2011-08-012024-05-14https://scholars.lib.ntu.edu.tw/handle/123456789/656364摘要：研究背景: 幽門螺旋桿菌感染之後，僅有1%左右的人會發生胃癌，約10-15%的人會發生胃潰瘍與12 指腸潰瘍，過去的研究顯示幽門螺旋桿菌感染之後，有些人的胃炎是以胃竇為主，這些人胃酸分泌會比較多，也比較容易發生12 指腸潰瘍，但卻比較不會得到胃癌或胃潰瘍。相反的，有些人的胃炎是以胃體部為主，這些人的胃酸分泌量會比較少，比較容易發生萎縮性胃炎、胃潰瘍及胃癌。導致不同表現型之胃炎(gastritisphenotype)以及不同之胃腸疾病(12 指腸潰瘍vs.胃癌或胃潰瘍)的原因，目前認為應該是宿主基因、細菌致病因子與環境因素之交互作用所造成的。然而到底是哪些基因導致這樣的差異，則尚未有定論。過去的研究顯示胃酸分泌量的差異是造成有些人會得胃潰瘍，但有些人會得12 指腸潰瘍的重要原因，但是個體基因之差異是否會導致每個人胃酸分泌量不同，並造成不同之疾病呢? 這個議題在過去的研究很少被探討。研究主題：: 因此我們提出這個三年期的計劃，欲探討胃酸分泌相關基因(ATP4A, ATP4B,Gastrin-releasing peptide GRP)、Carbonic anhydrase II (CAII)、Pepsinognen C之遺傳多態性(single nucleotide polymorphisms, SNPs)是否與(1)12 指腸潰瘍、胃潰瘍或胃癌之發生有相關;(2)胃酸分泌抑制劑的治療效果有相關; (3)個體胃酸分泌量的差異有相關。假設: 我們認為具有某些(ATP4A, ATP4B, GRP)基因變異(polymorphism)的人，胃酸分泌量會比較少，因此幽門螺旋桿菌會由胃竇轉移到胃體部，造成胃體部發炎，進而導致胃體部萎縮、胃酸分泌不足、最後造成胃癌。相對的，有些基因變異(polymorphism)的人，胃酸分泌量會比較多，因此幽門螺旋桿菌會持續局限在胃竇部，並進而導致12 指腸潰瘍。此外，由於proton pump 基因(ATP4A, ATP4B)的差異，也會導致個體對於proton pump inhibitor 治療的效果有所不同。各年度研究目標第一年:(1)由第一個population (marker identification:台大醫院病患)，以病例對照研究的方法，探討胃酸分泌相關基因之遺傳多態性在不同疾病間之基因型盛行率(genotype frequency)是否有差異?(2)因幽門螺旋桿菌感染接受含proton pump inhibitor 三合一治療的患者，幽門螺旋桿菌的根除率是否受胃酸分泌相關基因之遺傳多態性的影響?第二年: (3)由第二個population (marker validation: 台中榮總及義大醫院病患)，以病例對照研究的方法，探討胃酸分泌相關基因之遺傳多態性在不同疾病間之基因型盛行率(genotype frequency)是否有差異?(4) 由第一個及第二個populations 分析不同表現型之胃炎(gastritisphenotype) 是否與胃酸分泌相關基因之遺傳多態性有相關?第三年: (5)因胃食道逆流接受proton pump inhibitor 治療的患者，症狀改善的狀況是否受ATP4A/ATP4B 基因之遺傳多態性的影響?(6)檢測胃酸分泌量是否與胃酸分泌相關基因(ATP4A, ATP4B, Gastrin-RP)之遺傳多態性有相關?(7)檢測接受proton pump inhibitor 治療的患者，胃酸抑制的效果是否受ATP4A/ATP4B 基因之遺傳多態性的影響?研究方法：第一年: (1)利用近10 年來在台大醫院所收集的臨床資料與檢體進行genotyping 與分析，包括800 名胃癌患者、300 名12 指腸潰瘍患者、300 名胃潰瘍患者、110名MALToma 患者與1500 名僅有表淺性胃炎的患者。這些病人都有接受胃鏡及幽門螺旋桿菌的檢查。我們目前已完成了1000 人的genotyping 與分析。(2)近4 年來，我們收集了約600 名接受含lansoprazole 三合一治療患者的臨床資料與檢體， 我們將分析這些患者ATP4A/ATP4B 的基因型，並進一步分析這些基因型的變異，是否與幽門螺旋桿菌的根除率有相關。第二年: (3)利用近10 年來在台中榮總及義大醫院所收集的臨床資料與檢體進行genotyping 與分析，包括500 名胃癌患者、250 名12 指腸潰瘍患者、250 名胃潰瘍患者、50 名MALToma 患者與1000 名僅有表淺性胃炎的患者。這些病人都有接受胃鏡及幽門螺旋桿菌的檢查。(4)由第一個及第二個populations 之非胃癌患者，分析不同表現型之胃炎(gastritis phenotype)及胃炎嚴重程度(依更新版雪梨胃炎分類updatedSydney Classification)是否與胃酸分泌相關基因之遺傳多態性有相關。第三年: (5)近1 年來，我們收集了約120 名因胃食道逆流接受lansoprazole 治療患者的臨床資料與檢體，這些病人都有接受標準化問卷、胃鏡、抽血、以及幽門螺旋桿菌的檢查。於治療期間也有定期接受標準化問卷評估症狀改善之情況。我們預計在2012.12 之前，再持續收案480 名患者(共600 人)，我們將檢測這些患者ATP4A/ATP4B 的基因型，並進一步分析這些基因型的變異是否與症狀改善的狀況有相關。(6)我們將測定60 名患有胃酸相關疾病之患者的24 小時胃內pH 值，以及餐後血液中胃泌素(gastrin)的值，並檢測這些患者ATP4A/ATP4B 的基因型，以了解ATP4A /ATP4B 的基因型是否與胃酸分泌有相關。(7) 我們將測定30 名患有胃酸相關疾病之患者在接受lansoprazole 治療後的24小時胃內pH 值，以及餐後血液中胃泌素(gastrin)的值，並檢測這些患者ATP4A/ATP4B 的基因型，以了解胃酸抑制(lansoprazole)的效果是否受ATP4A/ATP4B 基因之遺傳多態性的影響。基因型測定: 我們由HapMap 資料庫找出華人在胃酸分泌相關基因(ATP4A, ATP4B,Gastrin-RP)之常見(allele frequency >5%)的遺傳多態性(SNPs)，並利用Sequenom 系統進行基因型測定。關鍵辭：質子幫浦、基因、遺傳多態性、胃癌、12 指腸潰瘍、胃潰瘍此研究之重要性(一) 透過這個研究計畫，可以幫助我們瞭解1. Proton pump 基因(ATP4A/ATP4B genes)的遺傳多態性(polymorphisms atATP4A/ATP4B)是否與個體胃酸分泌量以及幽門桿菌感染之後是否罹患胃癌、胃潰瘍或十二指腸等疾病有相關。ATP4A/ATP4B,GRP,carbonic anhydrase II(CAII), and Pepsinognen C genes 的遺傳多態性是否與個體是否罹患胃癌、胃潰瘍或十二指腸等疾病有相關。2. Proton pump 基因(ATP4A/ATP4B genes)的遺傳多態性是否與proton pumpinhibitor(PPI)藥物治療之療效有相關，在藥物基因學(pharmacogenomics)的研究上將有重要貢獻。若proton pump 基因的遺傳多態性與個體之療效有差異，未來在藥物或治療劑量的選擇上，就需要把這個基因的變異列為考量因素。3. 這是第一個探討proton pump 基因(ATP4A 及ATP4B)與胃酸分泌量、胃腸疾病(胃癌、消化性潰瘍)、以及藥物基因學相關性的研究。(二)此研究計畫的特點：1. 我們利用HapMap 找出proton pump (ATP4A 及ATP4B)、GRP、CAII、PepsinognenC 基因常見的SNPs。2.我們的研究分為(A).臨床觀察之流行病學研究及(B).基因功能之分析與測定。在第一部份，我們除了利用NTUH 的病人找出有相關的基因之外，我們也將選取另一個獨立之樣本(E-DA ＆ TCVGH)進行validation。3. 我們的樣本數很大，因此能有足夠的POWER 探討這些基因與疾病之相關性。4. 我們已具備初步之研究結果，顯示proton pump 基因(ATP4A 及ATP4B)基因與消化性潰瘍之發生可能有相關，因此很值得再增加樣本數，進一步進行研究與分析。<br> Abstract: Background: Previous studies have shown that gastric cancer and peptic ulcerdisease developed in only about 1% and 10-15% among Helicobacter pylori (H. pylori)infected patients. There are three types of gastritis phenotype after H. pylori infection:antrum predominant gastritis, corpus gastritis, and pangastritis. Patients with antrumpredominant gastritis tend to have higher gastric acid output, having higher risk ofdeveloping duodenal ulcer and lower risk of gastric cancer. In contrast, patients withcorpus predominant gastritis tend to have lower gastric acid output, higher risk ofatrophic gastritis, gastric ulcer, and gastric cancer. It is generally accepted that theinteractions of host genetic factors, bacterial virulence factors, and environmentalfactors contribute to the different outcomes (duodenal ulcer vs. gastric cancer).However, the exact genetic factors that contribute to these differences remainscontroversial and poorly understood. Previous studies have shown that the ability ofgastric acid secretion plays an important role in the pathogenesis of gastroduodenaldiseases. However, whether the host genetic factors contribute to the differences inthe amount of gastric acid secretion and lead to different outcomes after H. pyloriinfection is still largely unknown and poorly understood.Issue to be addressed: Therefore, we initiated this 3-year project to investigatewhether the genetic polymorphisms at proton pump (ATP4A/ATP4B) genes,gastrin-releasing peptide (GRP), Carbonic anhydrase II (CAII), Pepsinognen C genesare associated with (1) the development of duodenal ulcer, gastric ulcer, and gastriccancer; (2) the amount of gastric acid secretion; and (3) the treatment efficacy ofproton pump inhibitors.Hypothesis: We hypothesized that patients with certain genetic polymorphisms at theATP4A/ATP4B, and GRP genes are associated with lower gastric acid output. Thiswould lead to the migration of H. pylori from antrum to corpus, which in turn leads tocorpus predominant gastritis, corpus atrophy, and subsequently, gastric cancer. Incontrast, some polymorphisms at these genes might be associated with increasedgastric acid output and higher risk of duodenal ulcer disease. Besides, thepolymorphisms at the ATP4A/4B genes might have different affinity for PPIs and leadto different efficacy of PPIs.Specific Aims:Year 1:Aim (1): To assess the associations of the genetic polymorphisms at theATP4A/ATP4B, GRP, Carbonic anhydrase II (CAII), and Pepsinognen Cgenes with duodenal ulcer, gastric ulcer, gastric cancer, and MALToma in thefirst population (marker identification: patients in NTUH).Aim (2): To assess the impact of the genetic polymorphisms at the ATP4A/ATP4Bgenes on the eradication rate of PPI-triple therapy for H. pylori infection.Year 2:Aim (3): To validate the findings detected in the first year (NTUH population) using anindependent population at TCVGH and E-Da hospital.Aim (4): To assess whether the genetic polymorphisms at the ATP4A/ATP4B, GRP,Carbonic anhydrase II (CAII), and Pepsinognen C genes are associated withthe different phenotypes of gastritis.Year 3:Aim (5): To assess the impact of the genetic polymorphisms at the ATP4A/ATP4Bgenes on the efficacy (symptom relief) of GERD patients who receive PPItherapy.Aim (6): To assess whether the genetic polymorphisms at the ATP4A/ATP4B and GRPgenes are associated with gastric acid secretion (as determined by 24-hourintragastric pH monitoring and meal-related gastrin secretion)Aim (7): To assess whether the efficacy (gastric acid suppression) of PPI is affectedby the polymorphisms at the ATP4A/ATP4B genes.Materials and Methods:Year 1: (1) Genotyping will be done in 800 patients with gastric cancer, 110 patientswith MALT type gastric lymphoma, 300 patients with gastric ulcer, 300patients with duodenal ulcer, and 1500 patients with superficial gastritisalone in NTUH (specimen collected in the past 10 years). We have alreadyfinished genotyping in 1000 patients.(2) Genotyping will be done in 600 H. pylori infected patients who receivedtriple therapy containing lansoprazole. The eradication rate according to thegenotypes will be compared.Year 2: (3) Genotyping will be done in 500 patients with gastric cancer, 50 patientswith MALT type gastric lymphoma, 250 patients with gastric ulcer, 250patients with duodenal ulcer, and 1000 patients with superficial gastritisalone in TCVGH and E-DA hospital (specimen collected in the past 10years).(4) The severity and phenotype of gastritis in non-cancer patients (in NTUHand TCVGH/ E-Da hospital) will be assessed by the updated SydneyClassification. The associations between the severity and phenotypes ofgastritis and the genetic polymorphisms of these genes will be assessed.Year 3: (5) Genotyping will be done in 600 GERD patients who received lansoprazoletreatment. These patients were assessed with standardized questionnaire,endoscopy, and H. pylori testing before treatment. Standardizedquestionnaire was also used to assess the symptom relief after lansoprazoletreatment.(6) Intragastric pH and meal stimulated gastrin secretion will be measured in60 patients with gastric acid related disease.(7) Intragastric pH and meal stimulated gastrin secretion will be measured in60 patients with gastric acid related disease after treatment withlansoprazole.Genotyping: The polymorphisms of these genes among Chinese population weresearched from the HapMap database. PCR and sequencing using theSequenom system will be used for genotyping.Keywords: gastric acid secretion, gastric cancer, gastric ulcer, duodenal ulcer, andgenetic polymorphismClinical Significance1. Proton pump is a very important organelle involved in the final step of gastric acidsecretion. However, whether the genetic variations in the proton pump gene(ATP4A and ATP4B) is associated with differences in the gastric acid outputremains unknown. This is the first study to assess the impact proton pump genes(ATP4A and ATP4B genes) on the gastric acid output.2. Differences in the gastric acid secretion were shown to be associated with differentoutcomes (gastric cancer vs. duodenal ulcer) after H. pylori infection. However,whether the genetic variations in the proton pump genes are associated withdifferent outcomes has not been reported. This is the first study to assess theimpact proton pump genes (ATP4A and ATP4B genes) on the outcomes after H.pylori infection.3. Proton pump inhibitors (PPIs) are currently the most important drug used in thetreatment of gastric acid related disease. However, whether the genetic variationsin this pump are associated with different treatment efficacy has not been reported.This is the first study to assess the pharmacogenetic impact of proton pump geneson the efficacy of PPIs.質子幫浦基因遺傳多態性胃癌12指腸潰瘍胃潰瘍gastric acid secretiongastric cancergastric ulcerduodenal ulcerand genetic polymorphism