New insights into the pathogenesis of intestinal dysfunction: secretory diarrhea and cystic fibrosis

AP1S1 missense mutations cause a congenital enteropathy via an epithelial barrier defect

Congenital diarrheal disorders (CDD) comprise > 50 monogenic entities featuring chronic diarrhea of early-onset, including defects in nutrient and electrolyte absorption, enterocyte polarization, enteroendocrine cell differentiation, and epithelial integrity. Diarrhea is also a predominant symptom in many immunodeficiencies, congenital disorders of glycosylation, and in some defects of the vesicular sorting and transporting machinery. We set out to identify the etiology of an intractable diarrhea in 2 consanguineous families by whole-exome sequencing, and identified two novel AP1S1 mutations, c.269T>C (p.Leu90Pro) and c.346G>A (p.Glu116Lys). AP1S1 encodes the small subunit of the adaptor protein 1 complex (AP-1), which plays roles in clathrin coat-assembly and trafficking between trans-Golgi network, endosomes and the plasma membrane. An AP1S1 knock-out (KO) of a CaCo2 intestinal cell line was generated to characterize intestinal AP1S1 deficiency as well as identified mutations by stable expression in KO background. Morphology and prototype transporter protein distribution were comparable between parental and KO cells. We observed altered localization of tight-junction proteins ZO-1 and claudin 3, decreased transepithelial electrical resistance and an increased dextran permeability of the CaCo2-AP1S1-KO monolayer. In addition, lumen formation in 3D cultures of these cells was abnormal. Re-expression of wild-type AP1S1 in CaCo2-AP1S1-KO cells reverted these abnormalities, while expression of AP1S1 containing either missense mutation did not. Our data indicate that loss of AP1S1 function causes an intestinal epithelial barrier defect, and that AP1S1 mutations can cause a non-syndromic form of congenital diarrhea, whereas 2 reported truncating AP1S1 mutations caused MEDNIK syndrome, characterized by mental retardation, enteropathy, deafness, neuropathy, ichthyosis, and keratodermia.

Opioid misuse in gastroenterology and non-opioid management of abdominal pain

Opioids were one of the earliest classes of medications used for pain across a variety of conditions, but morbidity and mortality have been increasingly associated with their chronic use. Despite these negative consequences, chronic opioid use is increasing worldwide, with the USA and Canada having the highest rates. Chronic opioid use for noncancer pain can have particularly negative effects in the gastrointestinal and central nervous systems, including opioid-induced constipation, narcotic bowel syndrome, worsening psychopathology and addiction. This Review summarizes the evidence of opioid misuse in gastroenterology, including the lack of evidence of a benefit from these drugs, as well as the risk of harm and negative consequences of opioid use relative to the brain-gut axis. Guidelines for opioid management and alternative pharmacological and nonpharmacological strategies for pain management in patients with gastrointestinal disorders are also discussed. As chronic pain is complex and involves emotional and social factors, a multimodal approach targeting both pain intensity and quality of life is best.

Physiology, signaling, and pharmacology of opioid receptors and their ligands in the gastrointestinal tract: current concepts and future perspectives

Opioid receptors are widely distributed in the human body and are crucially involved in numerous physiological processes. These include pain signaling in the central and the peripheral nervous system, reproduction, growth, respiration, and immunological response. Opioid receptors additionally play a major role in the gastrointestinal (GI) tract in physiological and pathophysiological conditions. This review discusses the physiology and pharmacology of the opioid system in the GI tract. We additionally focus on GI disorders and malfunctions, where pathophysiology involves the endogenous opioid system, such as opioid-induced bowel dysfunction, opioid-induced constipation or abdominal pain. Based on recent reports in the field of pharmacology and medicinal chemistry, we will also discuss the opportunities of targeting the opioid system, suggesting future treatment options for functional disorders and inflammatory states of the GI tract.

Epac1 mediates protein kinase A-independent mechanism of forskolin-activated intestinal chloride secretion

Intestinal Cl⁻ secretion is stimulated by cyclic AMP (cAMP) and intracellular calcium ([Ca²⁺]_i). Recent studies show that protein kinase A (PKA) and the exchange protein directly activated by cAMP (Epac) are downstream targets of cAMP. Therefore, we tested whether both PKA and Epac are involved in forskolin (FSK)/cAMP-stimulated Cl⁻ secretion. Human intestinal T84 cells and mouse small intestine were used for short circuit current (I_sc) measurement in response to agonist-stimulated Cl⁻ secretion. FSK-stimulated Cl⁻ secretion was completely inhibited by the additive effects of the PKA inhibitor, H89 (1 µM), and the [Ca²⁺]_i chelator, 1,2-bis-(o-aminophenoxy)-ethane-N,N,N’,N’-tetraacetic acid, tetraacetoxymethyl ester (BAPTA-AM; 25 µM). Both FSK and the Epac activator 8-pCPT-2’-O-Me-cAMP (50 µM) elevated [Ca²⁺]_i, activated Ras-related protein 2, and induced Cl⁻ secretion in intact or basolateral membrane–permeabilized T84 cells and mouse ileal sheets. The effects of 8-pCPT-2’-O-Me-cAMP were completely abolished by BAPTA-AM, but not by H89. In contrast, T84 cells with silenced Epac1 had a reduced I_sc response to FSK, and this response was completely inhibited by H89, but not by the phospholipase C inhibitor U73122 or BAPTA-AM. The stimulatory effect of 8-pCPT-2’-O-Me-cAMP on Cl⁻ secretion was not abolished by cystic fibrosis transmembrane conductance (CFTR) inhibitor 172 or glibenclamide, suggesting that CFTR channels are not involved. This was confirmed by lack of effect of 8-pCPT-2’-O-Me-cAMP on whole cell patch clamp recordings of CFTR currents in Chinese hamster ovary cells transiently expressing the human CFTR channel. Furthermore, biophysical characterization of the Epac1-dependent Cl⁻ conductance of T84 cells mounted in Ussing chambers suggested that this conductance was hyperpolarization activated, inwardly rectifying, and displayed a Cl⁻>Br⁻>I⁻ permeability sequence. These results led us to conclude that the Epac-Rap-PLC-[Ca²⁺]_i signaling pathway is involved in cAMP-stimulated Cl⁻ secretion, which is carried by a novel, previously undescribed Cl⁻ channel.

How do the rotavirus NSP4 and bacterial enterotoxins lead differently to diarrhea?

Rotavirus is the major cause of infantile gastroenteritis and each year causes 611,000 deaths worldwide. The virus infects the mature enterocytes of the villus tip of the small intestine and induces a watery diarrhea. Diarrhea can occur with no visible tissue damage and, conversely, the histological lesions can be asymptomatic. Rotavirus impairs activities of intestinal disaccharidases and Na+-solute symports coupled with water transport. Maldigestion of carbohydrates and their accumulation in the intestinal lumen as well as malabsorption of nutrients and a concomitant inhibition of water reabsorption can lead to a malabsorption component of diarrhea. Since the discovery of the NSP4 enterotoxin, diverse hypotheses have been proposed in favor of an additional secretion component in the pathogenesis of diarrhea. Rotavirus induces a moderate net chloride secretion at the onset of diarrhea, but the mechanisms appear to be quite different from those used by bacterial enterotoxins that cause pure secretory diarrhea. Rotavirus failed to stimulate Cl- secretion in crypt, whereas it stimulated Cl- reabsorption in villi, questioning, therefore, the origin of net Cl- secretion. A solution to this riddle was that intestinal villi do in fact secrete chloride as a result of rotavirus infection. Also, the overall chloride secretory response is regulated by a phospholipase C-dependent calcium signaling pathway induced by NSP4. However, the overall response is weak, suggesting that NSP4 may exert both secretory and subsequent anti-secretory actions, as did carbachol, hence limiting Cl- secretion. All these characteristics provide the means to make the necessary functional distinction between viral NSP4 and bacterial enterotoxins.

Soluble extracts from Helicobacter pylori induce dome formation in polarized intestinal epithelial monolayers in a laminin-dependent manner

Helicobacter pylori colonizes the stomach at the interface between the mucus layer and the apical pole of gastric epithelial cells. A number of secreted and shed products from the bacteria, such as proteins and lipopolysaccharide, are likely to have a role in the pathogenesis at the epithelial level. To determine the physiological response of transporting polarized epithelia to released soluble factors from the bacterium, we used the T84 cell line. Monolayers of T84 cells were exposed to soluble extracts from H. pylori. The extracts induced rapid "dome" formation as well as an immediate decrease in transepithelial electrical resistance. Domes are fluid-filled blister-like structures unique to polarized epithelia. Their formation has been linked to sodium-transporting events as well as to diminished adherence of the cells to the substrate. H. pylori-induced dome formation in T84 monolayers was exacerbated by amiloride and inhibited by ouabain. Furthermore, it was associated with changes in the expression of the laminin binding alpha 6 beta 4 integrin and the 67-kDa laminin receptor. Domes formed primarily on laminin-coated filters, rather than on fibronectin or collagen matrices, and their formation was inhibited by preincubating the bacterial extract with soluble laminin. This effect was specific to H. pylori and independent of the urease, vacA, cagA, and Lewis phenotype of the strains. These data indicate that released elements from H. pylori can alter the physiological balance and integrity of the epithelium in the absence of an underlying immune response.

Acaroid mite, intestinal and urinary acariasis

AIM: To investigate epidemiology and pathogenic mite species of intestinal and urinary acariasis in individuals with different occupations.

METHODS: A total of 1994 individuals were tested in this study. History collection, skin prick test and pathogen identification were conducted. The mites were isolated from stool and urine samples by saturated saline flotation methods and sieving following centrifugation, respectively.

RESULTS: Among the 1994 individuals examined, responses to the skin prick test of “+++”, “++”, “+”, “±” and “-” were observed at frequencies of 3.96% (79), 3.21% (64), 2.31% (46), 1.25% (25) and 89.27% (1780), respectively. A total number of 161 (8.07%) individuals were shown to carry mites, with 92 (4.61%) positive only for stool samples, 37 (1.86%) positive only for urine samples and 32 (1.60%) for both. The positive rate of mites in stool samples was 6.22% (124/1994), being 6.84% (78/1140) for males and 5.39% (46/854) for females. No gender difference was observed in this study (χ² = 1.77, P > 0.05). The mites from stool samples included Acarus siro, TyroPhagus putrescentiae, Dermatophagoides farinae, D. pteronyssinus, Glycyphagus domesticus, G.ornatus, Carpoglyphus lactis and Tarsonemus granaries. The positive rate of mites in urine samples was 3.46% (69/1994). The positive rates for male and female subjects were found to be 3.95% (45/1140) and 2.81% (24/854) respectively, with no gender difference observed (χ² = 1.89, P > 0.05). Mites species in urine samples included Acarus siro, Tyrophagus putrescentiae, T. longior, Aleuroglyphus ovatus, Caloglyphus berlesei, C. mycophagus, Suidasia nesbitti, Lardoglyphus konoi, Glycyphagus domesticus, Carpoglyphus lactis, Lepidoglyphus destructor, Dermatophagoides farinae, D. pteronyssinus, Euroglyphus magnei, Caloglyphus hughesi, Tarsonemus granarus and T. hominis. The species of mites in stool and urine samples were consistent with those separated from working environment. A significant difference was found among the frequencies of mite infection in individuals with different occupations (χ² = 82.55, P < 0.001), with its frequencies in those working in medicinal herb storehouses, those in rice storehouse or mills, miners, railway workers, pupils and teachers being 15.89% (68/428), 12.96% (53/409), 3.28% (18/549), 2.54% (6/236), 5.10% (13/255) and 2.56% (3/117), respectively.

CONCLUSION: The prevalence of human intestinal and urinary acariasis was not associated with gender, and these diseases are more frequently found in individuals working in medicinal herb, rice storehouses or mills and other sites with high density of mites. More attention should be paid to the mite prevention and labor protection for these high-risk groups.

Cyclospore cayetanensis in Anhui, China

AIM: To investigate the infection of Cyclospore cayetanensis in Anhui Province.

METHODS: Identification of Cyclospore cayetanensis was made microscopically by finding the oocysts of Cyclospore cayetanensis in fecal smears taken from the infants, pupils and adults with obstinate diarrhea, and immunocompromised individuals by using a auramine-phenol stain and modified acid-fast stain. Cellular immune function was detected with biotin-streptavidin (BSA), and the specific antibody against Cyclospore cayetanensis was detected with method of ELISA.

RESULTS: (1) The positive rates of Cyclospore cayetanensis infection in infants, pupils, infants and adults with obstinate diarrhea and with immunocompromised individuals were significantly different (P < 0.01), with the rates of 0%, 0.50% (1/200), 5.62% (10/178), and 9.38% (3/32) respectively. (2) The infection rates of males and females were 2.61% (10/383) and 1.44% (4/227) respectively, with no significant difference (P < 0.05). (3) The positive rates of population with oocysts in urban and rural areas were 0.92% (3/325) and 3.86% (11/285) respectively. (4) The positive rates of CD₃⁺, CD₄⁺, CD₈⁺ and the ratio of CD₄⁺/CD₈⁺ of individuals with and without oocysts were significantly different (P < 0.05, P < 0.01), and their values were (64.28% ± 6.55%), (43.55% ± 5.80%), (28.23% ± 4.32%), 1.52 ± 0.32 and (58.97% ± 5.23%), (39.26% ± 4.93%), (30.54% ± 5.17%), 1.26 ± 0.21, respectively. (5) Specific IgG, IgM and IgG+IgM in serum of the patients with oocyst were significantly different (P < 0.01) with the positive rates of 63.41% (9/14), 17.07% (1/14) and 19.51% (4/14) respectively.

CONCLUSION: Cyclospore cayetanensis infection is present in Anhui, China and it was confirmed to be a new pathogen associated with children diarrhea, adults obstinate diarrhea and diarrhea in immunocompromised individuals. Among all the infected individuals, adult obstinate diarrhea patients and immunocompromised individuals are common. Feces examination of oocysts and serological examination of the specific antibody will be of much help in the diagnosis of Cyclospore cayetanensis infection.

Epidemiological survey of Blastocystis hominis in Huainan City, Anhui Province, China

AIM: To provide scientific evidence for prevention and controlling of blastocystosis, the infection of Blastocystis homonis and to study its clinical significance in Huainan City, Anhui Province, China.

METHODS: Blastocystis homonis in fresh stools taken from 100 infants, 100 pupils, 100 middle school students and 403 patients with diarrhea was smeared and detected with method of iodine staining and hematoxylin staining. After preliminary direct microscopy, the shape and size of Blastocystis homonis were observed with high power lens. The cellular immune function of the patients with blastocystosis was detected with biotin-streptavidin (BSA).

RESULTS: The positive rates of Blastocystis homonis in fresh stools taken from the infants, pupils, middle school students and the patients with diarrhea, were 1.0% (1/100), 1.0% (1/100), 0% (0/100) and 5.96% (24/403) respectively. Furthermore, the positive rates of Blastocystis homonis in the stool samples taken from the patients with mild diarrhea, intermediate diarrhea, severe diarrhea and obstinate diarrhea were 6.03% (14/232), 2.25% (2/89), 0% (0/17) and 12.31% (8/65) respectively. The positive rates of Blastocystis homonis in fresh stools of male and female patients with diarrhea were 7.52% (17/226) and 3.95% (7/177) respectively, and those of patients in urban and rural areas were 4.56% (11/241) and 8.02% (13/162) respectively. There was no significant difference between them (P > 0.05). The positive rates of CD₃⁺, CD₄⁺, CD₈⁺ in serum of Blastocystis homonis-positive and-negative individuals were 0.64 ± 0.06, 0.44 ± 0.06, 0.28 ± 0.04 and 0.60 ± 0.05, 0.40 ± 0.05 and 0.30 ± 0.05 respectively, and the ratio of CD₄⁺/CD₈⁺ of the two groups were 1.53 ± 0.34 and 1.27 ± 0.22. There was significant difference between the two groups (P < 0.05, P < 0.01).

CONCLUSION: The prevalence of Blastocystis hominis as an enteric pathogen in human seems not to be associated with gender and living environment, and that Blastocystis hominis is more common in stool samples of the patients with diarrhea, especially with chronic diarrhea or obstinate diarrhea. When patients with diarrhea infected by Blastocystis hominis, their cellular immune function decreases, which make it more difficult to be cured.