Effect of alcohol on gastrointestinal cell regeneration as a possible mechanism in alcohol-associated carcinogenesis

Ethanol exposure exacerbates 4-nitroquinoline-1-oxide induced esophageal carcinogenesis and induces invasive carcinoma with muscularis propria infiltration in a mouse model

Esophageal squamous cell carcinoma (ESCC) is one of the most fatal cancers worldwide. Most ESCC patients are diagnosed at an advanced stage; however, current research on in vivo animal models accurately reflecting their clinical presentation is lacking. Alcohol consumption is a major risk factor for ESCC and has been used in several disease models for disease induction. In this study, we used 4-nitroquinoline-1-oxide in combination with ethanol to induce an in vivo ESCC mouse model. Esophageal tissues were stained with hematoxylin and eosin for histopathological examination and lesion scoring. In cellular experiments, cell adhesion and migration invasion ability were observed using phalloidin staining, cell scratch and transwell assays, respectively, and the expression of epithelial-mesenchymal transition-related markers was detected using quantitative reverse transcription polymerase chain reaction and western blotting. The results showed that ethanol-exposed mice lost more weight and had an increased number of esophageal nodules. Histological examination revealed that the lesion scores of the ethanol-exposed esophageal samples were significantly higher than those of the unexposed esophageal samples. Furthermore, ethanol-exposed esophageal cancer samples had more severe lesions with infiltration of tumor cells into the muscularis propria. In vitro cellular experiments showed that ethanol exposure induced cytoskeletal microfilament formation, promoted cell migration invasion elevated the expression of N-cadherin and Snail, and decreased the expression of E-cadherin. In conclusion, ethanol exposure exacerbates ESCC, promotes tumor cell infiltration into the muscularis propria, and could be an effective agent for establishing innovative models of invasive carcinoma.

Alcohol-Associated Tissue Injury: Current Views on Pathophysiological Mechanisms

At-risk alcohol use is a major contributor to the global health care burden and leads to preventable deaths and diseases including alcohol addiction, alcoholic liver disease, cardiovascular disease, diabetes, traumatic injuries, gastrointestinal diseases, cancers, and fetal alcohol syndrome. Excessive and frequent alcohol consumption has increasingly been linked to alcohol-associated tissue injury and pathophysiology, which have significant adverse effects on multiple organ systems. Extensive research in animal and in vitro models has elucidated the salient mechanisms involved in alcohol-induced tissue and organ injury. In some cases, these pathophysiological mechanisms are shared across organ systems. The major alcohol- and alcohol metabolite-mediated mechanisms include oxidative stress, inflammation and immunometabolic dysregulation, gut leak and dysbiosis, cell death, extracellular matrix remodeling, endoplasmic reticulum stress, mitochondrial dysfunction, and epigenomic modifications. These mechanisms are complex and interrelated, and determining the interplay among them will make it possible to identify how they synergistically or additively interact to cause alcohol-mediated multiorgan injury. In this article, we review the current understanding of pathophysiological mechanisms involved in alcohol-induced tissue injury.

Wine Consumption and Oral Cavity Cancer: Friend or Foe, Two Faces of Janus

The health benefits of moderate wine consumption have been extensively studied during the last few decades. Some studies have demonstrated protective associations between moderate drinking and several diseases including oral cavity cancer (OCC). However, due to the various adverse effects related to ethanol content, the recommendation of moderate wine consumption has been controversial. The polyphenolic components of wine contribute to its beneficial effects with different biological pathways, including antioxidant, lipid regulating and anti-inflammatory effects. On the other hand, in the oral cavity, ethanol is oxidized to form acetaldehyde, a metabolite with genotoxic properties. This review is a critical compilation of both the beneficial and the detrimental effects of wine consumption on OCC.

Pathophysiological Mechanisms of Gastrointestinal Toxicity

Humans swallow a great variety and often large amounts of chemicals as nutrients, incidental food additives and contaminants, drugs, and inhaled particles and chemicals, thus exposing the gastrointestinal tract to many potentially toxic substances. It serves as a barrier in many cases to protect other components of the body from such substances and infections. Fortunately, the gastrointestinal tract is remarkably robust and generally is able to withstand multiple daily assaults by the chemicals to which it is exposed. Some chemicals, however, can affect one or more aspects of the gastrointestinal tract to produce abnormal events that reflect toxicity. It is the purpose of this chapter to evaluate the mechanisms by which toxic chemicals produce their deleterious effects and to determine the consequences of the toxicity on integrity of gastrointestinal structure and function. Probably because of the intrinsic ability of the gastrointestinal tract to resist toxic chemicals, there is a paucity of data regarding gastrointestinal toxicology. It is therefore necessary in many cases to extrapolate toxic mechanisms from infectious processes, inflammatory conditions, ischemia, and other insults in addition to more conventional chemical sources of toxicity.

Molecular Basis of Alcohol-Related Gastric and Colon Cancer

Many meta-analysis, large cohort studies, and experimental studies suggest that chronic alcohol consumption increases the risk of gastric and colon cancer. Ethanol is metabolized by alcohol dehydrogenases (ADH), catalase or cytochrome P450 2E1 (CYP2E1) to acetaldehyde, which is then further oxidized to acetate by aldehyde dehydrogenase (ALDH). Acetaldehyde has been classified by the International Agency for Research on Cancer (IARC) as a Group 1 carcinogen to humans. The acetaldehyde level in the stomach and colon is locally influenced by gastric colonization by Helicobacter pylori or colonic microbes, as well as polymorphisms in the genes encoding tissue alcohol metabolizing enzymes, especially ALDH2. Alcohol stimulates the uptake of carcinogens and their metabolism and also changes the composition of enteric microbes in a way to enhance the aldehyde level. Alcohol also undergoes chemical coupling to membrane phospholipids and disrupts organization of tight junctions, leading to nuclear translocation of β-catenin and ZONAB, which may contributes to regulation of genes involved in proliferation, invasion and metastasis. Alcohol also generates reactive oxygen species (ROS) by suppressing the expression of antioxidant and cytoprotective enzymes and inducing expression of CYP2E1 which contribute to the metabolic activation of chemical carcinogens. Besides exerting genotoxic effects by directly damaging DNA, ROS can activates signaling molecules involved in inflammation, metastasis and angiogenesis. In addition, alcohol consumption induces folate deficiency, which may result in aberrant DNA methylation profiles, thereby influencing cancer-related gene expression.

Dietary Total Antioxidant Capacity and Colorectal Cancer in the Italian EPIC Cohort

Background

Colorectal cancer is the third most common cancer worldwide. Diet has been hypothesized as involved in colorectal cancer etiology, but few studies on the influence of total dietary antioxidant intake on colorectal cancer risk have been performed.

Methods

We investigated the association between colorectal cancer risk and the total antioxidant capacity (TAC) of the diet, and also of intake of selected antioxidants, in 45,194 persons enrolled in 5 centers (Florence, Naples, Ragusa, Turin and Varese) of the European Prospective Investigation into Cancer and Nutrition (EPIC) Italy study. TAC was estimated by the Trolox equivalent antioxidant capacity (TEAC) assay. Hazard ratios (HRs) for developing colorectal cancer, and colon and rectal cancers separately, adjusted for confounders, were estimated for tertiles of TAC by Cox modeling, stratifying by center.

Results

Four hundred thirty-six colorectal cancers were diagnosed over a mean follow-up of 11.28 years. No significant association between dietary TAC and colorectal cancer incidence was found. However for the highest category of TAC compared to the lowest, risk of developing colon cancer was lower (HR: 0.63; 95% CI: 0.44–0.89, P trend: 0.008). By contrast, increasing TAC intake was associated with significantly increasing risks of rectal cancer (2nd tertile HR: 2.09; 95%CI: 1.19–3.66; 3rd tertile 2.48 95%CI: 1.32–4.66; P trend 0.007). Intakes of vitamin C, vitamin E, and ß-carotene were not significantly associated with colorectal cancer risk.

Conclusions

Further prospective studies are needed to confirm the contrasting effects of high total antioxidant intake on risk of colon and rectal cancers.

Implications of acetaldehyde-derived DNA adducts for understanding alcohol-related carcinogenesis

Among various potential mechanisms that could explain alcohol carcinogenicity, the metabolism of ethanol to acetaldehyde represents an obvious possible mechanism, at least in some tissues. The fundamental principle of genotoxic carcinogenesis is the formation of mutagenic DNA adducts in proliferating cells. If not repaired, these adducts can result in mutations during DNA replication, which are passed on to cells during mitosis. Consistent with a genotoxic mechanism, acetaldehyde does react with DNA to form a variety of different types of DNA adducts. In this chapter we will focus more specifically on N2-ethylidene-deoxyguanosine (N2-ethylidene-dG), the major DNA adduct formed from the reaction of acetaldehyde with DNA and specifically highlight recent data on the measurement of this DNA adduct in the human body after alcohol exposure. Because results are of particular biological relevance for alcohol-related cancer of the upper aerodigestive tract (UADT), we will also discuss the histology and cytology of the UADT, with the goal of placing the adduct data in the relevant cellular context for mechanistic interpretation. Furthermore, we will discuss the sources and concentrations of acetaldehyde and ethanol in different cell types during alcohol consumption in humans. Finally, in the last part of the chapter, we will critically evaluate the concept of carcinogenic levels of acetaldehyde, which has been raised in the literature, and discuss how data from acetaldehyde genotoxicity are and can be utilized in physiologically based models to evaluate exposure risk.

Commentary: acetaldehyde and epithelial-to-mesenchymal transition in colon

Elamin and colleagues in this issue report that acetaldehyde activates Snail, a transcription factor involved in epithelial-to-mesenchymal transition, in an intestinal epithelium. Snail mediates acetaldehyde-induced tight junction disruption and increase in paracellular permeability. Results of this study and other previous studies raise several important questions. This commentary addresses these questions by discussing the acetaldehyde concentration in colon, disruption of epical junctional complexes in the intestinal epithelium by acetaldehyde, and the consequence of long-term exposure to acetaldehyde on colonic epithelial regeneration, carcinogenesis, and metastases. The precise role of acetaldehyde in colonic epithelial modifications and promotion of colorectal cancers still remains to be understood.

Subsite-specific dietary risk factors for colorectal cancer: a review of cohort studies

Objective. A shift in the total incidence from left- to right-sided colon cancer has been reported and raises the question as to whether lifestyle risk factors are responsible for the changing subsite distribution of colon cancer. The present study provides a review of the subsite-specific risk estimates for the dietary components presently regarded as convincing or probable risk factors for colorectal cancer: red meat, processed meat, fiber, garlic, milk, calcium, and alcohol. Methods. Studies were identified by searching PubMed through October 8, 2012 and by reviewing reference lists. Thirty-two prospective cohort studies are included, and the estimates are compared by sex for each risk factor. Results. For alcohol, there seems to be a stronger association with rectal cancer than with colon cancer, and for meat a somewhat stronger association with distal colon and rectal cancer, relative to proximal colon cancer. For fiber, milk, and calcium, there were only minor differences in relative risk across subsites. No statement could be given regarding garlic. Overall, many of the subsite-specific risk estimates were nonsignificant, irrespective of exposure. Conclusion. For some dietary components the associations with risk of cancer of the rectum and distal colon appear stronger than for proximal colon, but not for all.

Concomitant consumption of marijuana, alcohol and tobacco in oral squamous cell carcinoma development and progression: recent advances and challenges

Oral squamous cell carcinoma (OSCC) corresponds to 95% of all malignant tumours of the mouth. The association between alcohol and tobacco is the major risk factor for this disease, increasing the chances for the development of OSCC by 35-fold. The plant, Cannabis sativa is smoked as cigarettes or blunts and is commonly used in association with tobacco and alcohol. Any type of smoking habit exposes individuals to a wide range of carcinogens or pro-carcinogens, such as polycyclic aromatic hydrocarbons, as well as some ethanol derived substances such as acetaldehyde (AA), and all are genotoxic in the same way. In addition, ethanol acts in the oral mucosa as a solvent and therefore increases the cellular membrane permeability to carcinogens. Carcinogens found in tobacco are also concentrated in marijuana, but the latter also contains high levels of cannabinoids, bioactive compounds responsible for several effects such as euphoria and analgesia. However, Δ(9)-tetrahydrocannabinol (Δ(9)-THC), the major psychotropic cannabinoid found in plants, causes a reduction of cellular metabolism and induction of apoptosis, both of which are anti-neoplastic properties. Apart from limited epidemiologic and experimental data, the effects of concomitant chronic exposure to marijuana (or Δ(9)-THC), tobacco and alcohol in OSCC development and progression is poorly known. This paper reviews the most recent findings on the effects of marijuana over cellular proliferation, as well as in the risk for OSCC, with emphasis on its interaction with tobacco and ethanol consumption.

Markers of the APC/β-catenin signaling pathway as potential treatable, preneoplastic biomarkers of risk for colorectal neoplasms

BACKGROUND

Malfunctioning of the adenomatous polyposis coli (APC)/β-catenin signaling pathway is both an early and common event in sporadic colorectal cancer. To assess the potential of APC/β-catenin signaling pathway markers as treatable, preneoplastic biomarkers of risk for colorectal neoplasms, we conducted a pilot colonoscopy-based case-control study (51 cases and 154 controls) of incident, sporadic colorectal adenoma.

METHODS

We evaluated APC, β-catenin, and E-cadherin expression in normal mucosa from the rectum and ascending and sigmoid colon using automated immunohistochemical and quantitative image analysis. Diet, lifestyle, and medical history were assessed with validated questionnaires.

RESULTS

In the normal rectal mucosa, the ratio of the proportion of APC expression in the upper 40% of crypts with total β-catenin expression (APC/β-catenin score) was 14.3% greater in controls than in cases [P = 0.02; OR, 0.40; 95% confidence interval (CI), 0.14-1.14]. Compared with controls, in cases, APC expression was 3.2% lower, β-catenin expression was 3.0% higher, and E-cadherin expression was 0.7% lower; however, none of these differences were statistically significant. The APC/β-catenin score statistically significantly differed according to categories of plausible risk factors for colorectal cancer [e.g., it was 17.7% higher among those with 25(OH) vitamin D(3) concentrations ≥ 27 ng/mL].

CONCLUSIONS

These preliminary data suggest that the combined expression of APC and β-catenin in the normal rectal mucosa may be associated with risk for incident, sporadic colorectal neoplasms, as well as with modifiable risk factors for colorectal neoplasms.

IMPACT

Our results may help advance the development of treatable, preneoplastic biomarkers of risk for colorectal neoplasms.

Quantitative evaluation of SPRR3 expression in esophageal squamous cell carcinoma by qPCR and its potential use as a biomarker

Esophageal squamous cell carcinoma (ESCC) is highly fatal due to late diagnosis and inefficient treatment. Early disease detection could improve diagnosis and patient survival. Esophageal squamous epithelial cells express SPRR3, a member of the small proline-rich protein family, which is downregulated in ESCC. Therefore, SPRR3 expression may be used as a biomarker to follow the transition from healthy mucosa to ESCC. Both SPRR3 mRNA splice variants, v1 and v2, were evaluated by real time PCR in tumor and histologically normal adjacent tissue biopsies from 84 ESCC patients and 18 healthy controls. SPRR3-v1 was most highly expressed in the esophageal mucosa of healthy subjects, with an increasingly lower expression in the adjacent mucosa of ESCC patients and in tumors, respectively. SPRR3-v2 expression was low in normal mucosa and in tumors but it was higher in the adjacent mucosa of ESCC patients. In addition, we found a significant correlation between a lower SPRR3-v1 and SPRR3-v2 expression and age and alcohol consumption, respectively. SPRR3 protein expression presented a good correlation with SPRR3 mRNA expression. Cut-off points to discriminate between healthy mucosa, tumor and adjacent mucosa were determined with receiver operating characteristic (ROC) curves. This analysis showed that SPRR3-v1 expression discriminates the esophageal mucosa of healthy subjects from the adjacent mucosa and the tumor of ESCC patients with high sensitivity and specificity. Our data shows that the quantitative analysis of SPRR3 mRNA is a robust and reliable method to monitor the malignant transformation of the healthy esophageal mucosa into ESCC.

Nucleolar organizer regions (AgNOR) and subepithelial vascularization as field cancerization markers in oral mucosa biopsies of alcoholic and smoking patients

OBJECTIVE

The aim of this study was to show that variations in nucleolar organizer regions (AgNOR) and the increase in subepithelial vascularization could reveal changes related to markers of field cancerization in alcoholic and smoking patients who have not yet expressed clinical or histological malignant lesions.

STUDY DESIGN

Quantitative variations in epithelial AgNOR and in the vascularization of the underlying connective tissue were assessed by image analysis in histologically normal biopsy specimens from alcohol drinkers and smoking patients (DS). AgNORs were evidenced by silver staining and vessel walls were labeled by immunohistochemical demonstration of the CD34 antigen. Samples of oral mucosa of nonalcoholic, nonsmoking patients (NDS) obtained during surgical procedures served as controls. Eight parameters related to number, volume, and shape of nuclei and AgNORs, and 4 parameters related to number and diameter of vascular sections were evaluated. Differences between DS and NDS groups were statistically evaluated by means of ANOVA test and posterior Bonferroni comparisons.

RESULTS

The morphometric analysis revealed more irregular-shaped AgNORs in the superficial and suprabasal layers of the oral mucosa of DS patients. The suprabasal layers also exhibited a significantly larger number of AgNORs. The normal oral mucosa of DS patients exhibited a greater vascular density, with predominance of small-caliber blood vessels underlying the basement membrane.

CONCLUSION

The variations in AgNOR and epithelial vascularization would be practical biomarkers to evaluate changes underlying the augmented risk of cancerization in oral mucosa.

Polyamines stimulate the formation of mutagenic 1,N2-propanodeoxyguanosine adducts from acetaldehyde

Alcoholic beverage consumption is associated with an increased risk of upper gastrointestinal cancer. Acetaldehyde (AA), the first metabolite of ethanol, is a suspected human carcinogen, but the molecular mechanisms underlying AA carcinogenicity are unclear. In this work, we tested the hypothesis that polyamines could facilitate the formation of mutagenic α-methyl-γ-hydroxy-1,N²-propano-2′-deoxyguanosine (Cr-PdG) adducts from biologically relevant AA concentrations. We found that Cr-PdG adducts could be formed by reacting deoxyguanosine with μM concentrations of AA in the presence of spermidine, but not with either AA or spermidine alone. The identities of the Cr-PdG adducts were confirmed by both liquid and gas chromatography-mass spectrometry. Using a novel isotope-dilution liquid chromatography-mass spectrometry assay, we found that in the presence of 5 mM spermidine, AA concentrations of 100 μM and above resulted in the formation of Cr-PdG in genomic DNA. These AA levels are within the range that occurs in human saliva after alcoholic beverage consumption. We also showed that spermidine directly reacts with AA to generate crotonaldehyde (CrA), most likely via an enamine aldol condensation mechanism. We propose that AA derived from ethanol metabolism is converted to CrA by polyamines in dividing cells, forming Cr-PdG adducts, which may be responsible for the carcinogenicity of alcoholic beverage consumption.

Novel and quantitative DNA dot-blotting method for assessment of in vivo proliferation

Immunohistochemical assessment of 5-bromo-2-deoxyuridine (BrdU) in tissue sections is a widely used method to evaluate cell proliferation in vivo. However, this method requires time-consuming preparation of paraffin sections and laborious counting of BrdU-labeled nuclei on multiple sections. Here, we report the development of a rapid and reliable method to quantitate BrdU incorporation in intestinal and liver tissues using a dot-blot method. In vivo models of colon or liver proliferation were used to analyze the usefulness and reliability of this new method. Mice were killed after BrdU injection, and genomic DNA was isolated from the tissues, denatured, and dot-blotted onto a nitrocellulose membrane. The incorporated BrdU was detected with a BrdU monoclonal antibody, and the signal intensity was densitometrically quantified. Results were compared with BrdU index determined by conventional immunohistochemistry on the same tissue samples. The patterns of colonic BrdU incorporation during fasting and refeeding, measured by the dot-blotting method and the immunohistochemical method, were similar. The BrdU incorporation in the regenerating liver after partial hepatectomy, evaluated by these two different methods, showed a strong correlation (R(2) = 0.91, P < 0.01). In addition, the inhibition of colon proliferation by the phosphoinositol 3-kinase inhibitor wortmannin was demonstrated by this dot-blotting method. In conclusion, the dot-blotting technique described in this report provides an accurate, more efficient, and possibly more reliable method for the assessment of in vivo proliferation compared with conventional immunohistochemical determination of BrdU-labeling index.

DNA adducts from acetaldehyde: implications for alcohol-related carcinogenesis

Alcoholic beverage consumption is classified as a known human carcinogen, causally related to an increased risk of cancer of the upper gastrointestinal tract. The formation of acetaldehyde from ethanol metabolism seems to be the major mechanism underlying this effect. Acetaldehyde is carcinogenic in rodents and causes sister chromatid exchanges and chromosomal aberrations in human cells. The best-studied DNA adduct from acetaldehyde is N(2)-ethyl-2'-deoxyguanosine, which is increased in liver DNA obtained from ethanol-treated rodents and in white blood cells obtained from human alcohol abusers. However, the carcinogenic relevance of this adduct is unclear in view of the lack of evidence that it is mutagenic in mammalian cells. A different DNA adduct, 1,N(2)-propano-2'-deoxyguanosine (PdG), can also be formed from acetaldehyde in the presence of histones and other basic molecules. PdG has been shown to be responsible for the genotoxic and mutagenic effects of crotonaldehyde. The PdG adduct can exist in either of two forms: a ring-closed form or a ring-opened aldehyde form. Whereas the ring-closed form is mutagenic, the aldehyde form can participate in the formation of secondary lesions, including DNA-protein cross-links and DNA interstrand cross-links. The formation of these types of complex secondary DNA lesions resulting from PdG may explain many of the observed genotoxic effects of acetaldehyde described above. Repair of PdG and its associated adducts is complex, involving multiple pathways. Inherited variation in the genes encoding the proteins involved in the repair of PdG and its secondary adducts may contribute to susceptibility to alcoholic beverage-related carcinogenesis.

Alcohol consumption and risk of colon cancer: evidence from the national health and nutrition examination survey I epidemiologic follow-up study

The epidemiologic findings on the relationship between alcohol consumption and colon cancer are inconsistent. The National Health and Nutrition Examination Survey (NHANES) I Epidemiologic Follow-Up Study (NHEFS) included a prospective cohort population representative of the general U.S. population, which had not been fully utilized for examining the risk between colon cancer and alcohol drinking. The NHEFS consisted of 10,220 participants prospectively followed over a decade. Alcohol consumption, amount and type of beverage, and drinking patterns at baseline were considered in examination of the effect of alcohol consumption on the risk of colon cancer. The consumption of one or more alcoholic beverages a day at baseline was associated with approximately a 70% greater risk of colon cancer [relative risk (RR)=1.69; 95% confidence interval (CI)=1.03, 2.79], with a strong positive dose-response relationship (P=0.04). This association appeared to be exclusively related to daily drinking of one or more drinks of liquor (RR=2.48; 95% CI=1.66, 4.53). Additionally, more than a 70% increased risk of colon cancer was observed for more than 34 yr of alcohol drinking history compared with nondrinkers (RR=1.73; 95% CI=1.08, 2.78). Overall, alcohol consumption was significantly associated with increased risk of colon cancer. The most important factor for colon cancer seems to be liquor consumption.

Alcohol-related diseases of the mouth and throat

Chronic consumption of alcoholic beverages is an accepted social custom worldwide. In the upper aerodigestive tract, local morphologic, metabolic and functional alterations are present due to alcohol consumption. A clinical link between the chronic consumption of alcohol and head and neck cancer has been observed for decades. While alcohol was described initially as a risk enhancer only in smokers, a number of epidemiological studies have now provided sufficient evidence that chronic alcohol consumption increases the risk of head and neck cancer independent of exposure to tobacco smoke. The systemic effects of alcohol interact with local changes in the morphology and function of the salivary glands. In addition, alcohol leads to accumulation of pathologic microbes within the mucosa, leading to chronic infection. Susceptibility to carcinogens and cell proliferation in the mucosa are increased, resulting in genetic changes with the development of dysplasia, leukoplacia and carcinoma. Chronic alcohol consumption is correlated with an increased risk of cancer and an increased mortality in a dose-effect relationship. A number of biologically plausible mechanisms exist by which alcohol may cause cancer. These mechanisms are discussed in this article.

Animal models and their results in gastrointestinal alcohol research

Alcohol-induced diseases of the gastrointestinal tract play an important role in clinical gastroenterology. However, the precise pathophysiological mechanisms are still largely unknown. Alcohol research depends essentially on animal models due to the fact that controlled experimental studies of ethanol-induced diseases in humans are unethical. Animal models have already been successfully applied to disclose and analyze molecular mechanisms in alcohol-induced diseases, partially by using knockout technology. Because of a lack of transferability of some animal models to the human condition, results have to be interpreted cautiously. For some alcohol-related diseases like chronic alcoholic pancreatitis, the ideal animal model does not yet exist. Here we provide an overview of the most commonly used animal models in gastrointestinal alcohol research. We will also briefly discuss the findings based on animal models as well as the current concepts of pathophysiological mechanisms involved in acute and chronic alcoholic damage of the esophagus, stomach, small and large intestine, pancreas and liver.

[Alcohol related diseases of the head and neck]

Chronic consumption of alcohol is an accepted social custom worldwide. In the upper aerodigestive tract, local morphologic, metabolic and functional alterations can be present due such consumption. Gastroesophageal reflux or alterations in sleep structure are typical examples of functional disorders. While alcohol was initially described as a risk enhancer only in smokers, a number of epidemiological studies have now shown that chronic alcohol consumption increases the risk of head and neck cancer independently of exposure to tobacco smoke. In addition, alcohol leads to an accumulation of pathologic microbes within the mucosa, leading to chronic infection. Susceptibility to carcinogens and cell proliferation in the mucosa are increased, resulting in genetic changes with the development of dysplasia, leucoplakia and carcinoma. Chronic alcohol consumption is correlated with an increased risk of cancer and increased mortality in a dose-dependent relationship. A number of biologically plausible mechanisms exist by which alcohol may cause cancer.

Alcohol-related diseases of the mouth and throat

Chronic consumption of alcoholic beverages is an accepted social custom worldwide. In the upper aerodigestive tract, local morphological, metabolic and functional alterations can be present as a result of alcohol consumption. A clinical link between the chronic consumption of alcohol and head and neck cancer has been observed for decades. While alcohol was described initially as a risk enhancer only in smokers, a number of epidemiological studies have now provided sufficient evidence that chronic alcohol consumption increases the risk of head and neck cancer independent of exposure to tobacco smoke. Systemic effects of alcohol interact with local changes in the morphology and function of the salivary glands. In addition, alcohol leads to the accumulation of pathological microbes within the mucosa, leading to chronic infection. Susceptibility to carcinogens and cell proliferation in the mucosa are increased, resulting in genetic changes with the development of dysplasia, leucoplakia and carcinoma. Chronic alcohol consumption has been correlated with an increased risk of cancer and increased mortality in a dose-effect relationship. A number of biologically plausible mechanisms exist by which alcohol may cause cancer. These mechanisms are discussed in this chapter.

Proliferating cell nuclear antigen expression on tongue of mice after intake of, or topical exposure to, alcohol

The purpose of the current study was to evaluate the effects of alcohol on cellular proliferation. Sixty mice were separated into three groups of 20 mice in each. The first group, exposed to alcohol continuously, ingested 40% [volume/volume (vol./vol.)] alcohol instead of water during the experiment. For the second group, exposed to alcohol topically, alcohol was applied to the dorsum of the tongue twice a week. The third group served as the control group. We used the proliferating cell nuclear antigen (PCNA) immunohistochemical expression technique to perform quantitative measurements of cellular proliferation in the basal and intermediate layers of the epithelial tissue of the tongue. Cell proliferation was quantified at three different time points: just before the beginning of the experiment and at 6 and 12 months. Results were compared for mice in each group and for the three groups. At 12 months, we observed an increase in cellular proliferation in the intermediate layer of the epithelium of mice in the group that consumed alcohol (P=.01). Results for topical alcohol-exposed and control groups did not show significant differences in cellular proliferation at any time point during the study. We concluded that the effects of alcohol on cellular proliferation may be caused by continuous intake of alcohol and occur throughout life.

Animal models in gastrointestinal alcohol research-a short appraisal of the different models and their results

Alcohol-related diseases of the gastrointestinal tract play an important role in clinical gastroenterology. However, the mechanisms and pathophysiology underlying the effects of ethanol on the organs of the digestive tract are not yet completely understood. Animal models represent an essential tool for investigating alcohol-related diseases because they give researchers the opportunity to use methods that cannot be used in humans, such as knockout technology. However, there is still a need for new animal models resembling the human condition, since for some alcohol-related diseases such as chronic alcoholic pancreatitis, the ideal animal model does not yet exist. In this chapter, we provide an overview of the most commonly used animal models in gastrointestinal alcohol research. We will also briefly discuss the current concepts of the pathophysiological mechanisms involved in acute and chronic alcoholic damage of the oesophagus, stomach, small and large intestine, pancreas and liver.

Neoplastic and antineoplastic effects of beta-carotene on colorectal adenoma recurrence: results of a randomized trial

BACKGROUND

In two large, randomized prevention trials, supplementation with beta-carotene increased the risk of lung cancer. Subjects in these studies were predominantly cigarette smokers, and the adverse effects were concentrated among those who also drank alcohol. Although beta-carotene supplementation appeared not to increase the risk of cancer generally, it is not clear if smoking and/or alcohol use alters the effect of beta-carotene on carcinogenesis at sites outside the lung.

METHODS

We studied the effect of beta-carotene supplementation on colorectal adenoma recurrence among subjects in a multicenter double-blind, placebo-controlled clinical trial of antioxidants for the prevention of colorectal adenomas. A total of 864 subjects who had had an adenoma removed and were polyp-free were randomly assigned (in a factorial design) to receive beta-carotene (25 mg or placebo) and/or vitamins C and E in combination (1000 mg and 400 mg, respectively, or placebo), and were followed with colonoscopy for adenoma recurrence 1 year and 4 years after the qualifying endoscopy. A total of 707 subjects had two follow-up examinations and provided smoking and alcohol use data. Adjusted multivariate risk ratios (RRs) and 95% confidence intervals (CIs) were used to assess the effects of beta-carotene on adenoma recurrence.

RESULTS

Among subjects who neither smoked cigarettes nor drank alcohol, beta-carotene was associated with a marked decrease in the risk of one or more recurrent adenomas (RR = 0.56, 95% CI = 0.35 to 0.89), but beta-carotene supplementation conferred a modest increase in the risk of recurrence among those who smoked (RR = 1.36, 95% CI = 0.70 to 2.62) or drank (RR = 1.13, 95% CI = 0.89 to 1.43). For participants who smoked cigarettes and also drank more than one alcoholic drink per day, beta-carotene doubled the risk of adenoma recurrence (RR = 2.07, 95% CI = 1.39 to 3.08; P for difference from nonsmoker/nondrinker RR <.001).

CONCLUSION

Alcohol intake and cigarette smoking appear to modify the effect of beta-carotene supplementation on the risk of colorectal adenoma recurrence.

Promitogenic effects of ethanol, methanol, and ethanolamine in insulin-treated fibroblasts

The zinc-dependent potentiating effect of ethanol (EtOH) on insulin-stimulated DNA synthesis was studied with a focus on the possible site of EtOH action and the ability of other alcohols to elicit similar promitogenic effects. In serum-starved (27 hr) NIH 3T3 fibroblasts, 200-300 mM methanol (MeOH) and 0.1-1.5 mM ethanolamine (Etn), but not 3- to 9-carbon normal alcohols, enhanced the effect of insulin on DNA synthesis to varying extents. The promitogenic effects of EtOH and MeOH, but not that of Etn, required the presence of 15-25 microM zinc. The potentiating effects of Etn were enhanced by 5 mM choline (Cho) and inhibited by 1-3 mM hemicholinium-3 (HC-3), an inhibitor of Cho transporter and Cho kinase. In the presence of 15 microM zinc, 40 mM EtOH, which had no effect on its own, inhibited the potentiating effects of Cho and enhanced the inhibitory effects of HC-3 on synergistic stimulation of DNA synthesis by Etn and insulin. On the other hand, both Cho and HC-3 partially inhibited the promitogenic effect of 80 mM EtOH in the presence of 25 microM zinc. After a 10-min incubation, EtOH decreased the amount of cell-associated [(14)C]Cho in the absence but not in the presence of HC-3. After a 40-min incubation, Cho (5 mM) partially inhibited the cellular uptake as well as the metabolism of [(14)C]Etn. Whereas after the 40-min incubation 80 mM EtOH had no effects on Etn metabolism, in the absence of Cho it decreased the amount of cell-associated [(14)C]Etn. However, EtOH had no detectable effects on cell association of [(14)C]Etn after the 10-min incubation. The results suggest that in NIH 3T3 fibroblasts EtOH is a remarkably specific promitogen, and that it may act via a cell membrane site(s), also regulated by Cho (agonist) and HC-3 (antagonist), which can influence membrane binding and the promitogenic activity of Etn.

Ethanol enhances the stimulatory effects of lysophosphatidic acid on DNA synthesis but not cell proliferation in human and mouse fibroblasts

Lysophosphatidic acid (LPA), a constituent of serum, is a positive regulator of cell growth, while ethanol (EtOH) has been shown to exert both inhibitory and stimulatory effects on mitogenesis. In this work, we examined possible interactions between the effects of EtOH and LPA on DNA synthesis, cell proliferation, activating phosphorylation of p44/p42 mitogen-activated protein kinases (MAPK), and p70 S6 kinase (p70 S6K) activity. In fibroblasts derived from human or mouse embryo or the skin of healthy human subjects, LPA (1-20 microM) and EtOH (40-80 mM) synergistically stimulated DNA synthesis in a zinc-dependent manner. Nevertheless, EtOH did not modify the stimulatory effect of LPA on the proliferation of human embryonal fibroblasts. In the presence of zinc, EtOH did not affect LPA-induced activating phosphorylation of p42/p44 MAPKs, although an inhibitor of MAPK kinase inhibited the combined effects of LPA and EtOH on DNA synthesis. In contrast, in the presence of zinc, EtOH enhanced the stimulatory effect of LPA on p70 S6K activity. The results indicate that in human fibroblasts, in the presence of zinc, EtOH enhances the stimulatory effects of LPA on DNA synthesis, but not on cell proliferation, by a mechanism probably involving activation of p70 S6K.

Ethanol has multiple effects on DNA synthesis in fibroblasts depending on the presence of secreted growth regulators and zinc as well as the level of protein kinase C activation

Earlier we showed that in serum-starved (27 h), washed mouse fibroblasts and other cell lines 40-80 mM concentrations of ethanol (EtOH) potentiate, in a zinc (Zn2+)-dependent manner, the combined stimulatory effects of calcium (Ca2+) and insulin (Ins) on DNA synthesis. We now report that the promitogenic EtOH effects require removal of the used medium at least 6 h prior to treatments with EtOH, Zn2+, and Ins. If serum-starved (27 h) cells were continuously incubated for another 18-h period without replacing the medium, a secreted cellular factor moderately enhanced the mitogenic effect of Ins and simultaneously blocked the potentiating effect of EtOH on DNA synthesis measured during the last hour of treatments. However, the presence of Ca2+ (2.8 mM) plus Zn2+ (25 microM) or 25-300 nM phorbol 12-myristate 13-acetate (PMA) during the serum starvation period partially restored the promitogenic effect of EtOH. The PMA effect was blocked by the protein kinase C (PKC) inhibitor GF 109203X added for the second (18 h) period. Even at 300 nM, PMA failed to fully downregulate PKC-alpha, the major PKC isoform, over a 28-h period, suggesting that an activated PKC enzyme was involved in the restoration of EtOH effect. When EtOH (40-80 mM) was added for the entire serum starvation period and the incubations were continued for 18 h without removing the medium, EtOH inhibited both the combined actions of Ins and cellular factor as well as the promoting effect of newly added EtOH on Ins-dependent DNA synthesis. Coaddition of Zn2+ and PMA with EtOH prevented these inhibitory effects of EtOH. The results indicate that in mouse fibroblasts EtOH can both enhance and inhibit Ins-dependent DNA synthesis depending on the timing of EtOH treatment as well as the presence of Zn2+, cellular factors, and activators of the PKC system.

The possible mechanism of synergistic effects of ethanol, zinc and insulin on DNA synthesis in NIH 3T3 fibroblasts

In serum-starved NIH 3T3 fibroblast cultures, zinc (15-40 microM) enhanced both the individual and combined stimulatory effects of insulin and ethanol (EtOH) on DNA synthesis. Zinc, but not EtOH, also promoted the stimulatory effects of insulin on activating phosphorylation of p42/p44 mitogen-activated protein (MAP) kinases. In the presence of zinc, insulin induced premature expression of cyclin E during early G1 phase; EtOH partially restored the normal timing (late G1 phase) of cyclin E expression. The results suggest that zinc and EtOH promote insulin-induced DNA synthesis by different mechanisms; while zinc acts by enhancing the effects of insulin on MAP kinase activation, EtOH may act by ensuring timely zinc-dependent insulin-induced expression of cyclin E.

Ethanol potentiates the mitogenic effects of sphingosine 1-phosphate by a zinc- and calcium-dependent mechanism in fibroblasts

In mouse embryo NIH 3T3 fibroblasts, ethanol (60-80 mM) was found to enhance the stimulatory effects of sphingosine 1-phosphate (S1P) on both DNA synthesis and cell proliferation. Well-detectable potentiating effects of ethanol on S1P-induced mitogenesis required the presence of calcium (>1 mM) and zinc (20-40 microM) in the incubation medium. The amphibian tetrapeptide bombesin, which is known to mobilize intracellular calcium in fibroblasts, had no effect alone, but it approximately doubled the combined stimulatory effects of ethanol and S1P on DNA synthesis. The synergistic mitogenic effects of ethanol and S1P were also slightly enhanced, rather than inhibited, by the alcohol dehydrogenase inhibitor 4-methylpyrazole (5 mM). Of the various growth regulatory enzymes examined, ethanol detectably enhanced the stimulatory effects of S1P on the phosphosphorylation (activation) of p42/p44 mitogen-activated protein (MAP) kinases, but not of p38 MAP kinase. Cotreatment of fibroblasts with ethanol for 10 min also enhanced the stimulatory effects of S1P on the activities of c-Raf-1 kinase and p70 S6 kinase, but neither S1P nor ethanol had effects on phosphatidylinositol 3'-kinase and Akt/PKB kinase activities. Ethanol-plus-S1P-induced DNA synthesis was partially inhibited by both PD 98059 (50 microM) and rapamycin (10 nM), inhibitors of p42/p44 MAP kinase kinase and mTOR/p70 S6 kinases, respectively. The results indicate that in NIH 3T3 fibroblasts, ethanol can enhance the mitogenic effects of S1P by a zinc- and calcium-dependent mechanism involving both the rapamycin-sensitive p70 S6 kinase-dependent and the c-Raf-1/MAP kinase-dependent growth regulatory pathways.

Cross-country comparisons suggest shared risk factors for carcinomas, including male lung adenocarcinoma and colon cancer development

Smoking is clearly the major risk factor for both squamous cell carcinomas (SCCs) and adenocarcinomas (ACs) of the lung, although less so for the latter, where other influences appear to be important. In order to determine whether cross-country comparisons might provide evidence of shared risk factors with cancers in other organs of males, an examination of IARC/WHO data for cancer incidence was made for countries/registries in Europe, North America, Australia and Asia. Significant simple correlations, which persisted on partial analysis, were observed between lung SCCs and tumors of the larynx (P < 0.001), but not the buccal cavity or oesophagus, along with a link to rectal ACs (P < 0.001). Incidences of lung ACs also correlated with those for colon ACs (P < 0.001) but not lung SCCs. Oesophageal ACs were only related to colon cancers at the simple correlation level, this not persisting on partial analysis or separation into Asian and Western groups. The results suggest that blood borne factors, like hormones, may be important as determinants for the increasingly prevalent lung AC.

Possible mechanisms by which alcohol may influence the development of oral cancer--a review

Although pure ethanol has never been shown to be carcinogenic in laboratory experiments, alcoholic beverages are now recognised as being important aetiological factors in the development of oral cancer. Despite this, the exact mechanism by which alcohol may exert an influence upon the oral mucosa has received less attention. An overview of the association of alcohol and oral cancer, both in combination with tobacco and without, is provided and consideration given to some of the pathways by which alcohol exerts its effect upon the oral mucosa.

Aetiology of oral cancer: alcohol

The effect of alcohol alone on the oral mucosa and its association with the development of oral cancer is difficult to establish, principally because alcohol consumption histories are difficult to verify, alter over time, both with respect to beverage type and quantity, and are frequently confounded by tobacco use. This review considers the various pathways by which alcohol may exert such an influence. Namely, due to topical exposure (e.g. direct effect on cell membranes, altered cell permeability, variation in enzymes that metabolise alcohol) and/or systemic effects (e.g. nutritional deficiency, immunological deficiency, disturbed liver function). Finally, the numerous papers that have sought to establish the relative risk for oral cancer in association with alcohol intake are reviewed.

Alcohol-stimulated promotion of tumors in the gastrointestinal tract

Alcohol is a major risk factor for cancers of the upper gastrointestinal tract but the association with cancers of the large bowel is not as clearly established. In recent studies, we have provided experimental support for the associations in the esophagus and oral cavity. Our studies also indicate that the tumor promotion ability of ethanol is related to its ability to generate oxygen free radicals as measured by an increase in indices of lipid peroxidation. This increase in lipid peroxidation was evident in the liver as well as the tissues targeted by the site-specific carcinogens and promoted by ethanol. Studies in mice showed that the increased lipid peroxidation as well as tumor incidence was inhibited by the administration of vitamin E, the potent antioxidant. Determination of fatty acid profiles showed significant alterations when ethanol was used as a tumor promoter after treatment with the carcinogen. Ethanol as a promoter caused an increase in esophageal polyunsaturated fatty acids (PUFA). Ethanol promotion was also evident in increased arachidonate and an exaggeration in PUFA that are involved in eicosanoid production. Thus, these results suggest that ethanol-related promotion may be the result of excessive cell proliferation induced by disordered lipid and eicosanoid metabolism that may cause a selective outgrowth of the carcinogen-initiated cells. Supporting evidence for ethanol-induced hyper-regeneration is also reviewed.

Effects of catechol, sodium chloride and ethanol either alone or in combination on gastric carcinogenesis in rats pretreated with N-methyl-N'-nitro-N-nitrosoguanidine

Combined effects of catechol, sodium chloride (NaCl) and ethanol on the post-initiation stage of gastric carcinogenesis were examined in rats pretreated with N-methyl-N'-nitro-N-nitrosoguanidine (MNNG). F344 male rats were given a single intragastric dose of 150 mg/kg b.w. MNNG at 6 weeks of age. Starting 1 week thereafter, groups of 15 rats were administered 0.8% catechol, 5% NaCl and 10% ethanol either individually or in combination, or basal diet alone for 51 weeks. Further groups of animals were similarly treated with these chemicals without the MNNG pretreatment. All rats were killed at the end of week 52 for histopathological examination. In the forestomach, treatment with catechol alone after MNNG initiation caused a 100% incidence of papillomas (versus 67% in the controls) as well as carcinomas (versus 0% in the controls). On the other hand, the treatment with ethanol alone significantly lowered the incidence of papillomas (13 versus 67% in the controls). The combined treatment with catechol, NaCl and ethanol significantly lowered the incidence of squamous cell carcinomas (57%) as compared to the catechol alone group value (100%). In the glandular stomach, catechol enhanced the development of adenocarcinomas (73 versus 0% in the controls), but this was decreased to 29% by the combined treatment with ethanol and NaCl. NaCl without MNNG pretreatment slightly enhanced epithelial cell proliferation in the forestomach. These results indicate that combined treatment with NaCl and ethanol exerts protective effects against catechol-induced forestomach and glandular stomach carcinogenesis, this apparently being largely due to the ethanol.

Effects of acetaldehyde on cell regeneration and differentiation of the upper gastrointestinal tract mucosa

BACKGROUND

The tumor-promoting effect of ethanol on cancer of the upper respiratory-digestive tract is not well understood. Although ethanol itself is not carcinogenic, the first product of ethanol metabolism-acetaldehyde is. Acetaldehyde can be produced from ethanol by oral bacteria, and high concentrations have been observed in human saliva after ethanol consumption. The purpose of this study was to investigate whether acetaldehyde administered orally to rats induces altered differentiation and proliferation in the animals' upper gastrointestinal tracts.

METHODS

Twenty Wistar rats were given either water containing acetaldehyde at a concentration of 120 mM or tap water to drink for 8 months. Tissue specimens were then taken from the tongue, epiglottis, and forestomach of each animal and immunohistochemically stained for markers of cellular proliferation (Ki67 nuclear antigen) or differentiation (cytokeratins 1, 4, 10, 11, 14, and 19). The mean epithelial thickness of each sample was measured via light microscopy, using an eyepiece containing grid lines. Differences between the control and acetaldehyde-treated groups were analyzed by use of the unpaired Student's t test. All reported P values are two-sided.

RESULTS

Although no tumors were observed, staining for cytokeratins 4 and 14 revealed an enlarged basal layer of squamous epithelia in the rats receiving acetaldehyde. In these animals, cell proliferation was significantly greater than that observed in the control animals for samples from the tongue (P<.0001), epiglottis (P<.001), and forestomach (P<.0001). In addition, the epithelia from acetaldehyde-treated rats were significantly thicker than in epithelia from control animals (P<.05 for all three sites).

CONCLUSIONS

Acetaldehyde, administered orally to rats, can cause hyperplastic and hyperproliferative changes in epithelia of the upper gastrointestinal tract. This finding suggests that microbially produced acetaldehyde in saliva may explain the tumor-promoting effect of ethanol on these epithelia.

Microbial metabolism of ethanol and acetaldehyde and clinical consequences

Many bacteria possess marked alcohol dehydrogenase activity and in the presence of ethanol they produce reactive and toxic acetaldehyde. Acetaldehyde production mediated by microbial alcohol dehydrogenases has been demonstrated in the oropharynx and bronchopulmonary washings. Also the most important gastric pathogen, Helicobacter pylori, and many skin bacteria associating with pathological dermatological conditions, possess alcohol dehydrogenase activity and produce acetaldehyde from ethanol. The most richly colonized site of the human body, however, is the large intestine, and therefore bacterial acetaldehyde production is most important in this organ. Alcohol ingested orally is transported to the colon by blood circulation and, after the distribution phase, intracolonic ethanol levels are equal to those in the blood. In the large bowel ethanol is oxidized by a bacteriocolonic pathway. In this pathway intracolonic ethanol is at first oxidized by bacterial alcohol dehydrogenase to acetaldehyde. Then acetaldehyde is oxidized either by colonic mucosal or bacterial aldehyde dehydrogenase to acetate. Part of intracolonic acetaldehyde may also be absorbed via the portal vein and metabolized in the liver. Bacteriocolonic pathway offers a new explanation for the disappearance of a part of ethanol calories. Due to the low aldehyde dehydrogenase activity of colonic mucosa acetaldehyde accumulates in the colon. Accordingly, during ethanol oxidation highest acetaldehyde levels of the body are found in the colon and not in the liver. High intracolonic acetaldehyde may contribute to the pathogenesis of alcohol-induced diarrhoea. Acetaldehyde has been proven to be a carcinogen in experimental animals. It may therefore contribute to the increased risk of colon polyps and colon cancer found to be associated with heavy alcohol consumption in man. Intracolonic acetaldehyde may also be an important determinant of blood acetaldehyde level and a possible hepatotoxin. In addition to acetaldehyde, gut-derived endotoxin is another potential candidate in the pathogenesis of alcohol-related liver injury.

Alcohol and gastrointestinal cancer: pathogenic mechanisms

Chronic heavy alcohol consumption leads to a significantly increased risk of cancer in the oropharynx, larynx and the oesophagus. In the liver, chronic alcohol abuse results in cirrhosis, a precursor of hepatocellular cancer. More recentepidemiologic studies also demonstrate that regular alcohol consumption, even in low amounts, has an enhanced risk for rectal cancer and cancer of the breast. Alcohol by itself is not a carcinogen. However, alcohol can increase the susceptibility of various organs to chemical carcinogens by a variety of mechanisms. Among these, increased activation of procarcinogens through microsomal enzyme induction, a change in the metabolism and/or distribution of carcinogens, interference with the system that repairs carcinogen-induced DNA alkylations, direct mucosal tissue damage with consecutive stimulation of cellular regeneration and alcohol-mediated malnutrition may be of importance. In the upper gastrointestinal tract the production of acetaldehyde and free radicals via cytochrome P450 2E1 and via alcohol dehydrogenase may lead to tissue damage and to secondary hyper-regeneration. In addition, local mechanisms may also be involved in the co-carcinogenic process. In the rectal mucosa acetaldehyde seems to be an important factor in carcinogenesis and may be predominantly produced by faecal bacteria.

Bacteriocolonic pathway for ethanol oxidation: characteristics and implications

Alcohol ingested orally is transported to the colon by blood circulation, and after the distribution phase, intracolonic ethanol levels are equal to those in the blood. Recent studies in our laboratory suggest that in the large bowel ethanol is oxidized by a bacteriocolonic pathway. In this pathway intracolonic ethanol is at first oxidized by bacterial alcohol dehydrogenase to acetaldehyde. Then acetaldehyde is oxidized either by colonic mucosal or bacterial aldehyde dehydrogenase to acetate. Part of intracolonic acetaldehyde may also be absorbed to portal vein and be metabolized in the liver. The bacteriocolonic pathway offers a new explanation for the disappearance of a part of ethanol calories. Due to the low aldehyde dehydrogenase activity of colonic mucosa, acetaldehyde accumulates in the colon. Accordingly during ethanol oxidation highest acetaldehyde levels of the body are found in the colon and not in the liver. High intracolonic acetaldehyde may contribute to the pathogenesis of alcohol-induced diarrhoea. Because acetaldehyde is a carcinogen in experimental animals, it may also contribute to the increased risk of colon polyps and colon cancer, which have been found to be associated with heavy alcohol consumption. Intracolonic acetaldehyde may also be an important determinant of the blood acetaldehyde level and a possible hepatotoxin. In addition to acetaldehyde, gut-derived endotoxin is another potential candidate in the pathogenesis of alcohol-related liver injury. Experimental alcoholic liver injury has recently been prevented by antibiotics, and this effect was related to the prevention of endotoxin-induced activation of Kupffer's cells.