Alimentary tract and pancreas

Alimentarni trakt i pankreas

ARCH GASTROENTEROHEPATOL 1999; 18 ( No 3 - 4 ):

Obren Popovic Helicobacter pylori infection and treatment with

Dusan Djurdjevic alkaline spring mineral water at Sijarinska Spa

Svetlana Milutinovic - Djuric

Sasa Grgov Helicobacter pylori infekcija i lecenje alkalnom

Miroslav Stefanovic izvorskom mineralnom vodom u Sijarinskoj Banji

Vukadin Ristic

( accepted August 10¸ 1999 )

Zvezdara University Medical

Centre¸Belgrade

Department of Medicine¸

Health Center¸ Leskovac¸

Sijarinska Spa

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Key words:: H.pylori¸ chronic active gastritis¸ duodenal ulcer¸ alkaline spring mineral water¸ Sijarinska Spa

ABSTRACT

Traditionally balneal treatment of peptic ulcer disease was very popular in Central Europe and in this country. It is well known that any agent which may exert favourable effect on peptic ulcer disease has to suppress H.pylori infection. Ten patients with duodenal ulcer diagnosed by endoscopy were allocated for ranitidine treatment with additional alkaline spring mineral water use at Sijarinska Spa ( 400ml qid; total 800ml/day for couple of weeks ). The diagnosis of H.pylori infection was made by biopsy of antral mucosa¸ ureasa test and histopathology.

All patients had H.pylori infection and chronic active gastritis. After one month all ulcers demonstrated endoscopic signs of healing. One month after finishing the treatment protocol endoscopic antral and fundic mucosal biopsies for H.pylori were repeated. All 10 patients were still H.pylori positive and had chronic active gastritis as well. The result of this study does not support our preliminary observation that in small proportion H.pylori positive ulcer patients afore - mentioned treatment works.

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Address correspondence to: Gastroenteroloska sekcija SLD¸

Obren Popovic¸ 01665¸ 1999.

Professor of Medicine¸

Zvezdara University Medical Center¸

D.Tucovica 161¸

YU - 11000 Belgrade¸ Yugoslavia.

INTRODUCTION

Traditionally balneologic¸ spa treatment of variety of digestive disorders including peptic ulcer disease was very popular in Central and Eastern Europe¸ and in this country too. Scientific approach in investigating this potential treatment modality was lacking due to complexity and variability of natural course of peptic ulcer disease. The spa treatment promoters relay its effectiveness to magenesium prokinetic ability¸ selenium antioxidant property¸ alkalinisation of stomach medium etc. The evidence for its effectiveness was largely anecdotal. Today we know that 94% of patients with duodenal and 84% with gastric ulcer have chronic active antral gastritis associated with H.pylori infection ( 1 ). H.pylori eradication abolishes ulcer recurrence ( 2 ).

Two years ago we reported the results of endoscopic study of a small group of duodenal ulcer patients ( n = 5 ) which were cured with the use of ranitidine. The antral mucosal biopsies demonstrated changes of chronic active gastritis and were H.pylori positive. After endoscopically demonstrated ulcer healing these patients were referred for further balneologic treatment in Sijarinska Spa for couple of weeks. They regularly drunk alkaline spring mineral water from the well called " Zdravlje " ( " Health " ) 800ml / day: 200ml aliquotes one hour before breakfast¸ one hour before and after lunch¸ and one hour before supper. One month after the end of the treatment repeated biopsies were H.pylori negative in two cases. Both patients demonstrated an amelioration of the activity of gastritis. One patient has been followed for two years¸ and no ulcer recurrence was registered. In other 3 patients H.pylori was repeatedly found in antral biopsy specimens.

PATIENTS AND METHODS

Ten patients were included in this study: 5 ( No 1 - 5 ) from Zvezdara University Medical Centre and 5 ( No 6 - 10 ) from Leskovac Health Cetre. Table 1. There were 6 males and 4 females; mean age was 49.3 years ( range: 22 - 78 ) Two patients were smokers ( No 1 and 9 ). In all cases duodenal ulcer was diagnosed by endoscopy. They were treated with ranitidine ( 300 mg / 24h ) 6 weeks. Ulcer healing was documented in all cases by endoscopy. In every case at endsocopy 3 antral mucosal biopsies were made¸ 2 for histopathology ( H&E and Giemsa staining for H.pylori )¸ and 1 for ureasa test ( Helicobacter test¸ Torlak¸ Belgrade ).

All patients spent couple of weeks at Sijarinska Spa which supported this study by providing all patients with free board and lodging facilities. The patients were drinking spring mineral water from the well called " Zdravlje " (“ Health “)¸ 800ml / day in total: 200ml aliquotes one hour after breakfast¸ one hour before and after lunch¸ and one hour before supper. They were under medical control and did not take any drug except occasionally antacids. The patients had no problems related with mineral water treatment.

Chemical composition of mineral water from the well " Zdravlje " (“ Health “) is characterized by very high concentration of sodium and flour¸ to a lesser degree of lithium and hydrocarbonate¸ and free H₂S and CO₂. The other electrolytes and heavy metals are not above the upper normal limits for drinking water. Specific gravity is 1.0028¸ pH 6.9¸ dry rest at 180^o¸ and temperature 30.9⁰C at outside temperature of air of 27⁰C.

One month after the end of treatment at Sijerinska spa¸ all patients underwent endoscopic control with

3 mucosal biopsies from antrum¸ and 3 from fundus for histopathology ( 2 ) and urease test ( 1 ).

Histopathologic parameters ( 1+ to 3+ ) were gastric inflammation ( density of mononuclear cells )¸ activity ( leukocytes )¸ atrophy¸ metaplasia¸ and H.pylori positivity and density.

RESULTS

Endoscopic appearances of the stomach ( antrum ) and duodenum was only slightly abnormal ( hyperemina¸ erythema ) before and after the treatment ( including varioliform¸ macronodular changes and scarce erosions )¸ Table 1.After the treatment fundus appeared normal in all cases.

Histopathologic investigation showed chronic inflammation and active antral gastritis of different degree both before and after the treatment. Table 2. The fundus demonstrated the same changes after the treatment in 4 patients. Atrophic changes were found in the antrum in 2 patients ( No 6¸7 ) and in 1 in the fundus ( No 7 )¸ metaplasia in none.

Histopathology was positive in the antrum for H.pylori in all 10 cases¸ both before and after the treatment. Patients who¸ by histopathology¸ had H.pylori in the fundus had positive urease test ( No 2 - 5 )¸ as well as 2 with negative microscopic findings ( No 6¸7 ).

General improvement of well being was characteristic for all studied patients after the treatment

completition what we already reported.

DISCUSSION

The first¸ pilot study on the influence of alkaline spring mineral water on H.pylori infection indicated the possible answer to the question: " Why peptic ulcer patients used to practice regular¸ spa treatment with alkaline spring mineral water yearly " ( 3 ). It was worth to test whether an old habit may be explained by the action of mineral water on H.pylori which is the most important cause of chronic active gastritis and peptic ulcer disease ( 4 ). In our pilot study we observed relatively high treatment success ( 40%¸ 2/5 ) which was comparable with the results with other single agents ( antimicrobials ) used for H.pylori infection treatment ( 5 ). Possible responsible constituent(s) for anti - H.pylori activity are high natrium and flour concentrations¸ relatively high lithium¸ hydrocarbonate and some free CO₂. Free H₂S is also another candidate for anti - H.pylori activity. On the contrary to H.pylori¸ Campylobacter genus synthetises H₂S but does not have urease activity ( 4¸5 ). Characteristics of alkaline spring mineral waters are similar to each other ( Sijarinska Spa¸ Vrnjacka Spa ) including that¸ one of us tested at famous Kislovodska on the Caucasus in Russia. All of them are used for the treatment of gastritis and peptic ulcer.

The result of this study could not provide any further evidence that the used spring mineral water has any affect on H.pylori. This study was designed to avoid false positive therapeutic results ( ureasa test¸ control of gastric fundus after the treatment ). However¸ antral mucosal biopsies were positive for H.ypori both before and after the treatment. We showed clearly that there were no influence of spring mineral water on H.pylori in this group of the patients. It seems that at the moment the treatment of H.pylori infection and peptic ulcer disease with alkaline spring mineral water has no justification. However we have to point out the result of our pilot study which showed that one of the patients responded to this treatment without ulcer relapse ( 3 ). He differed from all other patients only by that he had initially both duodenal and gastric ulcer.

REFERENCES

1. Kuipers EJ¸ Thijs JC¸ Festen HP. The prevalence of Helicobacter pylori in peptic ulcer disease

( Review ). Aliment Pharmacol Ther 1995; 9 ( suppl 2 ): 59 - 68.

2.van der Huilst RWM¸ Raus EAJ¸ Koycu B¸ et al. Prevention of ulcer recurrence after eradication

of Helicobacter pylori : a prospective long - term follow up study. Gastroenterology 1997; 113: 1082 - 6.

3.Popovic O¸ Djurdjevic D¸ Milutinovic - Djuric S¸ Ristic V. Helicobacter pylori infection and treatment with well water at Sijerinska Spa - A pilot study. 17th Gastroenterologic days of SMA Gastroenterologic Section. Abstrqct 19¸ Belgrade 1997.

4.Warren JR¸ Marshall B. Uniditified curved bacilli on gastric epithelium in active chronic gastritic. Lancet 1983; i: 1272 - 5.

5.Peterson WL¸ Graham DY. Helicobacter pylori . In: Feldman M¸ Scharschmit BF¸ Sleisenger MH¸ eds. Gastrointestinal and liver disease¸ 6th ed. Philadelphia: Saunders WB 1998; 604 - 19.

Table 1. Gastroduodenoscopic findings¸ before and after treatment with alkaline spring mineral water

at Sijarinska Spa.

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No Age in years Sex Endoscopy

Antrum ( Duodenum ) Fundus

before after after

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1. 49 M Hyperemia Varioliform changes Normal

2 . 50 M Erythema Hyperemia Normal

3. 56 M Erythema Hyperemia Normal

4. 22 M Hyperemia Hyperemia¸ erosions Normal

5. 78 F Normal Mosaic hyperemia Normal

6. 53 M Normal Oedema and scarce erosions Normal

7. 63 M Normal Hyperemia and scarce erisons Normal

8. 39 F Normal Normal Normal

9. 43 F Hyperemia Normal Normal

10. 40 F Normal Normal Normal

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7 .

Table 2. Histopathologic findings and H.pylori status¸ before and after the treatment with alkaline

spiring mineral water at Sijarinska Spa

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No Histopathology Ureasa test

Fundus Antrum Fundus

Before After After Before After After

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1. HP 2+ 2+ Negative + + Negative

Infl. 2+ 2+ Absent

Act. 2+ 2+ Absent

Atrophy Negative Negative Absent

Metapl. Negative Negative

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2. HP 3+ 1+ 1+ + + +

Infl. 3+ 3+ 2+

Act. 2+ 3+ 3+

Atrophy Negative Negative Negative