Clinical Journal of Gastroenterology 2024;17:216–221, https://doi.org/10.1007/s12328-023-01897-5
H. pylori infection은 AIG의 immunity에 어떤 영향을 미칠까..?
최근 논문이나 case들을 살펴보면, AIG의 immunity에 영향을 미쳐서 atrophy가 늦게 오도록 한다는 듯한 생각이 듭니다. 물론, 서로 영향이 전혀 없는데 계속 뭔가 있을 것 같이 의심하는 것일 수도 있구요. 전형적인 active H. pylori infection 환자에서 eradication을 시행하였고, 이후 AIG에 의한 progressive atrophy가 확인된 환자 case입니다. 살펴 보겠습니다.
Introduction
The effect of H. pylori infection on the pathogenesis of AIG remains unclear.
Few reports have examined the effect of H. pylori eradication on the gastric mucosa, especially whether eradication therapy improves gastritis in the corpus of patients with AIG.
We report a case of AIG diagnosis following the exacerbation of atrophic NG after H. pylori eradication therapy, with a history of prolonged atrophy progression.
Case report
61세 여자
Abnormal upper gastrointestinal barium radiography findings를 보여 EGD 시행 위해 내원 함.
Upper gastrointestinal endoscopy (UGE): H. pylori-positive NG in the antrum (Fig. 1)
H. pylori stool antigen test로 confirm 한 이후, eradication therapy실시 함.
Figure 1. Endoscopic image of the stomach in the (a) antrum and (b–d) corpus with white light imaging at the time of diagnosing H. pylori (before eradicating H. pylori). Small granular mucosa is observed in the antrum, and diffuse redness and enlarged folds are observed in the corpus.
* The stool antigen test confirmed successful eradication after the first eradication therapy.
<During a routine health check-up examination; UEG>
Kimura–Take moto classification from O1 after 6 years to O2 after 7 years
Ten years after H. pylori eradication treatment, a clear vascular image was obtained from the corpus to the fornix, and atrophic changes were observed (Fig. 2)
Figure 2. Endoscopic image of the stomach in the (a) antrum and (b–d) corpus with linked color imaging 10 years after H. pylori eradication (the time of the diagnosis of AIG). A clear vascular image was obtained from the corpus to the fornix, and extended atrophic changes were observed.
* AIG suspected, 10 years after H. pylori eradication --> serologic evaluation
Fasting serum gastrin, PGI, PGII, PGI/II values: 1200 pg/mL, 3.2 ng/mL, 9.9 ng/mL, 0.3
APCA: positive, >160
No history of autoimmune thyroid disease or rheumatic disease
The progression from H. pylori-positive NG eradication to AIG diagnosis (Fig. 3).
Figure 3. Endoscopic images showing the clinical course of this case. After 4 years of eradication therapy, nodularity of the antrum and diffuse redness of the corpus disappeared, but gastric mucosal atrophy evaluated by the Kimura–Takemoto classification progressed to O1 after 6 years and O2 after 7 years. Eight years after H. pylori eradication therapy, A clear vascular image was obtained from the corpus to the fornix, and atrophic changes were observed. Eleven years after H. pylori eradication therapy, a new sticky adherent dense mucus was observed in the fornix.
* Histological findings of the gastric corpus mucosa show marked atrophic changes.
Operative link on gastritis assessment (OLGA) staging: stage III
Operative link on gastritis intestinal metaplasia assessment (OLGIM) staging: stage 0
Endocrine cell micronests (ECM), and enterochromaffin-like cell (ECL) hyperplasia were also observed (Fig. 4)
Figure 4. Histological images of biopsy specimens from the greater curvature of the corpus. Hematoxylin and eosin staining showed decreased parietal cells and diffuse lymphocytic infiltration of the deep lamina propria (a × 80). Immunohistochemistry stain by chromogranin A revealed positive ECM and ECL hyperplasia (b × 80). ECL enterochromaffin-like cell (ECL), ECM endocrine cell micron ests.
Discussion
H. pylori eradication 전부터 AIG가 있었다가 eradication 이후에 나타났을 수 있고, 또는 AIG가 H. pylori eradication에 의해 유도 되었을 수도 있습니다. Table 1은 AIG 환자에서 H. pylori eradication의 효과를 다룬 reports 들을 정리하였습니다.
Table 1. Clinical characteristics of AIG reports with H. pylori eradication
* Several reports have described the development of AIG after H. pylori eradication
- Kotera et al.: diagnosed AIG early based on endoscopic findings of salmon roe-like nodules after 1 year of H. pylori eradication therapy.
- Ihara et al: case of AIG with rapid atro phy progression 2–4 months after H. pylori eradication.
* Ohana and Okazaki et al. suggested that H. pylori infection changes the microenvironment of the gastric mucosa by inducing a Th2 immune response in addition to a Th1 response and regresses AIG in neonatal thymectomized BALB/c mice. They considered that mice with Th1-dominant AIG altered the Th1/Th2 immune balance by the Th2 immune reaction of H. pylori infection and that the gastric mucosal damage caused by AIG was suppressed. This result suggests that eradicating H. pylori-positive AIG decreases Th2 responses and promotes Th1-dominant AIG progression, which may have clarified AIG by enhancing corpus mucosal damage.
(Ohana M, Okazaki K, Oshima C, et al. Inhibitory effects of Helicobacter pylori infection murine autoimmune gastritis. Gut. 2003;52:1102–10.)
(Okazaki K, Ohana M, Oshima C, et al. Interaction of Helico bacter pylori-induced follicular gastritis and autoimmune gastritis in BALB/c mice with post-thymectomy. J Gastroenterol. 2003;38:1131–7.)
---> AIG의 Th1 immunity 와 H. pylori의 Th2 immunity의 balance .. 이러한 부분에 대해 추가적인 연구가 필요할 듯 싶습니다!!
Abstract
A 61-year-old female patient underwent upper gastrointestinal endoscopy, which confirmed the presence of Helicobacter pylori (H. pylori)-positive nodular gastritis (NG). Routine upper gastrointestinal endoscopy after H. pylori eradication revealed atrophic changes of the corpus, having gradually progressed over the 10 years after successful eradication. Serological and biopsy specimen examination showed hypergastrinemia (1200 pg/mL), positive anti-parietal cell antibody (with a titer of more 160), and endocrine cell micronests after 11 years of H. pylori eradication. The patient was diagnosed with autoimmune gastritis (AIG) based on endoscopic, serological, and histological findings. This is the first report of AIG diagnosed in a patient with NG over a long period of time after H. pylori eradication.
Keywords: Autoimmune gastritis · Helicobacter pylori · Eradication · Nodular gastritis
Clinical Journal of Gastroenterology 2024;17:216–221, https://doi.org/10.1007/s12328-023-01897-5
H. pylori infection은 AIG의 immunity에 어떤 영향을 미칠까..?
최근 논문이나 case들을 살펴보면, AIG의 immunity에 영향을 미쳐서 atrophy가 늦게 오도록 한다는 듯한 생각이 듭니다. 물론, 서로 영향이 전혀 없는데 계속 뭔가 있을 것 같이 의심하는 것일 수도 있구요. 전형적인 active H. pylori infection 환자에서 eradication을 시행하였고, 이후 AIG에 의한 progressive atrophy가 확인된 환자 case입니다. 살펴 보겠습니다.
Introduction
The effect of H. pylori infection on the pathogenesis of AIG remains unclear.
Few reports have examined the effect of H. pylori eradication on the gastric mucosa, especially whether eradication therapy improves gastritis in the corpus of patients with AIG.
We report a case of AIG diagnosis following the exacerbation of atrophic NG after H. pylori eradication therapy, with a history of prolonged atrophy progression.
Case report
61세 여자
Abnormal upper gastrointestinal barium radiography findings를 보여 EGD 시행 위해 내원 함.
Upper gastrointestinal endoscopy (UGE): H. pylori-positive NG in the antrum (Fig. 1)
H. pylori stool antigen test로 confirm 한 이후, eradication therapy실시 함.
Figure 1. Endoscopic image of the stomach in the (a) antrum and (b–d) corpus with white light imaging at the time of diagnosing H. pylori (before eradicating H. pylori). Small granular mucosa is observed in the antrum, and diffuse redness and enlarged folds are observed in the corpus.
* The stool antigen test confirmed successful eradication after the first eradication therapy.
<During a routine health check-up examination; UEG>
Kimura–Take moto classification from O1 after 6 years to O2 after 7 years
Ten years after H. pylori eradication treatment, a clear vascular image was obtained from the corpus to the fornix, and atrophic changes were observed (Fig. 2)
Figure 2. Endoscopic image of the stomach in the (a) antrum and (b–d) corpus with linked color imaging 10 years after H. pylori eradication (the time of the diagnosis of AIG). A clear vascular image was obtained from the corpus to the fornix, and extended atrophic changes were observed.
* AIG suspected, 10 years after H. pylori eradication --> serologic evaluation
Fasting serum gastrin, PGI, PGII, PGI/II values: 1200 pg/mL, 3.2 ng/mL, 9.9 ng/mL, 0.3
APCA: positive, >160
No history of autoimmune thyroid disease or rheumatic disease
The progression from H. pylori-positive NG eradication to AIG diagnosis (Fig. 3).
Figure 3. Endoscopic images showing the clinical course of this case. After 4 years of eradication therapy, nodularity of the antrum and diffuse redness of the corpus disappeared, but gastric mucosal atrophy evaluated by the Kimura–Takemoto classification progressed to O1 after 6 years and O2 after 7 years. Eight years after H. pylori eradication therapy, A clear vascular image was obtained from the corpus to the fornix, and atrophic changes were observed. Eleven years after H. pylori eradication therapy, a new sticky adherent dense mucus was observed in the fornix.
* Histological findings of the gastric corpus mucosa show marked atrophic changes.
Operative link on gastritis assessment (OLGA) staging: stage III
Operative link on gastritis intestinal metaplasia assessment (OLGIM) staging: stage 0
Endocrine cell micronests (ECM), and enterochromaffin-like cell (ECL) hyperplasia were also observed (Fig. 4)
Figure 4. Histological images of biopsy specimens from the greater curvature of the corpus. Hematoxylin and eosin staining showed decreased parietal cells and diffuse lymphocytic infiltration of the deep lamina propria (a × 80). Immunohistochemistry stain by chromogranin A revealed positive ECM and ECL hyperplasia (b × 80). ECL enterochromaffin-like cell (ECL), ECM endocrine cell micron ests.
Discussion
H. pylori eradication 전부터 AIG가 있었다가 eradication 이후에 나타났을 수 있고, 또는 AIG가 H. pylori eradication에 의해 유도 되었을 수도 있습니다. Table 1은 AIG 환자에서 H. pylori eradication의 효과를 다룬 reports 들을 정리하였습니다.
Table 1. Clinical characteristics of AIG reports with H. pylori eradication
* Several reports have described the development of AIG after H. pylori eradication
- Kotera et al.: diagnosed AIG early based on endoscopic findings of salmon roe-like nodules after 1 year of H. pylori eradication therapy.
- Ihara et al: case of AIG with rapid atro phy progression 2–4 months after H. pylori eradication.
* Ohana and Okazaki et al. suggested that H. pylori infection changes the microenvironment of the gastric mucosa by inducing a Th2 immune response in addition to a Th1 response and regresses AIG in neonatal thymectomized BALB/c mice. They considered that mice with Th1-dominant AIG altered the Th1/Th2 immune balance by the Th2 immune reaction of H. pylori infection and that the gastric mucosal damage caused by AIG was suppressed. This result suggests that eradicating H. pylori-positive AIG decreases Th2 responses and promotes Th1-dominant AIG progression, which may have clarified AIG by enhancing corpus mucosal damage.
(Ohana M, Okazaki K, Oshima C, et al. Inhibitory effects of Helicobacter pylori infection murine autoimmune gastritis. Gut. 2003;52:1102–10.)
(Okazaki K, Ohana M, Oshima C, et al. Interaction of Helico bacter pylori-induced follicular gastritis and autoimmune gastritis in BALB/c mice with post-thymectomy. J Gastroenterol. 2003;38:1131–7.)
---> AIG의 Th1 immunity 와 H. pylori의 Th2 immunity의 balance .. 이러한 부분에 대해 추가적인 연구가 필요할 듯 싶습니다!!
Abstract
A 61-year-old female patient underwent upper gastrointestinal endoscopy, which confirmed the presence of Helicobacter pylori (H. pylori)-positive nodular gastritis (NG). Routine upper gastrointestinal endoscopy after H. pylori eradication revealed atrophic changes of the corpus, having gradually progressed over the 10 years after successful eradication. Serological and biopsy specimen examination showed hypergastrinemia (1200 pg/mL), positive anti-parietal cell antibody (with a titer of more 160), and endocrine cell micronests after 11 years of H. pylori eradication. The patient was diagnosed with autoimmune gastritis (AIG) based on endoscopic, serological, and histological findings. This is the first report of AIG diagnosed in a patient with NG over a long period of time after H. pylori eradication.
Keywords: Autoimmune gastritis · Helicobacter pylori · Eradication · Nodular gastritis