Role of exogenous and endogenous PG in the mechanism of gastric mucosal integrity and gastroprotection
It is well known that the stomach can defend himself from the injury caused
by a variety of strong topical irritants and obnoxious agents due to the activation
of several lines of defense, among them the most important being protective
mucus and bicarbonate secretion, mucosal hydrophobicity, gastric microcirculation,
generation of protective prostaglandins within gastric mucosa, increase in the
mucosa sulfhydryls and release of vasoactive neuropeptides from sensory nerve
afferents. In 1979, the phenomenon of "cytoprotection" was introduced into the
literature by Andre Robert (1), who described the unexpected and fascinating
finding that prostaglandins (PG), the major products of arachidonate metabolism
through cyclooxygenase activity can be crucial for the maintenance of the gastric
integrity. He provided the experimental evidence that PG when applied exogenously
in the non-antisecretory doses, exhibit high activity in preventing the mucosal
damage induced by necrotizing substances such as ethanol, hiperosmolar solutions,
strong acids (e.g. 0.6 N HCl), base (e.g. 0.2 N NaOH) and concentrated bile
including even the lesions caused by boiling water (1) (
Fig.1). The precise
mechanism of cytoprotective action of prostaglandins remained unknown but this
stimulatory action of these agents on gastric mucus and bicarbonate secretions,
an increase in the gastric microcirculation and the enhancement in the mucosal
sulfhydryl compounds were initially proposed to explain this phenomenon. We
were able confirmed not only this finding but also documented, for the first
time, that certain growth factors, especially EGF, could be considered as gastroprotective
because they were also capable of reducing aspirin-induced gastric ulcerations
in rats and cats under the conditions where biosynthesis of endogenous PG was
completely inhibited by the administration of this NSAID (2).
|
Fig. 1.
The effect of i.g. pretreatment of PGE2
methyl analog applied i.g. in graded doses ranging from 0.03 up to 1.5
µg per rat, on the on the number of gastric lesions induced by necrotizing
agents such as 100% ethanol, 25% NaCl, 0.2 n NaOH, 0.6 N HCl or boiling
water (1 ml/rat). Mean ± SEM of 4 per each experimental group. Minute
amount of exogenously applied methyl PGE2
analog was capable of attenuating of these lesions almost completely. |
Phenomenon of adaptive cytoprotection mediated by prostaglandins
It became evident that the one of the important forms of cytoprotection is "adaptive
cytoprotection", the term that was also introduced originally by Robert and
his associates (3) to describe the protective activity of endogenous prostaglandins
generated within gastric mucosa by mild topical irritants such as 20 % ethanol,
5 mM NaCl or 5 mM taurocholate in response to severe mucosal damage induced
by strong irritants such as 100 % ethanol, 25 % NaCl or 80 mM taurocholate (
Fig.
2). The concept of cytoprotection pioneered by Robert's experimentation's
was further extended by the observation that mild irritants offer the cross-protective
response, e.g. 5% NaCl was effective in attenuation of damage induced not only
by necrotizing 25 % NaCl but also by 100% ethanol, while 20% ethanol prevented
the damage caused by 100% ethanol or 25% NaCl (4). Moreover, using the bioassay
technique to measure a generation of prostacyclin (PGI
2)
and PGE
2 in the gastric mucosa, our group found
that the pretreatment of gastric mucosa with mild irritant resulted in an enhancement
of the mucosal generation of PGI
2 and PGE
2,
thus providing direct evidence for the involvement of endogenous PG in the mechanism
of adaptive cytoprotection (4) (
Fig. 3). We proposed that this protective
mucosal mild-irritation could be attributed to the local action of endogenous
PG because mild irritants failed to exhibit any protective activity when applied
systemically (4,5). It is of interest that exogenous PGE
2
exhibited cytoprotective activity against the damage induced by ethanol and
indomethacin to the isolated gastric mucosal cells and gastric glands
in vitro (6-8) indicating that this cytoprotective activity of PG
in vitro
conditions may contribute, at least in part, to the gastric protection observed
in the stomach pretreated with PG
in vivo. These studies supported the notion
that PG possessed the ability to directly attenuate the cell damage without
the contribution of neural and hormonal factors as well as gastric mucosal circulation
(8). This PG mediated cytoprotection in isolated cell systems has been a controversial
subject because some experimental evidence suggested that PG protection does
not exist
in vitro and questioned also the notion that PG are primary mediators
of adaptive cytoprotection. Instead of primary mediatory role of PG in adaptive
cytoprotection, other mechanisms were emphasized including enhanced gastric
blood flow and stimulation of mucus release in the gastric mucosa due to the
local irritating effect to of the mild irritant (9-11). Moreover, it was suggested
that the partial reversal of adaptive cytoprotection by indomethacin, an inhibitor
of PG biosynthesis, could be secondary to the some other action of this agent
such as reduction in gastric blood flow rather than the direct effects on prostanoid
synthesis enhanced in response to mild irritant (12).
|
Fig.
2. Comparison of the effect of various mild irritants (20% ethanol,
5% NaCl and 5 mM taurocholate) applied i.g. and short ischemic preconditioning
(IP) induced by 2 times 5 min occlusion of the rat celiac artery, on the
area of gastric lesions and alterations in the GBF induced by i.g. topical
application of necrotizing substances (100% ethanol, 25% NaCl or 80 mM
TC) or the exposure of gastric mucosa to 30 min of ischemia followed by
3 h or reperfusion (I/R). Short ischemic preconditioning mimics the gastroprotective
effect of mild irritants against lesions provoked by necrotizing agents
resulting in a significant attenuation of the gastric mucosa injury induced
by prolonged I/R. Mean ± SEM of 6-8 rats. Asterisk indicates a significant
change as compared to the value obtained in rats without pretreatment
with mild irritants or IP. |
|
Fig. 3.
Effect of intragastric (i.g.) application of vehicle, mild irritant (20%
ethanol; 1 ml/rat) or PGE2 (5 µg/kg)
without or with concurrent administration of indomethacin (5 mg/kg i.p.)
on the area of gastric lesions induced by the topical application of 100%
ethanol and accompanying changes in the generation of PGE2
in the gastric mucosa. Mean ± SEM of 6-8 rats. Asterisk indicates a significant
change as compared to the value obtained in animals treated with vehicle.
Cross indicates a significant change as compared to the value obtained
in rats without pretreatment with indomethacin. |
Non-prostaglandin mechanism of gastric mucosal protection and mucosal restitution following injury
The promise that potential pharmacological formulations containing PG may exert therapeutic efficacy against mucosal injury and in peptic ulcer disease in clinical settings had however, not been fulfilled. First, the potential clinical application of cytoprotective PG included not only their prevention of acute gastritis such as those caused by alcohol, aspirin and other NSAID or by biliary reflux but also the mechanism of inhibition of gastroduodenal disordes such as reflux esophagitis, peptic ulcer disease, ulcer recurrence and gastritis associated with gastric ulcer. It become quickly evident that PG at non-antisecretory doses can not accelerate ulcer healing being also ineffective in the prevention of ulcer recurrence and reflux esophagitis. Second, by definition, PG were originally implicated in cytoprotection of the all layer of the gastric mucosa against the damage induced by noxious-necrotizing substances but then it became apparent from detailed histological assessments of the gastric mucosa "protected" from the acute gastric injury by PG that these arachidonate metabolites failed to prevent morphologic disruption of surface epithelium and cell desquamation after ethanol administration (13). Although PG prevented the macroscopic injury induced by ethanol, they were not capable to prevent the destruction by this agent of superficial epithelial gastric mucosal cells but enhanced rapid restitution of the damaged mucosa by stimulation of mucosal cell migration from the intact foveolar and neck-gland area (13,14). The fact that the PG afforded protection to the deeper mucosal layers predominantly including regenerative zone of gastric glands, but failed to prevent injury to the superficial mucosal cells, turned however, into the question their "truly" cytoprotective properties (14,15).
The process of rapid repair or restitution of the gastric mucosa occurs to reestablish
epithelial continuity and barrier function after injury. Restitution was first
described
in vitro in the bullfrog gastric mucosa (16) but, at present,
it is considered as a more generalized response to the superficial injury along
the GI tract (17,18). By definition restitution means the rapid re-epithalization
after superficial gastric injury that is caused by migration of persisting
viable
epithelial cells from the areas surrounding the damage (16). In 1984, Ito
et al. (17) showed for the first time, that the ethanol damage to rat gastric mucosa
led to 99% necrotic destruction of luminal surface of the gastric mucosa within
30-45 sec but this damaged area started to restitute rapidly due to extensive
cell migration. Furthermore, restitution that requires also the energy from
aerobic glycolysis, to drive the migration of cells at the apical surface of
the mucosa, was shown to be completed within 4 h in amphibian gastric mucosa
(18). Studies by Ito at al. (17) provided morphologic and physiological evidence
that rapid restitution consists of two-part processes. First, uninjured cells
became flattened, extend lamelopodia and migrate from confluent sheet of epithelial
cells at the apical surface of the mucosa. Second, the monolayer of flattened
cells then reestablish tight junctions and cell polarity to restore barrier
functions. Since PG treatment failed to prevent initial morphologic damage,
even exerting a stimulatory effect on rapid restitution process, it was concluded
that the protective action of these arachidonate products could not be attributed
to their genuine "cytoprotective" activity. Furthermore, it was proposed that
adequate Ca
+2 and bicarbonate concentrations play
a major role in the mucosal restitution after the damage induced by hyperosmolar
solution because removal of Ca
+2 from the medium
or substitution of neutral buffer (HEPES) for HCO
-3
in the their gastric mucosa mounting system, markedly impaired the restitution
of the bullfrog gastric mucosa mounted in Ussing chamber
in vitro (18).
Studying other possible mediators of restitution, Paimela
et al. (19) have indicated
that growth factors such as bFGF can mediate microscopic and electrophysiological
recovery from the mucosal damage induced by hyperosmolar solution (1 mM NaCl).
The exact mechanism of restitution process remains unknown but recent observation
by Hagen
et al. (20) identified novel pathway Na
+driven
HCO
-3 transport
that could be involved in restitution, which seems to be independent from Na
+/H
+
exchange and Na
+-K+-2Cl
-
cotransport originally implicated in the ionic mechanism of process of restitution.
Besides PG, another important mediator, nitric oxide (NO), was later implicated
as a mediator of adaptive cytoprotection and in fact, some reports suggested
that PG might not be a primary mediator of this mucosal adaptive cytoprotection
(15,21). The contribution of NO to adaptive cytoprotection was based on the
finding that L-NNA reversed the effect of mild irritant with the extent similar
to that observed with administration of indomethacin (
Fig. 4). Furthermore,
concurrent treatment with L-arginine, a substrate for the NO-synthase activity,
co-administered with L-NNA or when exogenous PGE2 analog added to indomethacin,
they counteracted the inhibitory effect of L-NNA and indomethacin on adaptive
cytoprotection induced by 20% ethanol and diminished an increase in the GBF
induced by this mild irritant.
|
Fig. 4.
Scheme summarizing of the effect of necrotizing agents such as ethanol,
HCl and NaOH and ulcerogenic compounds and factors such as NSAID, bile
acid and stress resulting in gastric mucosal injury and the mechanism
of direct and adaptive cytoprotection mediated by protective factors such
as PG, growth factors, NO, CGRP and mild irritants (e.g. 20 % ethanol,
5% NaCl) to counteract the damage induced by these ulcerogens. |
Extensive experimental studies in the last decade revealed that NO released
from vascular endothelium, sensory afferent nerves, or that originating from
gastric epithelium is essential not only for adaptive cytoprotection but also
for the gastroprotection evoked by many physiological factors including growth
factors such as EGF, bFGF TGF
alpha and PDGF,
or gastrointestinal hormones, such as cholecystokinin (CCK), gastrin, leptin
and ghrelin (22-27).
EGF when applied subcutaneously, markedly attenuated the gastric lesions evoked
by ethanol and the protective activity of this peptide was inhibited by L-NNA,
indomethacin, DFMO, an inhibitor of ornithine decarboxylase (ODC)-polyamine
pathways (
Fig. 5). This study have indicated that growth factors may
exert protective effect on the gastric mucosa injured by ethanol
via mechanism
involving mucosal NO and PG as well as enhanced mucosal polyamines and/or sulfhydryls
biosynthesis (
Fig. 6). Furthermore, we documented that gastrointestinal
hormones such as CCK and gastrin exhibit a potent gastroprotective activity
against necrotizing injury induced by ethanol and mucosal damage caused by aspirin,
via prostaglandin-independent mechanism (24,25).
|
Fig. 5.
Effect of vehicle, various growth factors (EGF, TGFa, bFGF applied in
a dose of 50 µg/kg s.c.) and 16,16 dimethyl PGE2 (dm PGE2;
5 µg/kg i.g.) with or without the pretreatment with L-NNA (20 mg/kg i.p.)
on area of gastric lesions induced by 100% ethanol. Suppression of NO-synthase
activity by L-NNA significantly attenuated the reduction of gastric lesions
caused by growth factors and dmPGE2.
Mean ± SEM of 6-8 rats. Asterisk indicates a significant change as compared
to the value obtained in animals treated with vehicle. Cross indicates
a significant change as compared to the value obtained in animals without
L-NNA pretreatment. |
|
Fig. 6.
Possible mediators implicated in the growth factor-dependent cytoprotection.
Growth factors such as EGF, TGFalpha,
bFGF and PDGF exhibit gastroprotective action due to activation of mucosal
NO, PG and polyamines (PA), increase in the gastric blood flow (GBF) and
mucosal sulfhydryls and speeding up process of restitution of gastric
epithelial cells. |
The role of satiety hormons, especially ghrelin which recently triggered attention of numerous investigators, in the mechanism of gastric mucosal defense and gastroprotection has been little elucidated except for the report of Sibilia
et al. (28) who showed recently that central administration of ghrelin reduced the lesions induced by ethanol. This gastroprotective effect of ghrelin was attenuated by the blockade of NOS activity with L-NAME and by the functional ablation of sensory afferent nerves with capsaicin. The question remains whether ghrelin contributes to gastroprotection against gastric lesions caused not only by the artificial irritant such as ethanol but also by natural ulcerogenic conditions such as stress and what is the role for the cyclooxygenase (COX)-PG in the possible gastroprotective effect of this peptide. We found (29) that exposure to water immersion and restraint stress upregulates mRNA for ghrelin in the gastric mucosa suggesting that this hormone may act locally and activate various protective mechanisms and contribute to the maintenance of gastric mucosal defense against damage induced by noxious agents. It is of interest that the protective and hyperemic effects of central and peripheral ghrelin were completely abolished by vagotomy and significantly attenuated by suppression of COX-1 and COX-2 with indomethacin and rofecoxib supporting the notion that vagal nerves and COX-PG system play an imporatant role in ghrelin-induced protection and accompanying hyperemia.
Implication of cyclooxygenase (COX)-1 and COX-2 products in the mechanism of gastroprotection and gastric adaptation
Recent advances on the enzymatic pathways of arachidonate metabolism revealed
that PG synthesis depends upon the activity of cyclooxygenase (COX), a rate-limiting
enzyme in the synthesis of eicosanoids (
Fig. 7). Two isoforms of COX
were identified in many cells; a constitutive enzyme designated as COX-1 and
inducible isoform known as COX-2 (30). COX-1 appears to be responsible for the
production of PG that is physiologically important for homeostatic functions,
such as maintenance of the mucosal integrity and mucosal blood flow (31). Under
physiological conditions prostanoid synthesis depends upon the availability
of arachidonic acid and the COX-1 activity, that is a major target for nonsteroidal
anti-inflammatory drugs (NSAID) causing mucosal damage in the stomach (32).
PG derived from the activity of the COX isoforms, especially COX-1, play an
important role in mechanism of gastric integrity, gastroprotection and ulcer
healing (31,32). Recently, prostaglandins derived from COX-2 were implicated
in the protective and ulcer healing activities of growth factors by the demonstration
that COX-2 is upregulated on the edge of the gastric ulcer and this is significantly
enhanced by the treatment with growth factors (33). Moreover, endogenous prostaglandins
derived from COX-1 and COX-2 are involved in the mechanism of mucosal recovery
from ischemia/reperfusion-induced acute gastric erosions that subsequently progressed
into deeper ulcerations and that healing of these ulcers is associated with
an overexpression of COX-2 mRNA (32). Our notion that the expression of COX-2
plays an important role in the healing of gastric ulcers remains also in keeping
with the observation by Gretzer
et al. (34) who reported that PG derived
from COX-2, not only from COX-1, may be involved in adaptive cytoprotection
induced by a topically applied mild irritant, when a larger area of mucosa is
injured.
|
Fig. 7.
Schematic characteristics of prostaglandin (PG)-cyclooxygenases (COX)-1
and COX-2 that convert arachidonic acid to unstable endoperoxidase PGG2
and then to PG. COX-1 is expressed constitutively and releases PGE2
and PGI2 (prostacyclin) involved in cytoprotection
and accompanying increase in the gastric blood flow (GBF). Another product
of COX-1, thromboxane (TXA2) exhibits
vasoconstrictor and anti-platelet activity. COX-2 produces PG and enhances
activity of proteases and growth factors increasing cell proliferation
and contributing to ulcer healing and mucosal repair via enhancement
in the bicarbonate secretion and angiogenesis mediated by proangiogenic
growth factors such as VEGF and bFGF. |
NSAID such as aspirin (ASA) are widely used because of their well recognized
anti-inflammatory, anti-pyrogenic and anti-thrombotic properties, however the
major limitation of their clinical application are serious side-effects, including
damage of gastrointestinal mucosa, aggravation of stress lesions and exacerbation
of pre-existing gastric ulcerations (35). This deleterious action of conventional
NSAID was attributed to their topical irritating effect, suppression of gastric
mucosal PGE
2 activity, activation of neutrophils,
fall in the microcirculation and enhancement in the motility induced by these
agents (35).
An interesting, practical, and important discovery related to the gastric damage
induced by NSAID is an increase in mucosal tolerance or adaptation to the ulcerogenic
action of these drugs that develops with their repeated and more prolonged administration
(36-38). This remarkable attenuation of mucosal damage had been first demonstrated
in rats (36) and then confirmed in humans (37,38). Initially, aspirin caused
a widespread gastric mucosal injury which with repeated ASA application, was
followed by the adaptation of the mucosa and increased tolerance to withstand
further insult without significant injury (39). Interestingly, this remarkable
ability of the gastric mucosa to withstand the prolonged exposure to the ulcerogenic
action of aspirin does not depend upon the PG biosynthesis because this generation
is suppressed with the first dose of aspirin and remained suppressed during
repeated administration of this NSAID (39) (
Fig. 8). We observed that
following ASA ingestion, EGF, which is normally present in saliva and gastric
juice, and exerts potent mitogenic and gastroprotective activities, contributed
significantly to the increased cellular proliferation in gastric mucosa observed
during repetitive ASA insults thus probably playing a major role in the mechanism
underlying gastric mucosal adaptation (39). Moreover, the adaptation to repetitive
ASA insults was accompanied by the reduction in both the number of circulating
neutrophils and the severity of neutrophil infiltration into the gastric mucosa.
It is of interest, that the reduction in mucosal neutrophil infiltration and
the fall in blood neutrophilia were already seen after the first rechallange
with aspirin and it was accompanied by the significant increase of the gastric
blood flow in animals and human subjects (39,40). This increase in the gastric
blood flow accompanying ASA-induced gastric adaptation was blunted by L-NNA,
the inhibitor of NO-synthase, but this inhibitor failed to eliminate gastric
adaptation indicating that suppression of NO is essential in the mechanism of
the hyperemia but probably is not the major and the only factor in the development
of gastric adaptation to repeated treatment with NSAID. This adaptation does
not appear to be mediated by endogenous PG, since prolonged administration of
ASA was accompanied by almost complete suppression of COX-1 and COX-2 activity
in the gastric mucosa of experimental animals and humans (41,42). Furthermore,
our group demonstrated that the rat gastric mucosa adapts not only to topical
ulcerogens such as acidified ASA but also to other topical and non-topical abnoxious
factors such as ammonia (43) or stress caused under experimental conditions
by repetitive exposures to cold and restraint technique (44). It is of interest
that the acidified ASA- and stress-adapted gastric mucosa displayed enhanced
resistance to subsequent challenges with other topical irritants such as concentrated
ethanol, 25% NaCl and diluted bile solutions (
Fig. 9)
via mechanism
involving enhanced expression and release of EGF and increase in the gastric
mucosal cell proliferation triggered in the stomach by repeated ASA insults
(41). Furthermore, the reduction in microbleeding rate in ASA adapted patients
taking ASA for 14 days was dramatically counteracted in human subjects infected
with
Helicobacter pylori suggesting that this germ can impair the gastric
adaptation to continued ASA administration (
Fig. 10).
|
Fig.
8. Development of the gastric adaptation to aspirin (ASA) in rats.
Acidified ASA (100 mg/kg) was administered i.g. for the first time (once)
and this treatment was repeated subsequently for 4 days. The area of gastric
lesions was significantly decreased whereas the GBF was significantly
increased in rats treated repeatedly with aspirin despite almost complete
suppression of the gastric mucosal generation of PGE2
in animals exposed to single or repeated administration of acidified ASA.
Mean ± SEM of 6-8 rats. Asterisk indicates a significant decrease as compared
to the value obtained in animals treated with ASA applied once. Cross
indicates a significant change as compared to the value obtained in intact
gastric mucosa. |
|
Fig. 9.
Effect of single and 4 times daily administration of aspirin (150 mg/kg i.g.) on gastric the mean area of gastric lesions and the accompanying changes in the GBF in rats exposed at 3 h after the last dose of ASA to intragastric (i.g.) treatment with 100% ethanol (1 ml/rat), acidified taurocholate (TC; 80 mM/L), 25% NaCl (1 ml/rat) or to 3.5 h of water immersion and restraint stress (WRS). Gastric mucosa adapted to repetitive ASA treatment shows the enhanced resistance to the damage induced to other potent irritants. Mean ± SEM of 6-8 rats. Asterisk indicates a significant change as compared to the value obtained in non-adapted rats. |
|
Fig.
10. Influence of Helicobacter pylori (Hp) infection on the
process of gastric adaptation to 14 day treatment with aspirin (ASA) or
placebo, as reflected by the determination of the rate of blood loss (microbleeding)
in Hp-negative and Hp-positive patients. The blood loss was maximal at
day 3 after the start of ASA ingestion in both, Hp-negative and Hp-positive
subjects, but following ASA treatment at day 7 and day 14, it was significantly
reduced only in Hp-negative subjects. In contrast, Hp-positive patients
demonstrated similar value of blood loss at 3, 7 and 14 days indicating
the failure of gastric adaptation to continued ASA administration. Triple
eradication anti-Hp therapy in these patients restored the gastric adaptation
to continued ASA treatment with the extent similar to that observed in
Hp-negative gastric mucosa. |
NO releasing NSAID, the new drugs with the ability to spare gastrointestinal tract
Since gastrointestinal ulcerations are associated with the use of all NSAID,
a new strategy for the treatment of inflammatory states included a novel series
of NSAID that consist of an NSAID linked to a NO-releasing moiety (45). The
rationale behind the development of this NO-NSAID composite, was that NO released
from this compound would counteract two events that occur subsequent to the
suppression of PG synthesis by the NSAID, namely reduced gastric blood flow
and an increased adherence of neutrophils to the vascular endothelium of the
gastric microcirculation (45-47), thus, sparing the gastric mucosa. For instance
NO-releasing derivative, such as NO-aspirin (NO-ASA) constructed by adding an
nitroxy-butyl moiety to aspirin, was found to exhibit lower gastric toxicity
despite similar inhibition of both COX-1 and COX-2 activity in the gastric mucosa
and exerting anti-thrombotic effects comparable to its parent NSAID (47,48).
These NO-releasing NSAID by themselves exhibit only minimal ulcerogenic properties
in the gastrointestinal tract, despite exerting a potent anti-inflammatory and
analgesic action, similar to native NSAID (45,46). The major importance of NO
in the prevention of mucosal damage or in preservation of normal ulcer healing
is supported by previous studies showing that both endogenous NO released by
capsaicin or NO originating from L-arginine, a substrate for NO-synthase (NOS),
or that released from glyceryl trinitrate exert gastroprotective activity, mainly
due to hyperemia and the maintenance of blood flow in stressed gastric mucosa
(49). We found that classic NSAID such as indomethacin and ASA aggravated acute
gastric lesions induced by ethanol and stress mainly due to suppression of endogenous
PG, the products of COX-1 and COX-2 activity (48,50). This deleterious action
of classic NSAID such as indomethacin or aspirin was accompanied by the impairment
in GBF and excessive proinflammatory cytokine, IL-1ß and TNF-
alpha
expression and release, induced by these NSAID (50,51). The effects of both
specific and nonspecific COX-1 and COX-2 inhibitors on stress-induced gastric
damage were fully restored by the addition to these inhibitors of PGE
2
applied in minute doses which themselves failed to affect the stress-induced
gastric lesions (52). All these observations led to the conclusion that the
deleterious effect of classic NSAID on stress-induced gastric lesions can be
reproduced by selective COX-1 and COX-2 inhibitors suggesting that both COX
isoforms are involved in the pathogenesis of stress-induced gastric lesions
and the mechanism of mucosal repair and recovery of gastric mucosa from these
lesions (46,50-52).
Involvement of prostaglandins in the phenomenon of gastric preconditioning
As mentioned before PG play an important role in the mechanism of gastroprotection
and mucosal recovery from the acute gastric lesions but their contribution to
the mechanism of short ischemia-induced organ protection, called ischemic preconditioning
(53), have been little studied. This ischemic preconditioning refers to a phenomenon
in which a tissue is rendered resistant to the deleterious effect of prolonged
severe ischemia followed by reperfusion by previous exposures to brief moderate
vascular occlusions (54). These protective effects of short ischemia preconditioning
were first described in the heart by Murry and coworkers in 1986 (53) but very
little evidence was accumulated as to whether similar adaptation to injury induced
by ischemia-reperfusion exists in the gut. We have studied this phenomenon in
the gastric mucosa subjected to brief 2-5 episodes of short ischemic preconditioning
followed by prolonged ischemia-reperfusion that within 3 h causes gross and
microscopic erosions in the stomach (55) (
Fig. 11). It was demonstrated
for the first time (55) that a few short gastric ischemic episodes induced by
celiac artery occlusion results in the gastric protection from the gastric damage
induced by prolonged ischemia-reperfusion
via combining mechanism involving
endogenous prostaglandins (PG) derived from COX-1 and COX-2, nitric oxide (NO)
mostly due to the overexpression of iNOS and adenosine acting on A1 receptors
(
Fig. 12). Moreover, mRNA for COX-2 and COX-2 protein were upregulated
in the preconditioned gastric mucosa while mRNA and protein expression for COX-1
remained unchanged (55). Furthermore, we have shown that preconditioning of
the remote organs to the stomach such as heart or liver by brief episodes of
ischemia, that by itself failed to cause gastric damage and produced a small
rise in gastric blood flow, exerts a potent protective influence on gastric
mucosa subjected to prolonged ischemia-reperfusion (56). To our knowledge, it
was the first demonstration of the gastroprotection phenomenon against ischemia-reperfusion
by brief ischemic preconditioning of extra-gastric organs (56). Moreover, we
confirmed our previous observations that ischemic preconditioning which has
been originally described in various organs including heart, lungs, liver, pancreas
and intestine, could be considered as a powerful intervention in the stomach
resulting in a remarkable attenuation of the extent of mucosal damage evoked
by the severe ischemia-reperfusion (55-57). We assumed that remote preconditioning,
affording gastroprotection, involves crucial mediators including PG derived
mainly enhanced COX-2 activity and excessive release of neuropeptides from sensory
nerves playing a key role in the mechanism of this protection probably due to
rise in the GBF resulting in vasodilatation (
Fig. 13). This notion is
supported by our finding that gastroprotection and accompanying rise in the
GBF induced by gastric, cardiac or hepatic preconditioning were significantly
attenuated by non-selective (indomethacin) and selective COX-1 (SC-560) and
COX-2 (rofecoxib) inhibitors (56,57) and by capsaicin ablating functionally
sensory nerves that are known to release NO and various vasodilatatory neuropeptides
such as CGRP (58-62). Moreover, the concurrent treatment with synthetic PGE
2
analog to compensate for the deficiency of endogenous prostaglandin, or with
exogenous CGRP to replace the neuropeptide lost by deactivation with neurotoxic
dose of capsaicin of afferent nerves counteracted the deleterious effects of
COX-1 and COX-2 inhibitors and capsaicin-induced denervation in preconditioned
gastric mucosa exposed to subsequent ischemia-reperfusion (55-57) (
Fig. 14).
Thus, we conclude that PG and many other mediators such as NO, CGRP and polyamines,
play an important role in the maintenance of gastric mucosal integrity and in
the mechanism of ischemic preconditioning, gastroprotection and gastric adaptation
to repeated insults, especially by stress, while gastric adaptation to ASA appears
to be PG-independent but probably related to protective growth factors.
|
Fig. 11.
Macroscopic appearance of gastric lesions in the stomach induced by I/R
(upper panel) or ischemic preconditioning (2 times 5 min episodes of short
ischemia)(lower panel). Note, that there is prominent reduction in the
I/R-induced by gastric lesions in preconditioned gastric mucosa. |
|
Fig. 12.
The generation of PGE2 in the gastric
mucosa subjected to ischemic preconditioning (IP; 2 times 5 min episodes
of short ischemia) followed by 30 min of ischemia and 3 h of reperfusion
(I/R) with or without pretreatment with indomethacin (5 mg/kg i.p.) or
celecoxib (10 mg/kg i.p.). Mean ± SEM of 6 determinations. Asterisk indicates
a significant change as compared to the value obtained in animals exposed
to I/R. Cross indicates a significant value as compared to the value obtained
in gastric mucosa without COX inhibitors. |
|
Fig.
13. The effect of short ischemic preconditioning of the stomach (clamping
of the celiac artery twice for 5 min) and remote organs such as brain,
liver and kidney (2 times 5 min episodes of short ischemia) on the area
of gastric lesions and accompanying changes in the gastric blood flow
(GBF) in rats induced by prolonged I/R (30 min of ischemia plus 3 h of
reperfusion). Ischemic preconditioning significantly attenuates the lesions
induced by I/R in the stomach and remote organs, especially, brain and
liver. Mean ± SEM of 6-8 rats. Asterisk indicates a significant change
as compared to the value obtained in sham-treated animals exposed to prolonged
I/R. |
|
Fig. 14.
Schematic representation of the common neural pathways consisting of neuropeptides
such as calcitonin gene related peptide (CGRP) released from sensory afferent
nerves, endothelium derived nitric oxide (NO) and prostaglandins (PG)
from to the gastroprotection and hyperemia w (vasodilatation) induced
by mild irritants, low dose of capsaicin and ischemic preconditioning. |
In conclusion, endogenous gastric mucosal PG generated by COX-1 and COX-2 play crucial role in adaptive and ischemic gastroprotection activated by mild irritants, growth factors, flavonoids, certain gut hormones but other mediators, especially NO and CGRP released from activated sensory nerves may also contribute to these phenomena (63). Gastric adaptation to repeated NSAID application does not depend upon PG in animals and humans. In both, experimantal and clinical settings, the gastric mucosa exposed to ASA or other NSAID showed increased tolerance to repetitive NSAID treatment under the conditions where the PG generation was almost completely suppressed but probably the release of growth factors and NO are involved and accompanied by increased blood flow in NSAID-adapted stomach, an effect that could be reversed by NO-synthase inhibitor.
REFERENCES
- Robert A, Nezamis JE, Lancaster C, Hanchar AJ. Cytoprotection by prostaglandins in rats. Prevention of gastric necrosis produced by alcohol, HCl, NaOH, hypertonic NaCl and thermal injury. Gastroenterology 1979; 77: 433-440.
- Konturek SJ, Piastucki I, Brzozowski T, Radecki T, Dembinska-Kiec A, Zmuda
A, Gryglewski R. Role of prostaglandins in the formation of aspirin induced
gastric ulcers. Gastroenterology 1981; 80: 4-9.
- Robert A, Nezamis IE, Lancaster C, Davies IP, Field SO, Hanchar AJ. Mild irritant prevent gastric necrosis through adaptive cytoprotection mediated by prostaglandins, Am J Physiol 1983; 245: 113-116
- Konturek SJ, Brzozowski T, Piastucki I, Dembinski A, Dembinska-Kiec A. Role of locally generated prostaglandin in adaptive gastric cytoprotection, Dig Dis Sci 1982; 27: 967-77.
- Konturek SJ, Radecki T., Brzozowski T, Piastucki I, Dembinska-Kiec A,
Gryglewski R Prostaglandin E2 in gastric
mucosa and its role in the prevention of ulcers induced by acetyl salicylic
acid in cats. Digestion 1981; 21: 205-213.
- Terano A, Mach T, Stachura J, Tarnawski A, Ivey KJ. Effect of 16,16 dimethyl
prostaglandin E2 on aspirin induced damage
to rat gastric epithelial cells in tissue culture. Gut 1984; 25: 19-25.
- Ruwart MJ, Nichols NM, Hedeen K, Rush BD, Stachura J. 16,16-dimethyl PGE2
and fatty acid protect hepatocytes against CCl4-induced damage. in vitro
Cellul Develop Biol 1985; 21: 450-52.
- Tarnawski A, Brzozowski T, Sarfeh J, Krause WJ, Ulich TR, Gergely H, Hollander D. Prostaglandin protection of human isolated gastric glands against indomethacin and ethanol injury. Evidence for direct cellular action of prostaglandin. J Clin Invest 1998; 81: 1081-1089.
- Svanes K, Gislason H, Guttu K, Herfjord JK, Fevang J, Gronbech JE. Role of blood flow in adaptive protection of the cat gastric mucosa. Gastroenterology 1991; 100: 1249-1258.
- Cho, CH, Ko IK, Tang XL, The differential mechanism of mild irritants on adaptative cytoprotection, Eur J Gastroenterol Hepatol 1994; 9 (Suppl 1):24.
- Mutoh H, Ota S, Hiraishi H, Ivey KJ, Terano A, Sugimoto T. Adaptive cytoprotection in cultured rat gastric mucus-producing cells. Role of mucus and prostaglandin synthesis. Dig Dis Sci 1995; 40: 872-878.
- Hawkey CJ, Kemp RT, Walt RP, Bhaskar NK, Davies J, Filipowicz B, Evidence that adaptive cytoprotection in rats is not mediated by prostaglandins, Gastroenterology 1988; 94: 948-953.
- Lacy ER, Ito S. Microscopic analysis of ethanol damage to rat gastric mucosa after treatment with a prostaglandin. Gastroenterology 1982; 83: 619-625.
- Tarnawski A, Hollander D, Stachura J, Krause WJ, Gergely H. Prostaglandin protection of the gastric mucosa against alcohol injury - a dynamic time related process. Role of the mucosal proliferative zone. Gastroenterology 1985; 88: 334-52.
- Hawkey CJ, Rampton DS. Prostaglandins and the gastrointestinal mucosa: are they important in its function, disease or treatment? Gastroenterology 1985; 89: 1162-88.
- Ito S, Lacy ER, Rutten MJ, Critchlow J, Silen W. Rapid repair of injured gastric mcuosa. Scand J Gastroenterol 1984; 101(Suppl 1): 87-95.
- Critchlow J, Magee D, Ito S, Takeuchi K, Silen W. Requirements for restitution of the surface epithelium of frog stomach after mucosal injury. Gastroenterology 1985; 88: 237-249.
- Paimela H, Goddard PJ, Carter K, Khakee R, McNeil PL, Ito S, Silen W. Restitution of frog gastric mucosa in vitro: effect of basic fibroblast factor. Gastroenterology 1993; 104: 1337-45.
- Svanes K, Ito S, Takeuchi K, Silen W. Restitution of the surface epithelium of the in vitro frog gastric mucosa after damage with hyperosmolar sodium chloride. Morphologic and physiologic characteristics. Gastroenterology 1982; 82: 1409-26.
- Hagen SJ, Morrison SW, Law ChS, Yang DX. Restitution of the bullfrog gastric mucosa is dependent on a DIDS-inhibitable pathway not related to HCO-3 ion transport. Am J Physiol 2003; 286: 596-605.
- Smith GS, Myers SI, Bartula LL, Miller TA. Adaptive cytoprotection against alcohol injury in the rat stomach is not due to increased prostanoid synthesis. Prostaglandins 1991; 41:207-23.
- Konturek SJ, Brzozowski T, Majka J, Dembinski A, Slomiany A, Slomiany BL. Transforming growth factor and epidermal growth factor in protection and healing of gastric mucosal injury. Scand J Gastroentero, 1992; 27:649-655
- Whittle BJR, Lopez-Bolmonte J, Moncada S. Regulation of gastric mucosal integrity by endogenous nitric oxide: interactions with prostanoids and sensory neuropeptides in the rat. Br J Pharmacol 1990; 99: 607-611.
- Konturek SJ, Brzozowski T, Pytko-Polończyk J, Drozdowicz D: Exogenous and endogenous cholecystokinin protects gastric mucosa against the damage caused by ethanol in rats. Eur J Pharmacol 1995; 273: 57-62.
- Konturek SJ, Brzozowski T, Bielanski W, Schally AV. Role of endogenous gastrin in gastroprotection. Eur J Pharmacol 1995; 278:203-212.
- Brzozowski T, Konturek PCh, Pajdo R, Duda A, Pierzchalski P, Bielanski W et al. Leptin in gastroprotection induced by cholecystokinin or by a meal. Role of vagal and sensory nerves and nitric oxide. Eur J Pharmacol 1999; 374:263-276.
- Brzozowski, T, P.C. Konturek, S.J. Konturek, P. Pierzchalski, W. Bielanski,
R. Pajdo, D. Drozdowicz, S. Kwiecien and E.G. Hahn, Central leptin and cholecystokinin
in gastroprotection against ethanol-induced damage. Digestion 2000; 62:
126-138.
- Sibilia V, Rindi G, Pagani F. et al. Ghrelin protects against ethanol-induced gastric ulcers in rats: studies on the mechanisms of action. Endocrinology 2003; 144: 353-9.
- Brzozowski T, Konturek PC, Konturek SJ, Kwiecien S, Drozdowicz D, Bielański
W, Pajdo R, Ptak A, Nikiforuk A, Pawlik WW, Hahn EG. Exogenous and endogenous
ghrelin in gastroprotection against stress-induced gastric damage. Reg Pept
2004; 120: 39-51.
- Kargman S, Charleson S, Cartwright M, Frank J, Rindean D, Mancini J, Evans J, O'Neill G. Characterization of prostaglandin G/H synthase 1 and 2 in rat, dog, monkey and human gastrointestinal tracts. Gastroenterology 1996; 111:445-454.
- Eberhart CE, Dubois RN. Eicosanoids and the gastrointestinal tract. Gastroenterology 1995;109:258-301.
- Brzozowski T, Konturek PCh, Konturek SJ, Sliwowski Z, Drozdowicz D et al. Role of prostaglandin-generated by cyclooxygenase-1 and cyclooxygenase-2 in healing of ischemia-reperfusion induced gastric lesions. Eur J Pharmacol 1999;385:47-61.
- Brzozowski T, Konturek PC, Konturek SJ, Schuppan D, Drozdowicz D, Kwiecien
S, Majka J, Nakamura T, Hahn EG. Effect of local application of growth factors
on gastric ulcer healing and mucosal expression of cyclooxygenase-1 and
-2. Digestion 2001; 64: 15-29.
- Gretzer B, Ehrlich K, Maricic N, Lambrecht N, Respondek M, Peskar BM. Selective cyclooxygenase-2 inhibitors and their influence on the protective effect of a mild irritant in the rat stomach. Br J Pharmacol 1998; 123:927-935.
- Vane JR, Botting RM. New insights into the mode of action of anti-inflammatory drugs. Inflammation 1995; 44:1-10.
- St.John DJB, Yeomans ND, McDermott FT, de Boer WGRM: Adaptation of the gastric mucosa to repeated administration of aspirin in the rat. Am J Dig Dis 1973; 18:881-886.
- Graham DY, Smith JL, Torres E: Gastric adaptation. Studies in humans during continuous aspirin administration. Gastroenterology 1988; 85:327-333.
- Shorrock CJ, Rees WPW: Mucosal adaptation to indomethacin induced gastric
damage in man. Studies on morphology, blood flow and prostaglandin E2
metabolism. Gut 1992; 33:164-169.
- Konturek SJ, Brzozowski T, Stachura J, Dembinski A, Majka J. Role of gastric blood flow, neutrophil infliltration and mucosal cell proliferation in gastric adaptation to aspirin in the rat. Gut 1994; 35:1189-1196.
- Konturek SJ, Konturek JW: Gastric adaptation: basic and clinical aspects. Digestion 1994; 55:131-138.
- Brzozowski T, Konturek PC, Konturek SJ, Ernst H, Stachura J, Hahn EG: Gastric adaptation to injury by repeated doses of aspirin strenghtens mucosal defence against subsequent exposure to various strong irritants in rats. Gut 1995; 37:749-757.
- Konturek JW, Dembinski A, Stoll R, Domschke W, Konturek SJ: Mucosal adaptation to aspirin induced gastric damage in humans. Studies on blood flow, gastric mucosal growth, and neutrophil activation. Gut 1994; 35:1197-1204
- Brzozowski T, Konturek PC, Konturek SJ, Ernst H, Sliwowski Z, Hahn EG: Mucosal irritation, adaptive cytoprotection, and adaptation to topical ammonia in the rat stomach. Scand J Gastroenterol 1996; 31:837-846.
- Konturek SJ, Brzozowski T, Majka J, Drozdowicz D, Stachura J: Adaptation of the mucosa to stress. Role of prostaglandins and epidermal growth factor. Scand J Gastroenterol 1992; 27 (suppl 193):39-45.
- Wallace JL, Reuter B, Cicala C, McKnight W, Grishman M, Cirino G. A diclofenac derivative without ulcerogenic properties. Eur J Pharmacol 1994; 257:249-255.
- Elliott SN, McKnight W, Cirino G, Wallace JL. A nitric oxide-releasing non steroidal anti-inflammatory drug accelerates gastric ulcer healing in rats. Gastroenterology 1995; 109:524-530.
- Brzozowski T, Drozdowicz D, Szlachcic A, Pytko-Polonczyk J, Majka J et al. Role of nitric oxide and prostaglandins in gastroprotection induced by capsaicin and papaverine. Digestion 1993; 54:24-31.
- Takeuchi K, Suzuki K, Yammamoto H, Araki H, Mizoguchi H, Ukawa H. Cyclooxygenase-2 selective and nitric oxide-releasing nonsteroidal anti-inflammatory drugs and gastric mucosal responses. J Physiol Pharmacol 1998; 49:501-5.
- Fiorucci S, Antonelli E, Santucci L, Morelli O, Miglietti M, Federici B et al. Gastrointestinal safety of nitric oxide-derived aspirin is related to inhibition of ICE-like cysteine proteases in rats. Gastroenterology 1999; 116:1089-106.
- Brzozowski T, Konturek PC, Konturek SJ, Sliwowski Z, Drozdowicz D, Kwiecien
S, Pajdo R, Ptak A, Pawlik M, Hahn EG. Gastroprotective and ulcer healing
effects of nitric oxide-releasing non-steroidal anti-inflammatory drugs.
Dig Liver Dis 2000; 32: 583-594.
- Brzozowska I, Targosz A, Sliwowski Z, Kwiecien S, Drozdowicz D, Pajdo R, Konturek PC, Brzozowski T, Pawlik M, Konturek SJ, Pawlik WW, Hahn EG. Healing of chronic gastric ulcers in diabetic rats treated with native aspirin, nitric oxide (NO)-derivative of aspirin and cyclooxygenase (COX)-2 inhibitor. J Physiol Pharmacol 2004; 55: 773-90.
- Brzozowski T, Konturek PC, Konturek SJ, Kwiecien S, Sliwowski Z, Pajdo
R, Duda A, Ptak A: Implications of reactive oxygen species and cytokines
in gastroprotection against stress-induced gastric damage by nitric oxide
releasing aspirin. Int J Colorectal Dis 2003; 18(4): 320-329.
- Murry CE, Jenning RB, Reimer KA. Preconditioning with ischemia: a delay in lethal cell injury in ischemic myocardium, Circulation 1986; 74: 1124-26.
- Parratt JR, Protection of the heart by ischemic preconditioning: mechanism and possibilities for pharmacological exploitation, TiPS 1994: 19-20.
- Pajdo R, Brzozowski T, Konturek PC, Kwiecien S, Konturek SJ, Sliwowski
Z, Pawlik M, Ptak A, Drozdowicz D, Hahn EG. Ischemic preconditioning, the
most effective gastroprotective intervention: involvement of prostaglandins,
nitric oxide, adenosine and sensory nerves. Eur J Pharmacol 2001; 427: 263-276.
- Brzozowski T, Konturek PC, Konturek SJ, Pajdo R, Kwiecien S, Pawlik M, Drozdowicz
D, Sliwowski Z, Pawlik WW. Ischemic preconditioning of remote organs attenuates
gastric ischemia-reperfusion injury through involvement of prostaglandins
and sensory nerves. Eur J Pharmacol 2004; 499: 201-13.
- Brzozowski T, Konturek PC, Pajdo R, Kwiecien S, Sliwowski Z, Drozdowicz D, Ptak-Belowska A, Pawlik M, Konturek SJ, Pawlik WW, Hahn EG. Importance of brain-gut axis in the gastroprotection induced by gastric and remote preconditioning. J Physiol Pharmacol 2004; 55: 165-177.
- Brzozowski T, Konturek SJ, Sliwowski Z, Pytko-Polonczyk J, Szlachcic A, Drozdowicz D. Role of capsaicin-sensitive sensory nerves in gastroprotection against acid-independent and acid-dependent ulcerogens. Digestion 1996; 57: 424-430.
- Kwiecien S, Brzozowski T, Konturek PC, Pawlik MW, Pawlik WW, Kwiecien N, Konturek SJ. The role of reactive oxygen species and capsaicin-sensitive sensory nerves in the pathomechanism of gastric ulcers induced by stress. J Physiol Pharmacol 2003; 54: 423-437.
- Takeeda M, Hayashi Y, Yamato M, Murakami M, Takeuchi K. Roles of endogenous prostaglandins and cyclooxygenase isoenzymes in mucosal defense of inflammed rat stomach. J Physiol Pharmacol 2004; 55: 193-200.
- Konturek SJ, Konturek JW, Pawlik T, Brzozowski T. Brain-gut axis and its role in the control of food intake. J Physiol Pharmacol 2004; 55: 137-54.
- Biernat J, Pawlik WW, Sendur R, Dembinski A, Brzozowski T, Konturek SJ. Role of afferent nerves and sensory peptides in the mediation of hepatic artery buffer response. J Physiol Pharmacol 2005; 56: 133 - 45.
- Zayachkivska OS, Konturek SJ, Drozdowicz D, Konturek PC, Brzozowski T, Ghegotsky MR. Gastroprotective effects of flavonoids in plant extracts. J Physiol Pharmacol 2005; 56 (Suppl 1): 219-31.