Effect of oral cholecalciferol 2,000 versus 5,000 IU on serum vitamin D, PTH, bone and muscle strength in patients with vitamin D deficiency

Treatment of vitamin D deficiency for 3 months with oral cholecalciferol 5,000 IU daily was more effective than 2,000 IU daily in achieving optimal serum 25-hydroxyvitamin D (25OHD) concentrations. Optimal 25OHD serum level calculated to be 63.8 nmol/L. All parameters of muscle strength improved following administration of cholecalciferol for 3 months.

INTRODUCTION

The aim of this study was to determine the optimal dose of cholecalciferol required to achieve target serum 25OHD level ≥ 75 nmol/L and its relationship to both bone turnover and muscle strength.

METHODS

Thirty deficient patients (serum 25OHD ≤ 50 nmol/L) were randomly assigned into two groups-i.e. 2,000 and 5,000 IU/day. Data were collected at baseline, at 2 and 3 months post-therapy: (a) clinical demographics, (b) dietary calcium recall, (c) physical tests of muscle function and (d) biochemistry. Statistical analysis used paired student t test and analysis of variance. Regression analysis was used to determine relationship between serum 25OHD and parathyroid hormone (PTH).

RESULTS

Twenty-six (87%) patients completed 3 months of therapy. The percent increase in serum 25OHD (compared to baseline) was 82.7% in 2,000-IU group and 219.5% in 5,000-IU group. All participants (100%) achieved a serum 25OHD concentration >50 nmol/L; only 5 subjects (45.4%) in 2,000-IU group compared to 14 subjects (93.3%) in 5,000-IU group achieved final 25OHD concentration ≥ 75 nmol/L (p < 0.01). In the regression analysis, the reflexion point at which the PTH level increased above the normal range was calculated to be 63.8 nmol/L 25OHD. All parameters of muscle strength showed trends in improvements following the administration of both the 2,000 and 5,000 IU doses. No patient reported untoward side effects and no patient developed hypercalcaemia.

CONCLUSION

Treatment for 3 months with oral cholecalciferol 5,000 IU daily may be more effective than 2,000 IU daily in achieving optimal serum 25OHD concentrations in vitamin D-deficient patients.

Hepatic cytokine response can be modulated using the Kupffer cell blocker gadolinium chloride in obstructive jaundice

INTRODUCTION

Depletion of Kupffer cells by gadolinium chloride (GdCl(3)) reduces the systemic response during sepsis. The study aim was to investigate the effect of this depletion on hepatic proinflammatory cytokine response to portal endotoxaemia.

METHODS

Sixteen Wistar rats were randomised to receive either saline IV (n = 8) or GdCl(3) (10 mg/kg IV, n = 8) six days after bile duct ligation (BDL). 24 h later the animals were perfused for 2 h, using isolated hepatic perfusion. Aliquots of effluent perfusate were collected at 20-min intervals for cytokine analysis. Sections of liver were sampled and the hepatic Kupffer cell number of each group was measured using ED1 immunohistochemistry.

RESULTS

Pre-treatment with GdCl(3) resulted in significantly reduced serum bilirubin concentrations but significantly elevated serum ALP and AST levels compared to the control group. It was also associated with a significant reduction in Kupffer cell numbers and a corresponding significant reduction in hepatic TNFα and IL-6 production in response to portal endotoxaemia.

CONCLUSIONS

Pre-treatment with GdCl(3) in jaundiced animals reduced Kupffer cell numbers, attenuated liver enzyme abnormalities and reduced TNFα and IL-6 in response to portal endotoxaemia. Hepatic Kupffer cells, therefore, play a significant role in the development of an exaggerated inflammatory response in obstructive jaundice.

Expression of osteopontin coregulators in primary colorectal cancer and associated liver metastases

BACKGROUND

A transcription regulatory complex (TRC) that includes Ets1, Ets2, PEA3 and β-catenin/T-cell factors regulates osteopontin (OPN) that is implicated in colorectal cancer (CRC) dissemination. The consistency of OPN transcriptional control between primary CRC and metastases is unclear. This study investigates expression and prognostic significance of the OPN-TRC in primary human CRC and associated colorectal liver metastases (CRLM).

METHODS

Osteopontin-TRC factors were assayed by digital microscopy in 38 primary CRCs and matched CRLM specimens and assessed against clinical prognosis.

RESULTS

In primary CRC, OPN expression intensity correlated with that of its co-activators, PEA3 (r=0.600; P<0.01), Ets1 (r=0.552; P<0.01), Ets2 (r=0.521; P<0.01) and had prognostic significance. Osteopontin intensity in primary CRC inversely correlated with the interval between diagnosis and resection of CRLM. Overall OPN intensity was lower in CRLM than primary CRC and correlations with co-activators were weaker, for example, Ets1 (P=0.047), PEA3 (P=0.022) or nonsignificant (Ets2). The ratio of OPN expression in CRLM vs primary CRC had prognostic significance.

CONCLUSION

This study supports transcriptional control of OPN by known coregulators in both primary and secondary CRC. Weaker associations in CRLM suggest involvement of other unknown factors possibly from the liver microenvironment or resulting from additional genetic or epigenetic changes that drive tumour metastatic capability in OPN transcriptional control.

Management of liver trauma

BACKGROUND

Blunt and penetrating liver trauma is common and often presents major diagnostic and management problems.

METHODS

A literature review was undertaken to determine the current consensus on investigation and management strategies.

RESULTS

The liver is the most frequently injured organ following abdominal trauma. Immediate assessment with ultrasound has replaced diagnostic peritoneal lavage in the resuscitation room, but computerised tomography remains the gold standard investigation. Nonoperative management is preferred in stable patients but laparotomy is indicated in unstable patients. Damage control techniques such as perihepatic packing, hepatotomy plus direct suture, and resectional debridement are recommended. Major complex surgical procedures such as anatomical resection or atriocaval shunting are now thought to be redundant in the emergency setting. Packing is also recommended for the inexperienced surgeon to allow control and stabilisation prior to transfer to a tertiary centre. Interventional radiological techniques are becoming more widely used, particularly in patients who are being managed nonoperatively or have been stabilised by perihepatic packing.

CONCLUSIONS

Management of liver injuries has evolved significantly throughout the last two decades. In the absence of other abdominal injuries, operative management can usually be avoided. Patients with more complex injuries or subsequent complications should be transferred to a specialist centre to optimise final outcome.

Management of liver trauma

BACKGROUND

Blunt and penetrating liver trauma is common and often presents major diagnostic and management problems.

METHODS

A literature review was undertaken to determine the current consensus on investigation and management strategies.

RESULTS

The liver is the most frequently injured organ following abdominal trauma. Immediate assessment with ultrasound has replaced diagnostic peritoneal lavage in the resuscitation room, but computerised tomography remains the gold standard investigation. Nonoperative management is preferred in stable patients but laparotomy is indicated in unstable patients. Damage control techniques such as perihepatic packing, hepatotomy plus direct suture, and resectional debridement are recommended. Major complex surgical procedures such as anatomical resection or atriocaval shunting are now thought to be redundant in the emergency setting. Packing is also recommended for the inexperienced surgeon to allow control and stabilisation prior to transfer to a tertiary centre. Interventional radiological techniques are becoming more widely used, particularly in patients who are being managed nonoperatively or have been stabilised by perihepatic packing.

CONCLUSIONS

Management of liver injuries has evolved significantly throughout the last two decades. In the absence of other abdominal injuries, operative management can usually be avoided. Patients with more complex injuries or subsequent complications should be transferred to a specialist centre to optimise final outcome.

Tryptophan catabolites in mesenteric lymph may contribute to pancreatitis-associated organ failure

Background

Multiple organ failure (MOF) is the key determinant of mortality in acute pancreatitis (AP). Mesenteric lymph cytotoxicity contributes to organ failure in experimental models of systemic inflammation. The aim of this study was to evaluate the mesenteric lymph pathway and the lymph injury proteome in experimental AP-associated MOF, and to test the hypothesis that immunoregulatory tryptophan catabolites contribute to mesenteric lymph cytotoxicity.

Methods

Using an experimental model of AP in rats, the humoral component of mesenteric lymph in AP was compared with that from sham-operated control animals, using in vitro and in vivo cytotoxicity assays, high-throughput proteomics and high-performance liquid chromatography. The experimental findings were corroborated in a cohort of 34 patients with AP.

Results

Compared with biologically inactive lymph from sham-operated rats, mesenteric lymph in AP became cytotoxic 3 h after induction. Hierarchical clustering of lymph proteomic mass spectra predicted the biological behaviour of lymph. Levels of the immunoregulatory tryptophan catabolite, 3-hydroxykynurenine, were increased in cytotoxic lymph and re-created cytotoxicity in vitro. In humans with AP, plasma kynurenine concentrations correlated in real time with MOF scores and preceded a requirement for mechanical ventilation and haemodialysis.

Conclusion

These results support the concept that mesenteric lymph-borne kynurenines may contribute to pancreatitis-associated MOF.

The probiotic bacterium Lactobacillus plantarum species 299 reduces intestinal permeability in experimental biliary obstruction

AIMS

Extrahepatic biliary obstruction is associated with the failure of intestinal barrier function, allowing bacteria and other substances from the intestine to enter the circulation and initiate a systemic inflammatory response, causing impairment of organ function. Probiotic bacteria have been shown to have beneficial effects on intestinal barrier function in other conditions, but their effects have never been studied in biliary obstruction.

METHODS AND RESULTS

This study examined the effects of enteral administration of Lactobacillus plantarum species 299 (LP299) in oatmeal fibre compared with sterile oatmeal fibre in water or water alone in an animal model of biliary obstruction. Administration of LP299 was associated with reduced intestinal permeability compared with sterile oatmeal alone (0.262 +/- 0.105%vs 0.537 +/- 0.037%, P=0.019, percentage excretion of (14)Carbon), but there was no evidence of reduced endotoxin exposure or blunting of the systemic inflammatory response. Animals receiving sterile oatmeal fibre alone also failed to develop the hyperpermeability after biliary obstruction seen in animals receiving water only (0.512+/- 0.05%vs 0.788 +/- 0.18%), suggesting that oatmeal itself may have some beneficial effects on intestinal barrier function.

CONCLUSION

Enteral administration of the probiotic bacterium LP299 reduces intestinal hyperpermeability associated with experimental biliary obstruction.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study provides insight to direct further work into the modulation of intestinal barrier function by probiotic bacteria.

Glutamine improves intestinal barrier function in experimental biliary obstruction

OBJECTIVE

To determine the effects of enteral administration of glutamine on intestinal barrier function in experimental biliary obstruction.

BACKGROUND

Extrahepatic biliary obstruction is associated with the failure of intestinal barrier function, allowing bacteria and other substances from the intestine to enter the circulation and initiate a systemic inflammatory response, causing impairment of multiple organs. The amino acid glutamine has been shown to improve intestinal barrier function in other conditions, but its effects in biliary obstruction have not been fully examined.

METHODS

This study examined the effects of enteral administration of glutamine on intestinal permeability and on bacterial translocation from the intestine in a rodent model of biliary obstruction.

RESULTS

Glutamine was shown to reduce intestinal permeability measured as percentage excretion of 14C 7 days after biliary obstruction (0.35+/-0.03 vs. 0.56+/-0.085% in controls, p=0.028), and glutamine administration was also associated with a decreased incidence of bacterial translocation to extra-intestinal sites (p=0.03). Radiolabelled bacterial studies also demonstrated reduced translocation of bacterial fragments to extra-intestinal sites in glutamine-treated animals (p=0.01). There was also some evidence of decreased exposure to endotoxin, reduced systemic inflammation and increased bacterial killing by the immune system in glutamine-treated animals.

CONCLUSIONS

Glutamine modulates intestinal permeability and reduces bacterial translocation in an animal model of experimental biliary obstruction and may increase bacterial killing by the immune system.

Patterns of bacterial translocation in experimental biliary obstruction

INTRODUCTION

Biliary obstruction is associated with impaired intestinal barrier function and translocation of enteric bacteria to the systemic circulation. Traditional live culture techniques may overlook translocation of dead bacterial fragments that stimulate the inflammatory response. The aim of this study was to estimate the extent and pattern of bacterial translocation in experimental biliary obstruction.

MATERIALS AND METHODS

Thirty 9-week-old male Wistar rats were randomized to undergo bile duct ligation (BDL, n = 20) or sham operation (n = 10). Seven days after operation, each animal received 1 ml of (111)indium-oxyquinolone-labeled Escherichia coli p.o. Samples of liver, spleen, mesenteric lymph nodes, and lung were harvested 4 h later and analyzed for live bacteria and (111)indium activity.

RESULTS

There was significantly more live bacterial translocation detected in BDL animals than in sham-operated animals (P = 0.00008, chi(2)). Labeled bacterial fragments were detected in all locations sampled in all animals. Sham-operated animals had significantly more labeled bacterial fragments detected in the liver (P = 0.0001) and the spleen (P = 0.03) than the BDL animals. The mean total bacterial survival in the BDL group was 30 +/- 13% and 0% in the sham operated group.

CONCLUSION

These results demonstrate that non-viable bacterial fragments are present in sterile extra-intestinal sites in normal animals and that translocation of live bacteria is markedly increased in experimental biliary obstruction. These results also suggest that failure of bacterial killing is an important factor facilitating bacterial translocation in the presence of established biliary obstruction.

Anatomical orientation and cross-checking-the key to safer laparoscopic cholecystectomy

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Surgical treatment of hepatic hydatid cyst

Hydatid disease of the liver is caused by the tapeworm Echinococcus granulosus, and the highest incidence of human infestation occurs in sheep and cattle-raising areas. Although, still an uncommon occurrence, it is being seen with increasing frequency; hence, it is important that surgeons make themselves aware of the pathology and treatment of the disease. The liver is most commonly involved, although many other organs, including lungs and brain may also be affected. An echinococcal cyst of the liver was reported in a patient who is a resident in Northern Ireland but had originally lived and worked in mainland Britain. Details of the lifecycle, pathology, diagnostic techniques and surgical management of hydatid cysts are reviewed.

Carcinoid tumour of the extrahepatic bile duct--report of a case and literature review

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Management of severe acute pancreatitis

BACKGROUND

Acute pancreatitis is still associated with significant morbidity and mortality. Current management guidelines are sometimes equivocal, particularly in relation to the surgical treatment of severe disease. This review assesses available investigative and treatment strategies to allow the development of a formalized management approach.

METHODS

A literature review of diagnosis, staging and management of acute pancreatitis was performed.

RESULTS AND CONCLUSION

Recent evidence has helped to clarify the roles of computed tomography, endoscopic retrograde cholangiopancreatography, prophylactic antibiotics, enteral feeding and fine-needle aspiration for bacteriology in the management of acute pancreatitis. Despite a relative shortage of prospective randomized trials there has been a significant change in the surgical management of acute pancreatitis over the past 20 years. This change has been away from early aggressive surgical intervention towards more conservative management, except when infected necrosis is confirmed. A formalized approach, with appropriate use of the various non-surgical and surgical options, is feasible in the management of severe acute pancreatitis.

Host immune responses and intestinal permeability in patients with jaundice

BACKGROUND

Systemic endotoxaemia is implicated in the development of complications associated with obstructive jaundice. The aims of these studies were to assess the systemic immune response to intervention in patients with jaundice and to compare the effects of surgical and non-surgical biliary drainage on host immune function and gut barrier function.

METHODS

In the first study, 18 jaundiced and 12 control patients were studied to assess systemic immune responses before and after intervention. In the second study, immune responses and gut barrier function were assessed following surgical and non-operative biliary decompression in 45 patients with jaundice.

RESULTS

Endotoxin antibody concentrations fell significantly in patients with jaundice immediately after surgical intervention, but not after non-operative biliary drainage. This decrease was associated with a significant increase in serum P(55) soluble tumour necrosis factor (sTNF) receptor concentration (5.3 versus 10.5 ng/ml; P < 0.001), urinary excretion of P(55) TNF receptors (21.4 versus 78.8 ng/ml; P = 0.002) and intestinal permeability (lactulose : mannitol ratio 0.032 versus 0.082; P = 0.048). Intestinal permeability was significantly increased in patients with jaundice compared with controls (0.033 versus 0.015; P = 0.002).

CONCLUSION

These data suggest that obstructive jaundice is associated with impaired gut barrier function and activation of host immune function that is exacerbated by intervention. Surgery causes an exaggerated pathophysiological disturbance not seen with non-operative biliary drainage procedures.

Early and long-term results after necrosectomy for necrotizing pancreatitis

Background

Necrotizing pancreatitis is a difficult clinical problem associated with significant mortality and morbidity rates. Indications for surgical intervention, and the timing and type of intervention, remain controversial issues. A 10-year experience in the management of this condition in a tertiary referral centre is reviewed; treatment policies and early and long-term results are reported.

Methods

Between 1987 and 1997, 39 consecutive patients (32 men, seven women), with a mean age of 47 (range 13–74) years, underwent necrosectomy for severe necrotizing pancreatitis. Diagnosis was confirmed by contrast-enhanced computed tomography. Twenty-nine patients were referred from other hospitals in Northern Ireland. The aetiology included gallstones (15), alcohol (ten), idiopathic (seven), surgery (two), endoscopic retrograde cholangiopancreatography (two), blunt trauma (one), hyperlipidaemia (one) and pancreas divisum (one). Mean Acute Physiology And Chronic Health Evaluation (APACHE) II score on admission or arrival was 2 (range 5–21). Indications for surgical intervention were clinical deterioration with development of multiple organ failure, despite maximal medical support in the intensive care unit (ICU), or positive fine-needle aspiration for micro-organisms or radiographic evidence of infected necrosis (i.e. presence of gas within peripancreatic collection). The mean interval from onset to intervention was 23 (range 9–47) days. In 13 patients a conventional approach (necrosectomy with primary closure over drains) was used, 14 patients underwent planned staged necrosectomy with delayed closure over drains and in 12 patients necrosectomy with open laparostomy was undertaken.

Results

There were five deaths and 14 patients experienced significant hospital morbidity (fistula, ten; pseudocyst, two; renal failure, two). Variables which correlated with mortality rate were higher APACHE II score, acute renal failure requiring dialysis and early intervention. There was no difference in either mortality or morbidity rate between infected and sterile necrosis, or between the three surgical techniques. Long-term morbidity occurred in 20 surviving patients (incisional hernia, ten; endocrine pancreatic insufficiency, nine; exocrine pancreatic insufficiency, two; pseudocyst, two; chronic renal failure, two; recurrent pancreatitis, one; and chronic pain, one).

Conclusion

A low mortality rate can be achieved in patients with severe necrotizing pancreatitis with aggressive surgical intervention. Early maximal medical treatment and ICU support is essential before intervention, which should preferably be avoided early in the course of the disease and should be based on well defined criteria. The long-term morbidity rate remains high, although not always severe. This emphasizes the need for close follow-up.