenal ulcer (DU) and
gastric ulcer (GU) relapse,
13
and H pylori is
therefore recognised as an important acquired
factor in the pathogenesis of peptic ulcers. How-
ever, the mechanism by which this organism
promotes the recurrence of ulcers remains
unknown. To date, the eVects of H pylori on gas-
tric acid secretion, the most important factor for
development of peptic ulcer diseases, remain
controversial.
411
One reason for the controversy
is that most studies have examined a small
number of patients only, and direct elucidation
of the causal relation requires a comparison of
gastric acid secretions before and after H pylori
eradication in a large number of patients with
peptic ulcer disease. However, as far as we know
there have been very few such studies, especially
on patients with GU.
11
Recently we have developed a rapid simple
endoscopic method for evaluating gastrin stimu-
lated maximal acid output (endoscopic gastrin
test; EGT), the results fromwhich correlate very
closely with peak acid output determined by the
conventional gastric acid secretory test.
12
Using
EGT, we can perform endoscopic examination
and stimulated acid secretory testing simultane-
ously within about 15 minutes. In this study, we
evaluated by EGT the gastrin stimulated acid
output in a large number of patients with DU
and GU before and after H pylori eradication to
clarify the relation between H pylori infection
and gastric acid secretion, and compared it in
patients with DU and GU.
Subjects and methods
SUBJECTS
Twenty nine patients with DU and 35 patients
with GU in whom H pylori infection had been
conrmed were enrolled. Active ulcer disease
had been conrmed endoscopically within the
six months preceding entry into the study.
Patients with both GU and DU were excluded.
GUs were located on the lesser curvature of the
incisura angularis in 24 patients, in the corpus
in 10 patients, and in the antrum in one. H
pylori infection status was determined by the
rapid urease test and histology. None of the
patients had taken non-steroidal anti-
inammatory drugs, antibiotics, or proton
pump inhibitors within 15 days of study entry.
All patients were asked to stop taking H
2
blockers at least 48 hours before study entry.
At entry, each patient had upper gastro-
intestinal endoscopy, which included EGT and
biopsies from the antrum and body of the
stomach for histological examination and rapid
urease test, as well as determination of fasting
plasma gastrin concentrations. After this initial
assessment, patients received eradication treat-
ment consisting of omeprazole 20 mg a day,
metronidazole 500 mg twice a day, and
clarithromycin 200 mg twice a day for a week,
and H pylori status was redetermined by a
combination of histological examination, rapid
urease test, and
13
C-urea breath test one month
later. All patients in whom eradication was
conrmed at this point had a repeat deter-
mination of H pylori infection status seven
months later. Upper gastrointestinal endoscopy,
Abbreviations used in this paper: DU, duodenal
ulcer; EGT, endoscopic gastrin test; GU, gastric ulcer.
Gut 2000;46:2026 20
Third Department of
Internal Medicine,
Tohoku University
School of Medicine,
Sendai, Miyagi, Japan
K Iijima
S Ohara
H Sekine
T Koike
K Kato
S Asaki
T Shimosegawa
T Toyota
Correspondence to:
Dr K Iijima, Third
Department of Internal
Medicine, Tohoku University
School of Medicine, 1-1
Seiryo-machi, Aobaku,
Sendai 980-8574, Japan.
Accepted for publication
18 August 1999
including EGT, histological examination, and
plasma gastrin measurement, was repeated one
and seven months after the eradication treat-
ment. Asymptomatic subjects matched for age,
sex, and body weight were selected as controls
for H pylori positive patients with DU or GU,
from the subjects who underwent endoscopy
during the study period and were conrmed to
be H pylori negative by rapid urease test and
histological examination. The study was con-
ducted in accordance with the Helsinki Decla-
ration as revised in Tokyo, and informed
consent was obtained from each subject.
ENDOSCOPIC GASTRIN TEST
The technique for performing EGT has been
reported previously.
12
Briey, after an overnight
fast, subjects were injected intramuscularly with
tetragastrin (Gastopsin Nippon Kayaku, Tokyo,
Japan), 4 g/kg, before endoscopy. Endoscopy
was begun about 15 minutes after the tetragas-
trin injection. After the endoscope had entered
the stomach, pooled gastric uid was aspirated
and discarded. Gastric uid secreted between 20
and 30 minutes after the tetragastrin injection
was aspirated and collected under direct visuali-
sation during routine endoscopic examination of
the stomach and duodenal bulb. Biopsy speci-
mens were then taken when indicated, and the
endoscope was removed. The volume of sample
collected over the 10 minute period was
recorded, and its H
+
concentration was deter-
mined by titration. The acid output in the 10
minute period was calculated by multiplying
the volume by the H
+
concentration, and the
EGT value was expressed as mEq/10 min. We
have shown previously that EGT values corre-
late very closely with peak acid output deter-
mined by conventional methods (correlation
eYcient = 0.92) and have high reproducibility
(coeYcient of variation = 5.6%).
12
HISTOLOGICAL EXAMINATION
Biopsy specimens taken endoscopically from
the gastric antrum and upper body in the
greater curvature were evaluated histologically.
Using the Updated Sydney system, the degree
of inammation, activity, and atrophy were
scored from 0 to 3.
13
The inammation and
activity scores were added together to form a
gastritis score.
13
C-UREA BREATH TEST
The
13
C-urea breath test was performed as pre-
viously reported.
14
Briey, after a baseline
breath sample had been taken, fasting patients
were given 100 mg [
13
C]urea in 100 ml water.
An additional breath sample was taken 20
minutes after urea administration. Breath sam-
ples obtained at baseline and after drug admin-
istration were analysed for
13
CO
2
with a mass
spectrometer. We determined the cut oV value
for a positive urea breath test at 2.5.
GASTRIN DETERMINATION
A fasting blood sample was obtained for gastrin
determination, and the plasma stored at
20C. Plasma gastrin concentrations were
measured with a radioimmunoassay (Dainabot
Co, Tokyo, Japan).
STATISTICAL METHODS
The EGT values and gastrin concentrations
are expressed as means (SD), and Students
unpaired t test (for unpaired values), and Stu-
dents paired t test (for paired values) were used
to compare group means. Histological scores
were expressed as mean (SD), and the statisti-
cal signicance of diVerences in histological
scores was determined by the Mann-Whitney
test (for unpaired values) and the Wilcoxon
rank sum test (for paired values). p<0.05 was
considered to be statistically signicant.
Results
PATIENT PROFILES
H pylori eradication was achieved in 26 of 29
patients with DU, and in 33 of 35 patients with
GU. All patients in whom H pylori organisms
were cleared at one month after eradication
treatment remained free of H pylori infection at
seven months after the treatment. No patient
experienced a relapse during this period. Three
patients with DU (two men) and two with GU
(both men) in whom H pylori organisms were
not cleared were excluded from further study.
Table 1 shows details of the remaining subjects.
The mean age was higher in the group with GU
than in the group with DU, whereas the mean
body weight was identical in the two groups.
HISTOLOGICAL EXAMINATION
Gastritis score
Before eradication, there was no signicant dif-
ference between the patients with DUand those
with GUwith regard to the degree of gastritis in
the antrum (DU mean, 3.9 (1.0); GU mean,
3.5 (1.0); g 1A). In contrast, the mean gastri-
tis score in the gastric body of patients with GU
was 2.1 (1.1), which is signicantly higher than
the mean score of 1.3 (0.7) in patients with DU
(p<0.01) (g 1B). At one month after the
eradication, the mean gastritis score in the
antrum had decreased signicantly to 1.3 (0.6)
in the DU group (p<0.01) and 1.4 (0.5) in the
GU group (p<0.01); at seven months after
eradication, it showed a slight further decrease
in both groups (1.1 (0.4) in patients with DU,
0.9 (0.5) in patients with GU). The diVerence
in the mean gastritis score between one and
seven months after the eradication was signi-
cant only in the GU group (p<0.01). The
change in gastritis score in the body after eradi-
cation was similar to that in the antrum. The
mean gastritis score in the body fell significantly
from 2.1 (1.1), the value before eradication, to
0.4 (0.5) in patients with DU and from 1.3
(0.6) to 0.7 (0.5) in patients with GU at one
month (both p<0.01). It fell further to 0.2 (0.4)
Table 1 Comparison of demographics of patients with
Helicobacter pylori infection who also have either duodenal
ulcer (DU) or gastric ulcer (GU)
DU GU p Value
Patients (n) 26 33
Men/women (n) 18/8 28/5
Age (years) 35 (11) 55 (12) <0.01
Body weight (kg) 63 (16) 62 (10) NS
Serum gastrin (pg/ml) 104 (44) 110 (73) NS
EGT value (mEq/10 min) 5.1 (2.7) 2.9 (1.8) <0.01
Data represent mean (SD). EGT, endoscopic gastrin test.
H pylori infection and gastric acid secretion 21
in patients with DU and to 0.4 (0.5) in patients
with GU at seven months, but the decreases
between one and seven months were not
signicant in either group (g 2).
Atrophy score
Mucosal atrophy was more prevalent in
patients with GU than in those with DU in
both the antrum and body, whereas antral
atrophy was more marked than body atrophy in
both patient groups. Before eradication, the
mean atrophy score in the antrum of patients
with GU was 1.7 (0.8), and was signicantly
higher than the mean score of 0.8 (0.7) in
patients with DU (p<0.01) (g 3A). Similarly,
in the body, the mean atrophy score was
signicantly higher in patients with GU than in
those with DU (0.3 (0.6) and 0.04 (0.2)
respectively; p<0.05; g 3B). During follow up
after eradication, there was no statistically
signicant change in the degree of antral or
body atrophy in patients with either DU or
GU, although there was a trend toward
improvement in those with GU (antrum, 1.5
(0.8) at one month, 1.3 (1.0) at seven months,
p = 0.1; body, 0.2 (0.3) at one month, 0.1 (0.2)
at seven months, p = 0.07) (g 4).
FASTING PLASMA GASTRIN
Before eradication, fasting plasma gastrin con-
centrations were similar in H pylori positive
patients with DU and those with GU (DU, 104
(44) pg/ml; GU, 110 (73) pg/ml) (table 2), and
the concentrations in both groups were
Figure 1 Gastritis scores of the antrum (A) and body (B). Before eradication of H pylori, the mean gastritis score of the
antrum was not signicantly diVerent between the patients with duodenal ulcer (DU) and those with gastric ulcer (GU), but
in the gastric body, it was signicantly higher in the patients with GU than in those with DU. **p<0.01; NS, not signicant.
5
6 A
4
2
1
0
3
DU GU
G
a
s
t
r
i
t
i
s

s
c
o
r
e
NS
5
6 B
4
2
1
0
3
DU GU
**
Figure 2 Changes in gastritis score in the antrum (A) and body (B) caused by H pylori eradication. One month after the
eradication treatment, the mean gastritis score in the antrum had fallen signicantly in the patients with duodenal ulcer
(DU) as well as in those with gastric ulcer (GU). Between one and seven months, the value decreased signicantly only in
those with GU. In the gastric body, the mean gastritis score had decreased signicantly in both groups at one month. No
further decrease was found in either group between one and seven months after the eradication. Vertical bars represent SD of
the mean gastritis score. **p<0.01 compared with before.
5
0
1
2
3
4
G
a
s
t
r
i
t
i
s

s
c
o
r
e
Before 1 month
after
7 months
after
**
**
**
5 A B
0
1
2
3
4
Before 1 month
after
7 months
after
**
**
DU
GU
22 Iijima, Ohara, Sekine, et al
signicantly higher than those in H pylori nega-
tive controls (controls for patients with DU, 62
(16) pg/ml, p<0.01; controls for patients with
GU, 63 (22) pg/ml, p<0.01). At one month
after eradication, the mean gastrin concentra-
tions decreased signicantly to 60 (14) pg/ml in
patients with DU and to 69 (31) pg/ml in those
with GU. Neither of these values were
signicantly diVerent from those in H pylori
negative controls. After seven months, there
was no signicant fall in gastrin concentration
in either patient group compared with the one
month value (table 2).
ENDOSCOPIC GASTRIN TEST
Before eradication, the mean EGT value was
signicantly higher in patients with DU than in
those with GU (5.1 (2.7) v 2.9 (1.8) mEq/10
min, p<0.01) (table 2). In patients with DU
with H pylori infection, the mean EGT value
was signicantly higher than in H pylori
negative controls (5.1 (2.7) v 3.7 (1.4) mEq/10
min, p<0.01). One month after eradication, no
signicant change was seen in EGT values in
the patients with DU (5.2 (2.5) mEq/10 min),
whereas it had fallen signicantly at seven
months after the eradication (from 5.1 (2.7)
mEq/ 10 min before eradication to 3.9 (1.9)
mEq/10 min, p<0.01). The value at seven
months was not signicantly diVerent from
that in H pylori negative controls (g 5, table 2).
In patients with GU with H pylori infection,
the mean EGT value was signicantly lower
than in H pylori negative controls (2.9 (1.8) v
4.1 (1.6) mEq/10 min, p<0.01). The mean
EGT value of patients with GU with H pylori
Figure 3 Atrophy scores of the antrum (A) and body (B). Before eradication of H pylori, the mean atrophy score of the
antrum in patients with gastric ulcer (GU) was signicantly higher than that of patients with duodenal ulcer (DU).
Similarly, the mean atrophy score of the gastric body was signicantly higher in the patients with GU than patients with
DU. *p<0.05, **p<0.01.
A
2
1
0
3
DU GU
A
t
r
o
p
h
y

s
c
o
r
e
**
*
B
2
1
0
3
DU GU
Figure 4 Changes in atrophy score in the antrum (A) and body (B) caused by H pylori eradication. After the
eradication, the degree of antral or body atrophy did not change signicantly in patients with either duodenal ulcer (DU) or
gastric ulcer (GU). Vertical bars represent SD of the mean atrophy score.
3
0
1
2
A
t
r
o
p
h
y

s
c
o
r
e
Before 1 month
after
7 months
after
3 A B
0
1
2
Before 1 month
after
7 months
after
DU
GU
H pylori infection and gastric acid secretion 23
infection increased signicantly from 2.9 (1.8)
mEq/10 min before eradication to 4.9 (2.3)
mEq/10 min at one month (p<0.01), and then
decreased slightly but signicantly to 4.3 (1.9)
mEq/10 min at seven months (p<0.05, com-
pared with the one month value). The mean
EGT value at seven months was not signi-
cantly diVerent from that in H pylori negative
controls, but was still higher than that recorded
before eradication (4.3 (1.9) v 2.9 (1.8)
mEq/10 min, p<0.01) (g 6, table 2).
Discussion
In this study, we have shown by EGT that H
pylori eradication was accompanied by a
decrease in acid secretion in patients with DU,
while it actually increased after eradication in
patients with GU. Before H pylori eradication,
patients with DU had greater acid secretion
than H pylori negative normal subjects. This
nding is in agreement with a previous report.
15
On the other hand, in patients with H pylori
positive GU, the mean EGT value was signi-
cantly lower than that in H pylori negative nor-
mal subjects. It has been suggested that acid
secretion in patients with GU greatly varies
depending on the anatomical location of the
ulcers; those in the antrum are associated with
hypersecretion and those in the gastric body
are associated with hyposecretion.
15 16
In this
study, the results for patients with GU are in
agreement with our expectations because
antral ulceration was seen in only one patient.
One month after eradication, the mean EGT
value of patients with DU was unchanged
compared with before eradication. Previous
studies have shown that basal acid output
decreases rapidly after H pylori eradication,
apparently in direct association with decreased
serum gastrin.
6 9
However, the gastrin stimu-
lated acid output shown by EGT, which reflects
the total functional parietal cell mass, was
unchanged one month after eradication in our
study.
4 6
The disparity may be caused by the
diVerence in intervals required to achieve a
decrease in the basal and gastrin stimulated
acid outputs, as discussed below.
On the other hand, in patients with GU, the
mean EGT value had increased rapidly one
month after eradication. Recent studies have
reported that, although gastric acid secretion
was low in H pylori positive patients with
gastritis of the corpus, clearance of H pylori
organisms rapidly improved the decreased acid
secretion.
1719
Because body gastritis was more
pronounced in patients with GU than in those
with DU, in agreement with the ndings of
others,
20 21
the acid secretion, which was
subnormal before eradication, increased when
the gastric inammation subsided after eradi-
cation in patients with GU. The mechanism by
which body gastritis inhibits gastric acid secre-
tion is not clear, but inammatory cytokines
such as interleukin-1 or proteins produced by
H pylori may be responsible for reversible inhi-
bition of acid secretion.
2224
Table 2 Changes in endoscopic gastrin test (EGT) values and serum gastrin before and after Helicobacter pylori
eradication
DU GU
Before 1 month 7 months Control Before 1 month 7 months Control
Gastrin (pg/ml) 104 (44) 60 (14)** 59 (11)** 62 (16)** 110 (73) 69 (31)** 64 (22)** 63 (22)**
EGT (mEq/10 min) 5.1 (2.7) 5.2 (2.5) 3.9 (1.9)** 3.7 (1.4)** 2.9 (1.8) 4.9 (2.3)** 4.3 (1.9)** 4.1 (1.6)**
Data are expressed as mean (SD). DU, duodenal ulcer; GU, gastric ulcer.
**p<0.01, compared with the value before eradication; p<0.05, p<0.01 compared with the value at one month.
Figure 5 Changes in acid secretion in patients with duodenal ulcer (DU) after H pylori
eradication. In the H pylori positive patients with DU, the mean EGT value was
signicantly higher than that of H pylori negative controls. One month after the
eradication, no signicant change was found in the EGT value, but it had fallen
signicantly at seven months after the eradication. The value at seven months was not
signicantly diVerent from the control value. Vertical bars represent SD of the mean.
**p<0.01; NS, not signicant.
14
12
10
8
6
4
2
0
A
c
i
d

s
e
c
r
e
t
i
o
n

(
m
E
q
/
1
0

m
i
n
)
Before 1 month after 7 months after Control
**
**
NS NS
n = 26
**
Figure 6 Changes in acid secretion in patients with gastric ulcer (GU) after H pylori
eradication. In the H pylori positive patients with GU, the mean EGT value was
signicantly lower than that of H pylori negative controls. One month after the eradication,
the mean EGT value increased signicantly, and then decreased slightly but signicantly at
seven months. The value at seven months was not signicantly diVerent from the control
value, but it was still higher than that before eradication. Vertical bars represent SD of the
mean. *p<0.05, **p<0.01, NS, not signicant.
12
10
8
6
4
2
0
A
c
i
d

s
e
c
r
e
t
i
o
n

(
m
E
q
/
1
0

m
i
n
)
Before 1 month after 7 months after Control
**
* **
NS
n = 33
**
24 Iijima, Ohara, Sekine, et al
Between one and seven months after H pylori
eradication, signicant decreases in acid secre-
tion were seen in both patients with DU and
those with GU. The mechanism of this
decreased acid secretion may be related in part
to a fall in plasma gastrin, which was
commonly observed in association with both
diseases. That is, gastrin, which exerts trophic
eVects not only on parietal cells
25 26
but also on
enterochromaYn-like cells,
27
was suppressed
for a long time after the eradication, leading to
decreased acid secretion because of their
reduced cell mass. The half life of parietal cells
in mice is reported to be 23 days and may be
even longer in humans.
28
According to a previ-
ous study on a patient with curatively resected
gastrinoma, maximal acid output decreased
three to six months after the tumour
resection.
29
This result suggests that it will take
several months for acid secretion to decrease
through removal of the trophic eVect of gastrin
as seen in the present study. However, in
patients with GU, hypergastrinaemia may be
caused not only by H pylori itself
30 31
but also by
compensation for lower acid secretion.
32
Hence
the decrease in plasma gastrin after H pylori
eradication may be partly due to a concomitant
increase in acid secretion. However, the latter
mechanism seems less likely because the
changes in plasma gastrin before and after H
pylori eradication were similar between the DU
and GU groups, in spite of the diVerent behav-
iour with respect to acid secretion in the two
groups.
Interestingly, the decrease in acid secretion
observed between one and seven months after
eradication was somewhat less in patients with
GU than in those with DU, and, in fact, in a
small number of patients with GU, acid secre-
tion increased during this period. A recent
study reported that, in patients with fundic
atrophic gastritis, improvement in acid secre-
tion coincided with resolution of mucosal
atrophy.
33
As mucosal atrophy was greater in
patients with GU than in those with DU in this
study, it is possible that a reason for the slower
decrease in acid secretion in the GU group in
that period is that the benecial eVect of H
pylori eradicationthat is, a reduction in acid
secretion by long term normalisation of plasma
gastrinwas partially cancelled out by an
increase in acid secretion as the result of reso-
lution of gastric atrophy. Consequently, during
the seven month follow up period after H pylori
eradication, the mean EGT value decreased by
23% in patients with DU, whereas it increased
by 48% in those with GU, compared with the
pretreatment values, resulting in the EGT
values of both groups being in the same range
as H pylori negative normal controls.
The nature of long term changes in gastrin
stimulated acid secretion after H pylori eradica-
tion in patients with DU remains
controversial.
411
Parente and colleagues
7
and
Harris and colleagues
8
have reported that it was
decreased six months after eradication, and
Laszewicz and colleagues
11
have reported it to
be decreased one year after eradication,
ndings in agreement with the present study.
On the other hand, El-Omar and colleagues
9
and Gisbert and colleagues
10
have reported no
change at ve months and one year after eradi-
cation. In the study of El-Omar et al, gastrin
releasing peptide stimulated acid output was
decreased by 80% one year after eradication,
but the gastrin stimulated acid output had not
changed signicantly. However, the rate of the
decrease in gastrin stimulated acid output after
H pylori eradication, reported to be 16% by
Parente et al,
7
33% by Harris et al,
8
and 23% in
our study, was small compared with the
changes in gastrin releasing peptide stimulated
output. Therefore a larger population would be
needed to detect the slight diVerence in gastrin
stimulated acid output before and after H pylori
eradication in patients with DU. Gisbert and
colleagues
10
also did not nd signicant diVer-
ences in gastrin stimulated acid output before
and after H pylori eradication, although they
studied a relatively large sample of 26 patients
with DU. However, because in their study, acid
output in patients with H pylori infection was
not compared with that of H pylori negative
normal controls, it is unclear whether those
patients had gastric acid hypersecretion before
H pylori eradication. In fact, maximal gastrin
stimulated acid output before eradication was
somewhat lower in their study than in other
reports.
69
The most likely reason for the diVer-
ence was that more than half of the patients
with DU had body gastritis, which has been
shown to inhibit acid secretion reversibly in
oxyntic mucosa,
1719
whereas in general, most
patients with DU are considered to have
antrum predominant gastritis.
20 21
There have been few reports
11
on changes in
acid secretion before and after H pylori
eradication in patients with GU. This is the first
study showing that stimulated acid output
increases after H pylori eradication in patients
with GU, which supports the report of Furuta
and colleagues
34
that gastric juice pH in
patients with GU decreases after eradication.
However, it is possible that the rate of this
increase in acid secretion varies from subject to
subject, because acid secretion in patients with
GU varies greatly depending on the anatomical
location of the ulcers. In particular, in patients
with ulcers in the antrum, which are associated
with hypersecretion,
15 16
acid secretion may
decrease after H pylori eradication as in patients
with DU. In the H pylori positive patients with
GU in this study, elevated plasma gastrin may
have increased acid secretion through a direct
eVect or through a trophic eVect on parietal
cells and/or enterochromaYn-like cells. How
ever, this eVect may be neutralised by coexist-
ing gastritis of the body, which impaired the
acid secretory response to increased gastrin.
The net eVect was to leave these patients with
low acid secretion. In patients with GU, acid
secretion showed a biphasic response to
eradication of H pylori. Initially there was a
rapid increase in acid secretion concomitant
with resolution of body gastritis while the
trophic eVect remained active. Subsequently a
late decrease in acid secretion occurred when
the trophic eVect on oxyntic mucosa was
removed.
H pylori infection and gastric acid secretion 25
It has been shown that eradication of H pylori
appreciably decreases DU relapse rates,
13
and
our ndings support the concept that this may
be related, in part, to decreased acid secretion.
However, eradication of H pylori also decreases
GUrelapse rates,
2 3
in spite of the accompanying
increase in acid secretion. The great success of
specic antisecretory agents such as H
2
receptor
antagonists in the treatment of peptic ulcers has
been considered to be evidence that gastric
acidity plays a central role in the pathogenesis
of peptic ulcer. However, the role of antisecre-
tory drugs in preventing GU relapse seems not
to be as important as in DU.
3537
Although some
studies
3840
have shown that such drugs exert a
considerable eVect, other studies
41 42
have con-
cluded that they have little or no inuence on
GU recurrence. The latter ndings suggest
that, in patients with GU, mucosal defence fac-
tors are more important for ulcer recurrence
than detrimental factors such as acid secretion,
compared with patients with DU.
Considering the preceding studies and our
results together, H pylori eradication may
decrease the rate of relapse in GU by enhanc-
ing defence factors, possibly by permitting the
resolution of mucosal inammation. This
improved mucosal defence may outweigh the
eVect of increased acid secretion.
In conclusion, gastrin stimulated maximal
acid secretion is abnormal in patients with H
pylori infection who have peptic ulcer diseases.
Patients with DU display hypersecretion and
patients with GU display hyposecretion com-
pared with H pylori negative normal controls.
This secretory disturbance is resolved fully
after eradication of H pylori. These diVering
eVects of H pylori on acid secretion may be
related to the distribution of gastritis within the
stomach.
1 Forbes GM, Glaser ME, Cullen DJE, et al. Duodenal ulcer
treated with Helicobacter pylori eradication: seven-year
follow-up. Lancet 1994;343:25860.
2 Graham DY, Lew GM, Klein PD, et al. EVect of treatment
of Helicobacter pylori infection on the long-term recur-
rence of gastric or duodenal ulcer. Ann Intern Med
1992;116:7058.
3 Chiba N, Rao BV, Rademaker JW, et al. Meta-analysis of the
eYcacy of antibiotic therapy in eradicating Helicobacter
pylori. Am J Gastroenterol 1992;87:171627.
4 Levi S, Beardshall K, Desa LA, et al. Campylobacter pylori,
gastrin, acid secretion and duodenal ulcers. Lancet 1989;2:
613.
5 McColl KEL, Fullarton GM, Ghittajalu R, et al. Plasma
gastrin, day time intragastric pH, and nocturnal acid
output before and at 1 and 7 months after eradication of
Helicobacter pylori in duodenal ulcer subjects. Scand J
Gastroentrol 1991;26:33946.
6 Moss SF, Calam J. Acid secretion and sensitivity to gastrin
in patients with duodenal ulcer: eVect of eradication of
Helicobacter pylori. Gut 1993;34:88892.
7 Parente F, Maconi G, Sangaletti O, et al. Behaviour of acid
secretion, gastrin release, serum pepsinogen, and gastric
emptying of liquids over six months from eradication of
Helicobacter pylori on duodenal ulcer patients. A control-
led study. Gut 1995;37:21015.
8 Harris AW, Gummett PA, Misiewicz JJ, et al. Eradication of
Helicobacter pylori in patients with duodenal ulcer lowers
basal and peak acid outputs to gastrin releasing peptide and
pentagastrin. Gut 1996;38:6637.
9 El-Omar EM, Penman ID, Ardill JES, et al. Helicobacter
pylori infection and abnormalities of acid secretion in
patients with duodenal ulcer disease. Gastroenterology
1995;109:68191.
10 Gisbert JP, Boixeda D, Vila T, et al. Basal and stimulated
gastrin levels and gastric acid output ve months after
therapy for Helicobacter pylori eradication in duodenal
ulcer patients. J Clin Gastroenterol 1996;22:905.
11 Laszewicz W, Zaremba Woroniecka A, Gabryelewicz A.
Helicobacter pylori infection and gastric secretion in
duodenal and gastric ulcer patients: the eVect of
eradication after one year. J Physiol Pharmacol 1997;48:
35364.
12 Iijima K, Ohara S, Sekine H, et al. A new endoscopic
method of gastric acid secretory testing. Am J Gastroenterol
1998;93:211318.
13 Misiewicz JJ, Tytgat GN, Goodwin CS, et al. The Sydney
System; a new classication of gastritis. Working Party
Reports 1990;110.
14 Ohara S, Kato M, Asaka M, et al. Studies of 13C-urea
breath test for diagnosis of Helicobacter pylori infection in
Japan. J Gastroenterol 1998;33:613.
15 Brooks FP. Tests related to the stomach. In: Bockus HL, ed.
Gastroenterology. 4th ed. Philadelphia: WB Saunders, 1985:
36777.
16 Johnson HD. Gastric ulcer: classication, blood group char-
acteristics, secretion patterns and pathogenesis. Ann Surg
1965;162:9961004.
17 Gutierrez O, Melo M, Segura AM, et al. Cure of
Helicobacter pylori infection improves gastric acid secre-
tion in patients with corpus gastritis. Scand J Gatroenterol
1997;32:6648.
18 El-Omar EM, Oien K, El-Nujumi A, et al. Helicobacter
pylori infection and chronic gastric acid hyposecretion.
Gastroenterology 1997;113:1524.
19 Yasunaga Y, Shinomura Y, Kanayama S, et al. Improved fold
width and increased acid secretion after eradication of the
organism in Helicobacter pylori associated enlarged fold
gastritis. Gut 1994;35:15714.
20 Louw JA, Flalck V, van Rensburg C, et al Distribution of
Helicobacter pylori colonisation and associated gastric
inammatory changes: diVerence between patients
with duodenal and gastric ulcers. J Clin Pathol 1993;46:
7546.
21 Van der Hulst RWM, Tytgat GNJ. Helicobacter pylori and
peptic ulcer disease. Scand J Gastroenterol 1996;31(suppl
220):1018.
22 Wallace JL, Cucala M, Mugridge K, et al. Secretagogue-
specic eVects of interleukin-1 on gastric acid secretion.
Am J Physiol 199;261:G55964.
23 Noach LA, Bosma NB, Jansen J, et al. Mucosal tumor
necrosis factor-alpha, interleukin-1 beta, and interleukin-8
production in patients with Helicobacter pylori infection.
Scand J Gastroenterol 1994;29:4259.
24 Cave DR, Vargas M. EVect of a Campylobacter pylori protein
on acid secretion by parietal cells. Lancet 1989;2:1879.
25 Willems G, Lehy T. Radioautographic and quantitative
studies on parietal and peptic cell kinetics in the mouse.
Gastroenterology 1975;69:41626.
26 Johnson LR. The trophic action of gastrointestinal hor-
mones. Gastroenterology 1976;70:27882.
27 Bechi P, Romagnoli P, Bacci S, et al. Helicobacter pylori and
duodenal ulcer: evidence for histamine pathway-involving
link. Am J Gastroenterol 1996;91:233843.
28 Ragins H, Wincze F, Liu SM, et al. The origin and survival
of gastric parietal cells in the mouse. Anat Rec 1968;162:
99110.
29 Pisegna JR, Norton JA, Slimak GG, et al. EVects of curative
gastrinima resection on gastric secretory function and
antisecretory drug requirement in the Zollinger-Ellison
syndrome. Gastroenterology 1992;102:76778.
30 Levi S, Beardshall K, Haddad G, et al. Campylobacter pylori
and duodenal ulcers: the gastrin link. Lancet 1989;i:
11678.
31 Weigert N, SchaVer K, Schusdziarra V, et al. Gastrin secre-
tion from primary cultures of rabbit antral G cells: stimula-
tion by inammatory cytokines. Gastroenterology 1996;110:
14754.
32 Walsh JH, Richardson CT, Fordtran JS. pH dependence of
acid secretion and gastrin release in normal and ulcers sub-
jects. J Clin Invest 1975;55:4628.
33 Tucci A, Biasco G, Paparo GF. EVect of eradication of
Helicobacter pylori in patients with fundic atrophic gastri-
tis. N Engl J Med 1997;336:9578.
34 Furuta T, Baba S, Takashima M, et al. EVect of Helicobacter
pylori infection on gastric juice pH. Scand J Gastroenterol
1998;33:35763.
35 Burland WL, Hawkins BW, Beresford J. Cimetidine
treatment for prevention of recurrence of duodenal ulcer:
an international collaborative study. Postgrad Med J
1980;56:1736.
36 Gough KR, Bardhan KD, Crowe JP, et al. Ranitidine and
cimetidine in prevention of duodenal ulcer relapse. Lancet
1984;2:65962.
37 Lee F, Reed PI, Crowe JP, et al. Acute treatment of duode-
nal ulcer: a multicentre study to compare ranitidine 150 mg
twice daily with ranitidine 300 mg once at night. Gut 1986;
27:10915.
38 Hentschel E, Schutze K, Weiss W, et al. EVect of cimetidine
treatment in the prevention of gastric ulcer relapse: a one
year double blind multicentre study. Gut 1983;24:8586.
39 Machell RJ, Farthing MJG, Ciclitira PJ, et al. Cimetidine in
the prevention of gastric ulcer relapse. Postgrad Med J
1979;55:3935.
40 Birger JK, Mollmann KM, Rahbek I, et al. Prophylactic
eVect of cimetidine in gastric ulcer patients. Scand J
Gastroenterol 1979;14:1756.
41 Barr GD, Kang JY, Canalese J, et al. A two-year prospective
controlled study of maintenance cimetidine and gastric
ulcer. Gastroenterology 1983;85:1004.
42 Tatsuta M, Iishi H, Okuda S. EVects of cimetidine on the
healing and recurreence of duodenal and gastric ulcers. Gut
1986;27:121318.
26 Iijima, Ohara, Sekine, et al