Intraluminal fat digestion in the chronic alcoholic

Overexpression of apolipoprotein C-III decreases secretion of dietary triglyceride into lymph

Apolipoprotein C‐III (apoC‐III) is not only predominantly synthesized by the liver but also by the small intestine. Because apoC‐III is secreted from the intestine on the chylomicron along with lipid absorption, we questioned whether apoC‐III might play a role in intestinal lipid absorption and/or transport. Using both wild‐type (WT) and apoC‐III transgenic (apoC‐III Tg) mice, we showed that apoC‐III Tg mice have decreased lymphatic lipid transport compared with WT mice in response to an intraduodenal infusion of radiolabeled lipid. This is associated with accumulation of radiolabeled lipids in the luminal compartment of the apoC‐III Tg mice, indicating delayed lipid uptake from the lumen. The total amount of radioactive lipids in the mucosal compartment did not differ between apoC‐III Tg and WT mice, but the lipid distribution analysis indicated a predominance of free fatty acids and monoacylglycerol in the mucosa of apoC‐III Tg mice, implying impaired esterification capacity. Thus, the mechanisms underlying the reduced lymphatic lipid transport in apoC‐III Tg mice involve both a delayed lipid uptake into enterocytes, as well as impaired esterification to form triglyceride in the mucosa. These data document a novel role for apoC‐III in the uptake, re‐esterification, and lymphatic transport of dietary lipids in the intestine.

Delayed release pancrelipase for treatment of pancreatic exocrine insufficiency associated with chronic pancreatitis

Pancreatic enzyme supplements (PES) are used in chronic pancreatitis (CP) for correction of pancreatic exocrine insufficiency (PEI) as well as pain and malnutrition. The use of porcine pancreatic enzymes for the correction of exocrine insufficiency is governed by the pathophysiology of the disease as well as pharmacologic properties of PES. Variability in bioequivalence of PES has been noted on in vitro and in vivo testing and has been attributed to the differences in enteric coating and the degree of micro-encapsulation. As a step towards standardizing pancreatic enzyme preparations, the Food and Drug Administration now requires the manufacturers of PES to obtain approval of marketed formulations by April 2010. In patients with treatment failure, apart from evaluating drug and dietary interactions and compliance, physicians should keep in mind that patients may benefit from switching to a different formulation. The choice of PES (enteric coated versus non-enteric coated) and the need for acid suppression should be individualized. There is no current standard test for evaluating adequacy of therapy in CP patients and studies have shown that optimization of therapy based on symptoms may be inadequate. Goals of therapy based on overall patient presentation and specific laboratory tests rather than mere correction of steatorrhea are needed.

Alcohol-related diarrhea

Abstract Alcohol generates a large caloric yield without supplying any essential nutrients; alcoholics may thus maintain body weight while suffering from malnutrition. In addition, diarrhea is a common complaint of both acute and chronic alcoholics. Here, we review the effects of alcohol on gastrointestinal morphology, function, its nervous system and motility. Acute morphological changes such as erosions, inflammatory cell infiltrations and microvascular changes are seen in the stomach and small intestine in acute alcoholics. In addition, atrophic gastritis, reduced villous height and decreased mucosal surface area of the small intestine have been described in chronic alcoholics. Acute administration of alcohol inhibits absorption of nutrients and fluids, and can stimulate secretion of water and electrolytes. Bacterial overgrowth in the proximal small intestine and decreased pancreatic secretions have been also described in chronic alcoholics. The well-known deleterious effects of alcohol on the central nervous system raise the possibility of similar acute and chronic effects of the enteric nervous system. Such effects could alter motility and transit. Indeed, esophageal dysmotility and delayed gastric emptying have been observed with high concentrations of alcohol in experimental studies and in chronic alcoholics. Small bowel motility and transit may be abnormal in both acute and chronic alcoholics, and colonic propulsive motility is increased after acute administration of alcohol. Any, or all, of these changes in gastrointestinal functions may contribute to diarrhea in acute binge drinkers and chronic alcoholics. Unfortunately, there is a lack of systematic studies of the pathophysiology of alcohol abuse, and an integrating concept of the diarrhea of alcoholics is still not possible.

Alcohol and the small intestine

Several alterations of the small-intestinal morphology and function have been documented after alcohol ingestion. There are morphologic changes macroscopically and microscopically after acute alcohol administration in the proximal part of the small intestine, which are quickly reversible. There are no macroscopic changes and, in most patients, very discrete light microscopic changes in the small intestine after chronic alcohol ingestion. The ultrastructural changes are, however, profound, as seen by both transmission and scanning electron microscopy. The permeability is probably increased, permitting entrance of possible noxious agents, which may explain some of the extraintestinal tissue damage observed in chronic alcoholism. The transit is increased, at least after acute alcohol administration, perhaps contributing to the diarrhea commonly seen after heavy drinking. Several of the enzymes located in the brush border are affected; lactase activity can be depressed and perhaps result in a transient milk intolerance in predisposed individuals. The activity of GGT is increased and may partly account for the GGT elevation in serum after heavy drinking. Other enzymes, such as Na(+)-K(+)-ATPase, can be inhibited and result in a decreased absorption of substances that require active, energy-dependent transport mechanisms. The secretion of water and electrolytes may be increased (an effect on cAMP?). The absorption of several nutrients, vitamins, and other elements is disturbed. The bacterial flora is increased and changed, which may give rise to symptoms and also increase the production of acetaldehyde by bacterial metabolism of ethanol. Acetaldehyde is more toxic than ethanol, and an increased concentration of acetaldehyde can possibly accentuate the damage to the liver and other organs. The bacterial overgrowth can possibly cause endotoxinemia. Although studies on alcohol-related intestinal alterations have been relatively sparse, the acute and chronic effects of alcohol thus seem to be considerable. From available results it is, however, difficult to draw any definite conclusions about the clinical importance of many of the findings. Future research will need to study the relationship between, for example, the chronic morphologic changes, the absorptive dysfunction, and permeability alterations, on the one hand, and the gastrointestinal symptoms, the extraintestinal damage, and various deficiencies, on the other hand.

Physical-chemical behavior of dietary and biliary lipids during intestinal digestion and absorption. 2. Phase analysis and aggregation states of luminal lipids during duodenal fat digestion in healthy adult human beings

Following the feeding of a triacylglycerol-rich meal to healthy adult human beings, duodenal contents were aspirated for ex vivo chemical and physical-chemical analyses. The aspirates were collected during established lipid digestion and absorption into a "cocktail" of chemical inhibitors that rapidly inhibited ex vivo lipolysis. Following ultracentrifugation, the lipids separated into a floating oil layer, several interfacial layers, a "clear" or turbid "subphase", and a precipitated "pellet". By chemical and phase analyses, the floating layer was composed of oil-in-water emulsion particles with cores of triacylglycerol (TG), diacylglycerols (DG), and cholesteryl esters (CE) emulsified with a surface coat of partially ionized fatty acids (FA), monoacylglycerols (MG), diacylphosphatidylcholine (PL), and bile salts (BS). The interfacial layers contained similar emulsion particles dispersed among excess emulsifier which adopted a lamellar liquid-crystalline structure. Precipitated pellets were composed principally of emulsifying lipids, with smaller amounts of crystalline calcium soaps and BS. Relative lipid compositions of all but three subphases fell within a two-phase region of the condensed ternary phase diagram (Staggers et al., 1990, companion paper) where saturated mixed micelles composed of BS, FA "acid-soaps", MG, PL, cholesterol (Ch), and traces of DG (and TG) coexisted with unilamellar liquid-crystalline vesicles composed of the same lipids. Attempts to achieve clean separation of vesicles from micelles by repeat ultracentrifugation failed. Compared with the structure and sizes of lipid particles in equilibrated model systems (Staggers et al., 1990), quasielastic light scattering (QLS) analysis revealed that ex vivo micellar sizes (mean hydrodynamic radii, Rh) were similar (less than or equal to 40 A), whereas unilamellar vesicle sizes (Rh = 200-600 A) were appreciably smaller. Two-component QLS analysis of the subphases showed that much larger proportions of lipids were solubilized by micelles than were dispersed as unilamellar vesicles. When followed as functions of time, vesicles frequently dissolved spontaneously into mixed micelles, indicating that, in the nonequilibrium in vivo conditions, the constituent micellar phase was often unsaturated with lipids. These results are consistent with the hypothesis that, during hydrolysis of emulsified DG and TG by luminal lipases, unilamellar vesicles originate in lamellar liquid crystals that form at emulsion-water interfaces in the upper small intestine. In a BS-replete environment, unilamellar vesicles probably represent the primary dispersed product phase of human fat digestion and facilitate the dissolution of lipolytic products into unsaturated mixed micelles.(ABSTRACT TRUNCATED AT 400 WORDS)

Morphologic changes in the small intestine after chronic alcohol consumption

The morphology of the small-intestinal mucosa was studied in 11 alcoholic patients admitted to hospital for detoxification. A first biopsy specimen from the small intestine was taken as soon as possible after admission and a second specimen after about 6 weeks of abstinence. The specimens were studied in the light microscope, in the scanning electron microscope, and by immunohistochemistry. Morphometrically, a slight reduction in villus height in relation to crypt depth was observed. One patient had a subtotal villus atrophy. After abstinence the villus height was increased in five of the six patients who accepted a second biopsy. No obvious changes were seen in the frequency and appearance of peptidergic nerves or endocrine cells. Ultrastructurally, pronounced alterations were seen in the surface ultrastructure of the enterocytes. In two specimens bacterial adhesion to the mucosal surface was also found. The ultrastructural changes were unaltered after abstinence. In serum the concentrations of zinc were reduced, and the levels of copper were elevated compared with a group of teetotallers. A recently developed marker of high alcohol consumption, carbohydrate-deficient transferrin, was as good an indicator as the other conventional biochemical markers.

Metabolic effects of enteral formula feeding in alcoholic hepatitis

The etiology of malnutrition and the metabolic effect of aggressive nutritional support by enteral feeding were evaluated in patients with moderately severe alcoholic hepatitis. Among 21 patients presenting with jaundice, ascites, coagulopathy and low grade encephalopathy, the mean digestibilities (intake - fecal excretion/intake x 100) of total energy and fat were subnormal at 74.6 +/- 2.9 and 64.5 +/- 4.4%, respectively, and nitrogen balance was negative in half the patients with a mean value of +0.74 gm per day +/- 1.2. Based on initial ad libitum intake of hospital diet, patients were grouped as six patients with adequate caloric intake who underwent a repeated 3-day balance study to assess the effect of hospitalization (Group I) and eight anorectic patients who underwent a repeat balance study during constant nasoduodenal infusion of the liquid formula Isocal-HCN in an amount sufficient to provide 35 kcal per kg ideal body weight (Group II). During the initial phase of hospital tray diet, the mean digestibilities of energy, fat, protein and carbohydrate, and the mean nitrogen balance were similar in each group. The digestibilities of each diet constituent and nitrogen balance were similar in both phases of hospital tray diet in patients in Group I. On the other hand, the infusion of Isocal-HCN to patients in Group II resulted in significant increases over their baseline values in intakes of energy and protein and in digestibilities of energy, fat and protein, and in a 5-fold increase in nitrogen balance. Provision of essential nutrients by enteric infusion had no effect on fluid balance or degree of encephalopathy.(ABSTRACT TRUNCATED AT 250 WORDS)

Alcohol and the gastrointestinal tract

The effects of acute and chronic ethanol ingestion on esophageal motility and the potential complications of these alterations are reviewed. Injury to the gastric mucosa and the small intestine and alterations in intestinal absorption can also result from alcohol abuse.

Pancreatic scanning

The 75Se-selenomethionine pancreas scan cannot differentiate between chronic pancreatitis and carcinoma of the pancreas and may--although chiefly in certain defined clinical conditions--give a false-positive result. It is also rather more time-consuming than other radioisotopic scanning procedures. Its value in clinical practice stems from the fact that all the other methods currently available for studying the pancreas have their own disadvantages. Because a normal scan is only rarely seen in patients with carcinoma of the pancreas, pancreatic scanning can be particularly useful in helping to decide which patients should, and which should not, be subjected to other procedures involving greater discomfort or risk.