Pathophysiology of increased intestinal permeability in obstructive jaundice. World J Gastroenterol. 2007;13:6458-6464. [PMID: 18161914 DOI: 10.3748/wjg.13.6458]

Loss of bile salt export pump aggravates lipopolysaccharide-induced liver injury in mice due to impaired hepatic endotoxin clearance

BACKGROUND AND AIMS

Lipopolysaccharide (LPS) clearance is delayed in cholestatic liver diseases. While compromised clearance by Kupffer cells (KCs) is involved, the role of LPS uptake into hepatocytes and canalicular excretion remains unclear.

APPROACH AND RESULTS

Wild-type (WT) and bile salt export pump (Bsep) knockout (KO) mice were challenged i.p. with LPS. Liver injury was assessed by serum biochemistry, histology, molecular inflammation markers, and immune cell infiltration. LPS concentrations were determined in liver tissue and bile. Subcellular kinetics of fluorescently labeled LPS was visualized by intravital two-photon microscopy, and the findings in Bsep KO mice were compared to common bile duct-ligated (BDL) and multidrug resistance protein 2 (Mdr2) KO mice. Changes in gut microbiota composition were evaluated by 16S ribosomal RNA gene amplicon sequencing analysis. Bsep KO mice developed more pronounced LPS-induced liver injury and inflammatory signaling, with subsequently enhanced production of proinflammatory cytokines and aggravated hepatic immune cell infiltration. After LPS administration, its concentrations were higher in liver but lower in bile of Bsep KO compared to WT mice. Intravital imaging of LPS showed a delayed clearance from sinusoidal blood with a basolateral uptake block into hepatocytes and reduced canalicular secretion. Moreover, LPS uptake into KCs was reduced. Similar findings with respect to hepatic LPS clearance were obtained in BDL and Mdr2 KO mice. Pretreatment with the microtubule inhibitor colchicine inhibited biliary excretion of LPS in WT mice, indicating that LPS clearance is microtubule-dependent. Microbiota analysis showed no change of the gut microbiome between WT and Bsep KO mice at baseline but major changes upon LPS challenge in WT mice.

CONCLUSIONS

Absence of Bsep and cholestasis in general impair LPS clearance by a basolateral uptake block into hepatocytes and consequently less secretion into canaliculi. Impaired LPS removal aggravates hepatic inflammation in cholestasis.

Attenuated fibrosis in specific pathogen-free microbiota in experimental cholestasis- and toxin-induced liver injury

In advanced chronic liver disease (CLD), the translocation of intestinal bacteria and the resultant increase of proinflammatory cytokines in the splanchnic and systemic circulation may contribute to the progression of fibrosis. We therefore speculated that fibrosis and portal hypertension (PHT) would be attenuated in a mouse model of limited intestinal colonization with altered Schaedler flora (ASF) compared to a more complex colonization with specific pathogen-free (SPF) flora. We induced liver fibrosis in ASF and SPF mice by common bile duct ligation (BDL) or by carbon tetrachloride (CCl₄) treatment. We then measured portal pressure (PP), portosystemic shunts (PSSs), and harvested tissues for further analyses. There were no differences in PP between sham-treated ASF or SPF mice. After BDL or CCl₄ treatment, PP, PSSs, and hepatic collagen deposition increased in both groups. However, the increase in PP and the degree of fibrosis was significantly higher in ASF than SPF mice. Expression of fibrotic markers α-smooth muscle actin, desmin, and platelet-derived growth factor receptor β were significantly higher in ASF than SPF mice. This was associated with higher activation of hepatic immune cells (macrophages, neutrophils) and decreased expression of the intestinal epithelial tight junction proteins (claudin-1, occludin-1). In 2 models of advanced CLD, SPF mice presented significantly attenuated liver injury, fibrosis, and PHT compared to ASF mice. In contrast to our hypothesis, these findings suggest that a complex intestinal microbiota may play a "hepato-protective" role.-Moghadamrad, S., Hassan, M., McCoy, K. D., Kirundi, J., Kellmann, P., De Gottardi, A. Attenuated fibrosis in specific pathogen-free microbiota in experimental cholestasis- and toxin-induced liver injury.

Immune and Inflammatory Responses of the Intestinal Mucosa following Extended Liver Radiofrequency Ablation

Background and Aim

Extended liver radiofrequency ablation (RFA) has been shown to disrupt gut barrier integrity with subsequent bacterial translocation. The aim of the present project was to study the immune and inflammatory responses of the intestinal mucosa after extended RFA of the liver.

Methods

Twelve Wistar rats were either subjected to RFA of the left lateral hepatic lobe (approximately 30% of the liver mass) after midline laparotomy (group RFA, n = 6) or sham operation (group Sham, n = 6). Forty-eight hours later, ileal tissue specimens were excised for immunohistochemical assessment of CD68⁺ macrophages, CD4⁺ T-lymphocytes, CD8⁺ T-lymphocytes, mucosal addressin cell adhesion molecule-1 (MAdCAM-1), tumor necrosis factor-α (TNFα), interleukin-6 (IL-6), and nuclear factor-κB (NFκB) expression.

Results

Immune response biomarkers were upregulated in the RFA group. Expression of CD4⁺ and CD8⁺ T-lymphocytes was moderate, while that of CD68⁺ macrophages and MAdCAM-1 was high. Inflammatory response biomarkers were also upregulated in the RFA group. TNFα, IL-6, and NFκB expression was low, moderate, and high, respectively.

Conclusions

Extended liver RFA evokes both immune and inflammatory responses of the gut mucosa.

N-acetyl-l-cysteine Prevents Bile Duct Ligation Induced Renal Injury by Modulating Oxidative Stress

The aim of the present study was to evaluate the effect of N-acetyl-l-cysteine (NAC) on bile duct ligation (BDL) induced oxidative stress in kidneys. Male Wistar rats were randomly segregated into four groups; sham control (SC), SC + NAC, BDL and BDL + NAC group. Liver damage was induced following BDL and renal injury was assessed by kidney function tests along with lipid peroxidation, nitrite levels, thiols and antioxidant enzymes. Three weeks after BDL, rats developed renal dysfunction in terms of elevated serum creatinine levels. BDL animals exhibited an increase in lipid peroxidation, reduction in thiols and redox ratio in liver and kidney tissue along with altered antioxidant enzymes in kidneys. BDL animals that were orally administered NAC at a daily dose 100 mg/kg for duration of two weeks, showed significant reduction in serum creatinine levels. NAC was effective in lowering lipid peroxidation and was able to restore thiol levels along with GSH/GSSG ratio in both liver and kidneys along with the activity of antioxidant enzymes in the kidneys of BDL animals. The results clearly demonstrate the efficacy of NAC in attenuating oxidative stress in kidneys, suggesting a therapeutic role for NAC in individuals with renal dysfunction following BDL.

Resveratrol Protects Oxidative Stress-Induced Intestinal Epithelial Barrier Dysfunction by Upregulating Heme Oxygenase-1 Expression

BACKGROUND/AIM

Obstructive jaundice (OJ) is frequently complicated by infections and has been associated with increased bacterial translocation, intestinal epithelial hyperpermeability, and oxidative stress, but the mechanism remains unclear. The potential effect of resveratrol (Res) on modifying intestinal epithelial dysfunction was evaluated both in vitro and in vivo.

METHODS

Caco-2 cells (in vitro) and male Wistar rats (n = 60; in vivo) were used to evaluate the role of Res on intestinal epithelial dysfunction. Hydrogen peroxide was used to induce oxidative stress in the Caco-2 cells. In bile duct-ligated group, OJ was successfully established on Day 7 after bile duct ligation, whereas sham-operated and vehicle-treated rats served as controls. Western blot and RT-qPCR were performed to analyze TJ proteins expression in epithelium isolated from rat intestine.

RESULTS

Intestinal hyperpermeability was associated with decreased expression and phosphorylation of occludin and zonula occluden (ZO-1), but increased oxidation in Caco-2 cells and the intestinal epithelium. Res treatment increased the epithelial expression and phosphorylation of occludin and ZO-1 in a concentration-dependent manner. Moreover, Res which protected Caco-2 cells from H2O2-induced oxidative damage clearly reduced malondialdehyde level and intracellular reactive oxygen species accumulation, but increased the expression levels of superoxide dismutase and heme oxygenase-1 (HO-1). Further studies showed that Res also inhibited H2O2-induced protein kinase C activity and p38 phosphorylation. Interestingly, these effects of Res were abolished by the HO-1 inhibitor zinc protoporphyrin or knockdown of HO-1 by siRNA.

CONCLUSIONS

Res protected gut barrier function possibly by initiating HO-1-dependent signaling which is essential for common expression of key tight junction proteins. It also provides a rationale to develop Res clinical applications of intestinal disorders.

Increased Intestinal Permeability and Decreased Barrier Function: Does It Really Influence the Risk of Inflammation?

Background

Increased intestinal permeability due to barrier dysfunction is supposed to cause microbial translocation which may induce low-grade inflammation in various diseases. However, this series of events has not been comprehensively evaluated yet.

Summary

Intestinal epithelial barrier dysfunction and increased permeability have been described in patients with inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), alcoholic liver disease, nonalcoholic steatohepatitis (NASH), liver cirrhosis, acute pancreatitis, primary biliary cholangitis (PBC), type 1 and type 2 diabetes, chronic kidney disease, chronic heart failure (CHF), depression, and other diseases. Most clinical reports used either permeability assays of challenge tests or measurement of circulating bacterial markers like endotoxin for assessment of 'the leaky gut'. The intestinal permeability assessed by the challenge tests has often been related to the changes of tight junction proteins in the epithelium or circulating endotoxin levels. In patients with IBD, alcoholic liver disease, NASH, liver cirrhosis, PBC, obstructive jaundice, severe acute pancreatitis, and CHF, endotoxemia and proinflammatory cytokinemia have been found in addition to increased permeability. In the serum of patients with IBS and depression, antiflagellin antibodies and antilipid A antibodies were detected, respectively, together with increased permeability and proinflammatory cytokinemia. The site of infection, which is localized to the intestine in IBD and IBS, includes various extraintestinal organs in other diseases. The relation of gut dysbiosis to intestinal barrier dysfunction has gradually been clarified.

Key Messages

Although no direct cause-and-effect relationship has been confirmed, all clinical and experimental data suggest the importance of intestinal hyperpermeability in the inflammatory changes of various diseases. Increased intestinal permeability is a new target for disease prevention and therapy. Considering the close relationship of 'the leaky gut' and gut dysbiosis to the major diseases, we can conclude that meticulous dietetic and probiotic approaches to recover healthy microbiota have the potential to make a breakthrough in the management of these diseases tomorrow.

Immune dysfunction in patients with obstructive jaundice before and after endoscopic retrograde cholangiopancreatography

This prospective observational study investigated monocyte cytokine responses to lipopolysaccharide (LPS) in patients with obstructive jaundice (OJ) before and after endoscopic biliary drainage. Dendritic cell (DC) subsets and their expression of co-stimulatory molecules were also studied. Forty patients with OJ and ten non-jaundiced patients with normal gastroscopy findings were recruited. Ten healthy volunteers provided control blood samples for immunological assays. Patients with OJ had blood and duodenal mucosa sampled at the time of endoscopic retrograde cholangiopancreatography (ERCP) and further blood sampled during the recovery phase. Monocyte cytokine responses to LPS, DC subsets and co-stimulatory molecule expression were compared with controls. Duodenal morphology and occludin expression were also assessed. Monocytes obtained before ERCP from jaundiced patients demonstrated reduced cytokine responses to endotoxin compared with controls (IL-1β: 2678 compared with 4631 pg/ml, P=0.04 and IL-6: 3442 compared with 6157 pg/ml, P=0.002). Monocytes from patients with malignancy had poorer responses to endotoxin than from those with benign OJ (IL-1β: 2025 compared with 3332 pg/ml, P=0.001). After ERCP, the secretion of inflammatory cytokines by monocytes obtained from jaundiced patients increased (IL-1β: 2150 compared with 2520 pg/ml, P=0.03 and IL-6: 2488 compared with 3250 pg/ml, P=0.01). Occludin expression (85 compared with 95%, P=0.004) and mean duodenal villus height (334 compared with 404 μm, P=0.03) were lower in jaundiced patients. Before biliary drainage, patients with OJ had a higher percentage of myeloid dendritic cells (mDCs) and greater mDC expression of CD40 (P=0.04) and CD86 (P=0.04). Monocytes from patients with OJ had lower proinflammatory cytokine secretion in response to LPS, an effect reversed following biliary drainage.

Factors Affecting Surgical Site Infection Rates in Hepatobiliary Surgery

BACKGROUND

There are several studies regarding risk factors affecting surgical site infections (SSIs); nevertheless, there are an insufficient number of studies focusing on risk factors for SSI in hepatobiliary (HPB) surgery. In this study, we aimed to determine risk factors related to HPB surgery.

METHODS

A total of 1,418 patients were included in this study, all of whom underwent hepatobiliary system surgery in a five-year period between January 2005 and December 2009. Demographic data, patient- and surgery-related risk factors, and laboratory parameters were analyzed retrospectively from a database maintained prospectively.

RESULTS

The overall incidence of SSI was 3.94% for HPB surgery. In multivariable analysis, blood transfusion (OR: 20.9), the presence of surgical drains (OR: 10.7), a pre-operative hospital stay of more than eight days (OR: 8.1), diabetes mellitus (OR: 6.2), chronic obstructive pulmonary disease (OR: 6.127), inappropriate antimicrobial prophylaxis (OR: 6), obesity (OR: 3.2), the presence of an external-internal biliary drainage catheter (OR: 2), and a direct bilirubin concentrations more than 15 mg/dL (OR: 1.4) were determined as independent risk factors related to SSI. E.coli and Enterococcus spp. were the pathogens isolated most commonly in SSIs.

CONCLUSIONS

Most of the independent risk factors for hepatobiliary system surgery are similar to those for other general abdominal surgical procedures. The presence of an external-internal biliary drainage catheter and direct bilirubin concentrations higher than 15 mg/dL were found to be specific risk factors for HPB surgery.

Protective effect of curcumin on intestinal mucosal barrier in rats with obstructive jaundice

AIM: To investigate the protective action of curcumin on small intestinal mucosal barrier in rats with obstructive jaundice.

METHODS: Thirty-six male SD rats were randomly divided into a sham operated group (SO), an obstructive jaundice group (OJ) and a curcumin treatment group (Cur). Using a light microscope, small intestinal tissue morphological changes were observed, the intestinal villus height and mucosal thickness were measured, the levels of plasma endotoxin were determined by limulus reagent method, the levels of serum tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) were determined by radioimmunoassay, intestinal diamine oxidase (DAO) activity was determined by spectrophotometric method, and the expression of nuclear factor kappa B (NF-κB) and intercellular adhesion molecule-1 (ICAM-1) was detected by immunohistochemical method.

RESULTS: In the OJ group, intestinal villi were disordered, sparse and showed fracture and edema, and intestinal mucosal atrophy, epithelial cell necrosis and shedding, and inflammatory cell infiltration were observed. Intestinal mucosal changes in the Cur group were significantly reduced compared with the OJ group: intestinal villi were neatly arranged, intestinal mucosa was thickened, villous edema was mild, there was no obvious epithelial cell loss, and inflammatory cell infiltration was reduced. Compared with the SO group, the levels of endotoxin, TNF-α and IL-6 in the OJ group were significantly increased (P < 0.01), and the intestinal DAO activity, intestinal villus height and mucosal thickness were significantly decreased (P < 0.01). Compared with the OJ group, the levels of endotoxin, TNF-α and IL-6 in the Cur group were significantly decreased (P < 0.05 or 0.01), and the intestinal DAO activity, intestinal villus height and mucosal thickness were significantly increased (P < 0.05). Compared with the SO group, the expression of NF-κB and ICAM-1 in the OJ group was significantly up-regulated (P < 0.01); however, the expression of NF-κB and ICAM-1 in the Cur group was significantly down-regulated compared with the OJ group (P < 0.05 or 0.01).

CONCLUSION: Curcumin protects against intestinal mucosal barrier injury in rats with obstructive jaundice possibly by inhibiting expression of NF-κB, TNF-α, IL-6 and ICAM-1.

Microbiota and the gut-liver axis: Bacterial translocation, inflammation and infection in cirrhosis

Liver disease is associated with qualitative and quantitative changes in the intestinal microbiota. In cirrhotic patients the alteration in gut microbiota is characterized by an overgrowth of potentially pathogenic bacteria (i.e., gram negative species) and a decrease in autochthonous familiae. Here we summarize the available literature on the risk of gut dysbiosis in liver cirrhosis and its clinical consequences. We therefore described the features of the complex interaction between gut microbiota and cirrhotic host, the so called “gut-liver axis”, with a particular attention to the acquired risk of bacterial translocation, systemic inflammation and the relationship with systemic infections in the cirrhotic patient. Such knowledge might help to develop novel and innovative strategies for the prevention and therapy of gut dysbiosis and its complication in liver cirrhosis.

Impact of perioperative symbiotic therapy on infectious morbidity after Hpb Surgery in jaundiced patients: a randomized controlled trial

This study aimed at evaluating whether the administration of symbiotic therapy in jaundiced patients could reduce their postoperative infectious complications. The study was conducted between November 2008 and February 2011. Jaundiced patients scheduled for elective extrahepatic bile duct resection without liver cirrhosis, intestinal malabsorption or intolerance to symbiotic therapy were randomly assigned to receive [Group A] or not [Group B] symbiotics perioperatively. The primary endpoint was the infectious morbidity rate. Forty patients were included in the analysis (20 in each group). The patients in Group B presented a higher overall morbidity (70 vs 50%) and infectious morbidity rate (50 vs 25%), but the differences were not significant. Eleven patients in Group A (Group ndA) and 13 in Group B (Group ndB) did not receive preoperative biliary drainage. The results of the two groups were comparable. Infectious complications were higher in Group B [5 (34%) vs 0, p = 0.030], while the prevalence of natural killer (NK) cells was higher in Group ndA the day before surgery (17% ± 5.1 vs 10% ± 5.3, p < 0.01) and on post-operative day (POD) 7 (13.1% ± 4.1 vs 7.7% ± 3.4, p < 0.01). The rates of lymph node colonization were similar. The symbiotic therapy failed to reduce the rate of infectious morbidity in jaundiced patients. Further studies investigating the place of symbiotic in no-drainage patients are required.

Intestinal barrier dysfunction in HIV infection: pathophysiology, clinical implications and potential therapies

INTRODUCTION

Current pathogenetic aspects on HIV infection highlight the importance of a chronic immune activation ultimately leading to T lymphocyte homeostasis disruption and immune deregulation associated with disease manifestations and progression. It is widely accepted that this continuous immune activation in HIV infection is principally driven by the phenomenon of pathological microbial translocation (MT).

METHODS

Review of the literature on the role of intestinal barrier dysfunction in HIV infection, with emphasis on the implicated pathophysiological mechanisms, clinical implications and potentially effective therapeutic interventions.

FINDINGS

MT in HIV infection is promoted by a multifactorial disruption of all major levels comprising the intestinal barrier defense. Specifically, HIV infection disrupts the integrity of the intestinal biological (quantitative and qualitative alterations of gut microecology, overgrowth of pathogenic bacteria), immune (depletion of CD4(+) T cells, especially Th17 cells, increased CD4+ FoxP3+ Tregs, decreased mucosal macrophages phagocytic capacity, development of intestinal proinflammatory milieu) and mechanical barrier (enterocytes' apoptosis, disruption of tight junctions). Intestinal barrier dysfunction allows the passage of microbes and immunostimulatory bioproducts from the gut lumen first in the lamina propria and thereafter in the systemic circulation, thus continuously promoting a local and systemic inflammatory response. This chronic immune activation is associated with HIV disease progression, suboptimal response to HAART and development of non-AIDS comorbidities.

CONCLUSIONS

We have reached a point where the effective control of HIV viremia by HAART should be combined with emerging pharmacological approaches aiming at the restoration of the intestinal barrier, targeting its diverse levels of structure and function. Elimination of the MT phenomenon would mitigate its effect on immune homeostasis, which might improve the prognosis of the HIV-infected patient in terms of morbidity and mortality.

Protective effects of intravenous anesthetics on kidney tissue in obstructive jaundice

AIM: To evaluate the protective effects on kidney tissue of frequently used intravenous anesthetics (ketamine, propofol, thiopental, and fentanyl) in rats with obstructive jaundice.

METHODS: There is an increased incidence of postoperative acute renal failure in patients with obstructive jaundice. Thirty-two Wistar-albino rats were randomly divided into four equal groups. Laparatomy was performed on each animal in the four groups and common bile ducts were ligated and severed on day 0. After 7 d, laparotomy was again performed using ketamine, propofol, thiopental, or fentanyl anesthesia whose antioxidative properties are well known in oxidative stress in a rat liver model of obstructive jaundice. After 2 h, the rats were sacrificed. Renal tissue specimens were analyzed for catalase, superoxide dismutase and malondialdehyde enzymes activities. All values are expressed as the mean ± SD. P values less than 0.05 were considered statistically significant.

RESULTS: All animals survived without complications until the end of the study. Enlargement in the bile duct and obstructive jaundice were observed in all rats. Catalase was found to be significantly lower in the fentanyl group than in the ketamine (P = 0.039), propofol (P = 0.012), and thiopental (P = 0.001) groups. Superoxide dismutase activities were similar in all groups (P > 0.05). Malondialdehyde was found to be significantly lower in the ketamine group than in the propofol (P = 0.028), thiopental (P = 0.002) and fentanyl (P = 0.005) groups. Malondialdehyde was also lower in the fentanyl group than in the thiopental group (P = 0.001). The results showed that obstructive jaundice sensitizes renal tissue to damage under the different anesthetics.

CONCLUSION: Among the agents tested, ketamine and propofol generated the least amount of oxidative stres on renal tissues in this rat model of obstructive jaundice created by common bile duct ligation. The importance of free radical injury in renal tissue in obstructive jaundice under different intravenous anesthetics during hepatobiliary and liver transplant surgery should be considered for prevention of postoperative acute renal failure.

The increased gastroprotective effect of pioglitazone in cholestatic rats: role of nitric oxide and tumour necrosis factor alpha

The prevalence of gastric ulcers is high in cholestatic patients, but the exact mechanism of this increased frequency remains uncertain. It has been shown that pioglitazone accelerates the healing of pre-existing gastric ulcers. The present study was designed to investigate the effect of pioglitazone, on the gastric mucosal lesions in cholestatic rats. Cholestasis was induced by surgical ligation of common bile duct and sham-operated rats served as control. Different groups of sham and cholestatic animals received solvent or pioglitazone (5, 15, 30 mg/kg) for 7 days. On the day eight rats were killed after oral ethanol administration and the area of gastric lesions was measured. The serums of rats were also collected to determine serum levels of tumour necrosis factor alpha (TNF-α), IL-1β and bilirubin. The ethanol-induced gastric mucosal damage was significantly more severe in cholestatic rats than sham-operated ones. Pretreatment with pioglitazone dose-dependently attenuated gastric lesions induced by ethanol in both sham and cholestatic rats, but this effect was more prominent in cholestatic ones. The effect of pioglitazone was associated with a significant fall in serum levels of TNF-α in cholestatic rats. L-NAME, a non-selective nitric oxide synthase (NOS) inhibitor, and decreased pioglitazone-induced gastroprotective effect in cholestatic rats, while aminoguanidine, a selective inducible NOS inhibitor, potentiated pioglitazone-induced gastroprotective effect in the cholestatic rats. Chronic treatment with pioglitazone exerts an enhanced gastroprotective effect on the stomach ulcers of cholestatic rats compared to sham rats probably due to constitutive NOS induction and/or inducible NOS inhibition and attenuating release of TNF-α.

Changes of Tight Junction Protein Claudins in Small Intestine and Kidney Tissues of Mice Fed a DDC Diet

DDC (3,5-diethoxycarbonyl-1,4-dihydrocollidine)-fed mice are widely used as a model for cholestatic liver disease. We examined the expression of tight junction protein claudin subspecies by immunofluorescent histochemistry in small intestine and kidney tissues of mice fed a DDC diet for 12 weeks. In the small intestine, decreases in claudin-3, claudin-7 and claudin-15 were observed in villous epithelial cells corresponding to the severity of histological changes while leaving the abundance of these claudin subspecies unchanged in crypt cells. Nevertheless, the proliferative activity of intestinal crypt cells measured by immunohistochemistry for Ki-67 decreased in the mice fed the DDC diet compared with that of control mice. These results suggest the possibility that DDC feeding affects the barrier function of villous epithelial cells and thus inhibits the proliferative activity of crypt epithelial cells. On the other hand, in the kidney, remarkable changes were found in the subcellular localization of claudin subspecies in a segment-specific manner, although histological changes of renal epithelial cells were quite minimal. These results indicate that immunohistochemistry for claudin subspecies can serve as a useful tool for detecting minute functional alterations of intestinal and renal epithelial cells.

The effect of ursodeoxycholic acid in liver functional restoration of patients with obstructive jaundice after endoscopic treatment: a prospective, randomized, and controlled study

Background

In patients with obstructive jaundice, multi-organ dysfunction may develop.

Methods/Design

This trial is a prospective, open-label, randomized, and controlled study with the objective to evaluate the effect of ursodeoxycholic acid in liver functional restoration in patients with obstructive jaundice after endoscopic treatment. The aim of this study is to evaluate the effect of ursodeoxycholic acid in liver functional restoration of patients with obstructive jaundice after endoscopic treatment. The hypothesis of this trial is that patients with obstructive jaundice, in which will be administered UDCA, in the early phase after endoscopic intervention will have better and faster functional restoration of the liver than patients in the control group.

Patients with obstructive jaundice, randomly, will be divided into two groups: (A) test group in which will be administered ursodeoxycholic acid twenty-four hours after endoscopic procedure and will last fourteen days, and (B) control group.

Serum-testing will include determination of bilirubin, alanine transaminase, aspartate transaminase, gama-glutamil transpeptidase, alkaline phosphatase, albumin, and cholesterol levels. These parameters will be determined one day prior endoscopic procedure, and on the third, fifth, seventh, tenth, twelfth and fourteenth days after endoscopic intervention.

Discussion

This trial is a prospective, open-label, randomized, and controlled study to asses the effect of ursodeoxycholic acid in liver functional restoration of patients with obstructive jaundice in the early phase after endoscopic treatment.

Trial registration

ClinicalTrials.gov, NCT01688375

Liver radiofrequency ablation compromises the biological gut barrier

AIM

Liver radiofrequency ablation (RFA) has been shown to disrupt the mechanical component of the gut barrier. The aim of the present study was to investigate the consequences of liver RFA on the biological gut barrier in terms of the effects of bile production rate and bowel inflammatory state on intestinal microflora balance.

METHOD

A total of 25 New Zealand rabbits were assigned to five groups (n = 5 per group): group CBD: subjected to common bile duct (CBD) extracorporeal bypass; group CBD-RFA: subjected to CBD bypass plus one session of open liver RFA; group RFA: subjected to liver RFA; group sham: subjected to sham operation; and group TBD: subjected to total bile deviation (TBD). In groups CBD and CBD-RFA, bile production rate was assessed for 48 h. In groups sham and RFA, measurement of biliary glycine conjugates of cholic and deoxycholic acid levels, histopathologic examination of the non-ablated liver tissue, morphometric analysis, and histopathologic examination of the terminal ileum and microbiological analysis of fecal and tissue samples collected from the jejunum and the cecum (and in group TBD) were performed at 48 h post-operation.

RESULTS

One session of liver RFA resulted in ablation of 18.7 ± 2.7% of liver weight. Following liver RFA, bile production rate was reduced, while the levels of biliary bile salts were not affected. There was mild injury of the non-ablated liver parenchyma, mild intestinal wall inflammation, intestinal mucosa atrophy, and intestinal microbial population overgrowth.

CONCLUSION

Reduced in bile production and mild bowel inflammation secondary to liver RFA impaired the biological gut barrier as manifested by intestinal microflora imbalance.

In depression, bacterial translocation may drive inflammatory responses, oxidative and nitrosative stress (O&NS), and autoimmune responses directed against O&NS-damaged neoepitopes

OBJECTIVE

Depression is accompanied by activation of immuno-inflammatory and oxidative and nitrosative stress (IO&NS) pathways, and increased IgM/IgA responses to lipopolysaccharide (LPS) of gram-negative commensal bacteria. The latter suggests that bacterial translocation has caused IgM/IgA responses directed against LPS. Bacterial translocation may drive IO&NS responses.

METHOD

To examine the associations between IgM/IgA responses to LPS and IO&NS measurements, including plasma/serum interleukin-1 (IL-1), tumor necrosis factor (TNF)α, neopterin, lysozyme, oxidized LDL (oxLDL) antibodies, peroxides, and IgM (auto)immune responses against malondialdehyde (MDA), azelaic acid, phophatidyl inositol (Pi), NO-tryptophan and NO-tyrosine in depressed patients and controls.

RESULTS

We found significant positive associations between IgM/IgA responses to LPS and oxLDL antibodies, IgM responses against MDA, azelaic acid, Pi, NO-tryptophan, and NO-tyrosine. The IgA responses to LPS were correlated with lysozyme. There were no significant positive correlations between the IgM/IgA responses to LPS and IL-1 and neopterin.

CONCLUSION

The findings show that in depression there is an association between increased bacterial translocation and lysozyme production, an antibacterial compound, O&NS processes, and autoimmune responses directed against O&NS generated neoantigenic determinants. It is suggested that bacterial translocation may drive IO&NS pathways in depression and thus play a role in its pathophysiology.

Clinical review: The liver in sepsis

During sepsis, the liver plays a key role. It is implicated in the host response, participating in the clearance of the infectious agents/products. Sepsis also induces liver damage through hemodynamic alterations or through direct or indirect assault on the hepatocytes or through both. Accordingly, liver dysfunction induced by sepsis is recognized as one of the components that contribute to the severity of the disease. Nevertheless, the incidence of liver dysfunction remains imprecise, probably because current diagnostic tools are lacking, notably those that can detect the early liver insult. In this review, we discuss the epidemiology, diagnostic tools, and impact on outcome as well as the pathophysiological aspects, including the cellular events and clinical picture leading to liver dysfunction. Finally, therapeutic considerations with regard to the weakness of the pertinent specific approach are examined.

Occludin dislocation in brain capillary endothelium of rats with bile duct ligation induced cholestasis

The present study used a rat model with bile duct ligation to examine the effect of cholestasis, to the localization of occludin in brain capillary endothelium by means of electronic microscopy. The results demonstrated a dislocation of occludin away from the tight junction sites of brain endothelial cells. A significant increase of the occludin-interendothelial cleft distance was demonstrated in the midbrain and the cerebellum samples but not in the frontal cortex, compared to the control group samples. These findings imply a brain region selective derangement of occludin in response to liver disease.

The use of antiendotoxin peptides in obstructive jaundice endotoxemia

BACKGROUND

Two novel antiendotoxin peptides, P6 and C1, may reduce the inflammatory response. This study aimed to determine the effect of endotoxin on hepatic cytokine response and to assess P6 and C1-related attenuation of the proinflammatory response to endotoxemia, in experimental biliary obstruction.

MATERIALS AND METHODS

15 Male Wistar rats were randomized to one of three groups: bile duct ligation (BDL)+P6 (n=5), BDL+C1 (n=5), and BDL+no peptide (n=5). Rats were weighed and underwent BDL surgery on day 1. On day 8, the rats were reweighed and isolated hepatic perfusion was carried out. P6 or C1 peptide (10 μmol/l) was preincubated with 300 ml of endotoxin-containing Krebs perfusate. After perfusion of 10 min with endotoxin-free perfusate, the livers were perfused for another 10 min with 300 ml of perfusate-containing endotoxin on its own or endotoxin plus peptide. This was followed by a further 100 min of perfusion with endotoxin-free perfusate. Effluent perfusate was collected at 20-min intervals for subsequent biochemical and cytokine analyses.

RESULTS

Perfusion with endotoxin+P6 or endotoxin+C1 resulted in no significant difference in weight loss, or interleukin-6 response compared with perfusion with endotoxin alone. However, perfusion with endotoxin+P6 or endotoxin+C1 significantly reduced the tumor necrosis factor-α response to portal endotoxemia compared with perfusion with endotoxin alone.

CONCLUSION

This study demonstrates that novel antiendotoxin peptides may attenuate the hepatic inflammatory response in portal endotoxemia. In obstructive jaundice, preoperative peptide administration may reduce endotoxin-related postoperative complications.

Enterocytes’ tight junctions: From molecules to diseases

Tight junctions (TJs) are structures between cells where cells appear in the closest possible contact. They are responsible for sealing compartments when epithelial sheets are generated. They regulate the permeability of ions, (macro) molecules and cells via the paracellular pathway. Their structure at the electron microscopic level has been well known since the 1970s; however, only recently has their macromolecular composition been revealed. This review first examines the major macromolecular components of the TJs (occludin, claudins, junctional adhesion molecule and tricellulin) and then the associated macromolecules at the intracellular plaque [zonula occludens (ZO)-1, ZO-2, ZO-3, AF-6, cingulin, 7H6]. Emphasis is given to their interactions in order to begin to understand the mode of assembly of TJs. The functional significance of TJs is detailed and several mechanisms and factors involved are discussed briefly. Emphasis is given to the role of intestinal TJs and the alterations observed or speculated in diverse disease states. Specifically, intestinal TJs may exert a pathogenetic role in intestinal (inflammatory bowel disease, celiac disease) and extraintestinal diseases (diabetes type 1, food allergies, autoimmune diseases). Additionally, intestinal TJs may be secondarily disrupted during the course of diverse diseases, subsequently allowing the bacterial translocation phenomenon and promoting the systemic inflammatory response, which is often associated with clinical deterioration. The major questions in the field are highlighted.

Role of innate immunity and the microbiota in liver fibrosis: crosstalk between the liver and gut

Liver fibrosis occurs as a wound-healing scar response following chronic liver inflammation including alcoholic liver disease, non-alcoholic steatohepatitis, viral hepatitis, cholestatic liver disease and autoimmune liver diseases. The liver has a unique vascular system within the gastrointestinal tract, as the majority of the liver's blood supply comes from the intestine through the portal vein. When the intestinal barrier function is disrupted, an increase in intestinal permeability leads to the translocation of intestine-derived bacterial products such as lipopolysaccharide (LPS) and unmethylated CpG containing DNA to the liver via the portal vein. These gut-derived bacterial products stimulate innate immune receptors, namely Toll-like receptors (TLRs), in the liver. TLRs are expressed on Kupffer cells, endothelial cells, dendritic cells, biliary epithelial cells, hepatic stellate cells, and hepatocytes. TLRs activate these cells to contribute to acute and chronic liver diseases. This review summarizes recent studies investigating the role of TLRs, intestinal microbiota and bacterial translocation in liver fibrosis, alcoholic liver disease and non-alcoholic steatohepatitis.

Relationship between CLC-2 and intestinal mucosal barrier in rats with obstructive jaundice

AIM: To investigate the relationship between chloride channel-2 (CLC-2) and intestinal mucosal barrier in rats with obstructive jaundice (OJ).

METHODS: Rats were randomly divided into five groups: sham operation group, OJ group, lubiprostone (Lu) group, glucagon-like peptide-2 (GLP-2) group, and Lu + GLP group. Except for the sham operation group, OJ was induced by bile duct ligation in rats of other groups. The Lu group was subcutaneously injected with LU, and the GLP-2 group was injected with GLP-2. The Lu + GLP group was injected with both Lu and GLP-2. The animals were sacrificed 7 days after treatment. The ratio of lactulose to mannitol (L/M) and plasma endotoxin levels were measured. Western blot was used to examine the changes in the expression tight junction proteins zonula occludens-1 (ZO-1) and CLC-2 in epithelial cells in the terminal ileum.

RESULTS: The ratio of L/M was significantly higher in all the experiment groups than in the sham operation group (all P = 0.00), but was significantly lower in the Lu group, GLP-2 group and Lu + GLP group than in the OJ group (0.545 ± 0.03, 0.512 ± 0.03, 0.482 ± 0.05 vs 0.656 ± 0.04, all P = 0.00). Plasma endotoxin levels increased in all the experiment groups, highest in the OJ group and decreasing somewhat in the Lu group, GLP-2 group and Lu + GLP group. The relative expression of ZO-1 in the Lu group (0.209 ± 0.03) was higher than that in the OJ group (0.178 ± 0.03) but lower than that in the sham operation group (P = 0.02). The relative expression of ZO-1 in the Lu + GLP group was comparable to that in the sham operation group. The relative expression of CLC-2 descended more obviously in the OJ, GLP-2 and Lu + GLP groups than in the sham operation group (0.195 ± 0.04, 0.217 ± 0.05, 0.222 ± 0.03 vs 0.267 ± 0.04, all P = 0.00).

CONCLUSION: CLC-2 and tight junction protein participate in the maintenance of intestinal mucosal barrier. Acute biliary obstruction-induced destruction of intestinal mucosa barrier is associated with CLC-2 in enterocytes. CLC-2 activation could activate tight junction protein and repair impaired intestinal mucosa barrier.

Pringle maneuver deteriorates gut barrier dysfunction induced by extended-liver radiofrequency ablation

BACKGROUND

Large volume radiofrequency ablation (RFA) of the liver disrupts intestinal mucosa barrier with subsequent bacterial translocation.

AIMS

To investigate the effect of the Pringle maneuver applied concurrently with extended liver RFA on gut barrier integrity and bacterial translocation.

MATERIALS AND METHODS

Rats were subjected to 30% liver RFA following laparotomy (group RFA), RFA plus 30 min Pringle (group RFA + P), Pringle (group P) or sham operation (group S). Intestinal tissue specimens were excised for histopathological examination and assessment of mucosal morphometry, apoptotic activity, mitotic activity and oxidative state. Tissue specimens were collected from the mesenteric lymph nodes, non-ablated liver parenchyma, kidneys and lungs for bacterial culture. Blood samples were collected from the portal and systemic circulation for endotoxin level measurement.

RESULTS

In group RFA + P, intestinal histopathologic lesions, mucosal atrophy and crypt cell apoptosis were more prominent compared to group RFA. Mitotic activity was suppressed. Oxidative stress was equally induced in all experimental groups. The incidence of positive bacterial cultures, bacterial counts and endotoxin levels were higher in group RFA + P compared to the other groups.

CONCLUSION

The application of the Pringle maneuver concurrently with extended liver RFA aggravates gut barrier dysfunction with more aggressive translocation of endotoxins and intestinal bacteria.

Intestinal epithelial cell proliferation, apoptosis and expression of tight junction proteins in patients with obstructive jaundice

BACKGROUND

Intestinal hyperpermeability has been repeatedly confirmed in patients with obstructive jaundice and is considered a pivotal factor in the development of septic and renal complications in these patients. However, little is known on the mechanism(s) leading to this phenomenon. This study was undertaken to investigate the cellular and subcellular intestinal alterations in patients with obstructive jaundice.

DESIGN

Sixteen patients with obstructive jaundice of malignant (n = 8, group A) or benign (n = 8, group B) aetiology, without concomitant cholangitis, and eight healthy controls (group C) were subjected to duodenal biopsy distal to the ampulla of Vater. Specimens were examined histologically and the apoptotic activity in the cryptal epithelium was recorded. Epithelial proliferation was evaluated by immunohistochemical expression of Ki67 antigen. The expression of the tight junction (TJ) proteins occludin, claudin-1, claudin-4 and claudin-7 in the intestinal epithelium was also evaluated by immunohistochemistry.

RESULTS

Patients with malignant or benign obstructive jaundice presented significantly decreased intestinal epithelial cell proliferation rates compared with controls (P < 0·05), whereas no differences were detected in apoptotic activity. In a semiquantitative analysis of TJ protein expression, occludin, claudin-1 and -7 were significantly decreased (P < 0·001), whereas claudin-4 was significantly increased (P < 0·01) in jaundiced patients and their distribution was altered. No differences were detected between patients with malignant or benign obstructive jaundice for all intestinal barrier parameters studied.

CONCLUSION

Decreased enterocyte proliferation and altered TJ protein expression might represent important mechanisms for intestinal barrier dysfunction and hyperpermeability in patients with extrahepatic cholestasis. The potential pharmacological modulation of these factors may lead to better control of intestinal permeability in the jaundiced patient with improved clinical outcome.

Evidence for tight junction protein disruption in intestinal mucosa of malignant obstructive jaundice patients

OBJECTIVE

Experimental and clinical studies have shown that obstructive jaundice results in increased intestinal permeability. The mechanisms implicated in this phenomenon remain obscure. Integrated tight junctions (TJs) are essential for normal gut barrier function. TJ proteins, such as zonula occludens (ZO)-1, claudins and occludin, are indispensable to maintain the function of TJs. This study was undertaken to investigate whether TJ protein disruption occurs in the intestinal mucosa of malignant obstructive jaundice (MOJ) patients.

MATERIAL AND METHODS

Three groups were involved: Group A, MOJ patients whose bilirubin level was >or= 43 microM; Group B, MOJ patients without jaundice; and Group C, patients who underwent gastroscopy with negative findings (controls). Biopsy was done in all participants at the second part of the duodenum, distal to the ampulla of Vater. The morphological and ultrastructural changes of intestinal mucosa were observed. The distributions and expressions of the TJ proteins occludin, ZO-1, claudin-1 and claudin-4 in intestinal mucosa were evaluated by immunohistochemistry and Western blotting.

RESULTS

Histological examination showed a mild infiltration of the lamina propria by chronic inflammatory cells in Group A compared with Groups B and C. Duodenal architecture showed that the microvillus of Group A patients was loose, the structures of junctional complexes were disrupted and the gaps between cell junctions were wider. As shown by immunohistochemical staining and Western blotting, greatly reduced expressions of occludin, ZO-1 and claudin-1 protein were detected in Group A, whereas claudin-4 expression was significantly increased.

CONCLUSIONS

TJs in MOJ patients with jaundice were disrupted in the intestinal epithelium, which may have resulted from the alterations in TJ-related protein expression. TJ interruption may be a key factor contributing to intestinal mucosal barrier injury and increased intestinal permeability.

Protective effect and mechanisms of radix astragali injection on the intestinal mucosa of rats with obstructive jaundice

Objective. To research the protective effects and mechanisms of Radix Astragali injection on the intestinal mucosa of rats with obstructive jaundice (OJ). Methods. The rats were randomly divided into sham-operated, model control and Radix Astragali treated group. We observed the pathological changes of intestinal mucosa, expression levels of Bax and NF-κB proteins, and apoptosis indexes in intestinal mucosa as well as serum NO, MDA and SOD contents, respectively, on 7d, 14d, 21d and 28d after operation. Results. The pathological severity score (on 7d and 14d), apoptotic indexes (on 14d) of the intestinal mucosa and serum MDA content (on 14d) of treated group were significantly lower than those in the model control group (P < .05). The serum SOD contents (on all time points) of treated group were significantly higher than those in the model control group (P < .05). The sham-operated group (on 21d) of the product of staining intensity and positive rate of Bax protein was significantly lower than model control group (P < .05). Conclusion. Radix Astragali injection could protect the intestinal mucosa of OJ rats by increasing the content of SOD, reducing the content of MDA, inhibiting the apoptosis and relieving the pathological changes of intestinal mucosa.

Altered occludin expression in brain capillaries induced by obstructive jaundice in rats

The development of increased oxidative stress in the context of obstructive cholestasis has been proven in various rats' organs including the brain. The present study aimed to detect alterations of tight junction-associated occludin in rat brain capillaries after bile duct ligation (BDL). In experiment 1, occludin expression was evaluated by Western blot analysis in 5 animals 10 days after BDL and compared with 5 sham-operated ones. In experiment 2, groups of 9 animals each were used to assess occludin levels on the 1st, 5th, and 10th days after BDL and to associate these measurements with the in vivo superoxide radical production measured by means of an ultrasensitive fluorescent assay. The results indicated that occludin expression in BDL animals, as opposed to sham-operated, was significantly reduced at every time point studied, being lowest in the rats remaining on BDL condition for 10 days. Moreover, it was demonstrated that the time-dependent downregulation of occludin expression in the brain endothelial was significantly correlated with the time-dependent increase of brain superoxide radical level, implying a relationship between these two abnormalities. In conclusion, the evidence presented herein suggests the implication of occludin and, therefore, of blood-brain barrier in the pathophysiology of extrahepatic cholestasis.

Influence of Salvia miltiorrhizae on the mesenteric lymph node of rats with severe acute pancreatitis or obstructive jaundice

Objective. To observe the effect of salvia miltiorrhizae injection on inflammatory mediator levels and mesenteric lymph nodes in severe acute pancreatitis (SAP) and obstructive jaundice (OJ) rats and explore the protective mechanism of salvia miltiorrhizae on the lymph nodes of these rats. Methods. A total of 288 rats were used in SAP-associated and OJ-associated experiments. The rats were randomly divided into sham-operated group, model control group, and treated group. At various time points after operation, the pathological changes in mesenteric lymph nodes of rats in each group were observed, respectively. Results. The pathological severity scores in lymph nodes of SAP rats in treated group were significantly lower than those in model control group (P < .05) while the pathological changes in lymph nodes of OJ rats in treated group also showed varying degrees of mitigation. Conclusion. Salvia miltiorrhizae can exert protective effects on the lymph nodes of SAP or OJ rats via a mechanism that is associated with reducing the contents of inflammatory mediators in blood.

Diseases of the gallbladder and biliary tree

Most disorders of the biliary system are associated with increased activity of parenchymal transaminases (alanine aminotransferase, aspartate aminotransferase) and cholestatic enzymes (alkaline phosphatase and gamma glutamyl transferase) with or without hyperbilirubinemia or jaundice. While parenchymal liver disease is most common in the dog, inflammatory disorders involving the small- and medium-sized bile ducts and zone 1 (periportal) hepatocytes predominate in the cat. Historically, the incidence of disorders restricted to the gallbladder is low in both species; however, with routine diagnostic use of abdominal ultrasonography, the incidence of gallbladder mucoceles and cholelithiasis has increased. Extrahepatic bile duct obstruction is a well-recognized syndrome because of its association with pancreatitis and obvious jaundice. Less common disorders of the biliary system include a cadre of diverse conditions, including necroinflammatory processes, cholelithiasis, malformations, neoplasia, and an emerging syndrome of gallblader dysmotility.

Protective effects of Salvia miltiorrhizae on multiple organs of rats with obstructive jaundice

PURPOSE

we aim to explore the protective effects of Salvia miltiorrhizae injection on multiple organs of obstructive jaundice (OJ) rats through observing the impact of this injection on the pathological alterations in these organs and the contents of endotoxin, PLA(2), and TNF-alpha in the blood.

METHODS

A total of 90 mice were randomly divided into sham-operated group, model-control group, and Salvia miltiorrhizae-treated group (n = 30). According to the duration of postoperative administration, each group was further divided into two subgroups, namely, 21 d subgroup (consecutive administration for 21 d, n = 15) and 28 d subgroup (consecutive administration for 28 d, n = 15). After administration, the pathological alterations in multiple organs were observed and the contents of endotoxin, PLA(2), and TNF-alpha in the blood were determined.

RESULTS

Compared to model control group, the number of dead rats in treated group decreased though there was no statistical difference between the two groups. The pathological alterations in the liver, kidney, and spleen in treated group showed varying degrees of mitigation. At all time points, the contents of plasma endotoxin declined significantly. On day 28, plasma PLA(2) content in treated group was significantly lower than that in model-control group.

CONCLUSION

Salvia miltiorrhizae injection is able to obviously reduce the contents of inflammatory mediators in the blood of OJ rats and exert some protective effects on multiple organs of these rats.

Time-related alterations of superoxide radical levels in diverse organs of bile duct-ligated rats

The time-related alterations of superoxide radical measured in vivo by employing an ultrasensitive fluorescent assay in the liver, intestine, kidney and brain of rats with experimentally induced obstructive jaundice was investigated. Eighteen rats were randomly divided into Group A, rats subjected to sham operation, and Group B, rats subjected to bile duct ligation (BDL). Three rats from each group were subsequently killed at different time points post-operatively (1, 5 and 10 days). As compared to sham-operated, BDL rats showed a gradual increase with time of superoxide radical in the intestine, liver, kidney and brain: for animals sacrificed on the 1(st), 5(th) and 10(th) day the increase was 45%, 50% and 96% in the liver, 76%, 81% and 118% in the intestine, 64%, 71% and 110% in the kidney and 76%, 95% and 142% in the brain, respectively. This study provides direct evidence of an early appearance of oxidative stress in diverse organs, implying a uniform systemic response to biliary obstruction and emphasizing the need of early bile flow restoration.