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Unique Expression of Cytoglobin/Stellate Cell Activation-Associated ProteinAs An Oxygen Supplier Before Angiogenesis During Gastric Ulcer Healing inRatsKazunari Tominaga, Eiji Sasaki, Fumio Tanaka, Tetsuya Tanigawa, Masatsugu Shiba, KenjiWatanabe, Yasuhiro Fujiwara, Nobuhide Oshitani, Norifumi Kawada, KatsutoshiYoshizato, Tetsuo Arakawa

Background and Aims: Cytoglobin/stellate cell activation-associated protein (Cygb/STAP)discovered by a proteome analysis on the rat hepatic stellate cells as one of the heme-proteins may act as an oxygen transporter like hemoglobin and myoglobin. Induction ofangiogenesis is involved in remodeling of the injured tissues including gastric ulcer mediatedby the supply of oxygen as well as nutrient for the regenerating tissues. To examine thephysiological roles of Cygb/STAP, we investigated the expression and localization of Cygb/STAP in the ulcerated gastric tissues as well as hypoxia inducible factor (HIF)-1, a key factorunder the hypoxic condition, and vascular endothelial growth factor (VEGF), a key angiogenicfactor regulated by HIF-1. Methods: Gastric ulcers in rats (8-week-old Wistar rat) wereproduced by acetic acid. Rats were sacrificed on days 3, 11, 18, or 25 after production ofthe gastric ulcer. To determine the expressions of Cygb/STAP, VEGF, and HIF-1 at theulcerated tissue, western blotting was performed. Each mRNA expression of HIF-1 andVEGF of the ulcerated gastric tissues was measured by real time RT-PCR method. Localizationof Cygb/STAP, VEGF, HIF-1, and von Willebrand factor (VWF) for angiogenesis at theulcerated gastric tissues was examined by the immunohistochemical study. Results: Expres-sion of Cygb/STAP was increased at the ulcerated tissue on day 11 compared with the intacttissues from sham-operated rats, and then gradually decreased in correspondence with theprocess of ulcer healing. Changes in both protein and mRNA expression levels of HIF-1were in parallel with Cygb/STAP expression. However, protein and mRNA expressions ofVEGF began to increase after the reduction of Cygb/STAP and HIF-1 expression. Cygb/STAP was localized in the cytoplasm of mesenchymal cells in lamina propria mucosae inthe intact stomach. Number of Cygb/STAP-positive cells was increased at the regenerativemucosa of ulcerated gastric tissues. It was not co-localized at the VWF expression in theearly phase of regenerated areas. Notable angiogenesis was induced on day 18 when VEGFexpression but not Cygb/STAP and HIF-1 expressions was significantly increased in theulcerated tissues. Treatment with anti-ulcer drug initially enhanced an increase in Cygb/STAP protein expression at the ulcerated tissues in the early phase of healing. Conclusion:These results suggested that Cygb/STAP act as a transient oxygen supplier for the immatureregenerative mucosa during the ulcer healing until an appropriate angiogenesis was recog-nized at that area.

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Toll-Like Receptors Participate in Gastric Mucosal Protection Through COX-2and PGE2Yan Zhang, Ling Zheng, Terrence Riehl, William Stenson

Toll-like receptors (TLRs) play an important role in the response to infectious agents.However, TLRs have not been described as playing a role in the response to noninfectiousinjury in the stomach. TLRs signal through the adaptor protein MyD88. Ligands for TLRsinclude bacterial products (LPS, flagellin, etc) and host molecules (hyaluronan, heat shockproteins). PGE2 generated through Cox-2 is a downstream signaling molecule for TLRs inthe DSS model of colitis. PGE2 also plays a key role in cytoprotection in the stomach. Wehypothesized that TLRs play a role in the gastric response to noninfectious injury. Methods:Wild type mice, Cox-2-/- mice and MyD88-/- mice were exposed to gastric injury inducedby acidified ethanol given by gavage. Mice were sacrificed six hours later. Damage area,histologic change, and apoptosis were assessed. Proliferation was evaluated by BrDU incorp-oration. Cox-2 expression and tissue levels were assessed by immunohistochemistry andwestern blotting. PGE2 was measured by EIA. Results: After acidified ethanol injury Cox-2-/- and MyD88-/- mice had more severe damage than wild type mice. The histologic scoreswere 142.0+22.1, 159.7+47.0, 60.2+23.9 (p<0.01, p<0.01) respectively. Cox-2-/- mice andMyD88-/- mice also had lower proliferation indices than wild type mice (0.29+0.01,0.28+0.01, 0.33+0.02, p<0.01, p<0.01). Administration of a stable PGE2 analog, dmPGE2, at the time of the administration of acidified ethanol blocked the development of injuryin all three groups. Prior to injury there were scattered Cox-2 expressing cells in the laminapropria as assessed by immunohistochemistry. After injury in wild type mice Cox-2 expressionwas seen in perivascular cells situated between the endothelium and the smooth muscle.The Cox-2 expressing vessels were in the submucosal. Cox-2 staining in these perivascularcells was only seen in the wild type mice and only after acid ethanol injury. Conclusion:TLRs are activated in the gastric mucosa during acid ethanol injury. This activation resultsin a protective response that is mediated through the induction of Cox-2 expression inperivascular cells and the production of PGE2. In view of the absence of evidence for a rolefor microbial agents in acid ethanol injury the likely ligands for TLRs in this model are hostmolecules such as hyaluronan or heat shock proteins.

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Appetite Hormones Ghrelin, Orexin and Obestatin Are Involved in theMechanism of Gastric Ulcer HealingTomasz Brzozowski, Peter C. Konturek, Zbigniew Sliwowski, Michal Pawlik, Agata Ptak-Belowska, Wladyslaw Bielanski, Krystyna Zwirska-Korczala, Stanislaw J. Konturek,Wieslaw W. Pawlik

Ghrelin isolated from gastric mucosa, obestatin encoded by the ghrelin gene and orexin-A(OX-A) detected in enteric nerves of the gut belong to the family of appetite hormones buttheir effect on the healing of preexisting gastric ulcers remains unknown. In this study,gastric ulcers were induced by serosal application of acetic acid in Wistar rats treated for 9and 15 days with: 1) vehicle (saline), ghrelin, OX-A and obestatin (1-40 µg/kg i.p.) orcombination of both, ghrelin and obestatin (20 µg/kg i.p.); 2) blockade of GHS-1a andOX-R1 receptors with D-Lys3-GHRP-6 or SB334867 (5 mg/kg i.p.); 3) the non-selective

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(indomethacin, 2 mg/kg i.p.) or selective COX-1 (SC-560, 5 mg/kg i.p.) and COX-2(rofecoxib, 10 mg/kg i.g.) inhibitors, and 4) cutting of vagal nerves (vagotomy) and sensorydenervation by capsaicin (125 mg/kg s.c.) or inhibition of vanilloid receptor (VR-1) bycapsazepine (10 mg/kg i.g.). The ulcer area was measured by planimetry, the gastric bloodflow (GBF) at ulcer margin was determined by H2-gas clearance technique and COX-1-,COX-2-, IL-1β-, and TNF-α mRNAs and proteins and plasma ghrelin, OX-A and obestatinlevels were assessed by RT-PCR, Western Blot and RIA. Both, ghrelin and OX-A dose-dependently reduced the area of gastric ulcers; the ID50 dose being 12 µg/kg and 20 µg/kg-d, and these effects were accompanied by the rise in GBF at ulcer margin, plasma ghrelinand OX-A levels. Expression of prepro-ghrelin- and prepro-OX-A mRNAs was stronglyupregulated at the ulcer margin during healing. Obestatin by itself failed to influence thearea of gastric ulcers and when combined with ghrelin did not interfere with ghrelin-inducedulcer healing. D-Lys3-GHRP-6 and SB 334867 significantly attenuated ghrelin- and OX-A-induced acceleration of ulcer healing and the rise in the GBF. The ulcer healing effects ofghrelin and OX-A were significantly inhibited by indomethacin and rofecoxib and theseeffects were restored by co-administration of ghrelin and OX-A with 16,16 dm PGE2 (5 µg/kg-d i.p.). Vagotomy, capsaicin denervation or capsazepine also significantly reduced ghrelin-and OX-A-induced ulcer healing and addition of exogenous CGRP (10 µg/kg-d s.c.) restoredtheir healing and mucosal hyperemia in capsaicin-denervated rats. COX-2 mRNA and proteinwere upregulated but expression of IL-1β and TNF-α and their plasma levels were signific-antly attenuated by ghrelin or OX-A. We conclude that ghrelin and OX-A accelerate ulcerhealing via mechanism involving activation of specific receptors, PG/COX-2 system, vagaland sensory nerves and suppression of the proinflammatory cytokines, and 2) obestatindoes not affect ghrelin promoted ulcer healing.

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Impaired Epithelial Restitution in Trefoil Factor 2 (TFF2) Mutant MiceStomach After Microscopic DamageLin Xue, Marshall H. Montrose

Instruction: Trefoil factors (TFF) promote epithelial migration without stimulating cell prolif-eration in tissue culture models. Both TFF1 and TFF2 are expressed in stomach and havebeen suggested to contribute to epithelial restitution after injury as motogens that driveepithelial migration. Few data have directly examined this function of TFF in living animals.Aim: Our goal was to determine whether TFF2 affects the restitution of mouse gastricepithelium after microscopic lesions. Methods: Wild-type and TFF2 +/- (Het) mice wereexamined as the control versus TFF2 knockout (KO) mice to study the epithelial restitutioncourse after photodamage being added to tissue surface. Using photobleaching by two-photon laser light absorption (710 nm), photodamage was imposed on a ~3-5 cell regionof surface epithelium in an anesthetized mouse with exposed gastric mucosa. Responses todamage were evaluated during continuous recording with In Vivo confocal and two-photonmicroscopy; including area of damage and tissue morphology (NADH fluorescence, confocalreflectance) and extracellular microdomain pH near the damaged surface (Cl-NERF pHsensor in lightly buffered perfusate). Results: Among all genotypes, the size of initial damage(the area scanned ~5s by damaging high laser power) was not different, and the damagedarea expanded to reach its peak value in 2-4 min. In control and TFF2-KO mice, the maximaldamage size was 2290±322 (µm2), n=6 and 2563±274 (µm2), n=3, respectively (P>0.05).In control animals, damaged cells were then exfoliated and the damaged epithelium wasrepaired in 12±2 min n=6. In contrast, in TFF2-KO mice the disruption of epithelial layercould not be recovered over 30 min. Measuring the changing area of damage over time,the restitution rate was slower in TFF2-KO (1.0±0.3 µm2/s, n=3) compared to control mice(4.4±0.9 µm2/s, n=6; P<0.05). The resting surface pH was similar between control andTFF2-KO animals (pH 3.4±0.1 in control vs 3.6±0.2 in TFF2-KO, n=5; P>0.05). Extracellularalkalization following epithelial damage was recoded in control animals (∆pH 0.32±0.03,n=5), but was smaller in TFF2-KO mice (0.03±0.09, n=3). Conclusion: Absence of TFF2delayed the process of epithelial restitution, consistent with a role of the peptide to promotemigration after wounding. TFF2 also had a novel role to affect surface pH regulation afterdamage, potentially by affecting activation of ion transport systems causing the pH shift.Supported by NIH DK 54940.

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Treatment of the Liver Disease Associated with Niemann Pick Type C Diseasewith Ezetemibe and 2-Hydroxypropyl Beta Cyclodextrin Results in NearNormalization of ALT and ASTBenny Liu, Stephen D. Turley, John M. Dietschy

Introduction: Niemann Pick type C (NPC) disease is a genetic disorder involving disruptedintracellular cholesterol trafficking characterized by the accumulation of cholesterol withinthe late endosomal/lysosomal compartment of every tissue. Significant liver disease is fre-quently seen in patients with this disorder and is characterized by unesterified cholesterolaccumulation within hepatocytes, infiltration of lipid laden macrophages into the liverparenchyma, and hepatocyte apoptosis. Aim: To determine in a NPC mutant mouse (npc1-/-

) model whether liver injury associated with NPC disease can be prevented by the use ofezetemibe (EZE) which inhibits hepatic cholesterol accumulation through inhibition ofNPC1L1 (an intestinal cholesterol transporter) and 2-hydroxypropyl beta cyclodextrin(2HPBC), a compound known to extract cholesterol from plasma membranes. Methods:npc1-/- mice were either treated with daily oral EZE starting at birth, 2HPBC given as asingle subQ injection at day 7, or a combination of a subQ injection of 2HPBC at day 7along with oral EZE starting at day 7. Untreated npc1-/- mice were used as controls. Micewere studied at 49-56 days at which time body weight, liver weight, total hepatic cholesterolcontent, ALT, and AST were determined. Results (see table): Treatment of npc1-/- mice withthe combination of 2HPBC and EZE resulted in dramatic improvement in ALT and AST to nearnormal levels along with a reduction in total hepatic cholesterol content and improvement inhepatomegaly compared to either treatment alone or no treatment. Discussion: EZE hasbeen shown to improve liver function in NPC disease by inhibiting the intestinal absorptionof cholesterol which results in a decrease in hepatic cholesterol accumulation. The mechanismby which 2HPBC improves liver function in NPC disease is currently under investigation.

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sWe hypothesize that 2HPBC may be acting to blunt the effect of infiltrating macrophagesgiven that treatment with 2HPBC results in significant improvement in ALT and AST(similar to that seen in EZE treatment alone) without the corresponding reduction in hepaticcholesterol content as seen with EZE treatment. Combination therapy with EZE and 2HPBCmay prove to be an effective treatment for NPC associated liver disease by targeting bothhepatic cholesterol accumulation and possibly macrophage infiltration.

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The Role of Cytochrome P-4502e1 in DNA Damage and Ethanol-MediatedHepatic CarcinogenesisYing Wang, Sebastian Mueller, Gunda Millonig, J. Nair, H. Bartsch, Helmut-Karl Seitz

Background: Alcohol abuse exerts detrimental oxidative stress and lipid peroxidation inhumans which is possibly one of the mechanisms for the induction of liver cancer in heavydrinkers (Seitz & Stickel, Nat Rev Cancer 7:599,2007). We have previously demonstratedthat lipid peroxidation products-induced 1,N6-etheno-desoxyadenosine (edA) levels wereelevated in hepatic DNA of patients with alcoholic liver disease (ALD) (Frank et al, Carcino-genesis 25:1027,2004). Most recently, oxidized DNA products have been found to belower in Cytochrome P-4502E1 (CYP2E1) knock out mice compared withg wild-type mice(Bradford et al, Hepatology 41,33&:2005). Therefore, we investigated the role of CYP2E1on edA and 1,N6-etheno-desoxycitosine (edC) formation. Methods: HepG2 cell lines stablyinfected with CYP2E1 (E47) and a vector mock transfected control (C34) were used forthis study. Cells were treated with different concentrations of ethanol for various timeintervalls. At the end of the experiment edA and edC were determined by immunohistochem-istry using Mab EM-A-1 antibodies. To inhibtit CYP2E1 chlormethiazole (CMZ), a specificCYP2E1 inhibitor, was used. To study the correlation between CYP2E1 induction and edAand edC levels in humans, liver biopsies from 8 alcoholic patients with various degrees ofALD were investigated. Results: Ethanol treatment of HepG2 cells increased edA and edCstaining in the nuclei of E47 cells significantly in a time and concentration dependent manneras compared to C34 cells. CMZ significantly reduced the generation of these DNA adducts.Costaining of edA and CYP2E1 was detected in ..% of E47 cells treated with variousconcentrations of ethanol. Finally, a significant correlation was found between CYP2E1 andedA (r= 0.926, p=0.001) as well as edC (r=0.926, p=0.001) staining in liver biopsies frompatients with ALD. Our data show that ethanol treatment induces the formation of miscodingetheno-DNA adducts in CYP2E1 overexpressing HepG2 cells, that CMZ inhibits the formationof these adducts and that costaining of CYP2E1 and etheno adducts does occur. Mostimportantly, for the first time, a significant correlation between CYP2E1 induction andetheno DNA adducts was observed in liver biopsies from patients with ALD. Summary: Wetherefore conclude, that the hepatic induction of CYP2E1 by chronic alcohol consumptionis an important mechanism in ethanol-mediated hepatic carcinogenesis. Supported by theHeinz Götze Memorial Fellowship program and by the Dietmar Hopp Foundation.

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Nonalcoholic Fatty Liver Disease Is a Marker for Atherogenic DyslipidemiaTakeshi Kimura, Chihoko Yoshida, Seiju Sasaki, Osamu Takahashi, Sachiko Ohde, SonoeHiramatsu

Background & aim: The incidence of nonalcoholic fatty liver disease (NAFLD) has increasedalong with the growing trend of obesity. Recently, NAFLD has been shown to be associatedwith cardiovascular disease. Thus, it seems plausible that there is the specific atherogenicdyslipidemia in patients with NAFLD, but precise analysis has not yet been reported. Theaim of this study is to clarify whether specific lipoprotein profile alterations are observedin patients with NAFLD. Methods: 1018 adult participants in a voluntary health check-upprogram of our hospital were recruited during April 2005. After exclusion criteria wereapplied (alcohol intake; HBs Ag+; HCV Ab+; concurrent medication for hyperlipidemia;presence of hypertension, diabetes mellitus, ischemic heart disease, cerebrovascular disease),644 participants were included in the study for analysis. Data consisted of: waist circumfer-ence, complete blood cell count, blood chemistries, and abdominal ultrasound, which wereutilized to detect the presence of fatty liver. We categorized participants into two groups;those with fatty liver (NAFLD+) and those without fatty liver (NAFLD-). We adoptedthe International Diabetes Federation (IDF) criteria of metabolic syndrome (MS). Serumlipoproteins were analyzed by high-performance lipid chromatography (LipoSearch: Skylightbiotech, Akita, Japan). Cholesterol (C) and triglyceride (TG) levels were measured andcategorized into 3 very-low density (large, medium, small), 4 low-density (large, medium,small, very small), and 5 high-density (very large, large, medium, small, very small) lipopro-tein subclasses (VLDL, LDL and HDL). Data was analyzed using unpaired t test, chi-squaretest, and stepwise logistic regression. Results: Of the 644 participants, the percentage ofmales was 39.3%; average of age was 49.3yrs (SD+/-11.7yrs). The prevalence of NAFLDwas 111/644 (17.2%). The overall prevalence of MS was 9.2%. The prevalence of MS inNAFLD+ and NAFLD- was 29.7% and 4.9% respectively (p<0.001). Mean ALT for NAFLD+and NAFLD- subjects was 38.6 IU (SD+/-22.4IU) and 17.3 IU (SD+/-6.4IU), respectively(p <0.001). Stepwise logistic regression showed large VLDL-C (OR 0.74, 95% CI 0.56-0.97)and large VLDL-TG (OR 1.06, 95% CI 1.03-1.10) could predict NAFLD after gender, age,MS, ALT and other lipoprotein subclasses were adjusted for. Conclusion: In patients withNAFLD, both increase of large VLDL-TG and decrease of large VLDL-C are specific alterations

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in lipoprotein subclasses. This supports the inclusion of NAFLD as part of a syndromeplacing patients at higher risk of atherosclerotic diseases, that is separate and distinct from MS.

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Downexpression of Intestinal Niemann-Pick C1 Like 1 Protein (NPC1L1) ByEzetimibe Prevents Diet-Induced Fatty Liver Diseases in MiceHelen H. Wang, Piero Portincasa, David Q. Wang

Deletion of the liver X receptor α (LXRα) gene results in severe lipid accumulation in thelivers of mice challenged to a high fat diet because of dysfunctional lipid metabolism in theliver (Cell, 1998;93:693), suggesting that LXRα (-/-) mice are an excellent model of duet-induced fatty liver diseases. The Western diet containing high cholesterol and high fat isan important risk factor for fatty liver diseases. We observed recently that NPC1L1 has acrucial effect on the regulation of intestinal absorption of not only cholesterol but also fattyacid. Aims: We explored whether ezetimibe inhibits intestinal absorption of both fatty acidand cholesterol, and in turn, prevents diet-induced fatty liver diseases in mice. Methods:Male LXRα (-/-) mice (n=3-5 per group) were fed a rodent chow diet, or a special diet (15%butterfat, 1% cholesterol and 0.5% cholic acid) supplemented with ezetimibe at 0 or 200µg/day for 56 days. Intestinal absorption of fatty acid and cholesterol was determined bybalance methods. Plasma and liver lipids were measured by biochemical methods. Liverhistology with H&E and Oil red O staining was studied. Results: On chow, feeding ezetimibereduced intestinal absorption of fatty acid from 86±9% to 35±6%, and of cholesterol from50±6% to 5±1%, respectively. Under the special diet conditions, plasma concentrations oftriglyceride and cholesterol were significantly decreased by ezetimibe, from 162±15 mg/dlto 72±8 mg/dl and from 118±9 mg/dl to 80±6 mg/dl, respectively. Morphological andhistological studies of liver found that the number and size of intracellular vacuoles (character-istic of lipid deposits) was greater, and neutral lipid staining of liver sections verified thedeposition of increasing quantities of lipid in mice fed the special diet and receiving noezetimibe, compared with chow-fed mice. However, treatment of ezetimibe completelyprevented lipid accumulation in the liver, even under the special diet conditions. Further-more, hepatic total triglyceride (14±3 mg/g liver tissue) and cholesterol (10±2 mg/g livertissue) contents were significantly lower in ezetimibe-treated mice, compared with mice fedthe special diet and receiving no ezetimibe (75±10 mg/g liver tissue and 39±6 mg/g liver tissue,respectively). Conclusions: Ezetimibe can prevent fatty liver diseases in mice challenged toa high fat and high cholesterol diet by inhibiting intestinal absorption of both fatty acid andcholesterol through the NPC1L1 pathway.

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Recurrence of Nonalcoholic Steatohepatitis After Liver Transplantation -Frequency and OutcomesMaarouf A. Hoteit, Kymberly D. Watt, Julie K. Heimbach, Michael R. Charlton

Background: Nonalcoholic steatohepatitis (NASH)-related cirrhosis is an increasingly com-mon indication for liver transplantation (LT) in the United States. The risk of NASH recurrenceafter transplantation and its clinical significance are not well defined. Aim: To describe thefrequency, factors associated with and outcomes following histological recurrence of NASHposttransplantation. Methods: Patients undergoing LT at our institution between January1995 and December 2005 with histology-proven NASH as defined by the Brunt criteria,and with a follow up duration of at least 1 year were included. Patients were prospectivelyfollowed according to a standard protocol of evaluations, including protocol-based liverbiopsies. Results: A total of 42 patients (23 female, 19 male) were included. The mean ageat LT was 55.1±9.6 years. At the time of transplant, 29 patients (71.2%) were obese,24(57.1%) were diabetic, 19(45.2%) had hypertension, and 9(21.4%) had dyslipidemia.The median follow up was 4.0 years. During the follow up period, new onset diabetes mellitus(DM) was noted in 8 patients(19.1%), new hypertension was diagnosed in 15(35.7%), andnew dyslipidemia in 20 patients(47.6%). At least one follow up liver biopsy was availablein 38 of the 42 patients. Biopsy-proven recurrent NASH was observed in 12 patients (28.6%)at a median of 1.0 year after LT. Most patients had mild or no fibrosis (stage 0,1: 9/12,≥stage 2: 3/12). All 12 patients with NASH recurrence had DM in the post transplantperiod. Patients with recurrent NASH were more likely to have new onset post-LT DM thanpatients without recurrence (5/12 vs 4/30, p<0.05). Patients who lost at least 10% of bodyweight post-LT tended to have a lower recurrence rate of NASH compared to patients whodid not (18.2% vs 43.8%) but the difference was not statistically significant (p=0.16).No significant association was found between recurrent NASH and patient age, gender,hypertension or dyslipidemia. Cirrhosis was observed in 3 patients (25.0%) with recurrentNASH and in 2 patients (6.7%) without recurrence (p=0.09). Retransplantation was per-formed in 2 cases (4.5%), one for decompensated cirrhosis secondary to recurrent NASH,and one for hepatic vein thrombosis. Two patients with NASH recurrence and one withoutrecurrence died during follow up. None of the deaths were related to complications ofNASH. Conclusions: Recurrence of NASH after liver ransplantation is common and can, ina minority of cases, progress to cirrhosis. The association of recurrent NASH with new onsetpost transplantation diabetes mellitus may offer an opportunity for early identification ofpatients at risk of recurrence.

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Clinical Impact and Time Trends of Upper and Lower GastrointestinalComplicationsAngel I. Lanas, Luis A. Garcia-Rodriguez, Marta Ponce, Luis Rodrigo, Luis Bujanda, JavierP. Gisbert, Inmaculada Alonso-Abreu, Manuel Castro-Fernandez, Angeles Perez-Aisa,Mónica Polo-Tomás, Xavier Calvet, Santiago García

Background and aims: H. pylori infection and NSAIDs are the main cause of upper GIcomplications. NSAID use may be a cause of lower GI complications. Effective preventionstrategies have been designed to prevent upper but not lower GI complications. The aimof this study was to evaluate the clinical impact and time trends of both upper and lower