Zaburzenia czynności mioelektrycznej żołądka u dzieci i młodzieży z zakażeniem Helicobacter pylori i chorobą refluksową przełyku

Introduction

Myoelectric functional stomach disorders are closely associated with gastroesophageal reflux disease and with gastritis and/or duodenitis induced by Helicobacter pylori infection. The interaction of both these pathologies in some way happens by the influence on stomach motor functions.

In gastroesophageal reflux disease (GERD) pathogenesis the influence of stomach factors such as H. pylori infection and postponed stomach emptying caused by stomach-duodenum coordination disorders is analysed [1-3]. Abnormal stomach emptying causes stomach extension which leads to spontaneous relaxation of the lower oesophageal sphincter (LES). The disorders of tonic LES tension and the increase of idiopathic (not connected with swallowing) temporary spontaneous relaxations of the lower oesophageal sphincter are fundamental for pathological retraction of chime to the oesophagus [1].

In complicated regulation of digestive tract function motor neurons of the digestive tract have an important role. They are called the enteric nervous system (ENS) [4] and they generate two types of potentials: electrical control activity (ECA) and electrical response activity (ERA) which determine stomach motor functions. Electrical control activity is built of interstinal cells of Cajal (ICC) which appear in the longitudinal muscular coat [5-10]. Electrical control activity is connected with repetitive depolarization of the cell membrane and it does not initiate gastrospasm. In ECA stomach cells the basic activity is generated – 3 cycles/min (cpm). Electric impulses are dispersed in different places and change the muscular cells’ mucosa potential in the direction of the pylorus and duodenum [6, 9]. The correct rhythm of ECA is 3 cpm in the stomach. The abnormal frequency of the ECA is tachygastria, bradygastria, or mixed rhythm. They all cause abnormal motor functions of the stomach [6, 9, 11, 12]. Electrogastrography (EGG) is a non-invasive method which permits one to register myoelectric stomach function using probes placed on the skin of the stomach.

The interaction of H. pylori infection and GER is shown in many aspects. The infection may induce disorders of myoelectric functions and influence the frequency and the grade of acid pathological intensification of gastroesophageal reflux.

Aim

The aim of the study was to try to answer whether there are significant disorders in myoelectric stomach functions in children and teenagers with gastritis and/or duodenitis coexisting with H. pylori infection and GERD (gastroesophageal reflux disease).

Material and methods

One hundred and one patients over the age of 3 years with dyspeptic symptoms who underwent endoscopic examination of the upper part of the digestive tract, pH-metric oesophagus test, and electrogastrographic test (EGG) were qualified for the examination. The exclusion criteria were:

• previous diagnosis of H. pylori infection and its treatment,

• previous diagnosis of GERD and its treatment (neutralizing agents, proton pump inhibitors – PPI, H2 blockers),

• antibiotic therapy present or applied within 4 weeks’ time,

• PPI or H2 blockers treatment present or applied within 2 weeks’ time.

Patients were put into two groups:

A) patients with mucosa infection of stomach and/or duodenum coexisting with H. pylori and GER infection,

B) patients with mucosa infection of stomach and/or duodenum coexisting with H. pylori and without GER infection.

All the patients underwent endoscopic examination of the upper part of the digestive tract during which a prepyloric mucosa sample was taken to perform the urease test and histological examination. Confirmation or exclusion of H. pylori infection was done by performing the urea breathing test. Helicobacter pylori infection was confirmed in histopathological examination and/or in the urease test and the urea breathing test.

To assess the exposure of oesophageal mucosa to the gastric contents all the patients underwent pH-metric examination of the oesophagus. In this study the complete percentage duration of pH below 4 (reflux index exceeding 4%) shows the presence of pathological gastroesophageal reflux.

The myoelectric stomach activity was registered by using transdermal multichannel EGG with the use of a POLYGRAM NET TM device made by Medtronic. After standard preparation of the patient’s skin, six electrodes were attached – four active, one reference and one earthing. The third electrode was attached half way between the xiphoid process and the navel (it is the standard location in one-channel electrogastrography). The fourth electrode was attached 4 cm horizontally to the right in relation to the third one. The second and the first electrode were attached at a 45% angle up and left from the third electrode with a 4-6 cm span. The earthing electrode was attached on the left rib arch horizontally to the third electrode and the reference electrode was attached at the point of intersection of a horizontal line with the first electrode and at the point of intersection of a vertical line with the third electrode. The movement sensor was placed on the transabdominal above the fourth electrode.

The registration of myoelectric stomach activity was conducted for 30 min on an empty stomach and for 60 min after eating a standard meal (a sandwich with butter and with a boiled egg). This examination considered:

• the percentage value of normogastria (2.4-3.7 cpm),

• the percentage value of bradygastria (0.5-2.4 cpm),

• the percentage value of tachygastria (3.8-10 cpm),

• the percentage value of arrhythmia.

Using the test for two fractions the hypothesis about the lack of difference between normogastria, bradygastria, tachygastria and arrhythmia occurrence percentage before and after eating in children and teenagers with mucosa infection of stomach and/or duodenum coexisting with H. pylori and with GER and without GER infection was verified. The percentage of normogastria, bradygastria, tachygastria and arrhythmia registered by 4 electrogastrographic electrodes was analysed.

Results

he examinations were performed on 101 children of age 5-18 years (mean: 13.2 ±3.09 years). Among these there were 50 ill children and teenagers whose pH-metric examination result was abnormal (group A [n = 50]) and 51 patients had a reflux index below 4% (group B [n = 51]).

In the analysis of the difference in occurrence percentage of normogastria, bradygastria, tachygastria and arrhythmia before and after eating in children and teenagers with gastritis and/or duodenitis coexisting with H. pylori and with GER (group A) and in the group of children with the correct result of pH-metric examination (group B) a statistically significantly higher percentage of bradygastria was registered in group 1a in the before-eating recording made by the fourth electrode (C4) (p = 0.02). The exact data of the analysis are shown in Tables I and II and Figure 1.

Discussion

The influence of H. pylori infection on the upper part of the digestive tract seems to be connected with

the mechanism of Cajal cell functional damage by an induced inflammatory state which leads to disharmony in the ICC [13, 14]. It causes a change in regularity of ECA and secretion disorders and it also influences antrum adaptation [8]. The eradication of the infection should lead to the normalization of myoelectric stomach functions or should improve the EGG recording.

In the studies of Pytrus et al. [15] the percentage of dysrhythmia before and after eating was recorded in children with H. pylori infection. These scientists observed that after eradication of the infection there was a decrease of bradygastria percentage and an increase of normogastria percentage before and after eating. The same conclusions were reached by American scientists [16]. Motor function disorders of the upper part of the digestive tract are also the basis of gastroesophageal reflux and gastroesophageal disease [1].

The patients we examined were children and teenagers with dyspeptic symptoms. The phrase is rather extensive and relates to patients with symptoms which happen in H. pylori infection and in induced stomach mucosa inflammation and also in gastroesophageal disease. In our group of patients we confirmed or excluded acid pathological gastroesophageal reflux almost with the same frequency. It can be supposed that myoelectric stomach function registered by EGG will be different in both groups and the difference will relate to the pericardial area (C1 and C2). Remembering that the highest concentration of bacteria is in the prepyloric part of the stomach and in focuses of stomach metaplasia [after 17] deviations in the C3 and C4 probe recordings of multichannel electrogastrography can be expected. However, our results show more frequent occurrence of bradygastria in the before-eating recording in the prepyloric area of the stomach.

The pathomechanism of such a mutual dependence and also of the influence on the motor stomach activity between H. pylori infection and GERD is connected with the increase of gastrin, acidity and volume concentration in the stomach acid (stomach glands mainly remain in the body of the stomach and in the fundus of the stomach), with acceleration of emptying the stomach and with the decrease of LES tension [18, 19]. Unfortunately, there are only a few studies in the available literature which analyse similar parameters of multichannel electrogastrography recordings. The results of studies of single channel electrogastrography recordings are not comparable and they differ greatly.

In the studies of Toporowska-Kowalska et al. [13] in children with diabetes and H. pylori infection the before-eating bradygastria occurrence was more frequent than in the group without infection and in the control group. Sładek et al. [19] claimed that H. pylori infection did not have any influence on the myoelectric stomach functions. Zielińska et al. [21] noted in EGG recordings of children with acid gastroesophageal reflux an increased percentage of arrhythmia in the pericardial area which depended on reflux intensity. In the studies of Leahy et al. [22] in 90% of patients with gastroesophageal reflux the percentage of normogastria recording was 70% higher.

Conclusions

In children and teenagers with gastritis and duodenitis with coexisting GER, disorders of myoelectric stomach function occur. In this group of patients it would be advisable to administer prokinetic medicine.

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