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Protective effect of Apple Cider Vinegar on Stress Induced Gastric Ulcer

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A gastric ulcer is a break in the normal gastric mucosa integrity that extends through the muscularis mucosa into the sub-mucosa or deeper. This work aimed to study the effect of chronic administration of vinegar on gastric acid secretion, and if this action has any effect on stress-induced ulcer in male albino rats. Study groups included 24 rats divided into 2 main groups (12 rats/group): pyloric ligation group (A) and water immersion-induced gastric ulceration group (as a form of stress) (B). We evaluated; free and total HCL secretion in group A, ulcer score, ulcer index, percentage ulcer protection, , eNOS enzyme activity, COX-2 enzyme activity, glutathione reductase gene expression, CCK gene expression and proton pump (H+/K+ ATPase) gene expression in group B. We revealed significant decrease in free and total acidity, ulcer score and index, COX-2 enzyme activity and Proton pump (H+/K+ ATPase) gene expression among vinegar fed rats compared with the results of the control group. On the other hand there was significant elevation in the percentage ulcer protection, eNOS enzyme activity, Glutathione reductase gene expression and CCK gene expression among vinegar fed rats compared to control group. In conclusion, the present study revealed protective effect of vinegar on stress-induced gastric ulceration. Key words: Gastric ulcer, HCl, H+/K+ ATPase pump, H2-receptor blockers, vinegar.
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Protective effect of Apple Cider Vinegar on Stress Induced Gastric Ulcer
Authors
Hader Ibrahim Sakr1, Mohamed Mansour Khalifa1, Mohamed Al Sayed Saleh1
Laila Ahmed Rashed2, Akef Abdel Halim Khowiled1
1Departmentof Medical Physiology, Kasr Al Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
2Department of Biochemistry, Kasr Al Aini Faculty of Medicine, Cairo University, Cairo, Egypt
Corresponding Author
Hader Ibrahim Sakr, MD
Department of Medical Physiology, Kasr Al Ainy Faculty of Medicine, Cairo University, Cairo Egypt
Email: hadersakr209@yahoo.com, hadersakr@kasralainy.edu.eg Mobile phone: +201111616364
Postal code:11451
ABSTRACT
A gastric ulcer is a break in the normal gastric mucosa integrity that extends through the muscularis mucosa
into the sub-mucosa or deeper. This work aimed to study the effect of chronic administration of vinegar on
gastric acid secretion, and if this action has any effect on stress-induced ulcer in male albino rats. Study
groups included 24 rats divided into 2 main groups (12 rats/group): pyloric ligation group (A) and water
immersion-induced gastric ulceration group (as a form of stress) (B). We evaluated; free and total HCL
secretion in group A, ulcer score, ulcer index, percentage ulcer protection, , eNOS enzyme activity, COX-2
enzyme activity, glutathione reductase gene expression, CCK gene expression and proton pump (H+/K+
ATPase) gene expression in group B. We revealed significant decrease in free and total acidity, ulcer score
and index, COX-2 enzyme activity and Proton pump (H+/K+ ATPase) gene expression among vinegar fed rats
compared with the results of the control group. On the other hand there was significant elevation in the
percentage ulcer protection, eNOS enzyme activity, glutathione reductase gene expression and CCK gene
expression among vinegar fed rats compared to control group. In conclusion, the present study revealed
protective effect of vinegar on stress-induced gastric ulceration.
Key words: Gastric ulcer, HCl, H+/K+ ATPase pump, H2-receptor blockers, vinegar.
INTRODUCTION
Vinegar, from the French vinaigre, meaning “sour wine,” can be made from almost any fermentable
carbohydrate source1.The chemical and organoleptic properties of vinegars are a function of the starting
material and the fermentation method. Acetic acid, the volatile organic acid that identifies the product as
vinegar, is responsible for the tart flavor and pungent, biting odor of vinegars. However, acetic acid should
not be considered synonymous with vinegar. The US Food and Drug Administration (FDA) states that
diluted acetic acid is not vinegar and should not be added to food products customarily expected to contain
vinegar,2. Other constituents of vinegar include vitamins, mineral salts, amino acids, polyphenolic
compounds (eg, galic acid, catechin, caffeic acid, ferulic acid), and nonvolatile organic acids (eg, tartaric,
citric, malic, lactic)3.
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DOI: http://dx.doi.org/10.18535/jmscr/v4i1.28
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Numerous terms have been used to describe stress ulcer in critically ill patients, including stress
ulcer/ulceration, stress erosions, stress gastritis, hemorrhagic gastritis, erosive gastritis, and stress-related
mucosal disease4.
A major factor in the development of stress ulcer is splanchnic hypo-perfusion, which results from a number
of stress-related effects such as sympathetic nervous system activation, increased catecholamine release,
vasoconstriction, hypovolemia, decreased cardiac output, and release of pro-inflammatory cytokines5. The
inflammation induced in the gastric mucosa is accompanied by increased TNF-α production6, which
augments neutrophil-derived superoxide generation7and stimulates IL-1 production, leading to neutrophil
accumulation8. Neutrophils produce superoxide radical anion (O2•-), which belongs to group of ROS.
Superoxide radical anion reacts with cellular lipids, leading to the formation of lipid peroxides that are
metabolized to MDA (Malondialdehyde) and 4-hydroxynonenal (4-HNE)9.
During stress, the imbalance of aggressive and defensive factors in the stomach plays a pivotal role in gastric
hemorrhage and ulcer formation10. Thus, the aim of the work was to the possible effect of chronic
administration of vinegar on gastric acid secretion, and to study if this action has any effect on stress-
induced ulcers in male albino rats.
MATERIALS & METHODS
*Experimental animals: A total of 24 male albino rats weighing 150-175 gm were used. The rats were
housed in wire mesh cages at room temperature, veterinary care were provided by laboratory animal house
unit of Kasr Al-Ainy faculty of medicine, Cairo University. Before the day of experiments all rats were
starved for 24 h, with free access to water until the beginning of experimental protocol.
Rats were divided into two groups:
Group A: experimental design for pyloric ligation induced gastric ulcer: 12 rats were divided into 2
subgroups, each consists of 6 animals:
Subgroup i : fed for 6 weeks on a standard laboratory rat diet offered ad lib.
Subgroup ii: fed for 6 weeks on a standard laboratory rat diet enriched with 15% of natural vinegar11 (5%
acetic acid, Gallettis.n.c., via Faverzani, 13. 26046 San Danelepo. Cremona-Italia-Lic.) offered ad lib.
On the 35th day, the 2 groups of rats were fasted 24 h prior to induction of gastric ulcer. Pyloric ligation was
done by ligating the pyloric end of the stomach of rats11. Animals was allowed to recover and stabilized in
individual cage and deprived of water during post-operative period. After 3 h of surgery, rats were sacrificed
by cervical dislocation. Both free and total HCl secretions were measured in this group(A).
Group B: experimental design for water immersion restraint-induced gastric ulcer: 12 rats were
divided into two groups, each consists of 6 animals:
Subgroup i: fed for 6 weeks on a standard laboratory rat diet offered ad lib.
Subgroup ii: fed for 6 weeks on a standard laboratory rat diet enriched with 15% of natural vinegar (5%
acetic acid) offered ad lib
The rats fasted 24 hrs prior to stress induction. Rats were immobilized in a stress cage and then immersed to
the level of the xiphoid in a water bath at 23±0.2oC for 4 hours12. Then they were removed from the cage
and sacrificed by cervical dislocation. Ulcer score, ulcer index, percentage ulcer protection, histology of the
Stomach, eNOS enzyme gene expression, COX-2 enzyme activity, glutathione reductase enzyme gene
expression, CCK gene expression and proton-pump(H+/K+ ATPase enzyme) gene expression were measured
in this group (B).
*Determination of ulcer index: Stomachs of group B rats (water immersion rats) were opened at the
greater curvature, fixed on cork for determination of ulcer index. The ulcer index was calculated according
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to the method of Suzuki et al., 197613.The lesions were counted with the aid of hand lens (10X) and each
given a severity rating as follows:
1 Less than 1mm (Pin point)
2 1-2 mm
3 Greater than 2 mm and above
The ulcer score was divided by a factor of 10 to get the ulcer index.
*Determination of percentage ulcer protection: Percentage ulcer protection was calculated by the
formula14:
Ulcer protection (%) = (Uc-Ut/Uc) X 100
Where:
Uc = ulcer index of control group.
Ut = ulcer index of test group.
*Pyloric ligation: An aseptic surgical procedure was employed for group (A) animals. The rats were
anesthetized by intra-peritoneal injection with thiopental sodium (30mg/kg) 12, after that the abdomen was
opened by a small midline incision of approximately3 cm, at one cm below the xiphoid process. Stomach
was exposed and a tight knot was applied around the pyloric sphincter using 4-0 silk ligature. The stomach
was placed carefully and abdomen wall closed by interrupted sutures. Immediately after suturing the
incision, the wound was cleaned and was covered by local antibiotic ointment (Terramycin). The rats were
returned to their cages and left for 3 hours12.
*Animal sacrifice and samples collection: Animals were sacrificed by cervical dislocation, the thorax and
abdomen were opened, esophagus was ligated and the stomachs were dissected and removed quickly. The
contents of the stomach were collected.
*Measurement of gastric acid secretion: After collection of gastric fluid, the total volume of gastric
content was measured. The gastric contents were centrifuged at 1000 rpm for 10 min. One ml of the
supernatant liquid was pipetted out and diluted to 10 ml with distilled water. The solution was titrated
against 0.01N NaOH using Topfer’s reagent as indicator, to the endpoint when the solution turned to orange
color. The volume of NaOH needed was taken as corresponding to the free acidity. Titration was further
continued till the solution regained pink color. The volume of NaOH required was noted and taken as
corresponding to the total acidity15.
*Measurement of cox-2 enzyme activity: Cayman’s COX Activity Assay Kit (Cayman Chemical
Company, Michigan, USA) measures the peroxidase activity of COX. The peroxidise activity is assayed
colorimetrically by monitoring the appearance of oxidized N,N,N’,N’-tetramethyl-p-phenylenediamine
(TMPD) at 590 nm16. It can be used with both crude (cell lysates/tissue homogenates) and purified enzyme
preparations. The kit includes isozyme-pecific inhibitors for distinguishing COX-2 activity from COX-1
activity.
*Detection of eNOS, CCK, glutathione reductase and h+/k+ atpase gene expression: By real time
quantitative polymerase chain reaction (qPCR) (chemicals purchased from Cayman Chemical Company,
Michigan, USA).
qPCR differs from regular PCR by including in the reaction fluorescent reporter molecules that increase
proportionally with the increase of DNA amplification in thermo cycler. There are two types of fluorescent
chemistries for this purpose: double-strand DNA-binding dyes and fluorescently labeled sequence specific
probe/primer. SYBR Green I dye and TaqMan® hydrolysis probe are the common examples for these two,
respectively. The SYBR Green method doesn't need fluorescently labelled probe/primer and costs much less
than the TaqMan® method. The key equipment for qPCR is a specialized thermo cycler with fluorescence
detection modules which is used to monitor and record the fluorescence in real time as amplification occurs.
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A typical workflow of qPCR for gene expression measurement involves RNA isolation, reverse
transcription, qPCR assay development, qPCR experiment and data analysis.
RESULTS
The results of present work showed a significant (P-value < 0.05) decrease in the mean values of both total
and free acidity between subgroup Aii (Vinegar fed) and control subgroup Ai. As shown in Table 1 and
Figure 1, the mean value of total acidity of subgroup Ai was 71.683 mEq/L ± 1.076 and that of free acidity
was 29.733 mEq/L ± 0.628, while in subgroup Aii, the mean value of total acidity was 65.8 mEq/L ± 0.672
and that of free acidity was 25.567 mEq/L ± 0.612. The results of the present work also showed a significant
(P-value<0.05) decrease in ulcer index between Vinegar fed rats (subgroups Bii) with a mean value of 0.767
± 0.082 and control subgroup Bi in which the mean value of the ulcer indices was 1.117 ± 0.075 (Table 2
and Figure 2).The mean value of percentage ulcer protection among vinegar fed rats (subgroup Bii) was
25.942% ± 10.395.
The results of present work as shown in Table 3 - also showed a significant (P-value < 0.05) increase in
eNOS enzyme gene expression between subgroups Bii (vinegar fed) with a mean value of 0.63 ± 0.054 and
control subgroup Bi with a mean value of 0.283 ± 0.039 (Figure 3).
Furthermore, the results of present work also showed a significant (P-value < 0.05) decrease in COX-2
enzyme activity between subgroup Bii with a mean value of 6.687 mmol/ min/ml ± 0.335 and subgroup Bi
with a mean value of 11.647 nmol/min/ml ± 1.156 (Figure 4).
In addition, we showed a significant (P-value < 0.05) increase in glutathione reductase enzyme gene
expression between subgroup Bii with a mean value of 56.967 ± 4.869 and subgroup Bi with a mean value
of 30.733 ± 5.854 (Figure 5).
There was also a significant (P-value < 0.05) decrease in H+/K+ ATPase enzyme gene expression between
subgroups Bii with a mean value of 6.953 ± 0.71 and subgroups Bi with a mean value of 11.167± 0.794
(Figure 6).In addition, the results of present work have shown a significant (P-value < 0.05) increase in CCK
gene expression between subgroups Bii with a mean value of 0.643 ± 0.036 and subgroups Bi with a mean
value of 0.385 ± 0.079 (Figure7).
Moreover we demonstrated from macroscopic and microscopic (histo-pathological) examination more
significant protection against stress-induced gastric ulcer in vinegar fed rats in subgroup Bii (Figures 9 and
11)as compared to control subgroup Bi (Figures 8 and 10).
Table (1): Comparison of total acidity and free acidity between subgroups Ai (control) and Aii (Vinegar
fed).
Subgroup Ai
Subgroup Aii
Mean#
71.683
65.8
S.D. ±
1.076
0.672
Mean#
29.733
25.567
S.D. ±
0.628
0.612
P Value
<0.05*
# Mean is in mEq/L
*: statistically significant compared to corresponding value in subgroups Ai (P<0.05).
Table (2): Comparison of ulcer index between subgroups Ai (control) and Aii (vinegar fed).
Subgroup Bi
Subgroup Bii
Ulcer
index
Mean
1.117
0.767
S.D. ±
0.075
0.082
P Value
<0.05*
*: statistically significant compared to corresponding value in subgroups Bi (P<0.05).
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Table (3): Comparison of eNOS enzyme gene expression,COX-2 enzyme activity, glutathione reductase
enzyme gene expression and H+/K+ ATPase enzyme gene expression and between subgroups Bi (control)
and Bii (vinegar fed).
Subgroup Bi
Subgroup Bii
eNOS enzyme gene
expression
Mean
0.283
0.63
S.D. ±
0.039
0.054
COX-2enzyme activity
Mean#
11.647
6.687
S.D. ±
1.156
0.335
glutathione reductase
enzyme gene expression
Mean
30.733
56.967
S.D. ±
5.854
4.869
H+/K+ ATPase enzyme
gene expression
Mean
11.167
6.953
S.D. ±
0.794
0.710
CCK gene expression
Mean
0.385
0.643
S.D. ±
0.079
0.036
P Value
<0.05*
#Mean is in nmol/min/ml
*: statistically significant compared to corresponding value in subgroup Bi (P<0.05)
Figure (1): Comparison of total and free acidity between subgroups Ai (control) and Aii (vinegar fed).
Values are represented as mean ± SD.*: statistically significant compared to corresponding value in
subgroup Bi (P<0.05).
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Figure (2): Comparison of ulcer indices between subgroups Bi (control) and Bii (vinegar fed). Values are
represented as mean ± SD.*: statistically significant compared to corresponding value in subgroup Bi
(P<0.05).
Figure (3): Comparison of eNOS enzymes gene expression between subgroups Bi (control) and Bii (vinegar
fed).
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Figure (4): Comparison of COX-2 enzyme activity between subgroups Bi and Bii.
Figure (5): Comparison of glutathione reductase enzyme gene expression between subgroups Bi and Bii.
Figure (6): Comparison of H+/K+ ATPase enzyme gene expression between subgroups Bi and Bii.
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Figure (7): Comparison of CCK gene expression between subgroups Bi and Bii.
Figure (8): Macroscopic representation of gastric mucosa of Subgroup Bi (control group).
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Figure (9): Macroscopic representation of gastric mucosa of Subgroup Bii (vinegar fed group).
figure (10)
Serial sections of gastric excision biopsies revealing wide ulceration of the gastric mucosa (1), with
edematous lamina propria (2) with severe lymphoplasma cell infiltrate with excess neutrophils (3 dashed
arrows).
(A picture is consistent with severe acute ulcerative gastritis.)
Figure (10): Microscopic representation (10X and 20X) of gastric mucosa of subgroup Bi (control group)
stained with Hx & E.
(3)
(2)
(1)
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Figure (11)
Sections of gastric excision biopsies revealing focal superficial ulceration of the gastric mucosa above the
muscularis mucosa (1), accompanied by extrusion of a fibrin purulent exudates into the lumen (2), with
moderately edematous lamina propria with engorged capillaries, moderate lymphoplasma cell infiltrate with
neutrophils (3).
(A picture is consistent with moderate acute gastritis with focal superficial ulceration)
Figure (11): Microscopic representation (10X and 20X) of gastric mucosa of Subgroup Bii (vinegar fed
group) stained with Hx & E.
DISCUSSION
The results of the present work illustrated that feeding rats with vinegar (subgroups Bii) produced significant
reduction in stress-induced gastric ulcer.
On measuring total and free acidity, the results of present work demonstrated that vinegar fed rats (subgroup
Aii) had a highly significant decrease in the mean value of both total and free acidity compared to control
subgroup Ai. Vinegar fed rats had also a highly significant increase in the mean value of CCK gene
expression compared to control subgroup Ai.
The results of present work demonstrated that vinegar fed rats (subgroups Bii) had a highly significant
decrease in the mean value of gastric H+/K+ ATPase enzyme activity and the mean value of ulcer index
compared to the control group (subgroups Bi). Hyperacidity is a pathological condition due to uncontrolled
hypersecretion of hydrochloric acid from the parietal cells (PC) of gastric mucosa through the proton
pumping by H+/K+ ATPase harboured on the plasma membrane of PC17. H+/K+ ATPase is a regulatory
enzyme found in the plasma membrane of parietal cells involved in passage of protons into the lumen of
stomach causing acidity18.
Health benefits of apple have been reported19, and one of important category of apple active constituents is
phenols. Phenols are secondary plant metabolites and act as antioxidant, antibacterial20, and antiviral
agents21. Variety of substances, such as carotenoids, flavonoids, polyphenols, phenolic acid and uric acid are
very famous antioxidants22. Among these substances, polyphenols and their by-products are the most
important antioxidants in plants. Several studies in humans or in animals have demonstrated that
polyphenols possess significant chemo preventive properties due to their antioxidant capacity23. Polyphenols
are present in fruits, wines and their by-products like vinegars. Although the antioxidant role of many fruits
and different wines in vitro and in vivo upon healthy and different kind of disease subjects has been
extensively studied24, there are fewer studies to examine the antioxidant activity of vinegars.
(3)
(1)
(2)
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Vinegars contain different antioxidant compounds, and their final quality depends to the raw material used
as substrate, the acetification system used, and the ageing procedure used during their production25. Due to
the chemical diversity of antioxidant compounds present in vinegars, and perhaps, the additive, synergistic
and antagonistic interactions among these molecules and also the other nutrients present in them, do not
necessary reflect their total antioxidant capacity (TAC)26.
Antioxidant capacity was found to be positively correlated with both, sugar and phenol content of vinegars.
Regular apple vinegar (RAV), exhibited improved health benefits with the presence of residual phenols in
addition to acetic acid27.
Specific non-enzymatic scavengers, such as tocopherols, ascorbic acid, flavonoids, and phenols, can prevent
biological damages by trapping radical oxidants such as SOD28. Therefore, SOD active constituents in
vinegar would also have effects on maintaining normal vascular function29. Phenolic acids and their
derivatives are widely spread in plants30 and a number of phenolic acids are linked to various cell wall
components31. Free and bound phenolics are known to play a crucial role in the defence mechanism, offering
protection against oxidative stress (OS) caused by both biotic and abiotic factors. Phenolics have been
shown to possess antiulcer activity32. The antioxidant activity of phenolics may be an important contributing
antiulcer factor since free radicals (FR)/reactive oxygen species (ROS) are related to the occurrence of
ulcers33.
This is supported by the results of present work that have shown a highly significant increase in the mean
value of eNOS enzyme gene expression, a highly significant increase in the mean value of glutathione
reductase enzyme gene expression and a highly significant decrease in the mean value of COX-2 enzyme
activity in vinegar subgroup (Bii) compared to control subgroup (Bi).
SUMMARY AND CONCLUSION
In conclusion, the present study revealed that vinegar offered protective effect on the stomach of mediated
by anti-ulcer, antioxidant and gastric protective mechanisms on stress-induced gastric ulceration. For future
research work, it’s recommended to study the effect of vinegar on other modules of gastric ulceration and
their possible underlying mechanisms.
ACKNOWLEDGMENT
We would like to thank Dr. Ihab Osama Hafez (Assistant researcher at Theodor Bilharz Research Institute)
for his kind help in histological evaluation performed in this work
CONFLICT OF INTEREST
There is no conflict of interest.
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... PGC-1 reduces mitochondrial ROS production by changing electron transport chain redox status [55], promoting mSIRT3 gene expression [56] that binds to, deacetylates, and activates mitochondrial enzymes, including SOD2, through a post-translational mechanism [57]. Intracellular lipids, including membrane phospholipids, reacts with O 2 À forming lipid peroxides that are metabolized to MDA and 4-hydroxynonenal [58]. Ligand-activated PPAR-c induces the expression of scavenger receptor CD36 that mediates the recognition and internalisation of oxidized lipids [59]. ...
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