INTRODUCTION

Allergy has come to be regarded as a disease of civilization. The number of new allergens has grown due to the change of eating habits in the age of globalization. Moreover – the spread of food allergy and other allergic reactions has increased all over the world, especially within highly urbanized populations [2]. Different manifestations after food intake have become a common and constantly increasing problem in both adults and children. Research of the last two decades has revealed the growing incidence of food allergy. It has been pointed out that incidence of peanut allergy in the USA has doubled within the last 10 years. Still, regardless of the improvement in the recognition of diseases and progress of knowledge, food allergy is one of the main causes of anaphylactic reactions [3]. Research of the Polish population also indicates the social importance of allergic diseases. In the recently published research conducted by ECAP (Epidemiology of Allergic Disorders in Poland) it has been shown that food allergy affects 9% of children aged from 6 to 7 years, 7% of children aged from 13 to 14 years and as many as 4% of adults aged from 22 to 44 years [1,4].

Food allergy is defined as a reaction of the immunological system to a food protein resulting in the production of allergen-specific immunoglobulin E (IgE-dependent reactions). IgE-dependent reactions to food allergens may be a result of sensitization through the gastrointestinal tract, but also through the respiratory system sensitized by the airborne allergens (this includes mainly the occupational exposure e.g. to flour or vapours from the processed crustaceans). Sensitization may also occur due to the impaired skin barrier [5].

Another frequent clinical problem is cross-reactivity. This phenomenon is usually described as a coexistence of the inhalant allergy to plant-derived allergens with food allergy. It is estimated that this concerns 30% of people suffering from inhalant allergy [6].

In 1995 inconsistencies in terms of terminology and the way of classification of bodily disorders caused by food ingestion were regulated by the European Academy of Allergy and Clinical Immunology (EAACI). Their classification put an emphasis on two main adverse, non-toxic food reactions: food allergy reactions (conditioned by specific immunological mechanisms) and food intolerance (conditioned by a mechanism different than specific immunological reaction). In 2001 the task force of the EAACI presented a new general terminology and classification of allergic diseases (with adverse reactions to food) which included pathogenic mechanisms. The authors suggest using the term ’hypersensitivity’’ in its broad meaning to describe all clinical bodily reactions initiated by the exposure to allergens of various biological nature (airborne, food, contact). In accordance with this classification the term ’’food allergy’’ should denote a reaction stimulated by the ingested food in which the immunological mechanism is documented or highly probable [7].

The most significant and the most acute food allergens include proteins with the average molecular weight 15-40 kDa and glycoproteins soluble in water with the molecular weight 10-70 kDa. Some food allergens are very resistant to any modifications, others easily undergo the process of denaturation [8]. Clinical symptoms of food allergy may concern various organs and systems, and in many sick persons – especially in children – the symptoms are multiorgan. Symptoms within the gastrointestinal tract appear in 50-80% of the sick, within the respiratory system in 10-25% and skin symptoms appear in 20-40% [9]. Gastritis is one of the most frequent diseases of the stomach [9]. In patients with food allergy changes in the mucous membrane of the stomach characteristic of a chronic inflammation can be observed. Interactions between a wide range of cells are the source of the inflammation process typical of atopic diseases. Adhesion molecules (also referred to as addressins) including the immunoglobulin molecules play a vital role in the accumulation of cells within the shock organ as well as in their activation [10]. Many papers published in recent years stress the significant role of the adhesion molecules in the selective recruitment of eosinophils to the focus of allergic inflammation [8]. VCAM-1 and IL-1 β play also a crucial role in the migration process of the inflammatory cells. The aim of our study was to examine the difference in ICAM-1, VCAM-1 and IL-1 β concentrations in serum in patients with gastritis with and without food allergy.

MATERIAL AND METHODS

The analysis comprised 80 patients. A group of patients with food allergy and gastritis symptoms consisted of 50 patients (33 females and 17 males) aged from 18 to 65 (mean age 38.36 years). A group of patients with dyspeptic symptoms but without food allergy consisted of 30 patients (23 females and 7 males) aged from 18 to 54 (mean age 29.96 years).

All the patients who were subjected to our study remained under care of the Nicolaus Copernicus University of Torun Collegium Medicum in Bydgoszcz, Poland, Chair and Clinic of Allergology, Clinical Immunology and Internal Diseases and the Outpatient Clinic for Treating Food Allergy. The diagnosis of food allergy was based on a detailed medical history of the patient and physical examination which indicated a significant relation of the appearing symptoms to the ingested food, positive skin test results with food allergens, the use of elimination diet and measurement of the IgE antibodies.

The contraindications to take part in the study were reports of pain symptoms in the epigastric region and other dyspeptic symptoms such as pyrosis, eructation, flatulence, vomiting. Blood samples of each patient were taken to determine concentrations in serum of the soluble forms of adhesion molecules ICAM-1, VCAM-1 and IL-1 β. All patients had abdominal pains and patients with coexisting food allergy after ingestion of the sensitizing food allergen reported abdominal pains, lip and tongue burning sensation, pyrosis, nausea, vomiting and diarrhoea. Urticarial eruption, angiooedema and general itch were also observed in many of the patients. Symptoms coming from the respiratory system were also present – most often rhinorrhea and dyspnoea. Subjects with the history of antihistamine and anticoagulant therapy as well as patients with cardiac and pulmonary diseases, ulcerative colitis, Crohn’s disease, patients after gastric or intestinal resection, patients with disease of the connective tissue, patients with mycosis infections of the gastrointestinal tract, patients with tuberculosis and different types of cancer were excluded from the study. In patients with dyspeptic symptoms without food allergy a medical and family history of the atopic diseases came out negative. The skin prick tests with food allergens were also negative. All the patients underwent endoscopy of the upper gastrointestinal tract to reveal the macroscopic appearance of the mucous membrane of the stomach. During gastroscopy the specimens of the patients’ mucous membrane of the stomach were taken – 2 from the antrum and 2 from the gastric corpus (front and back wall) – in order to conduct histopathology.

• Allergological diagnosis

Skin prick tests with food allergens were performed in all patients. Tests were conducted in a typical way with the use of the prick method and with the use of standard food allergens of the Allergopharma. Wheal reaction of a given allergen equal to or higher than wheal reaction to histamine was to be regarded as an positive test result. Measurement of antibodies IgE total in blood serum was conducted in all patients with the use of the FEIA method on the UniCap 100 Phadia instrument ( FluoroEnzyme Immunoassay). Concentrations of adhesion molecules ICAM-1 and VCAM-1 were measured in blood serum with the ELISA method on the kits of Bender MedSystems. All evaluations were made in compliance with manufacturer’s recommendations. The readout was made on the microplate reader ELx800 produced by BIO-TEK INSTRUMENTS. All the measurements were carried out in the Department of Immunology of the Nicolaus Copernicus University of Torun, Collegium Medicum in Bydgoszcz, Poland, Chair and Clinic of Allergology, Clinical Immunology and Internal Diseases in the Dr Jan Biziel University Hospital No.2 in Bydgoszcz.

• Histopathological evaluation

All patients underwent endoscopy of the upper gastrointestinal tract with the use of fiberoscope GIF-E OLYMPUS. During the examination the mucous membrane of the stomach was microscopically assessed. Its kinetic and secretory functions were also evaluated. Specimens of the mucous membrane were taken – 2 from the antrum and 2 from the gastric corpus for histopathologic detection of H.pylori. The specimens were taken both from healthy and inflamed mucous membrane (but not from erosions or ulcerations). The histopathological investigation was carried out in the Department of Pathomorphology in the Dr Jan Biziel University Hospital No.2 in Bydgoszcz.

The specimens were dyed with eosin, eotoxin and Giemsa dye. The evaluation of the presence of inflammation of the mucous membrane of the stomach and its activity and stage of development was based on the commonly applied Sydney criteria with the Houston modification. In the histopathological evaluation great attention was paid to morphological composition of cellular infiltrate. The number of eosinophils in the inflamed mucous membrane of the stomach was thoroughly analyzed. The evaluation was carried out with the application of 10HPFx250 method. The presence of polynucleated cells in the composition of the cellular infiltratate indicated an active inflammation (gastritis chronica activa). The presence of H.pylori colonisation was measured through histopathological examination and dying (with eosin, haematoxyline and Giemsa dye). The (+) signified its presence and (-) signified its absence.

• Statistical evaluation

To analyse the differences between the parameters in the study group the Mann-Whitney U test was applied. To identify the quantitative data the following estimations were used:

- estimation of the arithmetical average (x) and geometrical average (g),
- estimation of standard deviation for the average (s).

RESULTS

In patients from the study group with food allergy the mean duration of the disease was 284.24 weeks (5.88 years). In patients without the coexisting food allergy the mean duration of the disease was shorter and amounted to 213.6 weeks (4.45 years).

• Results of immunological examinations

The average concentration of the total IgE in the blood serum in the patients with food allergy was 144.9±150.56 kU/l. In patients without coexisting food allergy the average values of the total IgE was 80.124±154.56 kU/l. These differences were statistically significant at p=0.00441.

• Histopathological evaluation of samples of the mucous membrane of the stomach

Eighty patients underwent gastroscopy. In patients with coexisting food allergy characteristics of chronic atrophic gastritis in the region of antrum were observed in 41 patients, including 16 patients showing reactive inflammation in the region of antrum. In the evaluation of specimens of the gastric corpus of mucous membrane taken from 33 patients with food allergy it was concluded that this region also revealed characteristics of inflammation, including 10 patients with characteristics of reactive inflammation of the gastric corpus. Simultaneous changes of the inflamed mucous membrane in the region of antrum and gastric corpus were observed in 33 patients. Histopathological investigation revealed no deviations in 4 patients. In patients with dyspeptic symptoms without food allergy characteristics of gastritis antralis were observed in 23 patients, including reactive inflammation in antrum in 5 patients. In the evaluation of gastric corpus in patients without allergy inflammation changes were observed in 15 patients, including reactive inflammation in 1 patient and characteristics of inflammation in the region of antrum and gastric corpus were observed in 15 patients. Histopathological investigation of the specimens of the mucous membrane revealed no deviations in 7 patients.

A thorough  morphological evaluation of the composition of the cellular infiltrate in patients with atopic diathesis detected the presence of eosinophils in 21 patients, including more than 10 eosinophils in the field of view at magnification 250x in 10 patients. In the study group without food allergy the presence of eosinophils in the cellular infiltrate was detected in 9 patients, including more than 10 eosinophils in the field of view at magnification 250x in 2 patients. In the study group with food allergy 19 patients and in the study group without food allergy 18 patients had H.pylori colonisation.

• Concentrations of ICAM-1, VCAM-1 and IL-1β

The ICAM-1 concentration in serum in atopic patients was 459.5±104.2 ng/ml and in patients without the coexisting allergy it amounted to 397.6±98.0 ng/ml at p=0.001. The VCAM-1 concentration in patients with food allergy was 1181.8±400.7 ng/ml and in patients without atopy it amounted to 944.4±216.9 ng/ml at p<0.05. The analysis of IL-1β concentrations in patients with food allergy revealed concentrations ranging from 8.4±7.6 pg/ml and in patients without food allergy it amounted to 5.1±4.2 pg/ml at p=0.04. The statistical analysis of the results obtained through the Mann-Whitney U test revealed statistically significant differences in concentration of soluble adhesion molecules ICAM-1, VACM-1 and IL-1β between the study group with gastritis and food allergy and the study group with dyspeptic symptoms without atopy.

DISCUSSION

Food allergy has a very rich and varied symptomatology – from a mild feeling of discomfort to a life-threatening anaphylactic shock. While dermatological symptoms and symptoms coming from the respiratory system in allergy are easily and quickly diagnosed, the allergic symptoms originating from the gastrointestinal tract tend to be difficult to diagnose, recognize and treat[11].

During the study in our clinic various symptoms after ingestion of sensitizing food were observed in the patients. Apart from gastric symptoms also skin symptoms, symptoms from the respiratory system and the central nervous system (migraine headaches) and many others were noted. It is commonly believed that the mucous membrane of the stomach is constantly exposed to potentially harmful factors such as ingredients of the ingested food and  adverse effects of bacteria and toxins. At times immune mechanisms and non-specific immune mechanisms may fail to fulfill their function. Natural immune mechanism include secretion of gastric juice and mucous which covers epithelioid cells, secretion of digestive enzymes, peristaltic movements or defined protein substances with antimicrobial properties such as defensins and cathelicidins [11].

Gastritis is one of the most frequent diseases of the stomach. There is no typical set of symptoms of this disease. Patients may report dyspeptic symptoms such as epigastric fullness, flatulence, epigastric pains (especially directly after food ingestion), lack of appetite and others [9]. In patients with impaired immunological tolerance (e.g. patients with atopic diathesis) the reoccurring exposure to food allergens may result in the local allergic reaction of stomach typical of inflammation of the mucous membrane [12].

The main criterion for gastritis recognition is the histological examination of the specimen during endoscopy [9]. Influx of inflammatory cells into the intestine is regulated, among others, by adhesion molecules engaged in the local stimulation of the lymphocytes and presentation of antigen in the region of the mucous membrane of the stomach. During the inflammation process the number of adhesion molecules is decreased [13]. Different cytokines, chemokines and adhesion molecules enable the development of adhesion cascade which ensures the specificity and regulation of the process [16].

It was proved that the increase of the ICAM-1 endothelial expression in the gastrointestinal tract occurs after LPS (Lipopolysaccharides) or TNF-α stimulation, with the peak expression in the fifth hour and a lasting increase of the concentration above the regular values 24 hours after endothelial cell activation [14]. Inflammatory cytokines such as TNF and IL-1 induce presentation of ICAM-1 and probably also MAdCAM-1 (mucosal vascular addressin cell adhesion molecule 1) in the endothelium of the mucous membrane of the gastrointestinal tract in the inflammation region [13]. An exact mechanism leading to the increase of ICAM-1 expression on the surface of the cell after its activation remains unclear [14]. Owing to the fact that coeliac blood flow seems to be the main source (second after lungs) of the soluble isoforms of ICAM-1, the level of serum in the soluble forms of ICAM-1 and soluble forms of other adhesion molecules (e.g. soluble form of P-selectin) can be useful in the prognosis of inflammation intensity in the gastrointestinal tract [14]. Interactions between different types of immunological cells modulate mucous response. ICAM-1 takes also part in the mutual reaction between fibroblasts and T-cells and has an influence on the inflammation process in the mucous membrane of the stomach [15].

Adhesion molecule of vascular cells VCAM-1-(CD-106), which belongs to the immunoglobulin superfamily and takes part in the adhesion of lymphocytes and monocytes to the endothelium, plays a vital role in adhesion. It also supports adhesion of lymphocytes, monocytes, NK cells, eosinophils and basophils and takes part in the adhesion outside vascular bed [16]. VCAM-1 is only present on the activated vascular endothelium [17]. This molecule provides preferential migration of eosinophils which take part in the promotion of the chronic inflammation to the place of inflammation [18]. Furthermore, one of the main mediators of the immunological and inflammatory response is interleukin 1(IL-1) which has an influence on almost all types of cells. Interleukin is produced by monocytes, macrophages, smooth muscles and endothelial cells. It’s molecular weight is 17 kDa [19]. IL-1 facilitates development of inflammatory reaction not only through chemotactic attraction of the neutrophils and monocytes, but also through the increase in the release of histamine by basophiles, degranulation of eosinophils and production of prostaglandins. By affecting the endothelium it increases the endothelial permeability and induces procoagulation activity. As a result of the increased expression of addressins such as: E-selectin, ICAM-1, VCAM-1;  IL-1 enhances adhesion of lymphocytes and neutrophils to endothelial cells [20].

The aim of this study was to assess the concentrations of the soluble form adhesion molecules ICAM-1, VCAM-1 and IL-1β in patients with gastritis with and without food allergy. We showed that the concentrations of the adhesion molecules in patients with food allergy were higher than in patients with dyspeptic symptoms and gastritis without coexisting atopic diathesis. These differences were statistically significant. Our study revealed also that in patients with gastritis and food allergy the concentration of IL-1β in blood serum was increased in comparison with the concentration of this substance in patients without allergy. These differences were statistically significant.

CONCLUSION

In our study we revealed that the concentration of adhesion molecules (ICAM-1, VCAM-1) and IL-1β increases in serum in patients with gastritis and that it is significantly higher in patients with the coexisting food allergy.

......................................................................................................................

REFERENCES:

......................................................................................................................

*Correspondence address:

Zbigniew Bartuzi
The Nicolaus Copernicus University of Torun,
Collegium Medicum in Bydgoszcz, Poland,
Chair and Clinic of Allergology,
Clinical Immunology and Internal Diseases,
The Dr Jan Biziel
University Hospital No.2 in Bydgoszcz,
ul. Ujejskiego 75, 85-168 Bydgoszcz
tel. +48 52 365 54 16
e-mail: zbartuzi@cm.umk.pl

Received: 13.04.2009 r.
Accepted: 10.05.2009 r.