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СТАНДАРТНАЯ АНТИХЕЛИКОБАКТЕРНАЯ ТЕРАПИЯ ПРИВОДИТ К АКТИВИЗАЦИИ ТРАНЗИТОРНОЙ ГРИБКОВОЙ ФЛОРЫ В ЖЕЛУДОЧНОЙ СЛИЗИ
Хомерики С. Г.
STANDARD THERAPEUTIC REGIMENS IN H. PYLORI INFECTION LEADS TO ACTIVATION OF TRANSITORY FUNGAL FLORA IN GASTRIC MUCUS
Khomeriki SG.
Sergey Khomeriki — Head of Laboratory of Pathomorphology Резюме
Использование антибиотиков широкого спектра действия в комбинации с антисекреторными средствами при лечении H. pylori-ассоциированной язвенной болезни приводит к снижению представительства нормальной микрофлоры кишечника и росту условнопатогенной, транзиторной микрофлоры, представителями которой являются дрожжеподобные грибы рода Candida. Одной из основных причин этого может являться нарушение микробного биоценоза в желудке, обусловленное эрадикацией H. pylori. В последние годы получены веские доказательства того, что H. pylori является источником пептидов, обладающих мощным фунгицидным действием. В ряде клинических исследований показано, что после курса стандартной эрадикационной терапии H. pylori-ассоциированной язвенной болезни грибы рода Candida выявляются в содержимом кишечника в 2 - 3 раза чаще, чем до лечения. При этом остается неясным, имеет место активация грибковой флоры, предсуществовавшей в кишечнике, или определенную роль могут играть фармакоиндуцированные нарушения микробиоценоза в желудке.
Нами проведено гистологическое и бактериоскопическое исследование биптатов, полученных из слизистой оболочки антрального отдела и тела желудка у 679 больных H. pylori -ассоциированной патологией верхних отделов желудочно-кишечного тракта до и после курса стандартной эрадикационной терапии. До лечения дрожжеподобные грибы в желудочной слизи удалось выявить преимущественно в виде одиночных клеток у 112 больных (16,5%). Эрадикация H. pylori при использовании тройной терапии (омепразол+амоксициллин+м етронидазол) была достигнута у 85% больных и при этом в 33% в желудочной слизи были выявлены дрожжепо-добные грибы преимущественно в виде крупных колоний и псевдомицелия.
Проведенное нами исследование свидетельствует о том, что в разрастании грибковой флоры кишечника после курса антихеликобактерной терапии может играть роль увеличение поступления в кишечник дрожжеподобных грибов из желудка. В условиях снижения кислотности желудочного сока на фоне антисекреторной терапии и отсутствия микробного антагонизма со стороны H. pylori в желудочной слизи, грибы рода Candida получают оптимальные условия для развития и дальнейшего пассажа в кишечник. В этих случаях для предотвращения явлений дисбактериоза после эрадикации H. pylori может потребоваться назначение антигрибковых препаратов.
Summary
Background. Administration of broad-spectrum antibiotics with antisecretory agents in treatment of H. pylori-associated diseases results in decreased representation of normal intestinal microflora and growth of transitory microflora, whose representatives are yeast-like fungi (Candida). This may primarily be caused by disordered microbial biocenosis in stomach, conditioned by eradication of H. pylori. Studies over recent years have yielded reliable information confirming that H. pylori is a source of peptides possessing a potent fungicidal activity. It still remains unclear whether there takes place an activation of fungal flora pre-existing in intestine, or drug-induced disorders of microbiocenosis in stomach.
Materials and Methods. We carried out a histological and bacterioscopic study of biopsy materials obtained from gastric antral mucosa in 679 patients with H. pylori-associated erosive or/and ulcerative gastric lesions, chronic gastritis and gastroesophageal reflux disease (GERD), with erosive or/and ulcerative duodenal lesions before and after eradication therapy.
Results. Prior to treatment, the yeast-like fungi in stomach were revealed in 112 patients (16.5%). Eradication of H. pylori was achieved in 85% of patients, with large growth of elements resembling yeast-like fungi and pseudomycelium being detected in gastric mucosa in 33% of case.
Центральный НИИ гастроэнтерологии, Москва, Россия
Sergey Khomeriki Shosse Entuziastov, 86, Moscow 111123, Russia. Telephone: +7-495-3050979 Fax: +7-495-3041942 E-mail: [email protected]
Conclusions. The findings obtained suggest that an increased influx of yeast-like fungi from stomach into the gut may play role in proliferation of intestinal fungal microflora following antihelicobacter therapy. Under the conditions of decreased acidity of gastric juice on the background of antisecretory therapy and the lack of microbial antagonism on behalf of H. pylori in gastric mucus, Candida-genus fungi receive optimal conditions for development and subsequent passage to the intestine.
Keywords: Eradication of H. pylori, Candida spp in human gastric mucosa
Introduction
Progress achieved during the last decade in the treatment of acid-induced H. pylori-associated diseases is based on disclosing the role of H. pylori in pathogenetic mechanisms of these diseases. However, following wide-scale implementation into clinical practice of potent antisecretory agents and antibiotics in order to destroy H. pylori, it became clear that eradication of H. pylori not uncommonly leads to development of other pathological conditions also impairing the normal life activity of the body [1].
Several studies revealed that one-week eradication regimen with amoxicillin and clarithromycin is followed by increased isolation of Candida albicans from the patients' stools [2]. Yeast-like fungi (including Candida albicans) are known as a classic representatives of the normal transitory microflora. Widely occurring in the environment, they easily get ready access to the oral cavity and respiratory pathways. In diminished immunological systemic resistance of the body, they are readily fixed on the surface of the multilayer squamous epithelium of the oral cavity or mucous membrane of the oesophagus. However, acidic medium and proteolytic enzymes of the stomach turn out to be virtually an insurmountable obstacle for them. Only an utterly limited number of the fungal cells (having hidden in gastric mucus) happen to get to the intestine wherein more favourable conditions for their growth and proliferation exist.
Studying inoculation of yeast-like fungi from gastric juice showed that the course of the standard triple therapy in H. pylori-positive patients, when pH of gastric juice increases two-fold, is followed by a 2.5-fold increase in isolation of Candida albicans therefrom. Moreover, antisecretory monotherapy with proton pump inhibitors in H. pylori-positive patients with a 3-fold increase in the pH value of gastric juice, is followed by a 3.5-fold
Objectives of the study
To investigate the incidence of H. pylori and yeast-like fungi of the Candida genus in gastric mucus in H. pylori-associated in upper gastrointestinal diseases, as well
Materials and methods of the study
This study includes 679 patients with various upper gastrointestinal diseases. Most of patients were females (394). According to the endoscopic findings patients were subdivided into next groups: with erosive or/and ulcerative gastric lesions, chronic gastritis and gastroesophageal reflux disease (GERD), with erosive or/ and ulcerative duodenal lesions, cicatricial duodenal deformity. The patients' age was from 21 to 83 years. Duodenal diseases were observed more often in patients under 50 years, while erosive or/and ulcerative gastric
increase in isolating Candida albicans therefrom [3]. Mention should be made that the species Candida albi-cans accounts for as little as 41% of the Candida-genus fungi isolated from the gastric contents. As for other representatives, more frequently occurring are: C. tropicalis (30%), C. glabrata (9%), or mixed cultures [4]. Is the body indifferent to an increase in the biomass of the fungal microflora in the stomach?
Some retrospective studies showed that the failure of H. pylori eradication with standard triple therapy leads to the development of relapses of peptic ulcer disease in 17% of cases, but when the eradication was successful — relapses occur in 10% of the cases. Adding a fungicidal agent makes it possible not only to decrease the isolation of Candida albicans from the gastric contents, but to completely exclude the development of relapses of the disease in cases where in eradication of H. pylori was successful [5]. Probably, activation of the fungal flora in the upper portions of the digestive tract is in some way engaged in the pathophysiological mechanisms of the persistently lingering inflammatory processes in the gastroduodenal zone.
Augmented or diminished manifestations of microbial antagonism between the yeast-like fungi and H. pylori may considerably influence the pattern of the pathological processes in the gastroduodenal mucosa [6]. Biochemical studies of the components of the microbial cell of H. pylori made it possible to isolate polypeptide factors possessing a potent fungicidal activity (especially against the mycelial form of fungi) [7]. Probably, the absence of H. pylori in the gastric mucosa and low values of intragastric pH prevent yeast-like fungi from penetration and development in the internal medium of the body, while inhibition of these factors during eradication therapy promotes activation of fungal flora.
as to elucidate the effect of the antihelicobacter therapy on single or concomitant persistence of these microorganisms in the mucus coating the gastric mucosa.
lesions and GERD prevailed in older patients. (Table 1). The materials to study were gastric antrum and corpus mucosa tissue samples obtained from patients at initial esophagogastroduodenoscopy and in control examinations after standard triple anti-Helicobacter therapy (OAM), recommended by Maastricht consensus reports [8]. The presence of H. pylori and yeast-like fungi in the gastric mucus was revealed using the histological method and cytological study of the crushed and Gram-stained biopsy materials.
Table 1.
Clinical characteristics of the examined patients
Fig. 1
Endoscopically verified diseases (%) Age groups
21 - 50 yr (n = 318) 51-83 yr (n = 361)
Exacerbation of chronic duodenal ulcer or erosive bulbitis 21 16
Exacerbation of chronic gastric ulcer or erosive gastritis 11 19
Cicatricial duodenal deformity 19 18
Chronic gastritis or chronic gastroduodenitis 46 38
Gastroesophageal reflux disease 3 9
Results
Yeast-like fungi in gastric mucus at the initial examination were revealed in 112 patients (16.5%). Only singly occurring cells of Candida spp. were observed on the background of large amounts of H. pylori. They could also be detected in the cytoplasm of neutrophilic granulocytes, although phagocytosis is known to be often incomplete. Yeast-like fungi are revealed also in histological examination, often in the lumen of the pyloric glands and on the epithelial surface. However, invasion through the layer of the epithelial cell is virtually never observed.
The control study after antihelicobacter therapy was carried out in 52 patients. Eradication of H. pylori in this group was confirmed in 85% of patients, while Candida spp. were revealed in 17 patients (33%) (Table 2). Yeastlike fungi were observed in the form of numerous colonies and even separate mycelial forms. (Fig. 1). Two patients were found to have simultaneous persistence of yeast-like fungi with H. pylori.
At the initial examination, the incidence of Candida spp. in various groups of patients varied considerably: it was maximal in patients with chronic gastroduodenitis and minimal in patients with GERD. No cases of simultaneous persistence of microorganisms were seen in the
group of patients with GERD, although H. pylori was revealed in 20% of the patients with GERD.
As would be expected, H. pylori was noted to occur more frequently in patients with erosive or/and ulcerative duodenal lesions. In this group of patients, yeast-like fungi were present in gastric mucus in 13% of patients, with a high incidence rate of concomitant persistence of these microorganisms (10%). The patients with cicatricial duodenal deformity were found to have decreased incidence of detecting H. pylori, with increased incidence of revealing Candida spp., while their concomitant persistence was observed twice rarely than during the exacerbation period.
Only 4% of patients showed concomitant persistence of H. pylori and Candida spp. in patients with erosive or/and ulcerative gastric lesions and chronic gastritis, although the incidence of Candida spp. in erosive or/and ulcerative gastric lesions was considerably lower.
The presence of yeast-like fungi in gastric mucus, as well as their concomitant persistence with H. pylori in patients over 50 years old occurs more rarely than in younger people (Table 3).
H. pylori also occurred more rarely. Considerable differences between the age-related groups are seen while carrying out antihelicobacter therapy. With virtually a similar level of eradication of H. pylori in different age groups, the incidence of yeast-like fungi in older age groups was twice higher. In old age concomitant persistence of microorganisms was not virtually observed. In the age groups under 50 years, after eradication therapy neither the incidence of yeast-like fungi, nor the incidence of their concomitant persistence with H. pylori virtually changed.
With a substantially higher incidence of detecting H. pylori in men as than in women, the incidence of yeast-like fungi in gastric mucus in them did not differ, however, concomitant persistence of microorganisms in women was found almost twice as rarely (Table 4).
Discussion
It is a common knowledge, that, in the normally functioning stomach, there are no conditions for mass penetration of opportunistic fungi into the gut through
the acid-peptide barrier. The presence of H. pylori in the stomach enhances this barrier largely at the expense of stimulating the secretion of hydrochloric acid, and,
Table 2.
Microorganisms revealed by bacterioscopy in gastric mucus in various diseases
H. pylori, % Candida spp., % Hpylori+Candida spp., %
Exacerbation of chronic duodenal ulcer or erosive bulbitis (n = 132) 60 13 10
Exacerbation of chronic gastric ulcer or erosive gastritis (n = 107) 30 16 4
Cicatricial duodenal deformity (n =120) 46 17 5
Chronic gastritis or chronic gastroduodenitis (n = 279) 26 21 4
Gastroesophageal reflux disease (n = 41) 20 5 0
After eradication therapy (n = 52) 15 33 4
H. pylori, % Candida spp., %
H. pylori+Candida spp., %
Group of patients aged from 21 to 50 years (n = 318)
47
18
6
After eradication therapy (n = 31)
16
16
Group of patients aged from 51 to 83 years (n = 361)
30
15
After eradication therapy (n = 21)
14
38
Table 3.
Age-related differences in detection of microorganisms in gastric mucus
6
4
0
H. pylori, % Candida spp., %
H. pylori+Candida spp., %
women (n = 394)
31
17
After eradication therapy (n = 27)
15
30
men (n = 285)
43
16
After eradication therapy (n = 25)
16
36
Table 4.
Sex-related differences in detection of microorganisms in gastric mucus
possibly, at the expense of activating the inflammatory reaction in the mucous membrane of the stomach. Besides, as has been shown in recent years, H. pylori per se possesses fungicidal properties. These properties are conditioned by the component of the microbial cell — i. e. the terminal fragment of ribosomal protein L1 consisting of 19 amino acid residues, and called HP (2-20) [9]. The effect of HP (2-20) on the membrane of the fungal cell leads to the impairment of its structure with the development of large pores through which potassium ions begin to escape into the external medium. This ends up in lysis of the fungal cell. The fungicidal effect of HP (2-20) is not accompanied by haemolysis of human RBCs, i. e., the influence on the membranes is of a selective nature.
What actually happens during the eradication therapy? Potent antisecretory agents do destroy the acidic-peptide barrier, while antibiotics do inhibit the vital functions of H. pylori with its fungicidal component. (Fig. 2). A combination of these impacts results in creating of a gastric medium favourable for development of fungal flora which then in large amounts enters the small intestine [10].
Mention should be made that detecting yeast-like forms and even fungal pseudomycelium in gastric mucus is not yet a criterion for making the diagnosis of gastric candidiasis (since in the majority of cases, there is neither adhesion of the fungal elements to the epithelial cells of the stomach, nor invasive growth). However, increasing biomass of yeast-like fungi is a prerequisite — a real risk factor for development of intestinal candidiasis (especially in the presence of the fungal pseudomycelium in the gastric contents). The mycelial forms of Candida spp. are known to easily adhere to enterocytes. The pseudomy-celium having entered the duodenum from the stomach has more chances to fix on the cellular structures of the duodenal epithelium and for rapid beginning of invasive growth in the initial portions of the small intestine with the development of the classic manifestations of intestinal candidiasis.
Our study showed that the successful H. pylori eradication therapy is followed by detecting yeast-like fungi in gastric mucus more frequently and in a considerably larger amount, forming sometimes whole colonies. The conditions for Candida spp. are so favourable that the
latter even form pseudomycelial structures, which is probably promoted by the lack of H. pylori, whose fun-gicidal components are especially active exactly against mycelial forms of the fungus.
It must be taken into consideration, however, the author-revealed cases of concomitant persistence of yeastlike fungi with H. pylori are not completely clear, especially following a failed eradication therapy. Probably, either not all strains of H. pylori are capable to produce fungicidal peptides, or amongst many species of Candida, there are some insensible to the fungicidal peptides of H. pylori, and may form pseudomycelium, even when surrounded by H. pylori. Besides, inhibition of vital functions of H. pylori under the effect of antibiotics initiating the bacillar-coccic transformation of the microorganism, may result in the loss of ability to generate fungicidal peptides. Further special studies are required in order to confirm these assumptions.
Fig. 2
Conclusion
Hence, yeast-like fungi in gastric mucus and on the epithelial surface in patients with organic gastroduodenal diseases occurs averagely in 16.5% of patients, predominantly in the form of singular cells.
Following a successful eradication therapy, yeast-like fungi occur in gastric mucus considerably more frequently (in 33% of patients) and, as a rule, in the form
of large colonies and pseudomycelium. Concomitant persistence of H. pylori and Candida spp. in gastric mucus is virtually absent in patients with GERD, while in patients with gastric lesions or cicatricial duodenal deformity it was noted to occur twice as more rarely than in exacerbation of erosive-and-ulcerative duodenal lesions.
4
0
8
Antihelicobacter therapy, widely used for treatment
of peptic ulcer disease creates real prerequisites for
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