# Catechins and Sialic Acid AttenuateHelicobacter pylori-Triggered Epithelial Caspase-1 Activity and Eradicate Helicobacter pylori Infection

Authors: Jyh-Chin Yang; Hung-Chih Yang; Chia-Tung Shun; Teh-Hong Wang; Chiang-Ting Chien; John Y. Kao
Journal: Evidence-Based Complementary and Alternative Medicine
 (2013)

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## Abstract

The inflammasome/caspase-1 signaling pathway in immune cells plays a critical role in bacterial pathogenesis; however, the regulation of this pathway in the gastric epithelium duringHelicobacter pylori infection is yet to be elucidated. Here, we investigated the effect of catechins (CAs), sialic acid (SA), or combination of CA and SA (CASA) on H. pylori-induced caspase-1-mediated epithelial damage, as well as H. pylori colonization in vitro (AGS cells) and in vivo (BALB/c mice). Our results indicate that the activity of caspase-1 and the expression of its downstream substrate IL-1β were upregulated in H. pylori-infected AGS cells. In addition, we observed increased oxidative stress, NADPH oxidase gp91phox, CD68, caspase-1/IL-1β, and apoptosis, but decreased autophagy, in the gastric mucosa of H. pylori-infected mice. We have further demonstrated that treatment with CASA led to synergistic anti-H. pylori activity and was more effective than treatment with CA or SA alone. In particular, treatment with CASA for 10 days eradicated H. pylori infection in up to 95% of H. pylori-infected mice. Taken together, we suggest that the pathogenesis of H. pylori involves a gastric epithelial inflammasome/caspase-1 signaling pathway, and our results show that CASA was able to attenuate this pathway and effectively eradicate H. pylori infection.


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## Body

## 1. Introduction

Helicobacter pyloriinfection, the major cause of some important gastroduodenal ulcers and malignancies, is one of the most prevalent bacterial infections worldwide [1]. After adhering to the gastric mucosa, H. pylori causes excessive production of reactive oxygen species (ROS), which then leads to epithelial cell damage [2–4]. The response of epithelial cells to H. pylori infection is a complex process reflecting the interactions among several factors, including bacterial virulence factors, specific receptors-linked signaling pathways, and the host immune response [5–7].Although patients infected withH. pylori develop an inflammatory response by recruiting and activating immune cells, the infection, unless treated with antibiotics, persists throughout the life of infected individuals. To date, many antibiotics-containing therapies have been recommended as the first-line and rescue therapy for treating H. pylori infection [8, 9]; however, the emergence of an increasing number of antibiotic-resistant H. pylori strains has led to a decline in the eradication rates. Therefore, there is strong interest in developing a nonantibiotic alternative therapy.We previously reported the anti-H. pylori properties of sialic acid (SA) and catechins (CAs) [3]. Specifically, SA has an antiadhesive effect [10], whereas CA has antioxidant and anti-microbial effects [11, 12]. While it is easy to obtain CA from typical plant-source diets, SA is an important component of gastrointestinal mucins and milk [13]. Both CA and SA have been shown to reduce H. pylori-triggered ROS production and Bax/Bcl-2-mediated apoptosis but enhance H. pylori-related Beclin-1-mediated autophagy [3]. Apoptosis and autophagy are considered to be noninflammatory programmed cell death pathways and therefore play important roles in tissue homeostasis and disease development in infected patients [14]. Since H. pylori infection universally causes gastritis, inflammatory pathways are thought to be involved in its pathogenesis.Inflammasomes, recently emerging as key regulators of the host response against microbial infections, are multiprotein complexes that mediate the activation of caspase-1, which subsequently induces not only the secretion of potent proinflammatory cytokines, such as interleukin-1β (IL-1β) and IL-18, but also an inflammatory form of cell death called pyroptosis [15–17]. Most reports characterizing inflammasomes have focused on cells of the myeloid lineage, such as macrophages or dendritic cells; however, epithelial cells are also capable of activating inflammasomes [15, 16, 18]. It has been shown that H. pylori activates caspase-1 and induces IL-1β secretion in macrophages [19] and dendritic cells [20]; however, the regulation of this pathway in gastric epithelial cells during H. pylori infection has not yet been described. Recently, the interactions between several cell death pathways, including apoptosis, autophagy, and pyroptosis, have also been reported [21–23]. Based on these studies, we hypothesize that H. pylori infection may directly cause the activation of the caspase-1 signaling pathway in gastric epithelial cells and that treatment with CA, SA, or combination of CA and SA (CASA) may attenuate this pathway. This hypothesis is consistent with the results from our previous research [3], as well as the evidence of crosstalk between different cell death pathways [21–23].In the current study, we examined the effect of CA, SA, or CASA on theH. pylori-induced caspase-1 pathway in gastric epithelial cells and the efficacy of CASA therapy in treating H. pylori infection. To the best of our knowledge, this study is the first to report that H. pylori infection caused the activation of caspase-1 signaling in gastric epithelial cells, which subsequently resulted in the upregulation of IL-1β secretion and pyroptosis in a human gastric cancer cell line (AGS) in vitro and BALB/c mice in vivo. We have also demonstrated that the administration of CASA attenuated the H. pylori-triggered caspase-1 signaling pathway and that posttreatment with CASA for 10 days eradicated up to 95% of H. pylori infection in mice. Taken together, these results suggest the involvement of inflammasome signaling in the pathogenesis of H. pylori-related diseases and may therefore be a potential target for H. pylori eradication.


## 2. Materials and Methods

### 2.1. Bacterial Strains and Drugs

AcagA-/vacA-positive clarithromycin-sensitive strain of H. pylori was obtained from gastric biopsy specimens of a patient with a duodenal ulcer, after obtaining informed consent. The standard strain ATCC 43504 was used as the internal control. Decaffeinated green tea extract containing various catechin compounds, including 328 mg/g epigallocatechin gallate, 152 mg/g epicatechin gallate, 148 mg/g gallocatechin gallate, 132 mg/g epicatechin, 108 mg/g epigallocatechin, 104 mg/g gallocatechin, and 44 mg/g catechin, was purchased from Taiyo Kagaku Co., Ltd. (Japan). SA was purchased from Sigma-Aldrich (St. Louis, MO, USA). Test strains were grown as described previously [24] and stored at −80°C until use.


### 2.2. Cell Culture System

To recoverH. pylori strains from frozen stocks, bacteria were cultured on Columbia agar plates containing 5% sheep blood at 37°C for 3 days under microaerophilic conditions. The human gastric cancer cell line ATCC CRL 1739 (AGS) was cultured in RPMI 1640 medium (Invitrogen, Grand Island, NY) containing 10% fetal bovine serum at 37°C in a humidified environment and 5% CO2, as described previously [25]. For coculture of H. pylori and AGS cells, bacteria were washed off agar plates and resuspended in phosphate-buffered saline (PBS) to an optical density of 1.0 at 450 nm, corresponding to a bacterial concentration of 2×108 CFU/mL. Bacteria were added to wells containing 2×105 gastric epithelial cells at an H. pylori/AGS cell ratio of 100 : 1 and then cocultured for 4 h in a cell culture incubator in the absence or presence of CA (32–640 μg/mL) and/or SA (8–160 μg/mL). H. pylori lipopolysaccharide (LPS) mediates the release of cytokines and chemokines from monocytes [19]. To further determine whether CASA inhibits H. pylori-induced production of inflammatory mediators, we evaluated the levels of IL-1β in AGS cells stimulated with 20 ng/mL LPS (Escherichia coli O55: B5; Sigma-Aldrich) [19]. The experimental procedures were similar to those for H. pylori infection of AGS cells.


### 2.3. Caspase-1/IL-1β Expression in AGS Cells, Measured by Western Blotting and Immunocytochemical Staining

The expression levels of caspase-1 and IL-1β were analyzed by western blotting as described previously [3]. In brief, samples were homogenized completely by vortexing in extraction buffer, which consisted of 10 mM Tris-HCl (pH 7.6), 140 mM NaCl, 1 mM PMSF, 1% NP-40, 0.5% deoxycholate, 2%  β-mercaptoethanol, 10 μg/mL pepstatin A, and 10 μg/mL aprotinin. After incubation at 4°C for 30 min, homogenates were centrifuged at 12,000 ×g for 12 min at 4°C. Supernatants were collected, and protein concentrations were determined by the BioRad Protein Assay (BioRad Laboratories, Hercules, CA, USA). Proteins were separated on 12.5% SDS-PAGE in the absence of urea and then stained with Coomassie brilliant blue. Each lane containing 30 μg of total proteins was transferred to nitrocellulose filters. Antibodies raised against caspase-1 (GeneTex, Irvine, CA, USA), IL-1β (Millipore Bioscience Research Reagents, formerly Chemicon, Temecula, CA, USA), NADPH oxidase (gp91phox; Santa Cruz Biotechnology, Santa Cruz, CA, USA), and β-actin (Sigma-Aldrich) were used. Immunoreactive bands were detected by incubation with the specific antibodies described above and then an alkaline phosphatase-conjugated secondary antibody, followed by 30-min incubation at room temperature in a stock solution containing nitroblue tetrazolium and 5-bromo-4-chloro-3-indolyl phosphate p-toluidine salt (Roche Diagnostic GmbH, Mannheim, Germany). The density for bands of appropriate molecular masses was determined semiquantitatively with densitometry by using an image analysis system (Alpha Innotech, San Leandro, CA, USA).H. pylori-induced overexpression of caspase-1 signaling in AGS cells was evaluated by IL-1β staining in triplicate. For immunofluorescence staining, cells grown on culture slides were fixed with 4% paraformaldehyde in PBS for 30 min at 25°C and washed 3 times with cold PBS buffer (5 min each) at 25°C. Cells were permeabilized with 0.5% Triton X-100 in PBS for 5 min at 25°C, covered by blocking buffer (5% BSA in PBS) for 1 h at 25°C, and subsequently incubated for 1 h at 37°C with diluted (1 : 100) rabbit anti-IL-1β antibodies (Santa Cruz Biotechnology). After hybridization with primary antibodies, cells were washed 3 times with PBS (5 min each) and incubated for 1 h at 25°C with blocking buffer containing secondary antibodies (1 : 200) conjugated with either Alexa Fluor 594 goat anti-rabbit IgG (H + L) or Alexa Fluor 488 goat anti-mouse IgG 1 (Invitrogen). After 3 washes with PBS (5 min each), culture slides were mounted with fluorescence mounting medium (ProLong Gold and SlowFade Gold Antifade Reagents; Invitrogen). Finally, cells were observed under a fluorescence microscope (Leica DMRD; Wetzlar, Germany), and cellular fluorescence was quantified using Image-J (National Institutes of Health, USA). The ratio of IL-1β positive cells per 100 cells was then analyzed.


### 2.4. Mouse Model

Specific-pathogen-free male BALB/c mice aged 5-6 weeks were obtained from the National Laboratory Animal Center and housed at the Experimental Animal Center, National Taiwan University, at a constant temperature and with a consistent light cycle (lights on from 07:00 to 18:00). Food and water were provided ad libitum. All animal experiments were reviewed and approved by the Institutional Animal Care and Use Committee at the National Taiwan University College of Medicine.The mouse model was modified from our previous study [3]. Specifically, bacteria were recovered at 37°C for 3 days under microaerophilic conditions, transferred to Brucella broth supplemented with 5% fetal bovine serum, 1% IsoVitalex, and antibiotics and maintained for 48 h. The concentration was adjusted to about 1011 bacteria/L for inoculation. Mice (n=210) were divided into 8 groups for duplicate experiments (Table 1). While mice in group A (uninfected control) received distilled water only, 7 groups (B–H) of mice were inoculated intragastrically 2 times on successive days with 0.5 mL of bacterial suspension. Two weeks after inoculation, mice in group B (infected control) received only 1% glucose water for 14 days, whereas mice in group C (TT, triple therapy) were treated twice daily for 7 days with 0.5 mL of distilled water containing esomeprazole, amoxicillin, and clarithromycin (1.3, 33.3, and 16.7 mg/kg body weight, resp.). CA, SA, and CASA were dissolved in 1% glucose solution to reduce the bitter taste of CA, as described in Table 1. This modification allowed mice to drink similar amounts of fluid (solution and water), approximately 5-6 mL per mouse per day. Mice in groups D–H were posttreated with 0.5 mL of distilled water containing CA (640 μg/mL) and/or SA (160 μg/mL) at 2 weeks after H. pylori inoculation and then given free access to CA, SA, or CASA in 1% glucose solution. Mice in group D (CA7) or E (SA7) were given free access to CA or SA solution for 7 days, whereas those in groups F (CASA7), G (CASA10), and H (CASA14) were given free access to CASA solution for 7, 10, and 14 days, respectively.Table 1
Treatment regimens and eradication rates among various groups of mice infected byH. pylori.
Group
Name
n
Treatment regimen1
H. pylori (+)/(−)
Eradication2
Exp1
Exp2
rate (%)
A
UC (uninfected control)
10
—
0/5
0/5
NA
B
IC (infected control)
20
—
10/0
10/0
0
C
TT (treatment control 1)
20
Triple therapy for 7 days
1/9
1/9
90*
D
CA7 (treatment control 2)
20
CA solution for 7 days
10/0
9/1
5
E
SA7 (treatment control 3)
20
SA solution for 7 days
9/1
10/0
5
F
CASA7
40
CASA solution for 7 days
6/14
4/16
75*
G
CASA10
40
CASA solution for 10 days
1/19
1/19
95*#
H
CASA14
40
CASA solution for 14 days
1/19
1/19
95*#
1CA solution, 1% glucose and 640 mg/L CA; SA solution, 1% glucose and 160 mg/L SA; CASA solution, 1% glucose and a mixture of 640 mg/L CA and 160 mg/L SA.
2NA: not available. *P < 0.001, compared to the CA7 or SA7 group; #P = 0.01, compared to the CASA7 group.Four weeks after treatment, mice were sacrificed by anesthesia with 0.5 mL of 50% urethane. Mouse stomachs were resected and longitudinally divided into 3 parts for histological, biochemical, and microbiological examination. Gastritis was graded by a pathologist without knowledge of the treatment protocol, according to the updated Sydney system [26]. The presence of H. pylori was identified by histology, bacterial culture, and PCR, and the CFUs ofH. pylori were counted as described previously [3].


### 2.5.In Situ Detection of Oxidative Stress, Inflammation, Pyroptosis, Apoptosis, and Autophagy

Since increased oxidative stress might be associated with the occurrence of inflammation, pyroptosis, and apoptosis, we evaluated the expression of 3-nitrotyrosine (3-NT) and NADPH oxidase gp91phox, as well asO2∙- production, for oxidative stress. For analyzing inflammation, pyroptosis, apoptosis, and autophagy, we performed CD68 (a macrophage/monocyte biomarker) staining, caspase-1/IL-1β staining, terminal deoxynucleotidyl transferase-mediated nick-end labeling (TUNEL), and Beclin-1 staining, respectively, in paraffin-embedded sections of gastric tissues.Tissue sections obtained from 10% formalin fixation and paraffin embedding were deparaffinized, rehydrated, and stained immunohistochemically. For 3-NT staining, tissue sections were incubated with rabbit antinitrotyrosine IgG antibodies (NITT12-A; Alpha Diagnostic) and stained with avidin-biotinylated horseradish peroxidase using a commercially available kit (ABC Elite; Vector Laboratories) [3]. The gastric O2∙- production was measured using a Chemiluminescence Analyzing System (CLD-110; Tohoku Electronic In., Co., Sendai, Japan) [27]. Briefly, 5 mg of homogenized tissue samples and 0.5 mL of 0.1 mmol/L lucigenin in PBS (pH 7.4) were injected into the chamber for the chemiluminescence assay. The assay was performed in triplicate, and results were expressed as the chemiluminescence count per 10 s [27]. For staining of CD68, Beclin-1, or caspase-1/IL-1β, tissue sections were incubated overnight at 4°C with mouse anti-rat CD68 antibody (BioSource International, Camarillo, CA, USA), Beclin-1 antibody (BD Biosciences, San Jose, CA, USA), or caspase-1 and IL-1β antibody (1 : 100), respectively. Subsequently, biotinylated secondary antibodies (Dako, Botany, NSW, Australia) were applied, followed by incubation with streptavidin-conjugated horseradish peroxidase (Dako). The chromogen used in this study was Dako Liquid diaminobenzidine. Twenty high-power (×400) fields were randomly selected from each gastric section, and the value of brown deposits/total section area for CD68, caspase-1, IL-1β, or Beclin-1 positive stain was analyzed with Adobe Photoshop 7.0.1 image software.TUNEL was performed according to a previously described method [27]. Briefly, 5-μm-thick sections of gastric tissues were prepared, deparaffinized, and stained using the TUNEL-ABC method. Twenty high-power (×400) fields were randomly selected from each section, and the number of apoptotic cells were counted. Finally, the value of apoptotic cells/(apoptotic cells and methyl green-stained cells) was calculated.


### 2.6. Statistical Analysis

All values were expressed as mean ± standard error of the mean (SEM), except that gastritis scores and bacterial counts were expressed as mean ± standard deviation (SD). The one-way ANOVA and Duncan’s multiple-range tests were used to examine differences among groups in the cell culture system, as well as immunohistochemical staining results of various mouse groups. Two-sample proportion tests were used to compare the eradication rates for each pair of groups. The one-way ANOVA or Kruskal-Wallis test, along with Dunnett’s multiple comparison with a control, was used to evaluate differences in gastritis scores and bacterial counts among groups in the mouse model. Differences withP<0.05 were considered significant. Graphing and the statistical analysis were performed using the SigmaPlot 12.0 software (Systat Software, Inc., Chicago, IL).


## 2.1. Bacterial Strains and Drugs

AcagA-/vacA-positive clarithromycin-sensitive strain of H. pylori was obtained from gastric biopsy specimens of a patient with a duodenal ulcer, after obtaining informed consent. The standard strain ATCC 43504 was used as the internal control. Decaffeinated green tea extract containing various catechin compounds, including 328 mg/g epigallocatechin gallate, 152 mg/g epicatechin gallate, 148 mg/g gallocatechin gallate, 132 mg/g epicatechin, 108 mg/g epigallocatechin, 104 mg/g gallocatechin, and 44 mg/g catechin, was purchased from Taiyo Kagaku Co., Ltd. (Japan). SA was purchased from Sigma-Aldrich (St. Louis, MO, USA). Test strains were grown as described previously [24] and stored at −80°C until use.


## 2.2. Cell Culture System

To recoverH. pylori strains from frozen stocks, bacteria were cultured on Columbia agar plates containing 5% sheep blood at 37°C for 3 days under microaerophilic conditions. The human gastric cancer cell line ATCC CRL 1739 (AGS) was cultured in RPMI 1640 medium (Invitrogen, Grand Island, NY) containing 10% fetal bovine serum at 37°C in a humidified environment and 5% CO2, as described previously [25]. For coculture of H. pylori and AGS cells, bacteria were washed off agar plates and resuspended in phosphate-buffered saline (PBS) to an optical density of 1.0 at 450 nm, corresponding to a bacterial concentration of 2×108 CFU/mL. Bacteria were added to wells containing 2×105 gastric epithelial cells at an H. pylori/AGS cell ratio of 100 : 1 and then cocultured for 4 h in a cell culture incubator in the absence or presence of CA (32–640 μg/mL) and/or SA (8–160 μg/mL). H. pylori lipopolysaccharide (LPS) mediates the release of cytokines and chemokines from monocytes [19]. To further determine whether CASA inhibits H. pylori-induced production of inflammatory mediators, we evaluated the levels of IL-1β in AGS cells stimulated with 20 ng/mL LPS (Escherichia coli O55: B5; Sigma-Aldrich) [19]. The experimental procedures were similar to those for H. pylori infection of AGS cells.


## 2.3. Caspase-1/IL-1β Expression in AGS Cells, Measured by Western Blotting and Immunocytochemical Staining

The expression levels of caspase-1 and IL-1β were analyzed by western blotting as described previously [3]. In brief, samples were homogenized completely by vortexing in extraction buffer, which consisted of 10 mM Tris-HCl (pH 7.6), 140 mM NaCl, 1 mM PMSF, 1% NP-40, 0.5% deoxycholate, 2%  β-mercaptoethanol, 10 μg/mL pepstatin A, and 10 μg/mL aprotinin. After incubation at 4°C for 30 min, homogenates were centrifuged at 12,000 ×g for 12 min at 4°C. Supernatants were collected, and protein concentrations were determined by the BioRad Protein Assay (BioRad Laboratories, Hercules, CA, USA). Proteins were separated on 12.5% SDS-PAGE in the absence of urea and then stained with Coomassie brilliant blue. Each lane containing 30 μg of total proteins was transferred to nitrocellulose filters. Antibodies raised against caspase-1 (GeneTex, Irvine, CA, USA), IL-1β (Millipore Bioscience Research Reagents, formerly Chemicon, Temecula, CA, USA), NADPH oxidase (gp91phox; Santa Cruz Biotechnology, Santa Cruz, CA, USA), and β-actin (Sigma-Aldrich) were used. Immunoreactive bands were detected by incubation with the specific antibodies described above and then an alkaline phosphatase-conjugated secondary antibody, followed by 30-min incubation at room temperature in a stock solution containing nitroblue tetrazolium and 5-bromo-4-chloro-3-indolyl phosphate p-toluidine salt (Roche Diagnostic GmbH, Mannheim, Germany). The density for bands of appropriate molecular masses was determined semiquantitatively with densitometry by using an image analysis system (Alpha Innotech, San Leandro, CA, USA).H. pylori-induced overexpression of caspase-1 signaling in AGS cells was evaluated by IL-1β staining in triplicate. For immunofluorescence staining, cells grown on culture slides were fixed with 4% paraformaldehyde in PBS for 30 min at 25°C and washed 3 times with cold PBS buffer (5 min each) at 25°C. Cells were permeabilized with 0.5% Triton X-100 in PBS for 5 min at 25°C, covered by blocking buffer (5% BSA in PBS) for 1 h at 25°C, and subsequently incubated for 1 h at 37°C with diluted (1 : 100) rabbit anti-IL-1β antibodies (Santa Cruz Biotechnology). After hybridization with primary antibodies, cells were washed 3 times with PBS (5 min each) and incubated for 1 h at 25°C with blocking buffer containing secondary antibodies (1 : 200) conjugated with either Alexa Fluor 594 goat anti-rabbit IgG (H + L) or Alexa Fluor 488 goat anti-mouse IgG 1 (Invitrogen). After 3 washes with PBS (5 min each), culture slides were mounted with fluorescence mounting medium (ProLong Gold and SlowFade Gold Antifade Reagents; Invitrogen). Finally, cells were observed under a fluorescence microscope (Leica DMRD; Wetzlar, Germany), and cellular fluorescence was quantified using Image-J (National Institutes of Health, USA). The ratio of IL-1β positive cells per 100 cells was then analyzed.


## 2.4. Mouse Model

Specific-pathogen-free male BALB/c mice aged 5-6 weeks were obtained from the National Laboratory Animal Center and housed at the Experimental Animal Center, National Taiwan University, at a constant temperature and with a consistent light cycle (lights on from 07:00 to 18:00). Food and water were provided ad libitum. All animal experiments were reviewed and approved by the Institutional Animal Care and Use Committee at the National Taiwan University College of Medicine.The mouse model was modified from our previous study [3]. Specifically, bacteria were recovered at 37°C for 3 days under microaerophilic conditions, transferred to Brucella broth supplemented with 5% fetal bovine serum, 1% IsoVitalex, and antibiotics and maintained for 48 h. The concentration was adjusted to about 1011 bacteria/L for inoculation. Mice (n=210) were divided into 8 groups for duplicate experiments (Table 1). While mice in group A (uninfected control) received distilled water only, 7 groups (B–H) of mice were inoculated intragastrically 2 times on successive days with 0.5 mL of bacterial suspension. Two weeks after inoculation, mice in group B (infected control) received only 1% glucose water for 14 days, whereas mice in group C (TT, triple therapy) were treated twice daily for 7 days with 0.5 mL of distilled water containing esomeprazole, amoxicillin, and clarithromycin (1.3, 33.3, and 16.7 mg/kg body weight, resp.). CA, SA, and CASA were dissolved in 1% glucose solution to reduce the bitter taste of CA, as described in Table 1. This modification allowed mice to drink similar amounts of fluid (solution and water), approximately 5-6 mL per mouse per day. Mice in groups D–H were posttreated with 0.5 mL of distilled water containing CA (640 μg/mL) and/or SA (160 μg/mL) at 2 weeks after H. pylori inoculation and then given free access to CA, SA, or CASA in 1% glucose solution. Mice in group D (CA7) or E (SA7) were given free access to CA or SA solution for 7 days, whereas those in groups F (CASA7), G (CASA10), and H (CASA14) were given free access to CASA solution for 7, 10, and 14 days, respectively.Table 1
Treatment regimens and eradication rates among various groups of mice infected byH. pylori.
Group
Name
n
Treatment regimen1
H. pylori (+)/(−)
Eradication2
Exp1
Exp2
rate (%)
A
UC (uninfected control)
10
—
0/5
0/5
NA
B
IC (infected control)
20
—
10/0
10/0
0
C
TT (treatment control 1)
20
Triple therapy for 7 days
1/9
1/9
90*
D
CA7 (treatment control 2)
20
CA solution for 7 days
10/0
9/1
5
E
SA7 (treatment control 3)
20
SA solution for 7 days
9/1
10/0
5
F
CASA7
40
CASA solution for 7 days
6/14
4/16
75*
G
CASA10
40
CASA solution for 10 days
1/19
1/19
95*#
H
CASA14
40
CASA solution for 14 days
1/19
1/19
95*#
1CA solution, 1% glucose and 640 mg/L CA; SA solution, 1% glucose and 160 mg/L SA; CASA solution, 1% glucose and a mixture of 640 mg/L CA and 160 mg/L SA.
2NA: not available. *P < 0.001, compared to the CA7 or SA7 group; #P = 0.01, compared to the CASA7 group.Four weeks after treatment, mice were sacrificed by anesthesia with 0.5 mL of 50% urethane. Mouse stomachs were resected and longitudinally divided into 3 parts for histological, biochemical, and microbiological examination. Gastritis was graded by a pathologist without knowledge of the treatment protocol, according to the updated Sydney system [26]. The presence of H. pylori was identified by histology, bacterial culture, and PCR, and the CFUs ofH. pylori were counted as described previously [3].


## 2.5.In Situ Detection of Oxidative Stress, Inflammation, Pyroptosis, Apoptosis, and Autophagy

Since increased oxidative stress might be associated with the occurrence of inflammation, pyroptosis, and apoptosis, we evaluated the expression of 3-nitrotyrosine (3-NT) and NADPH oxidase gp91phox, as well asO2∙- production, for oxidative stress. For analyzing inflammation, pyroptosis, apoptosis, and autophagy, we performed CD68 (a macrophage/monocyte biomarker) staining, caspase-1/IL-1β staining, terminal deoxynucleotidyl transferase-mediated nick-end labeling (TUNEL), and Beclin-1 staining, respectively, in paraffin-embedded sections of gastric tissues.Tissue sections obtained from 10% formalin fixation and paraffin embedding were deparaffinized, rehydrated, and stained immunohistochemically. For 3-NT staining, tissue sections were incubated with rabbit antinitrotyrosine IgG antibodies (NITT12-A; Alpha Diagnostic) and stained with avidin-biotinylated horseradish peroxidase using a commercially available kit (ABC Elite; Vector Laboratories) [3]. The gastric O2∙- production was measured using a Chemiluminescence Analyzing System (CLD-110; Tohoku Electronic In., Co., Sendai, Japan) [27]. Briefly, 5 mg of homogenized tissue samples and 0.5 mL of 0.1 mmol/L lucigenin in PBS (pH 7.4) were injected into the chamber for the chemiluminescence assay. The assay was performed in triplicate, and results were expressed as the chemiluminescence count per 10 s [27]. For staining of CD68, Beclin-1, or caspase-1/IL-1β, tissue sections were incubated overnight at 4°C with mouse anti-rat CD68 antibody (BioSource International, Camarillo, CA, USA), Beclin-1 antibody (BD Biosciences, San Jose, CA, USA), or caspase-1 and IL-1β antibody (1 : 100), respectively. Subsequently, biotinylated secondary antibodies (Dako, Botany, NSW, Australia) were applied, followed by incubation with streptavidin-conjugated horseradish peroxidase (Dako). The chromogen used in this study was Dako Liquid diaminobenzidine. Twenty high-power (×400) fields were randomly selected from each gastric section, and the value of brown deposits/total section area for CD68, caspase-1, IL-1β, or Beclin-1 positive stain was analyzed with Adobe Photoshop 7.0.1 image software.TUNEL was performed according to a previously described method [27]. Briefly, 5-μm-thick sections of gastric tissues were prepared, deparaffinized, and stained using the TUNEL-ABC method. Twenty high-power (×400) fields were randomly selected from each section, and the number of apoptotic cells were counted. Finally, the value of apoptotic cells/(apoptotic cells and methyl green-stained cells) was calculated.


## 2.6. Statistical Analysis

All values were expressed as mean ± standard error of the mean (SEM), except that gastritis scores and bacterial counts were expressed as mean ± standard deviation (SD). The one-way ANOVA and Duncan’s multiple-range tests were used to examine differences among groups in the cell culture system, as well as immunohistochemical staining results of various mouse groups. Two-sample proportion tests were used to compare the eradication rates for each pair of groups. The one-way ANOVA or Kruskal-Wallis test, along with Dunnett’s multiple comparison with a control, was used to evaluate differences in gastritis scores and bacterial counts among groups in the mouse model. Differences withP<0.05 were considered significant. Graphing and the statistical analysis were performed using the SigmaPlot 12.0 software (Systat Software, Inc., Chicago, IL).


## 3. Results

### 3.1. Effect of CA and SA onH. pylori-Triggered Activation of Caspase-1 Signaling in AGS Cells

It has been shown that the activation of caspase-1 is necessary for the pro-IL-1β maturation [15–17] and that IL-1β is a crucial proinflammatory cytokine elicited by H. pylori infection. Here, we used the AGS cell culture system to determine whether H. pylori infection activates caspase-1 signaling in gastric epithelial cells. We also studied the effect of CA, SA, or CASA on the expression of caspase-1 and IL-1β in these cells.As shown in Figures1 and 2, the expression levels of caspase-1 and IL-1β in H. pylori-infected AGS cells were found to have increased (by 18%  ± 3% and 4-fold, resp.), compared to that for control cells, and such increases were significantly inhibited by treatment with CA, SA, or CASA. Interestingly, CASA treatment also significantly reduced the caspase-1 expression in control AGS cells, suggesting that CASA has an anti-inflammatory effect. Together, these observations indicate that the combination of CA and SA is effective in suppressing the inflammatory responses elicited by H. pylori infection.Figure 1
Effects of catechins (CAs) and/or sialic acid (SA) on caspase-1 expression in AGS cells at 4 h afterH. pylori (HP) infection. Upper panel, a representative western blot; lower panel, the fold change of the caspase-1 levels relative to the expression in the untreated uninfected control, which was set at 1.0. β-actin was used as a loading control. Each column with a vertical line represents mean ± SEM (n=3). P*<0.05, compared to the untreated uninfected control;  P#<0.05, compared to H. pylori infection alone.Figure 2
Effects of catechins (CAs) and/or sialic acid (SA) on IL-1β expression in AGS cells at 4 h after H. pylori (HP) infection. Upper panel, a representative western blot; lower panel, the fold change of the IL-1β levels relative to the expression in the untreated uninfected control, which was set at 1.0. Each column with a vertical line represents mean ± SEM (n=3). P*<0.05, compared to the untreated uninfected control; P#<0.05, compared to H. pylori infection alone.Immunofluorescence staining for IL-1β further confirmed the inhibitory effect of CASA on H. pylori-triggered caspase-1 signaling in AGS cells. As shown in Figures 3(a) and 3(b), IL-1β staining in uninfected cells was less intense than that in cells infected with H. pylori for 4 h (IL-1β-positive cells, 0.8%  ± 0.2% versus 29.6  ± 4.3%). While CASA treatment was found to reduce the number of IL-1β-positive cells among infected AGS cells (10.5%  ± 2.3%) (Figure 3(c)), it did not increase IL-1β staining in uninfected control cells (Figures 3(d) and 3(e)), indicating that AGS cells were unharmed at this dosage of CASA.Figure 3
Effects of catechins (CAs) and/or sialic acid (SA) on IL-1β expression measured by immunofluorescence staining in AGS cells at 4 h after infection with H. pylori (HP) ((a–e), ×200 magnification) or LPS ((f–j), ×400 magnification). Arrows indicate IL-1β-positive stains (bright red and bright green). (a, f) Control AGS cells; (b) H. pylori-infected AGS cells; (c) CASA-treated H. pylori-infected AGS cells; (g) LPS-treated AGS cells; (h) CASA-treated LPS-treated AGS cells; (d, i) CASA-treated control AGS cells; and (e, j) IL-1β immunofluorescence staining results analyzed using Image-J software. Data show changes in the percentage of IL-1β-positive cells, compared to the untreated uninfected control, which was set at 1.0. Each column with a vertical line represents mean ± SEM (n=4). P*<0.05, compared to the untreated uninfected control; P#<0.05, compared to H. pylori infection or LPS treatment alone.We next investigated the effects of CASA on LPS-induced damage in AGS cells. We show that the percentage of IL-1β-positive cells was increased by LPS stimulation (18.9%  ± 3.6%; Figures 3(g) and 3(j)), compared to control untreated cells (1.9%  ± 0.3%; Figures 3(f) and 3(j)). Notably, CASA administration significantly decreased the percentage of IL-1β-positive cells among LPS-treated cells (5.3%  ± 1.2%; Figures 3(h) and 3(j)); in contrast, it did not increase the number of IL-1β-positive cells among untreated control cells (Figures 3(i) and 3(j)).


### 3.2. Effect of CA and SA on the Eradication ofH. pylori Colonization in the Mouse Model

We previously reported the anti-H. pylori properties of CASA [3]. In this study, to evaluate the optimal dosing of CASA for treating H. pylori infection, the standard doses of CASA were administered to H. pylori-infected mice for different durations.All mice in the infected control group were successfully infected, whereas 90%, 5%, and 5% of mice were found to beH. pylori-negative in groups treated with triple therapy, CA solution, and SA solution, respectively (Table 1). These results indicate that CA or SA alone failed to effectively eradicate infection in the mouse model in vivo. In contrast, H. pylori-infected mice administered with CASA for 7, 10, or 14 days achieved eradication rates of 75%, 95%, or 95%, respectively. These data demonstrate that the treatment efficacy in the CASA10 and CASA14 groups was similar to that achieved by triple therapy and was significantly higher than that in the CASA7 group. Taken together, our results suggest that the combination of CA and SA synergistically enhances the efficacy in eradicating H. pylori infection, as well as that the optimal duration of CASA therapy should not be less than 10 days.The histological features of gastritis in mice were graded using a visual analog scale according to the updated Sydney system and recorded as the summed scores of 2 following semiquantitative parameters: (1) chronic inflammation score, the density of mononuclear cells ranging from 0 to 3 (score 0, normal; 1, mild; 2, moderate; 3, marked) and (2) acute inflammation score, the density of neutrophils ranging from 0 to 3 (score 0, normal; 1, mild; 2, moderate; 3, marked) [26]. As shown in Figure 4(a), the mean gastritis scores for the infected and uninfected control groups were 2.1 and 0.1, respectively. Treatment with CA or SA alone, though unable to eradicate H. pylori colonization, was found to significantly reduce the mean gastritis scores (1.0 or 1.5, resp.), indicating that CA or SA treatment may decrease H. pylori-induced inflammation. Moreover, treatment with CASA significantly decreased the mean gastritis score to 0.6, 0.2, and 0.1 for the CASA7, CASA10, and CASA14 groups, respectively. Importantly, although the mice in the CASA10 and CASA14 groups exhibited similar eradication rates to triple therapy group (95% versus 90%), they were found to have significantly lower mean gastritis scores than those in the triple therapy group. Specifically, the mean gastritis scores for the CASA10 and CASA14 groups were similar to those for the uninfected control group. In addition, H. pylori-infected mice treated with CASA also exhibited faster and stronger reduction of inflammation in the gastric mucosa than those treated with triple therapy, suggesting that CASA treatment reduces inflammation scores by decreasing not only the bacterial number of H. pylori colonization but also the production of ROS in the gastric epithelium. This is further confirmed by the observation of similar bacterial counts among these 3 groups (Figure 4(b)).Effects of catechins (CAs) and/or sialic acid (SA) on gastritis scores and bacterial counts in theH. pylori-infected mouse model. Each group of mice was treated with different dosage of CA and/or SA (UC, uninfected control, n=10; IC, infected control, n=20; TT, triple therapy, n=20; CA7, CA solution for 7 days, n=20; SA7, SA solution for 7 days, n=20; and CASA7, 10, and 14, CASA solution for 7, 10, and 14 days, resp., n=40). Each column with a vertical line represents mean ± SD. P*<0.05, compared to UC; P#≤0.01, compared to IC; P§<0.05, compared to TT.
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### 3.3. Effect of CASA onH. pylori-Enhanced Oxidative Stress and NADPH Oxidase gp91phox Expression

The intensity of 3-NT immunostaining in the stomach ofH. pylori-infected mice (Figure 5(b)) was stronger than that in uninfected control mice (Figure 5(a)). Figure 5(c) demonstrates that CASA treatment was able to efficiently reduce 3-NT staining in the stomach of H. pylori-infected mice. Importantly, we observed that the administration of CASA did not enhance 3-NT staining or induce morphologic changes in the stomach of uninfected mice (Figure 5(d)), suggesting the absence of toxicity at this CASA dose. Similarly, H. pylori infection was found to significantly increase the production of O2-∙ (Figure 5(e)), as well as the expression of NADPH oxidase gp91phox subunit (Figure 5(f)), in the gastric homogenates of infected mice. We further show that these effects were efficiently reduced by CASA treatment.Effects of the combination of catechins and sialic acid (CASA) on oxidative stress in the stomach of mice. (a–d) The 3-NT expression in uninfected control mice (a),H. pylori-infected mice (b), CASA-treated H. pylori-infected mice (c), and CASA-treated uninfected mice (d). Brown color in (b) indicates 3-NT-positive staining. (e, f) The production of O2-∙ (e) and the expression NADPH oxidase gp91phox subunit (f). Each column with a vertical line represents mean ± SEM (n=4). P*<0.05, compared to the untreated uninfected control; P#<0.05, compared to H. pylori infection alone.
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### 3.4. Effect of CASA onH. pylori-Triggered Caspase-1-Mediated Inflammatory Damage of Gastric Mucosa in the Mouse Model

Here, we demonstrateH. pylori-promoted overexpression of caspase-1/IL-1β, the crosstalk among different cell death pathways, and the inhibitory effect of CASA on these pathways in the gastric mucosa of the mouse model. Specifically, in the H. pylori-infected group, the number of infiltrating leukocytes (Figures 6(a2) and 6(a4)); CD68-positive cells (Figures 6(b2) and 6(b4)), caspase-1-positive (Figures 6(c2) and 6(c4))and  IL-1β-positive (Figures 6(d2) and 6(d4)) cells; and TUNEL-positive cells (Figures 6(e2) and 6(e4)) were significantly higher than those observed in control mice. In contrast, lower expression of Beclin-1 was found in the epithelial and submucosal layers of the stomach from infected mice (Figures 6(f2) and 6(f4)). In the CASA10 posttreatment group, CASA was found to reduce the number of infiltrating leukocytes (Figure 6(a3)), CD68 (Figure 6(b3)), caspase-1 (Figure 6(c3)), and IL-1β stains (Figure 6(d3)), as well as TUNEL-positive cells (Figure 6(e3)) in the gastric mucosa after H. pylori eradication. In the case of Beclin-1, the expression was partly recovered in the CASA10 group (Figure 6(f3)). Taken together, these results demonstrate that CASA treatment was able to significantly reduce H. pylori-induced inflammation, pyroptosis, and apoptosis and restore the autophagy formation in the stomach of infected mice.Hematoxylin and eosin staining (H&E) of infiltrated leukocytes (IL; arrows in a2) and immunohistochemical staining of CD68, caspase-1, IL-1β, TUNEL, and Beclin-1 in the mouse gastric mucosa (×200 magnification; length of axis, 480 μm). (a1, b1, c1, d1, e1, and f1) Uninfected control mice; (a2, b2, c2, d2, e2, and f2) H. pylori-infected mice; and (a3, b3, c3, d3, e3, f3) catechins and sialic acid (CS) treated H. pylori-infected mice. Arrows indicate positive staining for CD68, caspase-1, IL-1β, TUNEL, and Beclin-1 (brown color). Statistical data are presented in (a4, b4, c4, d4, e4, and f4). Each column with a vertical line represents mean ± SEM. P*<0.05, compared to the untreated uninfected control (Control); P#<0.05, H. pylori infection plus CASA (HP + CS) versus H. pylori infection (HP).
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## 3.1. Effect of CA and SA onH. pylori-Triggered Activation of Caspase-1 Signaling in AGS Cells

It has been shown that the activation of caspase-1 is necessary for the pro-IL-1β maturation [15–17] and that IL-1β is a crucial proinflammatory cytokine elicited by H. pylori infection. Here, we used the AGS cell culture system to determine whether H. pylori infection activates caspase-1 signaling in gastric epithelial cells. We also studied the effect of CA, SA, or CASA on the expression of caspase-1 and IL-1β in these cells.As shown in Figures1 and 2, the expression levels of caspase-1 and IL-1β in H. pylori-infected AGS cells were found to have increased (by 18%  ± 3% and 4-fold, resp.), compared to that for control cells, and such increases were significantly inhibited by treatment with CA, SA, or CASA. Interestingly, CASA treatment also significantly reduced the caspase-1 expression in control AGS cells, suggesting that CASA has an anti-inflammatory effect. Together, these observations indicate that the combination of CA and SA is effective in suppressing the inflammatory responses elicited by H. pylori infection.Figure 1
Effects of catechins (CAs) and/or sialic acid (SA) on caspase-1 expression in AGS cells at 4 h afterH. pylori (HP) infection. Upper panel, a representative western blot; lower panel, the fold change of the caspase-1 levels relative to the expression in the untreated uninfected control, which was set at 1.0. β-actin was used as a loading control. Each column with a vertical line represents mean ± SEM (n=3). P*<0.05, compared to the untreated uninfected control;  P#<0.05, compared to H. pylori infection alone.Figure 2
Effects of catechins (CAs) and/or sialic acid (SA) on IL-1β expression in AGS cells at 4 h after H. pylori (HP) infection. Upper panel, a representative western blot; lower panel, the fold change of the IL-1β levels relative to the expression in the untreated uninfected control, which was set at 1.0. Each column with a vertical line represents mean ± SEM (n=3). P*<0.05, compared to the untreated uninfected control; P#<0.05, compared to H. pylori infection alone.Immunofluorescence staining for IL-1β further confirmed the inhibitory effect of CASA on H. pylori-triggered caspase-1 signaling in AGS cells. As shown in Figures 3(a) and 3(b), IL-1β staining in uninfected cells was less intense than that in cells infected with H. pylori for 4 h (IL-1β-positive cells, 0.8%  ± 0.2% versus 29.6  ± 4.3%). While CASA treatment was found to reduce the number of IL-1β-positive cells among infected AGS cells (10.5%  ± 2.3%) (Figure 3(c)), it did not increase IL-1β staining in uninfected control cells (Figures 3(d) and 3(e)), indicating that AGS cells were unharmed at this dosage of CASA.Figure 3
Effects of catechins (CAs) and/or sialic acid (SA) on IL-1β expression measured by immunofluorescence staining in AGS cells at 4 h after infection with H. pylori (HP) ((a–e), ×200 magnification) or LPS ((f–j), ×400 magnification). Arrows indicate IL-1β-positive stains (bright red and bright green). (a, f) Control AGS cells; (b) H. pylori-infected AGS cells; (c) CASA-treated H. pylori-infected AGS cells; (g) LPS-treated AGS cells; (h) CASA-treated LPS-treated AGS cells; (d, i) CASA-treated control AGS cells; and (e, j) IL-1β immunofluorescence staining results analyzed using Image-J software. Data show changes in the percentage of IL-1β-positive cells, compared to the untreated uninfected control, which was set at 1.0. Each column with a vertical line represents mean ± SEM (n=4). P*<0.05, compared to the untreated uninfected control; P#<0.05, compared to H. pylori infection or LPS treatment alone.We next investigated the effects of CASA on LPS-induced damage in AGS cells. We show that the percentage of IL-1β-positive cells was increased by LPS stimulation (18.9%  ± 3.6%; Figures 3(g) and 3(j)), compared to control untreated cells (1.9%  ± 0.3%; Figures 3(f) and 3(j)). Notably, CASA administration significantly decreased the percentage of IL-1β-positive cells among LPS-treated cells (5.3%  ± 1.2%; Figures 3(h) and 3(j)); in contrast, it did not increase the number of IL-1β-positive cells among untreated control cells (Figures 3(i) and 3(j)).


## 3.2. Effect of CA and SA on the Eradication ofH. pylori Colonization in the Mouse Model

We previously reported the anti-H. pylori properties of CASA [3]. In this study, to evaluate the optimal dosing of CASA for treating H. pylori infection, the standard doses of CASA were administered to H. pylori-infected mice for different durations.All mice in the infected control group were successfully infected, whereas 90%, 5%, and 5% of mice were found to beH. pylori-negative in groups treated with triple therapy, CA solution, and SA solution, respectively (Table 1). These results indicate that CA or SA alone failed to effectively eradicate infection in the mouse model in vivo. In contrast, H. pylori-infected mice administered with CASA for 7, 10, or 14 days achieved eradication rates of 75%, 95%, or 95%, respectively. These data demonstrate that the treatment efficacy in the CASA10 and CASA14 groups was similar to that achieved by triple therapy and was significantly higher than that in the CASA7 group. Taken together, our results suggest that the combination of CA and SA synergistically enhances the efficacy in eradicating H. pylori infection, as well as that the optimal duration of CASA therapy should not be less than 10 days.The histological features of gastritis in mice were graded using a visual analog scale according to the updated Sydney system and recorded as the summed scores of 2 following semiquantitative parameters: (1) chronic inflammation score, the density of mononuclear cells ranging from 0 to 3 (score 0, normal; 1, mild; 2, moderate; 3, marked) and (2) acute inflammation score, the density of neutrophils ranging from 0 to 3 (score 0, normal; 1, mild; 2, moderate; 3, marked) [26]. As shown in Figure 4(a), the mean gastritis scores for the infected and uninfected control groups were 2.1 and 0.1, respectively. Treatment with CA or SA alone, though unable to eradicate H. pylori colonization, was found to significantly reduce the mean gastritis scores (1.0 or 1.5, resp.), indicating that CA or SA treatment may decrease H. pylori-induced inflammation. Moreover, treatment with CASA significantly decreased the mean gastritis score to 0.6, 0.2, and 0.1 for the CASA7, CASA10, and CASA14 groups, respectively. Importantly, although the mice in the CASA10 and CASA14 groups exhibited similar eradication rates to triple therapy group (95% versus 90%), they were found to have significantly lower mean gastritis scores than those in the triple therapy group. Specifically, the mean gastritis scores for the CASA10 and CASA14 groups were similar to those for the uninfected control group. In addition, H. pylori-infected mice treated with CASA also exhibited faster and stronger reduction of inflammation in the gastric mucosa than those treated with triple therapy, suggesting that CASA treatment reduces inflammation scores by decreasing not only the bacterial number of H. pylori colonization but also the production of ROS in the gastric epithelium. This is further confirmed by the observation of similar bacterial counts among these 3 groups (Figure 4(b)).Effects of catechins (CAs) and/or sialic acid (SA) on gastritis scores and bacterial counts in theH. pylori-infected mouse model. Each group of mice was treated with different dosage of CA and/or SA (UC, uninfected control, n=10; IC, infected control, n=20; TT, triple therapy, n=20; CA7, CA solution for 7 days, n=20; SA7, SA solution for 7 days, n=20; and CASA7, 10, and 14, CASA solution for 7, 10, and 14 days, resp., n=40). Each column with a vertical line represents mean ± SD. P*<0.05, compared to UC; P#≤0.01, compared to IC; P§<0.05, compared to TT.
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## 3.3. Effect of CASA onH. pylori-Enhanced Oxidative Stress and NADPH Oxidase gp91phox Expression

The intensity of 3-NT immunostaining in the stomach ofH. pylori-infected mice (Figure 5(b)) was stronger than that in uninfected control mice (Figure 5(a)). Figure 5(c) demonstrates that CASA treatment was able to efficiently reduce 3-NT staining in the stomach of H. pylori-infected mice. Importantly, we observed that the administration of CASA did not enhance 3-NT staining or induce morphologic changes in the stomach of uninfected mice (Figure 5(d)), suggesting the absence of toxicity at this CASA dose. Similarly, H. pylori infection was found to significantly increase the production of O2-∙ (Figure 5(e)), as well as the expression of NADPH oxidase gp91phox subunit (Figure 5(f)), in the gastric homogenates of infected mice. We further show that these effects were efficiently reduced by CASA treatment.Effects of the combination of catechins and sialic acid (CASA) on oxidative stress in the stomach of mice. (a–d) The 3-NT expression in uninfected control mice (a),H. pylori-infected mice (b), CASA-treated H. pylori-infected mice (c), and CASA-treated uninfected mice (d). Brown color in (b) indicates 3-NT-positive staining. (e, f) The production of O2-∙ (e) and the expression NADPH oxidase gp91phox subunit (f). Each column with a vertical line represents mean ± SEM (n=4). P*<0.05, compared to the untreated uninfected control; P#<0.05, compared to H. pylori infection alone.
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## 3.4. Effect of CASA onH. pylori-Triggered Caspase-1-Mediated Inflammatory Damage of Gastric Mucosa in the Mouse Model

Here, we demonstrateH. pylori-promoted overexpression of caspase-1/IL-1β, the crosstalk among different cell death pathways, and the inhibitory effect of CASA on these pathways in the gastric mucosa of the mouse model. Specifically, in the H. pylori-infected group, the number of infiltrating leukocytes (Figures 6(a2) and 6(a4)); CD68-positive cells (Figures 6(b2) and 6(b4)), caspase-1-positive (Figures 6(c2) and 6(c4))and  IL-1β-positive (Figures 6(d2) and 6(d4)) cells; and TUNEL-positive cells (Figures 6(e2) and 6(e4)) were significantly higher than those observed in control mice. In contrast, lower expression of Beclin-1 was found in the epithelial and submucosal layers of the stomach from infected mice (Figures 6(f2) and 6(f4)). In the CASA10 posttreatment group, CASA was found to reduce the number of infiltrating leukocytes (Figure 6(a3)), CD68 (Figure 6(b3)), caspase-1 (Figure 6(c3)), and IL-1β stains (Figure 6(d3)), as well as TUNEL-positive cells (Figure 6(e3)) in the gastric mucosa after H. pylori eradication. In the case of Beclin-1, the expression was partly recovered in the CASA10 group (Figure 6(f3)). Taken together, these results demonstrate that CASA treatment was able to significantly reduce H. pylori-induced inflammation, pyroptosis, and apoptosis and restore the autophagy formation in the stomach of infected mice.Hematoxylin and eosin staining (H&E) of infiltrated leukocytes (IL; arrows in a2) and immunohistochemical staining of CD68, caspase-1, IL-1β, TUNEL, and Beclin-1 in the mouse gastric mucosa (×200 magnification; length of axis, 480 μm). (a1, b1, c1, d1, e1, and f1) Uninfected control mice; (a2, b2, c2, d2, e2, and f2) H. pylori-infected mice; and (a3, b3, c3, d3, e3, f3) catechins and sialic acid (CS) treated H. pylori-infected mice. Arrows indicate positive staining for CD68, caspase-1, IL-1β, TUNEL, and Beclin-1 (brown color). Statistical data are presented in (a4, b4, c4, d4, e4, and f4). Each column with a vertical line represents mean ± SEM. P*<0.05, compared to the untreated uninfected control (Control); P#<0.05, H. pylori infection plus CASA (HP + CS) versus H. pylori infection (HP).
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## 4. Discussion

Due to antibiotic resistance or low compliance, the current antibiotic-based therapies for treatingH. pylori infection are not absolutely effective. Our current study demonstrates that up to 95% of H. pylori infection in the mouse model was eradicated after CASA was administered for 10 days. The main sources of CA include tea, red wine, fruit, and some plants, whereas SA is widely distributed in animal tissues (e.g., gastrointestinal mucins) and milk, especially in glycoproteins and gangliosides [10, 13, 28]. Both CA and SA are widely considered to be safe for clinical use. The promising eradication rate achieved by CASA combination therapy makes it a potential nonantibiotic alternative therapy for treating H. pylori infection.Increased ROS production from mitochondria or other intracellular compartments may induce 3 types of programmed cell death—apoptosis, autophagy, or pyroptosis—by activating caspases, lysosomal proteases, or endonucleases, respectively [14, 27, 29–31]. In this study, we observed an increase in ROS production with an increased number of CD68 cells, as well as an increase in the expression of activated NADPH oxidase gp91phox, upon H. pylori infection. These events subsequently led to the activation of inflammasome/caspase-1/IL-1β signaling. On the other hand, the antiapoptotic proteins Bcl-2 and Bcl-XL have been shown to bind and suppress the activity of inflammasomes [21]. In addition, Saitoh et al. reported that loss of the autophagy protein Atg16L1 enhanced endotoxin-induced IL-1β production [32]. Depletion of the autophagy proteins LC3B and Beclin-1 has also been shown to enhance the activation of caspase-1 and the secretion of IL-1β and IL-18 [33]. Given the observation that the NLRP3 inflammasome activity was suppressed by ROS blockade, it is possible that ROS-induced autophagic suppression indirectly inhibits the inflammasome activity [16]. Our previous research [3], together with the results of this current study, shows that CASA was able to effectively eradicate H. pylori colonization, reverse gastric epithelial cell damage, and significantly reduce the ROS production and Bax/Bcl-2-mediated apoptosis, but enhance Beclin-1-mediated autophagy. Previously, we also have shown that both CA and SA suppressed ROS production in the blood of patients with renal diseases, as well as in damaged rat liver tissue not related to H. pylori [34, 35]. Based on these findings, we suggest that the mechanism of CASA suppression of H. pylori-triggered caspase-1 signaling may be modulated in the following 2 ways. (1) The number of bacteria on the gastric epithelial surface decreases because of the antiadhesive and antimicrobial properties of CASA, and (2) ROS production and apoptotic formation are downregulated and autophagy is upregulated by CASA. These effects and interactions are summarized in Figure 7.Figure 7
A proposed mechanism by which catechins and sialic acid suppressH. pylori-triggered caspase-1 signaling. First, on the luminal surface, catechins and sialic acid decrease the H. pylori density via their antibacterial and antiadhesive properties. Second, catechins and sialic acid are powerful antioxidants that are able to suppress the production of CD68 and NADPH oxidase gp91phox-derived ROS, both of which may induce apoptosis and caspase-1 activation during H. pylori infection. In addition, catechins and sialic acid also enhance autophagy, thereby decreasing caspase-1 activation and IL-1β secretion.IL-1β is not only an important proinflammatory cytokine but also a powerful inhibitor of gastric acid secretion. The IL-1β expression in the gastric mucosa was shown to be upregulated in the presence of H. pylori infection and therefore was suggested to play a central role in initiating the inflammatory response to the infection [36]. To date, the association between the IL-1β genetic polymorphism and the increased risk of gastric cancer has only been demonstrated in the presence of H. pylori infection [37]. While H. pylori was shown to activate caspase-1 and induce mature IL-1β and IL-18 secretion in immune cells [20], the molecular mechanism of H. pylori-induced IL-1β overexpression in gastric epithelial cells is still not clear. In this study, we discovered that H. pylori infection upregulated the caspase-1 expression via the ROS-triggered inflammasome activation in gastric epithelial cells. The caspase-1 activation subsequently promoted IL-1β secretion and pyroptosis, resulting in the release of intracellular inflammatory contents to stimulate additional inflammatory signaling pathways that conversely aggravated the tissue damage. Taken together, we suggest that H. pylori-induced AGS cell damage and mucosa inflammation are associated with the activation of caspase-1 signaling. We further show that these responses were inhibited by the application of CASA. Therefore, the attenuation of inflammation during longstanding H. pylori infection might be associated with the prevention of consequent chronic atrophic gastritis or gastric carcinogenesis.Recent studies have suggested that inflammasome deficiency may be associated with enhanced inflammation-induced tumorigenesis in the intestine, due to alterations in the microbiota communities and the emergence of normally suppressed bacteria that have proinflammatory activities [18, 38, 39]. The microbiota community in the stomach is quite different from that in the intestine, because gastric acid plays an important physiological role in the microbial ecology. The host inflammatory response to H. pylori has a key functional role in disrupting acid homeostasis, which impacts directly on the colonization patterns of H. pylori and therefore the extent of gastritis [7]. Moreover, ROS derived from inflammation are well-known mutagens, and hypochlorhydria also permits superinfection of other bacteria that enhance the production of highly carcinogenic N-nitroso compounds [37]. Therefore, contrary to previous findings in the colon, H. pylori-induced inflammasome activation in the stomach may promote carcinogenesis.Inflammasomes have been shown to participate in the antimicrobial immune responses [40]. However, the host immune response to H. pylori infection is ineffective, because the bacterium persists on the gastric epithelium and the inflammation continues for decades [6]. Therefore, understanding the mechanisms of immune evasion could lead to new opportunities for enhancing eradication and preventing infection and its associated diseases. In addition, we previously reported that H. pylori altered the DC-polarized Th17/Treg balance toward a Treg-biased response, resulting in a suboptimal Th17 response and a failure to eradicate the offending pathogen [41]. One important question here is whether H. pylori activates different inflammasome pathways in different cell types (e.g., epithelial versus dendritic cells), which would lead to different disease outcomes (e.g., inflammation versus immune tolerance). The novel finding of H. pylori-related inflammasome activation in gastric epithelial cells in this study reflects the importance of characterizing the interactions of these epithelial inflammasomes with additional innate immune pathways and downstream adaptive immune responses in the regulation of anti-H. pylori immunity in vivo.Based on our previous results of the susceptibility test for the combined effect of CA and SA againstH. pylori in vitro, as well as its efficacy in controlling H. pylori infection in mice in vivo [3], we used a solution containing 640 μg/mL CA and/or 160 μg/mL SA as the standard doses to be used in the present study. In the in vitro cell culture system, the CA dosage ranging from 64 μg/mL to 640 μg/mL was found to efficiently scavenge ROS activities and decrease the IL-1β levels in AGS cells (data not shown). The dosage of CA tested in our in vitro study was similar to those used in a previous report (31.2, 125, and 500 μg/mL of green tea extract) [42]. Epigallocatechin gallate, the most abundant and biologically active polyphenol in green tea extract, did not negatively affect the viability or morphological features of AGS cells at the dose of 21–210 μg/mL (46–462 μM). Natural decaffeinated green tea extracts containing several types of catechins, though not pure types of catechins, have been used in animal studies [3, 43, 44] and clinical trials [34] and have been shown to reduce proinflammatory and proapoptotic oxidative injury by inhibiting the ROS production and NF-B activation. Because the intake of caffeine has been associated with gastritis [45], removal of caffeine from green tea extract may reduce a possibility of gastric injury. In our previous clinical study, human subjects orally received 455 or 910 mg/day of CA (9.1–18.2 mg/kg body weight) without adverse events [34]. In this study, the mean volume (5-6 mL) of CA solution contained approximately 3.2–3.8 mg/day catechins per mouse (80–95 mg/kg body weight per day). No detrimental effects were observed in previous studies using 23 mg/kg [3], 50 mg/kg [43], or 25–125 mg/kg [44] or in this study using 80–95 mg/kg. Based on these data, we consider that CA at a dosage of 23–95 mg/kg body weight per day is safe in rodents.In summary, we demonstrate thatH. pylori infection caused the activation of inflammasome signaling in epithelial AGS cells, which resulted in the upregulation of IL-1β and apoptosis biomarkers both in vitro and in vivo. Moreover, the administration of CASA efficiently eradicated H. pylori and attenuated H. pylori-induced epithelial cell death. The high efficacy of CASA treatment against H. pyloripresented in this study makes CASA a promising novel nonantibiotic therapy for treating H. pylori. Confirmation of these results in future clinical trials will advance the medical management of panantibiotic-resistant H. pylori, for which no therapy is currently available.



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