Effect of biliary decompression on reticuloendothelial function in jaundiced rats

Effect of probiotic supplementation on bacterial translocation in common bile duct obstruction

OBJECTIVE

To investigate the effects of probiotics on bacterial translocation in the obstructive common bile duct with comparison to an enteral product containing arginine and glutamine.

MATERIAL AND METHOD

In our study, 40 Sprague-Dawley rats each weighing 250-300 g were used. Animals in Group 1 (sham) were laparatomized and fed standard chow supplemented with physiologic saline at daily doses of 2 ml through orogastric tube for 7 days. Common bile ducts of the animals in the other groups were ligated with 3/0 silk sutures. Group 2 (control group) was fed standard chow supplemented with daily doses of 2 ml physiologic saline. Group 3 (probiotic group) was fed standard chow supplemented with a probiotic solution (Acidophilus plus) containing strains of Lactobacillus acidophilus, Bifidobacterium bifidum and Lactobacillus bulgaricus at a daily doses of 2 × 10(9) colony forming units (CFU). Group 4 (formula group) was fed only an enteral solution (Stresson Multi Fiber) containing glutamine, arginine and a medium-chain fatty acid at daily doses of 2 g/kg. At the end of the 7th day, all animals were relaparatomized, and to determine bacterial translocation, aerobic, and anaerobic cultures were obtained from the specimens of mesenteric lymph nodes, intestinal mucosa, and blood samples. Smear cultures prepared from caecum were examined to determine the number of CFU. Finally, for histological examination specimens were excised from terminal ileum, and oxidative damage was assessed in liver tissues. Afterwards all animals were killed.

RESULTS

Moderately lesser degrees of bacterial translocation, and mucosal damage were seen in Groups 3, and 4 relative to Group 2 (p < 0.05). In Group 4, any difference was not seen in the number of cecal bacteria relative to baseline values, while in Group 3, significant decrease in cecal colonization was seen. Among all groups, a significant difference between levels of malondialdehyde, and glutathione was not observed.

CONCLUSION

At the end of our study, we have concluded that both probiotics, and enteral diets which contain immunomodulators such as glutamine, and arginine alleviate bacterial translocation, and impairment of intestinal mucosa.

The alterations in hepatic microcirculation and Kupffer cell activity after biliary drainage in jaundiced mice

BACKGROUND/PURPOSE

The aim of this study is to examine the effects of biliary drainage on hepatic microcirculation and Kupffer cell activity in the liver with obstructive jaundice.

METHODS

Common bile duct ligation and division was performed on C57BL/6 mice to induce obstructive jaundice. Seven or 14 days after surgery, some mice underwent biliary drainage. Three days after biliary drainage, sinusoidal perfusion, leukocyte rolling and sticking in the postsinusoidal venules, and the diameters of sinusoids containing blood flow were evaluated using intravital microscopy. Kupffer cell phagocytic activity was estimated as the ratio of Kupffer cells that phagocytosed fluorescent-labeled particles to sinusoids containing blood flow.

RESULTS

Sinusoidal perfusion after biliary drainage was significantly increased compared with that in livers with obstructive jaundice, but remained decreased compared with controls. Although the number of rolling leukocytes and sticking leukocytes was significantly decreased, the diameters of sinusoids remained reduced, associated with an increase in Kupffer cell phagocytic activity compared with controls even after biliary drainage.

CONCLUSIONS

Leukocyte-endothelial cell interaction is ameliorated but sinusoids remain narrowed due to swelling of activated Kupffer cells; this might cause deterioration of hepatic microcirculation during the early phase of biliary drainage.

Evaluation of the uptake function of liver in rats with obstructive jaundice before and after relief from obstruction by superparamagnetic iron oxide-enhanced magnetic resonance imaging

The aim of this study was to investigate the changes in the uptake function of the liver in rats with obstructive jaundice prior to and following relief from obstructive jaundice, and to investigate whether superparamagnetic iron oxide (SPIO)-enhanced magnetic resonance imaging (MRI) could be used to assess liver uptake function. In total, 40 male Sprague Dawley rats were randomly assigned into four groups: Obstructive jaundice, internal drainage, external drainage and sham surgery. The common bile ducts in the obstructive jaundice group were ligated. Internal drainage (ID) and external drainage (ED) groups were ligated, followed by internal drainage or external drainage, respectively. The T2 and T2* values of the liver parenchyma were measured. Liver sections were stained with Perls' Prussian blue, and hematoxylin and eosin. The number of SPIO-nanoparticle clusters was counted manually using a microscope. Total bilirubin of the blood was measured. Results showed that the T2 and T2* values and total bilirubin of the obstructive jaundice group were significantly higher compared to the other three groups. The number of SPIO-nanoparticle clusters in the obstructive jaundice group was significantly lower compared to the other three groups. In conclusion, obstructive jaundice suppresses liver uptake function in rats, which may be reversed by internal and external biliary drainage. However, no significant difference was found between the therapeutic effect of ID and ED on liver uptake function. Thus, SPIO-enhanced MRI may be used to evaluate the uptake function of the liver.

Role of Kupffer cells in the infection of biliary tract

Acute infection of biliary tract was a frequent severe case in hepatobiliary surgery and also a common cause of sepsis, multiple organ system failure (MOSF) and even death. The biliary system could suppress infection through physical, chemical and immune mechanisms. Kupffer cell (KC) is an important ingredient of the monocyte-phagocyte system and also a natural barrier against the infection of biliary tract, thus plays an important role both in the development and prevention of biliary tract infection. How to regulate the function of Kupffer cells and prevent multiple organ system failure in biliary duct infection are the most important problems to be solved.

Choledocholithiasis, ascending cholangitis, and gallstone pancreatitis

Gallstone disease is encountered commonly in clinical practice. The diagnosis of biliary stones has become less problematic with current, less-invasive imaging methods. The relatively invasive endoscopic techniques should be reserved for therapy and not used for diagnosis. Acute cholangitis and gallstone pancreatitis are two major complications that require prompt recognition and timely intervention to limit morbidity and prevent mortality or recurrence. Appropriate noninvasive diagnostic studies, adequate monitoring/supportive care, and proper patient selection for invasive therapeutic procedures are elements of good clinical practice.

Management of ascending cholangitis

Acute ascending cholangitis is a potential life-threatening emergency characterized by infection and obstruction of the biliary tree. This article reviews the pathogenesis and clinical approach to patients with ascending cholangitis and examines the literature on this topic.

Inflammatory response in patients with malignant obstructive jaundice

OBJECTIVE

Surgery in patients with malignant obstructive jaundice is associated with increased risks for postoperative septic complications. The aim of this study was to investigate the inflammatory and the local cellular immune response in patients accepted for surgery because of tumours in the hepatic-pancreatic-biliary (HPB) tract.

MATERIAL AND METHODS

Patients with obstructive jaundice (group HPB(+)) were compared with those without (HPB(-)). Patients undergoing surgery for benign abdominal disorders served as controls. Obstructive jaundice was present in 18 out of 33 HPB patients. Preoperatively, blood was analysed for bacteria, endotoxins and cytokines (TNF-alpha, IL-6 and IL-10). At operation, mesenteric lymph nodes (MLNs) were excised for bacterial cultures using standard microbiological techniques, and immunohistochemistry, using antibodies CD4 and CD8 (mainly staining T lymphocytes), CD68 (macrophages), and anti-caspase-3 (to determine the rate of apoptosis).

RESULTS

Bacterial translocation was not demonstrated in any of the patients. Increased preoperative concentrations of endotoxins were found in group HPB(+). The number of macrophages and the rate of apoptosis in MLNs were increased in jaundiced patients, while the number of T lymphocytes was decreased.

CONCLUSIONS

Malignant obstructive jaundice causes increased blood concentrations of endotoxins and cytokines, an increased number of macrophages in MLNs, a higher rate of apoptosis in MLNs, but a decreased number of T lymphocytes in MLNs. The lymphocyte depletion is probably due to the increased rate of apoptosis, and might reduce the ability of jaundiced patients to eradicate infection.

The effect of caffeic acid phenethyl ester on bacterial translocation and intestinal damage in cholestatic rats

We investigated the effect of caffeic acid phenethyl ester in rat ileum injury induced by chronic biliary obstruction. Swiss albino rats were divided into three groups: Group 1, sham (n = 7); Group 2, common bile duct ligation (n = 7); and Group 3, common bile duct ligation plus caffeic acid phenethyl ester (n = 7). In the caffeic acid phenethyl ester-treated rats, ileum tissue levels of malondialdehyde and myeloperoxidase were significantly lower than those of the bile duct-ligated rats (P < 0.001). The levels of tumor necrosis factor-alpha, interleukin-6, and interleukin-1alpha in the caffeic acid phenethyl ester group were significantly lower than those in the bile duct ligation group (P < 0.03, P < 0.01, and P < 0.02 respectively). The present study demonstrates that intraperitoneal administration of caffeic acid phenethyl ester in bile duct-ligated rats reduces intestinal oxidative stress. This effect may be useful in the preservation of intestinal damage in cholestasis.

Internal biliary drainage improves decreased number of gut mucosal T lymphocytes and MAdCAM-1 expression in jaundiced rats

BACKGROUND

Although the effect of preoperative biliary drainage in patients with obstructive jaundice is controversial, bacterial or endotoxin translocation is one of the main postoperative problem in jaundiced patients. Failure in gut barrier functions causes bacterial translocation; homing and distribution of T lymphocytes in the intestinal lamina propria are important for gut mucosal immune defense. This study was performed to examine whether bile regulates the numbers of T lymphocyte subsets or the expression of mucosal addressin cell adhesion molecule-1 (MAdCAM-1) in experimental jaundice in rats with and without external and internal biliary drainage.

METHODS

Four groups of Wistar rats were used: those that received a sham operation (SHAM), common bile duct ligation (CBDL), CBDL followed by external drainage (ED), and CBDL followed by internal drainage (ID). Numbers of CD4(+) and CD8(+) T lymphocytes and MAdCAM-1-positive cells in the lamina propria were counted immunohistochemically in the specimens of jejunum and ileum of each group. Bacterial translocation was examined by culturing from the mesenteric lymph node complex isolated from rats in each group.

RESULTS

A significant decrease in numbers of CD4(+) and CD8(+) T lymphocytes and MAdCAM-1-positive cells in the lamina propria was seen in obstructive jaundice, although numbers of peripheral blood lymphocytes increased in comparison with the sham-operated control. The numbers of CD4(+) and CD8(+) T lymphocytes and MAdCAM-1 expression in the lamina propria did not recover to a normal level after external drainage, but did so after internal drainage. Frequencies of bacterial translocation were high in the CBDL and ED group. In contrast, bacterial translocation was not present in any animals in the SHAM group and was at a low percentage in the ID group.

CONCLUSIONS

Changes in the number of T lymphocytes and MAdCAM-1 expression are associated with the presence of bile in the gastrointestinal tract and are inversely correlated with the frequency of bacterial translocation induced by CBD ligation. MAdCAM-1 expression maintained by the presence of bile may regulate T-lymphocyte homing to the lamina propria in obstructive jaundice.

Effects of ursodeoxycholic acid, glutamine and polyclonal immunoglobulins on bacterial translocation in common bile duct ligated rats

BACKGROUND

The present study was conducted to investigate the effects of ursodeoxycholic acid (UDCA), glutamine and i.v. polyclonal immunoglobulins (IVIG) on the bacterial translocation (BT) and intestinal integrity of obstructive jaundice (OJ) in an animal model.

METHODS

Fifty rats were randomized into five groups containing 10 rats each. All procedures were performed aseptically under general anaesthesia using intramuscular ketamine (25 mg/kg). The abdomen was opened and the common bile duct was identified, mobilized, doubly ligated using 5-0 silk and divided. In group 1 (the 'sham' group), the rats had a similar incision followed by mobilization of the common bile duct (CBD), without ligation or division. In group 2 rats, only common bile duct ligation (CBDL) was performed. In group 3, CBDL was performed and UDCA was administered by orogastric intubation once daily. In group 4 rats, CBDL was performed and glutamine was given by orogastric intubation once daily. Therapeutic substances were started orally on the day CBDL was fulfilled and were continued for 7 days. In group 5, IVIG was administrated via a femoral vein catheter just before CBDL. The animals were killed at the end of the 7th day, and serum levels of total bilirubin (TB), alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP) and gamma-glutamyl transpeptidase (GGT) were measured. Mesenteric lymph nodes (MLN), liver, spleen and blood were cultured. The terminal ileum specimens were examined histopathologically.

RESULTS

Bacterial translocation significantly increased in the MLN and spleen of rats in group 2 as compared to groups 3, 4 and 5 (P < 0.05, P = 0.001, P = 0.001, respectively). The BT of the liver in group 2 was significantly higher than that of group 5 (P < 0.05). In the blood, the BT was significantly higher in group 2 than groups 3, 4 and 5 (P < 0.05). The bacterial counts, colony-forming units per gram tissue (cfu/g), were found significantly higher in MLN, liver and spleen of rats in group 2 than those of groups 3, 4 and 5 (P = 0.000). The average villus height in the group 4 was significantly higher than that of groups 2, 3 and 5 (P = 0.000).

CONCLUSION

The present experimental study has demonstrated that the administration of glutamine, UDCA and IVIG reduce the incidence of BT and additionally glutamine preserves intestinal mucosal integrity.

Interleukin-1 receptor type I gene-deficient bile duct-ligated mice are partially protected against endotoxin

Cholestatic liver injury is associated with an increased susceptibility toward endotoxin-induced toxicity. To determine the role of interleukin 1 (IL-1) herein, extrahepatic cholestasis was induced by bile duct ligation (bdl) in IL-1 receptor type I gene-deficient (IL-1R(-/-)) mice, which are unresponsive to IL-1alpha and IL-1beta, and normal IL-1R(+/+) mice. Bdl elicited increases in hepatic IL-1alpha and IL-1beta messenger RNA (mRNA) and protein. Hepatocellular injury at 2 weeks after bdl was similar in IL-1R(-/-) and IL-1R(+/+) mice as shown by clinical chemistry and histopathology. Administration of endotoxin to cholestatic mice at 2 weeks after bdl was associated with enhanced cytokine release, more severe liver damage, and occurrence of death when compared with sham-operated mice. Endotoxin effects in sham-operated IL-1R(-/-) and IL-1R(+/+) mice were largely similar, but cholestatic IL-1R(-/-) mice were better protected against toxic effects of endotoxin, as reflected by lowered cytokine release, less profound liver injury, and reduced mortality. These data indicate that IL-1alpha and IL-1beta are produced in the liver after bdl, but that these cytokines do not play a significant role in cholestatic liver damage; however, endogenous IL-1 activity is an important denominator of enhanced endotoxin sensitivity that is observed during cholestasis induced by bdl.

The effect of preoperative biliary drainage on postoperative complications after pancreaticoduodenectomy

BACKGROUND

The benefit of preoperative biliary drainage in jaundiced patients undergoing pancreaticoduodenectomy for a suspected malignancy of the periampullary region is still under debate. This study evaluated preoperative biliary drainage in relation to postoperative outcomes.

STUDY DESIGN

At the Academic Medical Center, Amsterdam, the Netherlands, a cohort of 311 patients undergoing pancreaticoduodenectomy from June 1992 up to and including December 1999 was studied. Of this cohort 21 patients with external or surgical biliary drainage were excluded and 232 patients who had received preoperative internal biliary drainage were divided into three groups corresponding with severity of jaundice according to preoperative plasma bilirubin levels: < 40 microM (n = 177), 40 to 100 microM (n = 32), and > 100 microM (n = 23) were designated as groups 1, 2, and 3, respectively. These groups were compared with patients who underwent immediate surgery (n = 58) without preoperative drainage.

RESULTS

The median number of stent (re)placements was 2 (range 1 to 6) with a median drainage duration of 41 days (range 2 to 182 days) and a stent dysfunction rate of 33%. Although patients in group 1 were better drained than patients in groups 2 and 3 (median reduction of bilirubin levels 82%, 57%, and 37%, respectively, p < 0.01), there was no difference in overall morbidity among the drained groups (50%, 50%, and 52%, respectively). There was no significant difference in overall morbidity between patients with and without preoperative biliary drainage (50% and 55%, respectively).

CONCLUSIONS

Preoperative biliary drainage did not influence the incidence of postoperative complications, and although it can be performed safely in jaundiced patients it should not be used routinely.

Acute (ascending) cholangitis

Cholangitis is an infection of an obstructed biliary system, most commonly due to common bile duct stones. Bacteria reach the biliary system either by ascent from the intestine or by the portal venous system. Once the biliary system is colonized, biliary stasis allows bacterial multiplication, and increased biliary pressures enable the bacteria to penetrate cellular barriers and enter the bloodstream. Patients with cholangitis are febrile, often have abdominal pain, and are jaundiced. A minority of patients present in shock with hypotension and altered mentation. There is usually a leukocytosis, and the alkaline phosphatase and bilirubin levels are generally elevated. Noninvasive diagnostic techniques include sonography, which is the recommended initial imaging modality. Standard CT, helical CT cholangiography, and magnetic resonance cholangiography often add important information regarding the type and level of obstruction. Endoscopic sonography is a more invasive means of obtaining high-quality imaging, and endoscopic or percutaneous cholangiography offers the opportunity to perform a therapeutic procedure at the time of diagnostic imaging. Endoscopic modalities currently are favored over percutaneous procedures because of a lower risk of complication. Treatment includes fluid resuscitation and antimicrobial agents that cover enteric flora. Biliary decompression is required when patients do not rapidly respond to conservative therapy. Definitive therapy can be performed by a surgical, percutaneous, or endoscopic route; the last is favored because it is the least invasive and has the lowest complication rate. Overall prognosis depends on the severity of the illness at the time of presentation and the cause of the biliary obstruction.

Intestinal barrier dysfunction in clinical and experimental obstructive jaundice and its reversal by internal biliary drainage

Intestinal mucosal barrier function in obstructive jaundice was assessed in an animal model and in patients. The effect of internal biliary drainage in patients was also examined. Bile duct ligation for 1 week in the rat resulted in significant bacterial translocation (in seven of 12 animals following ligation versus none of the shamoperated controls, P < 0.01). Intestinal permeability, measured by the urinary recovery of orally administered polyethylene glycol, was also significantly increased (+66.2 per cent for ligation versus -11.6 per cent for sham, P < 0.01). A prospective study was performed on 33 patients with obstructive jaundice undergoing internal biliary drainage, and results were compared with those in six non-jaundiced patients undergoing laparotomy or endoscopic retrograde cholangiopancreatography and in 11 health volunteers. The lactulose: mannitol ratio was used as an intestinal permeability index. Mean(s.e.m.) intestinal permeability assessed before operation was significantly increased in jaundiced patients compared with control patients (0.050(0.010) versus 0.016(0.003), P < 0.005). The mean(s.e.m.) lactulose: mannitol ratio in the healthy volunteers was 0.020(0.003), which was similar to that in control patients. In the jaundiced group of patients the intestinal permeability index fell to within normal levels after 28 days of internal biliary drainage (0.050 before operation versus 0.021 at 28 days, P < 0.02). These data indicate that intestinal barrier function is impaired in obstructive jaundice and that this impairment is reversed by return of bile to the gastrointestinal tract.

Biliary decompression promotes Kupffer cell recovery in obstructive jaundice

BACKGROUND

Jaundiced patients undergoing surgical procedures have an increased risk of Gram negative sepsis with potential morbidity and mortality. Depressed Kupffer cell clearance capacity (KCCC) predisposes jaundiced patients to endotoxaemia and its sequelae. Biliary decompression remains the main therapeutic strategy in obstructive jaundice.

AIMS

This study investigates the efficacy of internal (ID) and external biliary drainage (ED) on KCCC in an experimental model of extrahepatic biliary obstruction.

METHODS

Adult male Wistar rats (250-300 g) were assigned to one of six groups: sham operated, where the bile duct was mobilised but not divided; bile duct ligation (BDL) for three weeks, and sham operated or BDL for three weeks followed by a second laparotomy and further 21 days of ID or ED, by way of choledochoduodenostomy or choledochovesical fistula respectively. KCCC was measured using an isolated hepatic perfusion technique with FITC labelled latex particles (0.75 mu) as the test probe. Plasma was assayed for bilirubin, endotoxin, and anticore glycolipid antibody (ACGA) concentrations.

RESULTS

Jaundiced rats had reduced KCCC (p < 0.001), increased concentrations of ACGA (p < 0.001), and endotoxin (p < 0.001) compared with controls. Biliary drainage for three weeks produced a recovery in KCCC and normalisation of endotoxin and ACGA concentrations, however, external drainage was less effective than ID (p < 0.01).

CONCLUSIONS

These data support the hypothesis that endotoxaemia and its mediated effects are integral in the pathophysiology of jaundice. Furthermore, a short period of internal biliary drainage is a useful therapeutic strategy in restoring Kupffer cell function and negating systemic endotoxaemia and consequent complications in biliary obstruction.

Leukocyte and platelet depletion protects the liver from damage induced by cholestasis and ischemia-reperfusion in the dog

BACKGROUND

Ischemia-reperfusion injury has been studied in various organs. The effects of leukocyte and platelet depletion on cholestasis and ischemia-reperfusion-induced liver damage were evaluated in the dog liver.

METHODS

The left hepatic duct was ligated for 4 weeks to create a cholestatic lobe. An ischemic condition was produced for 60 min by stopping the peristaltic pump supplying blood to the liver. The metabolism of substances modulated in the liver during cholestasis and I-R was assessed in non-treated and in leukocyte- and platelet-depleted animals.

RESULTS

The extraction rate of insulin and indocyanine green decreased during cholestasis and ischemia-reperfusion. Cholestasis accelerated the release of thromboxane A2 but not prostaglandin I2 after ischemia-reperfusion. Ischemia-reperfusion accelerated the release of prostaglandin I2 and thromboxane A2 from the liver. Further, ischemia-reperfusion increased the ratio of thromboxane A2 to prostaglandin I2. Cholestasis promoted an increase in the level. Ischemia-reperfusion caused an increase in the lipid peroxide level, and no change in the alpha-tocopherol level. Ischemia-reperfusion caused an increase in the lipid peroxide level, a decrease in the alpha-tocopherol level, and no change in the glutathione level. Depletion of leukocytes and platelets reduced these changes during cholestasis and ischemia-reperfusion.

CONCLUSIONS

Depletion of leukocytes and platelets thus appears to protect liver function from cholestasis and ischemia-reperfusion injury by reducing peroxidation of lipids composing the cell membrane and the rate of thromboxane A2 prostaglandin I2, which predicts cellular damage, and by increasing the levels of alpha-tocopherol and glutathione, believed to be free radical scavengers.

Reticuloendothelial system function in acute liver injury induced by D-galactosamine

AIMS/METHODS

Reticuloendothelial system function, as assessed by clearance of radiolabelled bacteria, was evaluated in acute liver injury induced by D-galactosamine in rats, and compared with that after 70% liver resection model.

RESULTS

Reticuloendothelial system function was significantly impaired in both instances, but the extent and the pattern of reticuloendothelial system impairment differed in the two models. While the elimination rate of the radiolabelled bacteria (k-value) decreased in both the liver resection and D-galactosamine groups (19% and 52%, respectively), the corrected phagocytic index (alpha) increased in 70% liver resection (247%), indicatine increased activity among the remaining reticuloendothelial system cells of the liver. Estimation of subserosal organ blood flow showed decreased flow to the cecum and distal small intestine (correction of intesting) in both groups, whereas it was significantly increased (477%) in the remaining parts of the liver in the liver resection group.

CONCLUSIONS

These findings show that reticuloendothelial system activity is deranged in both these groups, which may explain the increased occurrence of bacterial complications observed in corresponding clinical conditions.

Biliary drainage in obstructive jaundice: experimental and clinical aspects

Jaundiced patients undergoing invasive diagnostic and therapeutic procedures are at increased risk of complications and death. Despite the large number of clinical and experimental investigations carried out to identify relevant risk factors, no single parameter has been found to be consistently useful in predicting morbidity or mortality. Biliary decompression was initially employed by surgeons and subsequently by interventional radiologists. More recently, endoscopic retrograde cholangiopancreatography has provided an alternative route for decompression of the biliary tree and preliminary data using this method are encouraging. Although there are enthusiastic proponents of various therapeutic techniques, controlled trials have not been convincing in highlighting the benefits of biliary drainage or in determining the best approach. This article reviews the literature pertaining to this complex surgical problem; an attempt has been made to balance the advantages and disadvantages of biliary decompression as palliation and/or preliminary treatment for extrahepatic biliary obstruction.