Effect of Acid Suppression on Peripheral T-Lymphocyte Subsets and Immunohistochemical Esophageal Mucosal Changes in Patients With Gastroesophageal Reflux Disease
Authors: Ahmed Osman Heba , Aly Sanaa S. , Mahmoud Hasan S. , Ahmed Eman H. , Salah Eldin Eman M. , Abdelrahim Eman A. , El masry Muhammad A. , Herdan Rania A. , Hassan Mohammed H. 
Published: August 2018

Background and Aims:
Gastroesophageal reflux disease (GERD) is a common prevalent disease. We aimed to assess the dynamic changes in the peripheral T lymphocytes and lymphocytes infiltrating the esophageal mucosa after treatment with proton-pump inhibitor (PPI) in patients with GERD.

Patients and Methods:
A total of 200 patients who presented with upper GIT symptoms were included in this prospective study. All patients were subjected to full history taking, clinical examination, and complete blood count. Upper endoscopy was performed to detect the grade of GERD, followed by 4 quadrant biopsies before and 1 month after acid suppressive drug therapy. Histopathologic and immunohistochemical examination were carried out for all biopsies. Flow cytometry analysis for the peripheral T lymphocytes and cytokine profile assay before therapy and after therapy were also carried out.

Results:
In total, 200 patients comprising 132 male individuals (66%) and 68 female individuals (34%) with a mean age of 47.9±18.3 were included. The risk factors for development of GERD were smoking in 87 (43.5%), spicy food intake in 26 (13%), analgesics in 46 (23%), excessive tea and coffee in 35 (17.5%), and nondetected risk factors in 6 (3%). Endoscopic examination using Los Angeles grading system revealed that 102 patients (51%) were grade A, 57 patients (28.5%) were grade B, 38 patients (19%) were grade C, and 3 patients (1.5%) were grade D. No statistically significant differences could be detected in HGB levels and WBC, PLT, monocyte, granulocyte, and eosinophil counts before and after treatment with PPI. Histopathologic examination of esophageal biopsies showed significant posttreatment improvement in 132 cases (66%); however, 66 cases (33%) including the 2 cases (1%) of Barrett’s esophagus showed nonsignificant pathologic improvement compared with the pretreatment picture. Immunohistochemical staining of esophageal biopsies with CD3 (T-cell marker) and CD20 (B-cell marker), before and 1 month after treatment, showed the presence of a very large number of infiltrating B cells in the esophageal mucosa (700±30/10 HPF) with large aggregations; in contrast, T-cell infiltration appeared less marked (570±23/10 HPF), and they formed smaller aggregates than those of B cells in pretreated patients, with P<0.01. However, 1 month after treatment with PPI, esophageal biopsies revealed a marked decrease in the number of both B (10±2/10 HPF) and T (290±12/HPF) cells in 66% of patients, with a P<0.01 in comparison with the pretherapy pattern. However, the remaining 33% of patients still showed a significantly high number of T cells (490±28/HPF), with a P <0.05 in comparison with the responder group that formed small aggregates with larger cell sizes, indicating their activation. Cytokine profiles before and after treatment revealed significant posttreatment reduction in their levels in the 132 cases with improvement in their clinical manifestations, and endoscopic and histopathologic findings, but there is no obvious change in the measured cytokine levels in 66 patients who simultaneously had no improvement in their endoscopic, histopathologic findings and mild improvement in their clinical manifestations. Moreover, significant posttreatment reduction of IL-8 and IL-1β in the 98 (49%) patients with Los Angeles grading B, C, and D was observed. With regard to serum levels of IL-10 and IL-4, there were no statistically significant differences before and after treatment with PPI. Peripheral blood immunologic parameters revealed a statistically significant reduction of the total CD3+ absolute count, T-helper lymphocyte (CD4+/CD3+) percentage, T-helper lymphocyte absolute count, and the percentage and absolute cytotoxic T-lymphocyte count (CD8+/CD3+) after treatment with PPI. Moreover, the same significant difference of peripheral blood lymphocytes was detected after exclusion of patients with Los Angeles grade A, which may be considered normal.

Conclusions:
Acid-induced T-cell–related cytokine production plays an important role in inflammation occurring in patients with GERD. Mucosal and peripheral inflammation reduces with PPI use.