Expression of renal Oat5 and NaDC1 transporters in rats with acute biliary obstruction

AIM: To examine renal expression of organic anion transporter 5 (Oat5) and sodium-dicarboxylate cotransporter 1 (NaDC1), and excretion of citrate in rats with acute extrahepatic cholestasis.

METHODS: Obstructive jaundice was induced in rats by double ligation and division of the common bile duct (BDL group). Controls underwent sham operation that consisted of exposure, but not ligation, of the common bile duct (Sham group). Studies were performed 21 h after surgery. During this period, animals were maintained in metabolic cages in order to collect urine. The urinary volume was determined by gravimetry. The day of the experiment, blood samples were withdrawn and used to measure total and direct bilirubin as indicative parameters of hepatic function. Serum and urine samples were used for biochemical determinations. Immunoblotting for Oat5 and NaDC1 were performed in renal homogenates and brush border membranes from Sham and BDL rats. Immunohistochemistry studies were performed in kidneys from both experimental groups. Total RNA was extracted from rat renal tissue in order to perform reverse transcription polymerase chain reaction. Another set of experimental animals were used to evaluate medullar renal blood flow (mRBF) using fluorescent microspheres.

RESULTS: Total and direct bilirubin levels were significantly higher in BDL animals, attesting to the adequacy of biliary obstruction. An important increase in mRBF was determined in BDL group (Sham: 0.53 ± 0.12 mL/min per 100 g body weight vs BDL: 1.58 ± 0.24 mL/min per 100 g body weight, P < 0.05). An increase in the urinary volume was observed in BDL animals. An important decrease in urinary levels of citrate was seen in BDL group. Besides, a decrease in urinary citrate excretion (Sham: 0.53 ± 0.11 g/g creatinine vs BDL: 0.07 ± 0.02 g/g creatinine, P < 0.05) and an increase in urinary excretion of H⁺ (Sham: 0.082 ± 0.03 μmol/g creatinine vs BDL: 0.21 ± 0.04 μmol/g creatinine, P < 0.05) were observed in BDL animals. We found upregulations of both proteins Oat5 and NaDC1 in brush border membranes where they are functional. Immunohistochemistry technique corroborated these results for both proteins. No modifications were observed in Oat5 mRNA and in NaDC1 mRNA levels in kidney from BDL group as compared with Sham ones.

CONCLUSION: Citrate excretion is decreased in BDL rats, at least in part, because of the higher NaDC1 expression. Using the outward gradient of citrate generated by NaDC1, Oat5 can reabsorb/eliminate different organic anions of pathophysiological importance.

Antioxidant Effect of Sepia Ink Extract on Extrahepatic Cholestasis Induced by Bile Duct Ligation in Rats

OBJECTIVE

The aim of our study was to assess the complications of hepatic fibrosis associated with bile duct ligation and the potential curative role of sepia ink extract in hepatic damage induced by bile duct ligation.

METHODS

Rattus norvegicus rats were divided into 3 groups: Sham-operated group, model rats that underwent common bile duct ligation (BDL), and BDL rats treated orally with sepia ink extract (200 mg/kg body weight) for 7, 14, and 28 d after BDL.

RESULTS

There was a significant reduction in hepatic enzymes, ALP, GGT, bilirubin levels, and oxidative stress in the BDL group after treatment with sepia ink extract. Collagen deposition reduced after sepia ink extract treatment as compared to BDL groups, suggesting that the liver was repaired. Histopathological examination of liver treated with sepia ink extract showed moderate degeneration in the hepatic architecture and mild degeneration in hepatocytes as compared to BDL groups.

CONCLUSION

Sepia ink extract provides a curative effect and an antioxidant capacity on BDL rats and could ameliorate the complications of liver cholestasis.

Protective effect of the aqueous extract from the root of Platycodon grandiflorum on cholestasis-induced hepatic injury in mice

CONTEXT

The root of Platycodon grandiflorum (Jacq.) A. DC. (Campanulaceae) has been widely studied for its hepatoprotective effects against various hepatotoxicants.

OBJECTIVE

The present study evaluated the protective effect of the standardized aqueous extract of P. grandiflorum (BC703) on cholestasis-induced hepatic injury in mice.

MATERIALS AND METHODS

BC703 is a standardized aqueous extract of P. grandiflorum in reference to platycodin D (at least 0.8%). The mice were allocated into five groups as follows: Sham-operated, bile duct ligation (BDL) alone, and BDL with BC703 (1, 5, and 10 mg/kg BW) treated group. BC703 was given for 3 consecutive days before BDL operation. The animals were sacrificed by CO₂ anesthesia post-24 h of BDL operations.

RESULTS AND DISCUSSION

Serum alanine aminotransferase and serum aspartate aminotransferase increased to 395.2 ± 90.0 and 266.0 ± 45.6 Unit/L in the BDL alone group and decreased with BC703 in a dose-dependent manner. Especially the 10 mg/kg of BC703-treated mice showed a 77% decrease of serum alanine aminotransferase and 56% of aspartate aminotransferase as compared with BDL alone. Decreased antioxidant enzyme levels in BDL alone group were elevated in BC703-treated groups ranging from 7 to 29% for glutathione and from 13 to 25% for superoxide dismutase. BC703 treatment also attenuated malondialdehyde (from 3 to 32%) and nitric oxide levels (from 32 to 50%) as compared with BDL alone. Histopathological studies further confirmed the hepatoprotective effect of BC703 in BDL-induced cholestesis.

CONCLUSION

BC703 could attenuate liver injury by BDL in mice, and test results indicate that BC703 might be useful in cholestatic liver injury.

[Results of surgical treatment of patients with subhepatic cholestasis of non-tumor etiology]

There were studied the results, termed from 12 to 24 months, of operatively treated patients for subhepatic cholestasis of nontumoral etiology. The general clinical examination, ultrasonographic investigation were performed to the patients, as well as morphological changes estimation in hepatic fine-needle biopsies samples, biochemical indices and the state of systemic hepatic blood circulation. Application of complex staged operative interventions, added by hepatoregenerative operations, have had favored normalization of laboratory indices and structural hepatic changes as well as the hepatic blood supply improvement due to systolic inflow enhancement by 26% and microcirculatory bed blood circulation -- by 51%.

Initial site of bile regurgitation following extrahepatic biliary obstruction in living rats

BACKGROUND AND AIM

The precise mechanism of bile regurgitation from the biliary system to the blood stream still remains to be elucidated. The aim of this study was to examine the initial site of bile regurgitation in vivo after common bile duct (CBD) obstruction by digitally enhanced fluorescence microscopy.

METHODS

The fluorescence excreted into bile canaliculi after the administration of sodium fluorescein was continuously observed in CBD obstruction, using video-enhanced contrast (VEC) microscopy equipped with a silicon intensified target (SIT) camera. The liver histology and the localization of Mg(2+)-ATPase were examined by light and electron microscopy.

RESULTS

By the continuous recording of canalicular fluorescence, the sequential regurgitation of the fluorescence from the canaliculi to the hepatocyte cytoplasm to the sinusoids was distinctively recognized after CBD obstruction. Bile canalicular fluorescence was enhanced, and then the fluorescence of the hepatocyte cytoplasm increased in intensity, followed by regurgitation of the fluorescence to the sinusoids. These in vivo sequences closely correlated with changes in CBD pressure. In zone 1, canalicular fluorescence focally burst into hepatocyte cytoplasm, thus resulting in the formation of fluorescent cells. By light and electron microscopy, the fluorescent cells were found to correspond to the liver cell injury. The reaction products of Mg(2+)-ATPase were incorporated into vesicles with a decreased canalicular activity, and then were transported to the sinusoidal surface after CBD obstruction.

CONCLUSIONS

The initial site of bile regurgitation may be transcellular, and partly involves liver cell injury in zone 1 in extrahepatic biliary obstruction, associated with increased pressure of the biliary system.

Stone or stricture as a cause of extrahepatic cholestasis--do liver function tests predict the diagnosis?

BACKGROUND

Cholestasis, roughly divided into intrahepatic and extrahepatic forms, is a clinical challenge. Extrahepatic cholestasis, characterized by dilated bile ducts, is caused by either a bile duct stone or stricture, with stricture most often related to a malignancy. The aim of the present study was to analyze the value of common liver function tests in separating patients with malignant bile duct strictures from those with stones.

METHODS

All consecutive patients admitted for endoscopic retrograde cholangiopancreatography (ERCP) were included in the study population if a bile duct stricture related to a malignancy was found by ERCP (n=103) or if a bile duct stone was successfully extracted during ERCP, thus confirming the diagnosis of a stone (n=109). Plasma alkaline phosphatase, gamma-glutamyltransferase, alanine aminotransferase and bilirubin values were determined in the morning before ERCP.

RESULTS

Plasma bilirubin (p<0.001), alkaline phosphatase (p<0.001) and alanine aminotransferase (p=0.040) levels were significantly higher in patients with malignant bile duct strictures than in those with bile duct stones. In addition, gamma-glutamyltransferase levels seemed to be higher in patients with malignant strictures than in those with stones, although the difference did not reach statistical significance (p=0.053). In receiver operating characteristic analyses, bilirubin proved to be the best laboratory test in differentiating patients (p=0.001 vs. alkaline phosphatase, p<0.001 vs. alanine aminotransferase and p<0.001 vs. gamma-glutamyltransferase). With a plasma bilirubin cutoff value of 145 micromol/L, four out of five patients were categorized correctly.

CONCLUSIONS

Plasma bilirubin seems to be the best liver function test in distinguishing patients with malignant bile duct strictures from those with bile duct stones. This routine test should receive more attention in clinical decision-making than has previously been given.

Elevated CA 19-9 Levels in a Patient with Mirizzi Syndrome: Case Report

CA 19-9 is a marker of malignancy of the pancreas and biliary tract. We report the case of a patient who had significantly elevated serum CA 19-9 levels and imaging studies suggestive of malignancy. On laparotomy, the patient was found to have Mirizzi syndrome, an uncommon cause of biliary obstruction from an impacted gallstone. This case illustrates that elevated serum CA 19-9 levels must be interpreted cautiously in cases of biliary obstruction.

Obstructive cholestasis alters intestinal transit in mice: role of opioid system

Acute cholestasis is associated with increased activity of the endogenous opioid system. It is also known that opioid receptor agonists like morphine decrease the intestinal transit. The purpose of the present study was to investigate the effect of cholestasis on the small intestine transit and the possible involvement of opioid system in this phenomenon in mice. Cholestasis was induced by bile duct-ligation and intestinal transit was measured with charcoal meal and calculation of percent of transit through small intestine. The effect of chronic administration of naltrexone and acute pretreatment with morphine on intestinal transit was evaluated in bile duct-ligated (BDL) as well as unoperated (CTL) and sham-operated (SHAM) animals. The plasma alkaline phosphatase and alanine aminotransferase activities were also measured. A significant decrease in small intestine transit (%transit) was observed in BDL mice compared to SHAM animals, which was prominent even after 24 h of cholestasis. Chronic pretreatment with an opioid receptor antagonist, naltrexone, (10 mg/kg, i.p for 2, 4 or 6 days) completely restored the cholestasis-induced decrease in %transit to that of control animals. Although the acute administration of morphine (2 mg/kg, s.c.) 20 min before charcoal feeding caused a significant decrease in the intestinal transit of CTL and SHAM animals, it did not decrease the %transit of BDL animals on the day 5 after operation. Our findings show that acute cholestasis is associated with a prominent decrease in small intestine transit in mice and opioid receptors maybe involved in this phenomenon.

Microsurgical extrahepatic cholestasis in the rat: a long-term study

An experimental model of microsurgical cholestasis is studied as an alternative to the most frequently used surgical techniques, based on the section of the common bile duct. This microsurgical technique consists of the resection of the extrahepatic biliary tract, that is, of the common bile duct in continuity with the bile ducts that drain the four lobes of the rat liver. At 30 days of evolution, rats with microsurgical cholestasis do not develop biliary pseudocysts or intraperitoneal hilar hepatopulmonary abscesses and show an increase (p < 0.001) in total bilirubin (9.50 +/- 1.50 mg/dL vs. 1.60 +/- 0.35 mg/dL), bile acids (225 +/- 87 micromol/L vs. 12.5 +/- 14.50 micromol/L), gamma-glutamyltranspeptidase (375 +/- 143 U/L vs. 8 +/- 11 U/L), and alkaline phosphatase (73 +/- 25 U/L vs. 23 +/- 4 U/L) levels. The histological study shows fibrosis with biliary proliferation. The microsurgical cholestasis technique is a valid alternative to other techniques and can be an adequate experimental model for the study of etiopathogenic mechanisms of obstructive jaundice and especially to study extrahepatic biliary atresia.

Treatment of EFA deficiency with dietary triglycerides or phospholipids in a murine model of extrahepatic cholestasis

Essential fatty acid (EFA) deficiency during cholestasis is mainly due to malabsorption of dietary EFA (23). Theoretically, dietary phospholipids (PL) may have a higher bioavailability than dietary triglycerides (TG) during cholestasis. We developed murine models for EFA deficiency (EFAD) with and without extrahepatic cholestasis and compared the efficacy of oral supplementation of EFA as PL or as TG. EFAD was induced in mice by feeding a high-fat EFAD diet. After 3 wk on this diet, bile duct ligation was performed in a subgroup of mice to establish extrahepatic cholestasis. Cholestatic and noncholestatic EFAD mice continued on the EFAD diet (controls) or were supplemented for 3 wk with EFA-rich TG or EFA-rich PL. Fatty acid composition was determined in plasma, erythrocytes, liver, and brain. After 4 wk of EFAD diet, induction of EFAD was confirmed by a sixfold increased triene-to-tetraene ratio (T/T ratio) in erythrocytes of noncholestatic and cholestatic mice (P < 0.001). EFA-rich TG and EFA-rich PL were equally effective in preventing further increase of the erythrocyte T/T ratio, which was observed in cholestatic and noncholestatic nonsupplemented mice (12- and 16-fold the initial value, respectively). In cholestatic mice, EFA-rich PL was superior to EFA-rich TG in decreasing T/T ratios of liver TG and PL (each P < 0.05) and in increasing brain PL concentrations of the long-chain polyunsaturated fatty acids (LCPUFA) docosahexaenoic acid and arachidonic acid (each P < 0.05). We conclude that oral EFA supplementation in the form of PL is more effective than in the form of TG in increasing LCPUFA concentrations in liver and brain of cholestatic EFAD mice.

Profile of hepatocyte growth factor in patients with obstructive jaundice

BACKGROUND/AIMS

Hepatocyte growth factor is a potent growth-stimulating factor of many kinds of tissue. Hepatocyte growth factor was demonstrated in the blood of various liver diseases, and its concentration was reported to correlate with liver function after partial hepatectomy. In this study, we monitor the dynamics of bile hepatocyte growth factor in patients with obstructive jaundice.

METHODOLOGY

In a university hospital, 68 paired blood and bile samples from 42 patients with hyperbilirubinemia were determined with ELISA. The hepatocyte growth factor bile/blood ratio and both daily hepatocyte growth factor clearance and output were calculated for each pair. The correlations between these values with other biochemical parameters were then determined.

RESULTS

The blood hepatocyte growth factor concentration correlated positively with serum bilirubin (r = 0.556, p < 0.001) level, whereas bile hepatocyte growth factor concentration, hepatocyte growth factor bile/blood ratio, hepatocyte growth factor clearance and daily hepatocyte growth factor output correlated negatively with serum bilirubin level (p = 0.006, < 0.001, < 0.001 and 0.002, respectively). Similar strong positive correlations also were found to exist between these hepatocyte growth factor measurements and other liver function parameters.

CONCLUSIONS

In this study we demonstrated that the hepatocyte growth factor was significantly higher in bile than in blood and that the excretion of hepatocyte growth factor in the bile was decreased in patients with obstructive jaundice. The higher blood hepatocyte growth factor level in patients with obstructive jaundice might be due to decreased hepatocyte growth factor excretion. The higher hepatocyte growth factor level in bile also might explain why liver cirrhosis occurs after prolonged jaundice.

[Biochemical investigation of patients with jaundice of tumor genesis]

The study comprised surgical patients presenting with tumours of the extrahepatic biliferous ducts. The above patients revealed a high activity of gamma-glutamyltransferase, alkaline phosphatase at the expense of the hepatic isoenzye, to a lesser extent--of asparaginaminotransferase, alaninaminotransferase, a high level of conjugated bilirubin, an insignificant increase in the level of cholesterol and triglycerides. The above biochemical indices combined with results of other methods of investigation can be used for early diagnosis of mechanical jaundice of the tumour genesis.

Extrahepatic bile duct stricture and elevated CA 19-9: malignant or benign?

Biliary obstruction due to a proximal bile duct stricture is commonly a result of cholangiocarcinoma. We describe a patient who began having intermittent episodes of jaundice 3 years after cholecystectomy. Despite endoscopic placement of a biliary stent and adequate biliary decompression, the serum CA 19-9 level remained elevated at 58 U/ml (normal <37 U/ml). Segmental bile duct resection and Roux-en-Y hepaticojejunostomy were done. The stricture was caused by a traumatic bile duct neuroma. Diagnostic and therapeutic considerations of this entity are discussed, with special emphasis on the value of noninvasive biliary imaging by magnetic resonance imaging (MRI), the utility and interpretation of the CA 19-9 level, and the role for resection or surgical biliary decompression.

[Multifactorial analysis of results of the open and endo-biliary surgical treatment of patients with obstructive jaundice due to the distal obstruction of the bile ducts]

The were analyzed the results of treatment of patients with the obstructive jaundice (OJ) due to obstruction of the biliary ducts distal part using surgical and endobiliary decompression using the variation statistics methods (distribution of patients on groups depending on the values of the investigated parameters, calculation of the mean values, evaluation of the authenticity of the indexes distinction), the multifactoral correlative-regressive analysis, the complex evaluation of indexes and probit-analysis. The dependence of results of treatment from value of clinical parameters was established, their prognostic significance was determined. The content of the bilirubin more than 300 mmol/l in distal level of affection of biliferous ducts cause high probability of the postoperative complications occurrence (coefficient of determination 34.8%), determining necessity of performance of draining endobiliary intervention on the first stage of surgical treatment. The dependence of lethality from age of patients and duration of the OJ was noted.

Bone density and 25-hydroxyvitamin D level in extrahepatic biliary atresia

Biliary atresia (BA) represents a common cholestatic affliction of the gastrointestinal tract affecting infants and children. The objective of the present study was to evaluate 42 patients (20 with and 22 without jaundice) diagnosed with extrahepatic BA for bone mineral content and serum 25-hydroxyvitamin D (HVD) levels. Physical examination and anthropometric nutritional assessment were performed. The investigation included liver function tests and serum calcium (Ca), phosphate (P), magnesium (Mg), and 25-HVD levels. Dual-energy X-ray absorptiometry was used to measure the bone mineral density (BMD) of the lumbar spine (L(1)-L(4)). Our results showed that 16 jaundiced patients (80%) and only 3 nonjaundiced patients (13.6%) showed osteoporosis (P< 0.05). All patients had normal serum Ca and P levels. Only 1 nonjaundiced patient had a low serum Mg level. Serum 25-HVD levels (mean +/- SD) were 20.71 +/- 8.24, 16.12 +/- 4.3, and 9.18 +/- 5.84 ng/ml, respectively, in subjects with normal bone density (n=7), osteopenia (n=3), and osteoporosis (n=11). Bone disease represents a well-known complication among long-term survivors of BA. To date, the pathogenesis has remained unexplained. Since, as demonstrated in the present study, jaundiced patients develop osteoporosis more frequently than nonjaundiced patients, hyperbilirubinemia may have an influence. Bone-mineral deficiency can be detected earlier by means of BMD measurement (non-invasive method) than by measuring serum Ca, P, and Mg levels in these patients.

The effect of pentoxifylline on the healing of intestinal anastomosis in rats with experimental obstructive jaundice

The aims of this study were (1) to investigate the effect of experimental obstructive jaundice on the healing of intestinal anastomosis, and (2) to investigate the effect of pentoxifylline on the healing of intestinal anastomosis in rats with obstructive jaundice. Obstructive jaundice was induced in rats by the ligation and division of the common bile duct. Four days after this operation, either pentoxifylline or isotonic saline solution was administered intraperitoneally to these jaundiced rats and controls, and then intestinal anastomosis was performed. The concentrations of serum tumor necrosis factor alpha (TNF-alpha) and serum triglyceride of jaundiced and nonjaundiced rats were measured, and the quality of healing was evaluated by measuring the bursting pressure and hydroxyproline content of the anastomoses on the fifth and tenth days of anastomotic healing. Obstructive jaundice resulted in an impaired wound healing of the intestinal anastomosis in the rats. The administration of pentoxifylline to the jaundiced rats resulted in better anastomotic wound healing. The beneficial effects of pentoxifylline on anastomotic healing in rats with obstructive jaundice was attributed to its inhibitor effect on the endotoxin-induced TNF-alpha release from macrophages and monocytes, and the stabilizing effect on the neutrophils.

Effects of obstructive jaundice on the antioxidative capacity of human red blood cells

Transient haemolysis and shortened erythrocyte lifespan are reported in association with extrahepatic biliary tract obstruction. An increase in lipid peroxidation has been noted as evidence of oxidative damage in red cells due to cholestasis. The influence of surgical relief on the antioxidative capacity of the erythrocyte is less well defined. The ability of erythrocytes to regenerate the antioxidative capacity after side-to-side choledo-choduodenostomy was assessed by measuring the two principal antioxidant enzymes, namely superoxide dismutase (SOD) and catalase (CAT), as well as the glutathione (GSH) content in the red blood cells (RBC) taken from patients with obstructive jaundice. A comparison of patients and healthy volunteers revealed a consistent decrease in enzyme activities (pSOD = 0.01, pCAT = 0.0002) and glutathione concentrations (PGSH = 0.0000) in cholestatic patients. Statistical analysis proved a clear correlation between the surgical relief of common bile duct obstruction and restored antioxidative capacity of red cells. These observations suggest that the red cells from patients with multiple common bile duct stones almost completely regenerated their antioxidative capacity four weeks after side-to-side choledochoduodenostomy.

Protective effect of melatonin against oxidative stress induced by ligature of extra-hepatic biliary duct in rats: comparison with the effect of S-adenosyl-L-methionine

In the present research, we studied the effect of the administration of melatonin or S-adenosyl-L-methionine (S-AMe) on oxidative stress and hepatic cholestasis produced by double ligature of the extra-hepatic biliary duct (LBD) in adult male Wistar rats. Hepatic oxidative stress was evaluated by the changes in the amount of lipid peroxides and by the reduced glutathione content (GSH) in lysates of erythrocytes and homogenates of hepatic tissue. The severity of the cholestasis and hepatic injury were determined by the changes in the plasma enzyme activities of alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (AP), g-glutamyl-transpeptidase (GGT), and levels of albumin, total bilirubin (TB) and direct bilirubin (DB). Either melatonin or S-AMe were administered daily 3 days before LBD, and for 10 days after biliary obstruction. LDB caused highly significant increases in plasma enzyme activities and in bilirubin and lipid peroxides levels in erythrocytes and hepatic tissue. At the same time, this procedure produced a notable decrease in the GSH pools in these biological media. Both melatonin and S-AMe administration were effective as antioxidants and hepatoprotective substances, although the protective effects of melatonin were superior; it prevented the GSH decrease and reduced significantly the increases in enzyme activities and lipid peroxidation products produced by biliary ligature. S-AMe did not modify the increased GGT activity nor did it decrease greatly the TB levels (43% melatonin vs. 14% S-AMe). However, S-AMe was effective in preventing the loss of GSH in erythrocytes and hepatic tissue, as was melatonin. The obtained data permit the following conclusions. First, the LDB models cause marked hepatic oxidative stress. Second, the participation of free radicals of oxygen in the pathogenecity and severity of cholestasis produced by the acute obstruction of the extra-hepatic biliary duct is likely. Third, the results confirm the function of S-AMe as an antioxidant and hepatoprotector. Finally, melatonin is far more potent and provides superior protection as compared to S-AMe. Considering the decrease in oxidative stress and the intensity of cholestasis, these findings have interesting clinical implications for melatonin as a possible therapeutic agent in biliary cholestasis and parenchymatous liver injury.

Endotoxin priming and liver damage by experimental duodenal obstruction in the rat

To verify whether endotoxin (LPS) might act as a priming cofactor of liver injury caused by obstructing the duodenum, four groups of male Wistar rats were studied. The first two groups comprised rats in which a closed duodenal loop (CDL) was created: CDL, n = 6 and CDL + LPS, n = 7; the next two groups comprised sham-operated animals: Sham n = 6 and Sham + LPS, n = 6. LPS, 400 microg/kg bodyweight, was administered i.p. to the rats belonging to groups CDL + LPS and Sham + LPS, 24 h before laparotomy. Twenty-four hours after laparotomy the animals were killed. Damage to bile ducts, extent and grading of coagulative and lytic spotty necrosis in liver tissue were evaluated morphologically. Coagulative necrosis was severe in four of seven rats of the group CDL + LPS, mild in six of six rats of group CDL, and absent in four of six and five of six rats of groups Sham and Sham + LPS (chi2 32.8, P = 0.0001). The animals of group CDL + LPS had more frequently diffuse lytic spotty necrosis than the animals in the three other groups (chi2 9.57 P<0.01). The results of our study indicate that, in rodents subjected to a closed duodenal loop, priming with LPS exacerbates liver injury due to cholate stasis.

Repetitive short-term obstructions of the common bile-pancreatic duct induce severe acute pancreatitis in the opossum

Gallstone pancreatitis is triggered by migrating stones that cause transient or continuous bile-pancreatic duct obstruction. One might hypothesize that the great clinical variability of acute pancreatitis is related to the inconsistent number and duration of a series of stone migrations. A new setting for the opossum model of acute pancreatitis was developed allowing reversible bile-pancreatic duct obstructions. We compared the effects, on the pancreas and pancreatitis severity, of repeated transient obstructions to those of continuous obstruction of varying duration. Repetitive intermittent duct obstruction in American opossums was achieved using an extraductal balloon occluder connected to a subcutaneous port system that was inflated three times for 24 hr within a five-day period. Continuous duct obstruction was achieved by duct ligation. Sham-operated animals served as controls. After one, three, or five days of continuous obstruction and at the end of the third consecutive 24-hr obstruction (day 5), animals were killed and the severity of pancreatitis was determined quantitating the extent of acinar cell necrosis, pancreatic edema, and acinar cell fragility. Three repetitive one-day periods (total 72 hr) of bile-pancreatic duct obstruction resulted in acute necrotizing pancreatitis. The severity of pancreatitis was similar to that observed after five days of continuous obstruction and was more severe than that noted after three days (72 hr) of continuous obstruction. In conclusion, these observations suggest that the pancreas is susceptible to sensitization by factors related to transient duct obstruction. A series of minor events such as repeated stone passage may thus contribute to the progression to severe pancreatitis.

[CA19-9 has no value as a tumor marker in obstructive jaundice]

In the differential diagnosis of pancreatic cancer, CA19-9 appears to be the most sensitive and specific marker currently in use. In the absence of jaundice and at levels greater than 1000 U/ml, the specificity is almost 100%. Levels higher than 1000 U/ml are very uncommon for benign diseases. We report a case of obstructive jaundice due to an impacted stone in the common bile duct with cholangitis, where a CA19-9 level of 61,800 U/ml prompted suspicion of a malignant cause. After treatment the CA19-9 returned to a normal level. One year postoperatively neither abdominal ultrasound nor CT-scan showed any sign of intraabdominal malignancy. Reviewing the literature, we conclude that even very high levels of CA19-9 in cases with obstructive jaundice can be caused by benign diseases. Unlike other tumour markers (alpha-foetoprotein, carcinoembryonic antigen), where exceedingly high levels are definitely caused by malignancy, high levels of CA19-9 can be caused by benign obstructive jaundice. In such cases CA19-9 is useless as a tumour marker. The biliary obstruction must be treated successfully and more diagnostic procedures or even laparotomy performed, to exclude malignancy or treat a benign disease.

Different lobular distributions of altered hepatocyte tight junctions in rat models of intrahepatic and extrahepatic cholestasis

Hepatocyte tight junctions (TJs), the only intercellular barrier between the sinusoidal and the canalicular spaces, play a key role in bile formation. Although hepatocyte TJs are impaired in cholestasis, attempts to localize the precise site of hepatocyte TJ damage by freeze-fracture electron microscopy have produced limited information. Recently, several TJ-associated proteins like ZO-1 and 7H6 have been identified and characterized. Immunolocalization of 7H6 appears to closely correlate with paracellular permeability. We used rat models of intrahepatic cholestasis by ethinyl estradiol (EE) treatment and extrahepatic cholestasis by bile duct ligation (BDL) to precisely determine the site of TJ damage. Alterations in hepatocyte TJs were assessed by double-immunolabeling for 7H6 and ZO-1 using a confocal laser scanning microscope. In control rats, immunostaining for 7H6 and ZO-1 colocalized to outline bile canaliculi in a continuous fashion. In contrast, 7H6 and ZO-1 immunostaining was more discontinuous, outlining the bile canaliculi after BDL. Immunostaining for 7H6, not ZO-1, decreased and predominantly appeared as discrete signals in the submembranous cytoplasm of periportal hepatocytes after BDL. After EE treatment, changes in immunostaining for 7H6 and ZO-1 were similar to those seen in periportal hepatocytes after BDL, but distributed more diffusely throughout the lobule. This study is the first to demonstrate that impairment of hepatocyte TJs occurs heterogenously in the liver lobule after BDL and suggests that BDL and EE treatments produce different lobular distributions of increased paracellular permeability.

Biliary bacterial infection decreased the secretion of bile acids and bilirubin into bile

BACKGROUND

Bacterial cholangitis is frequently associated with serious complications.

METHODS

The plasma disappearance rates and the biliary output of bile acids and bilirubin after percutaneous transhepatic biliary drainage (PTBD) were examined in 29 patients with extrahepatic biliary obstruction.

RESULTS

Twenty-nine patients were divided into the bacteria-minus (n = 17) and bacteria-plus (n = 12) groups. Decreases in the plasma bile acid and bilirubin levels of the bacteria-minus group (t1/2 = 0.38 and 3.8 days for bile acids and bilirubin, respectively) were faster than those of the bacteria-plus group (t1/2 = 1.7 and 7.5 days). The bile flow rate was significantly increased in the bacteria-plus group compared with the bacteria-minus group. The calculated values of bilirubin and bile acid in the bile were higher in the bacteria-minus group than in the bacteria-plus group.

CONCLUSIONS

Bacterial colonization in the bile stimulates bile duct cells to increase bile volume and inhibits the hepatocyte transport activity of bile acids and bilirubin.

False elevation of CA 19-9 levels in a patient with a history of pancreatic cancer

CA 19-9 is the most sensitive and specific marker currently used in the diagnosis of pancreatic cancer. Its interpretation, however, can be limited in the presence of certain nonmalignant diseases that have been correlated with elevated serum levels of CA 19-9. We report an unusual case of falsely elevated CA 19-9 levels in a patient with a history of resected pancreatic cancer. This patient presented 4 yr after resection with painless jaundice and markedly elevated CA 19-9 levels (2327 U/ml). Although it was initially suspected that the patient had recurrent cancer, further evaluation proved that her jaundice and increased CA 19-9 value were due to a benign stricture that led to cholestatic jaundice and concomitant cholangitis. No previous cases of falsely elevated CA 19-9 levels have been reported in the context of a known history of pancreatic cancer. Physicians should be aware of the perturbations that extrahepatic cholestasis and certain inflammatory diseases of the pancreas and hepatobiliary system may impose on CA 19-9 levels. Furthermore, this case demonstrates that even markedly elevated CA 19-9 levels in patients being assessed for recurrence of pancreatic cancer need to be carefully interpreted in the context of other clinical findings.

Increased intercellular adhesion molecule-1 serum concentration in cholestasis

BACKGROUND/AIMS

Increase of serum levels of the soluble intercellular adhesion molecules in patients with the cholestatic liver diseases primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) are known and have been thought to indicate activation of the immune system and the grade of the inflammatory process. In hepatitis and cholestatic diseases, expression of adhesion molecules was found on the surface of bile duct epithelia and hepatocytes.

MATERIALS AND METHODS

Serum levels of sICAM-1 in patients with intrahepatic cholestasis in PBC (n = 42) and extrahepatic cholestasis (n = 18) due to choledocholithiasis were investigated. sICAM-1 levels and "classical" cholestasis parameters as alkaline phosphatase (ALP), gamma-glutamyl-transpeptidase (gamma-GTP) and bilirubin levels were compared. Furthermore, sICAM-1 concentrations and "classical" cholestasis parameters were analysed before and after therapy with ursodeoxycholic acid (UDCA). In addition, sICAM-1 was detected in serum and bile fluid of four patients with cholestasis due to choledocholithiasis. Soluble ICAM-1 levels in sera and, if accessible, in bile fluids were determined using a commercially available ELISA system. Statistics were done by Wilcoxon's signed rank exact test and Spearman's rank correlation test. Sensitivity and specificity of cholestasis parameters and sICAM-1 concentrations was analysed by receiver operating characteristic (ROC) curves.

RESULTS

Increased sICAM-1 serum concentrations in a similar range were found in patients with PBC (range 251-2620 micrograms/l; median 966 micrograms/l) as well as in patients with extrahepatic cholestasis (257-2961 micrograms/l; median 760 micrograms/l) compared to healthy controls (n = 12; 220-500 micrograms/l; median 318 micrograms/l). sICAM-1 levels correlated significantly to histological stage I to IV (p < 0.001), ALP (range 107-1877 U/l; median 545 U/l; r = 0.496, p = 0.0008), bilirubin (range 0.3-26 mg/dl; median 0.8 mg/dl; r = 0.52; p < 0.0004) and gamma-GTP levels (range 43-705 U/l; median 221 U/l; r = 0.36; p = 0.02) in PBC patients. In PBC patients a histological stage III or IV (n = 21) could be predicted with high sensitivity (95%) and specificity (85%) if sICAM-1 levels were above 840 micrograms/l. After treatment of PBC patients with UDCA, sICAM-1 levels decreased significantly with decline of other "classical" cholestasis parameters. Increased sICAM-1 levels (range 257-2961, median 745 micrograms/l) in extrahepatic cholestasis correlated also significantly with serum concentrations of bilirubin (r = 0.8; p < 0.01; range 0.3-19.7, median 1.6 mg/dl), gamma-GTP (r = 0.55; p = 0.03; range 33-1401, median 179 U/l) and ALP (r = 0.61; p = 0.1; range 110-1378, median 562 U/l). sICAM-1 was detectable in bile fluid (264-919 micrograms/l) of four patients with extrahepatic cholestasis and nose-biliary catheterisation.

CONCLUSIONS

sICAM-1 concentrations were found to discriminate between histological stage I/II and stage III/IV of PBC with higher sensitivity and specificity than "classical" cholestasis parameters. Increased serum concentrations for sICAM-1 in intra- and in extrahepatic cholestasis and detection of sICAM-1 in the bile may indicate that sICAM-1 is eliminated through the bile. In other words, not only increased synthesis but also decreased elimination may be responsible for increased sICAM-1 serum levels in patients with cholestatic liver diseases.

Electron microscopic investigation on Ito cells and Disse's space in patients with extrahepatic cholestasis. Immunohistochemistry of collagen type IV and fibronectin in hepatic sinusoids

Extrahepatic cholestasis is one of the main factors causing liver fibrosis. Surgical biopsies of six patents were studied: one with normal liver (control patient), and five with different degrees of extrahepatal cholestasis with hepatocellular degenerative and necrotic changes. Monospecific antibodies directed against type IV collagen and fibronectin were localized by light microscopical immunohistochemistry. Type IV collagen was found in all basement membranes: ductal, vascular, neural, Intensive, almost continuous deposits of it were found along the entire length of the sinusoid. Fibronectin, the structural glycoprotein, was codistributed with type IV collagen in portal matrix and in perisinusoidal location. It did not decorate the basement membranes of bile ducts and stained more intensely than type IV collagen at the border between portal stroma and parenchyma. The intensity of the two antibodies increased corresponding with the heaviness of parenchymal deterioration. There was weaker staining behavior of the extracellular matrix regarding collagen IV and fibronectin in the area of heavy bilirubin impregnation. The sinusoid morphology in the regions with fibrosis and increased extracellular matrix formation in periportal areas was reported. Disses's space was distended and occupied by collagen bundles, amorphous matrix, swollen hepatocyte microvilli, and basement membrane-like material. Ito cells transformed into transitional cells or myofibroblast-like cells. Sinusoidal changes and increased collagen IV as well as perisinusoidal fibronectin formation coincided with the aggravation of cholestasis.

Effect of cyclosporin A on platelet aggregation and thromboxane/prostacyclin balance in a model of extrahepatic cholestasis in the rat

Cyclosporin A (CsA), a potent immunosuppressor used in organ transplants and autoimmune diseases, is associated with adverse effects in the kidney, liver, and nervous system. This drug was recently shown to stimulate platelet aggregation, to increase thromboxane synthesis, and to decrease vascular prostacyclin synthesis. In experimental cholestasis, thrombocyte function is altered. The present study was designed to assess the effects of CsA on platelet function in extrahepatic biliary obstruction (EBO) in rats. Cyclosporin or its excipient (Cremaphore El, polyethoxylated castor oil) did not modify collagen-induced platelet aggregation. In animals with EBO, platelet aggregation decreased by 50%. The administration of CsA (5 or 10 mg/kg) or Cremaphore El increased aggregation by 163%, 253% and 123% respectively. Thromboxane production increased by 119% after Cremaphore El was administered, but was not significantly modified by CsA. Cholestasis increased thromboxane synthesis by 48.4%, whereas CsA showed a direct dose-dependent effect, and excipient had no significant effect. Excipient inhibited the vascular synthesis of 6-keto-PFG1 alpha by 67.2%, as did 5 mg/kg (56.8%) and 10 mg/kg CsA (27.6%). EBO led to a nonsignificant increase in the vascular synthesis of 6-keto-PFG1 alpha. Cremaphore EI inhibited prostacyclin synthesis by 79%; inhibition by CsA was dose-dependent (31% at 5 mg/kg, 60% at 10 mg/kg). Our findings show that cholestasis enhances the effects of CsA on platelet aggregation and thromboxane/prostacyclin balance. These results may reflect the vascular effects of CsA, which in turn may be enhanced by cholestasis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Characterization of lipoproteins during human cholestasis

We have characterized changes in lipoproteins from cholestatic individuals and reproduced them by incubating lipoproteins from healthy individuals with cholic acid. The cholestatic patients showed an increase in low density lipoprotein (LDL) (>85%), with a smaller proportion of esterified cholesterol, and a fall in high density lipoprotein (HDL) (<10%), with a larger proportion of phospholipids. The protein composition of cholestatic HDL1 was characterized by a smaller proportion of apo A (I, II) and a prominent apo E fraction (39% vs. 9%). These changes involved an increase in degree of molecular packing (order) of HDL1. The addition of cholic acid to serum from healthy individuals altered the lipoprotein distribution, with an increase in LDL, the disappearance of HDL2 and HDL3 and the appearance of HDL1. These HDL1 were characterized by increased phospholipid and reduced apo AI fractions. They also showed a lower density and appeared as spherical particles in contrast to cholestatic HDL. Incubation of healthy HDL with cholic acid in vitro reproduces some of the alteration observed in cholestatic HDL.

Intestinal endotoxins as co-factors of liver injury in obstructive jaundice

The concept of endotoxin-mediated rather than direct liver injury in biliary obstruction was investigated using the experimental rat model of bile duct ligation (BDL) and small bowel bacterial overgrowth (SBBO). Small identical doses of intravenous endotoxin (bacterial LPS) caused a significantly more severe liver injury in rats with BDL, compared with sham-operated rats, suggesting the possible contribution of LPS in this type of liver damage. BDL was then combined with surgically created jejunal self-filling blind loops, which resulted in SBBO. Plasma LPS level increased significantly, and once again a more severe liver injury, determined by liver histology and serum gamma-glutamyl transpeptidase levels, was observed compared with the control group of rats with BDL+self-emptying blind loops. The data presented suggest that small amounts of exogenous LPS and/or the ordinarily innocous amounts of LPS constantly absorbed from the intestinal tract may be critical in the hepatic damage caused by obstruction of the biliary tract.

The "pseudo-cholangiocarcinoma sign" in patients with cavernous transformation of the portal vein and its effect on the serum alkaline phosphatase and bilirubin levels

OBJECTIVES

The goal of this study was to identify the underlying disorder responsible for portal venous thrombosis and cavernous transformation of the portal vein (CTPV). All patients with this finding underwent a thorough medical examination with intent to determine the cause and biochemical consequences of CTPV.

METHODS

During an 8-yr period, a total of 1247 patients with clinical evidence of portal hypertension were examined using ultrasonography. Forty four of these 1247 patients were found to have CTPV. In each case, the finding of CTPV was confirmed by portography using either splenoportography or arterial portography, with digital subtraction angiography. These 44 patients were studied in an effort to determine the etiology of the cavernous transformation. In addition, the specific reason for the increased serum bilirubin and alkaline phosphatase levels in 35 of the 44 cases was evaluated by endoscopic retrograde cholangiopancreatography (ERCP) (34 patients), percutaneous transhepatic cholangiography (one patient), and by CT in 19. The surgical findings in 10 of these 44 patients, who ultimately underwent splenectomy and portal venous decompression for bleeding, were reviewed in light of the ultrasonographic, portographic, and ERCP findings in the same 10 patients.

RESULTS

The underlying disorder responsible for cavernous transformation was found to be Behcet's disease in seven patients, chronic liver disease in four, congenital hepatic fibrosis in five, congenital protein C deficiency in one, and a prior abdominal operation for cholelithiasis in one patient. Despite a full clinical, radiological, hematological, and chemical evaluation, no etiology for CTPV was found in the remaining 26 patients. All of these later cases had no indication for liver biopsy or evidence for parenchymal liver disease. In these 26 patients, the serum levels of bilirubin and alkaline phosphatase ranged from mild to moderately increased compared with the moderately to markedly increased levels present in the 18 patients having an identifiable underlying liver disease. Irregular, undulating narrowing and nodular extrinsic defects, the so-called "pseudo-cholangiocarcinoma sign" was present in 33 of the 35 patients who underwent either ERCP or percutaneous transhepatic cholangiography. No such findings were observed in 10 control cirrhotic patients with portal hypertension but without CTPV, who also underwent ERCP.

CONCLUSION

The results of this study indicate that mildly increased serum alkaline phosphatase and direct reacting bilirubin levels occur in cases with CTPV associated with a pseudo-cholangiocarcinoma sign. Presumably, these enzyme elevations are a result of compression of the biliary tree by the venous collaterals that run along the extrahepatic biliary tree. None of the 33 cases with this sign had cholangiolar carcinoma. Thus, when a patient with splenomegaly but without documentable parenchymal liver disease demonstrates an increase in the serum direct reacting bilirubin and alkaline phosphatase levels, CTPV and the presence of large extrahepatic venous collaterals partially obstructing the biliary tree should be suspected.

Time-resolved immunofluorometric assay of trypsin-2 complexed with alpha 1-antitrypsin in serum

We developed a sensitive time-resolved immunofluorometric assay (IFMA) for trypsin-2 complexed with alpha 1-antitrypsin (AAT). We used a trypsin-2-specific monoclonal antibody on the solid phase and a europium-labeled polyclonal antibody to AAT as tracer. The detection limit is 0.05 microgram/L and the range of linearity extends to 100 micrograms/L. We compared the clinical utility of the trypsin-2-AAT assay with that of free trypsinogen-2 and amylase in serum by studying 120 healthy subjects, 29 patients with acute pancreatitis, 11 with extrahepatic biliary obstruction, and 34 with acute abdominal disorders of extrapancreatic origin. In patients with acute pancreatitis the median concentration of trypsin-2-AAT in serum was 59-fold that in healthy controls, 42-fold that in patients with biliary obstruction, and 33-fold that in patients with acute abdominal disorders of extrapancreatic origin. These differences are greater than those for trypsinogen-2 (19-, 20-, and 28-fold, respectively) and amylase (5.4-, 6.5-, and 5.4-fold, respectively). Compared with the assays of free trypsinogen-2 and amylase, our assay of trypsin-2-AAT improved the clinical specificity for acute pancreatitis by eliminating false-positive results in our control groups. Increased concentrations of trypsin-2-AAT and trypsinogen-2 were also observed in patients with chronic renal failure undergoing dialysis.

Study of plasma and red cell phospholipid fatty acids in extrahepatic cholestatic jaundice

The poor outcome in patients with extrahepatic cholestatic jaundice seems in some way related to reticuloendothelial dysfunction. Similar dysfunction can be caused by abnormal tissue phospholipid fatty acid patterns. Little is, however, known about such patterns in extrahepatic cholestatic jaundice. The phospholipid fatty acid patterns in 42 controls were compared with 42 patients with extrahepatic cholestatic jaundice. Many abnormalities were found. The general pattern was of a fall in polyunsaturated fatty acids and a rise in monounsaturated fatty acids, with a consequent fall in the double bond index (mean number of double bonds per fatty acid) showing an overall rise in saturation. All three major substrates for eicosanoid production were reduced in the jaundiced group. The changes seemed to be associated with jaundice itself, rather than the cause of the jaundice. The central roles of fatty acids in the determination of membrane function and in the provision of substrates of eicosanoid production, mean that these changes may explain some of the reticuloendothelial dysfunction found in extrahepatic cholestatic jaundice.

Omitting side-holes in biliary stents does not improve drainage of the obstructed biliary system: a prospective randomized trial

Sludge, which occludes biliary stents, forms mainly around the side-holes of such stents. It has been reported that omitting the side-holes results in less sludge formation and theoretically improves drainage. To compare the clinical efficacy of biliary stents with and without side-holes, we randomized patients with malignant or benign strictures to receive 10FG polyethylene stents either with side-holes (SH) or without side-holes (NSH). The patients were seen at 4, 12, 20, and 28 weeks after stenting for symptom evaluation and serum liver enzyme and bilirubin assays. The stents were replaced only when clinical symptoms of cholangitis developed. Each group included 35 patients. The mean age of patients in the SH group was 68 years, and the ratio of men to women was 1:1.3. In the NSH group, the mean age of patients was 67 years, and the ratio of men to women was 1:1.4. Eight patients with SH stents and eight with NSH stents died before the stents were removed; two NSH stents migrated into the duodenum. During a mean follow-up period of 8.1 weeks (range, 1.1 to 28 weeks for the SH group and 0.6 to 28 weeks for the NSH group), 18 stents were found to be occluded in the SH group and 17 in the NSH group. The median time before total occlusion was 7.8 weeks (range, 2.6 to 28) for SH stents and 7.9 weeks (range, 0.6 to 28) for NSH stents (p > 0.1, NS). The occluded stents removed from these patients were freeze-dried and weighed to quantitate the sludge blocking the stent lumen.(ABSTRACT TRUNCATED AT 250 WORDS)

Release of bile canalicular membrane antigen into blood in experimental extrahepatic cholestasis of the rat

The level of a bile canalicular membrane antigen in serum during extrahepatic cholestasis was serially analyzed using HAM.4, a monoclonal antibody against a bile canalicular membrane glycoprotein of normal rat hepatocytes. After bile duct ligation, the level of HAM.4 antigen in serum promptly increased within 1 hr, reached a maximum at 3 hr, and declined somewhat until 48 hr, where it plateaued. Elevated levels of HAM.4 antigen in serum preceded those of well-known biliary marker enzymes activities. Immunohistochemical studies showed that the expression of HAM.4 antigen in hepatocytes and bile duct cells was not altered appreciably after bile duct ligation even when HAM.4 antigen in serum reached a maximal level. The serum and hepatic HAM.4 antigen had a molecular weight of 110 kDa. These results suggest that HAM.4 antigen may be regarded as a potential marker of the early stage of cholestasis, with release occurring before apparent histological changes.

Serum beta-N-acetylhexosaminidase, carcinoembryonic antigen & sialic acid in benign & malignant extrahepatic biliary obstruction

Study of tumour markers to differentiate benign and malignant extra hepatic biliary obstructions showed that levels fo serum beta-N-acetylhexosaminidase and lipid associated sialic acid were not different in the two groups. The levels of carcinoembryonic antigen (CEA) and total sialic acid (TSA), on the other hand, were significantly higher in patients with the malignant biliary obstruction. At a cut-off value of 6.4 ng/ml (mean + 2SD) CEA had 66.7 per cent true positivity in malignancy 100 per cent true negativity in control and 78 per cent true negativity in the benign group. Similarly, TSA at a cut off value of 60 mg/dl had 61 per cent true positivity in malignancy, 90 per cent true negativity in controls and 70 per cent true negativity in the benign group. These two tumour markers appear to have similar diagnostic potential for malignant extrahepatic biliary obstruction. Surgical management of the malignant obstruction did not result in a decline in the elevated levels of these two markers during the post-surgical period of 7 days.

Minimal biliary excretion and enterohepatic recirculation of metoclopramide in patients with extrahepatic cholestasis

The biliary excretion and apparent oral clearance of metoclopramide (MCL) were determined after oral administration of 1 mg MCL/kg body weight to 10 patients suffering from extrahepatic cholestasis with nasobiliary tube for drainage of the common bile duct. A bilioduodenal endoprosthesis was subsequently fitted in 6 of these patients, i.e. the enterohepatic circulation was restored, and the apparent oral clearance was re-determined. Biliary excretion, comprising free MCL and the products of conjugation, accounted for less than 1% of the administered dose. In accordance with this, the median areas under the plasma concentration-time-curves AUC(0-15 h) in patients with intact and interrupted enterohepatic recirculation were of similar size. The pharmacokinetic values in patients with cholestasis (median apparent oral clearance 0.5 l.kg-1.h-1; median t1/2 4.5 h) were similar to those previously reported in patients with healthy liver function. We conclude that it is not necessary to adjust single doses of MCL in patients recovering from obstructive jaundice.

[Ceftriaxone in malignant occlusive jaundice. Studies of serum and bile concentration in disordered bile excretion]

METHODS

In 12 patients with inoperable malignant obstructive jaundice, percutaneous transhepatic biliary drainage was performed to decompensate the bile ducts. For a period of 7 days, the patients received a single daily i.v. dose of 1 g CFTX, and the serum and bile concentrations were measured at defined intervals.

RESULTS

The dose sufficed to kill about 85% of the expected organisms. Although an accumulation of the substance as documented under conditions of normal bile flow was not demonstrable under cholestatic conditions, effective levels were nevertheless found in the bile and showed a tendency to increase with increasing bile flow.

The influence of cholestasis on CA 50 and CA 242 in pancreatic cancer and benign biliopancreatic diseases

The tumour markers CA 50 and CA 242 were determined in serum from 70 cholestatic patients--35 with pancreatic cancer and 35 with benign biliopancreatic diseases. Both markers correlated (r = 0.37) with serum bilirubin in all patients. When the patients were subdivided into groups, the only correlation apparent was between CA 50 and bilirubin in patients with benign diseases (r = 0.40). The serum concentrations of both markers were much higher in patients with pancreatic cancer. Serial sampling before and after decompression of the cholestasis showed reduction of CA 50 and CA 242 concurrently with bilirubin and alkaline phosphatases in nine patients with benign disease but unchanged levels in six cancer patients. When the two markers were compared, sensitivity was superior for CA 50 (94% versus 73%), whereas specificity was better for CA 242 (65% versus 34%), as was positive prediction (76% versus 59%), whereas negative prediction was higher for CA 50 (86% versus 61%). Higher cut-off levels yielded better specificity for CA 50 but not for CA 242. Both markers indicate pancreatic cancer irrespective of cholestasis, but moderate elevations occur in some patients with benign disorders.

[Pancreas penetration by ofloxacin--a pilot study]

The use of antibiotics in patients with necrotizing pancreatitis is indicated since bacterial complications are the most common cause of death in this condition. Olfloxacin was studied in six patients regarding its permeation into pancreatic juice and bile and into pancreatic tissue in cases of chronic pancreatitis and pancreatic carcinoma. The peak concentrations in pancreatic juice (3.7 mg/l) and bile (12.9 mg/l) were found 20 minutes after i.v. administration of 3 mg/kg ofloxacin, these are 79 and 275% of the corresponding serum level, respectively. Pancreatic tissue concentrations varied between 54 and 333% of serum values in relation to the removal time of specimens and to the stage of inflammation. After three days and five days of ofloxacin treatment with doses of 2 x 200 mg daily even in pancreatic necroses concentrations were detected between 0.8 and 3.7 mg/kg wet weight. This suggests that in all pancreatic compartments analyzed, sufficient antibacterial ofloxacin levels above the MIC of relevant germs were found. Therefore, from a pharmacokinetic point of view, ofloxacin could be a potentially effective drug in prophylaxis and therapy of bacterial infections of the pancreas.

Plasma lecithin cholesterol acyl transferase activity, high density lipoprotein cholesterol and cholesterol ester in cholestasis

Lecithin cholesterol acyl transferase activity, cholesterol ester and high density lipoprotein cholesterol concentrations were determined in Nigerian subjects suffering from cholestatic jaundice. Plasma lecithin cholesterol acyl transferase activities in all the study groups were similar. High density lipoprotein cholesterol and cholesterol ester were significantly increased in extrahepatic cholestasis while reduced levels were found in intrahepatic cholestasis. Enhanced cholesterol esterification may occur in extrahepatic cholestasis.

3 alpha-Hydroxylated bile acid profiles in clinically normal cats, cats with severe hepatic lipidosis, and cats with complete extrahepatic bile duct occlusion

Concentrations of 3 alpha-hydroxylated bile acids were measured in serum and urine of clinically normal (healthy) cats (n = 6), cats with severe hepatic lipidosis (n = 9), and cats with complete bile duct occlusion (n = 4). Bile acid concentrations were measured by use of a gradient flow high-performance liquid chromatography procedure with an acetonitrile and ammonium phosphate mobile phase and an in-line postanalytic column containing 3 alpha-hydroxy-steroid dehydrogenase and a fluorescence detector. Specific identification of all bile acid peaks was not completed; unidentified moieties were represented in terms of their elution time (in minutes). Significant differences in serum and urine bile acid concentrations, quantitative and proportional, were determined among groups of cats. Cats with hepatic lipidosis and bile duct occlusion had significantly (P > or = 0.05) greater total serum and urine bile acids concentrations than did healthy cats. The proportion of hydrophobic bile acids in serum, those eluting at > or = 400 minutes, was 1.9% for healthy cats, 3.3% for cats with lipidosis, and 5.4% for bile duct-obstructed cats. Both groups of ill cats had a broader spectrum of unidentified late-eluting serum bile acids than did healthy cats; the largest spectrum developed in bile duct-occluded cats.(ABSTRACT TRUNCATED AT 250 WORDS)

[Elevation of serum apo E-rich HDL concentration in a patient with cholestatic liver disease]

A remarkable elevation of serum HDL cholesterol concentration (165mg/dl) was found in a 42-year-old Japanese male with chronic pancreatitis who had been cholestatic for several years. An abnormal slow alpha-migrating lipoprotein, larger in particle size and more enriched with cholesteryl ester and apo E than normal HDL, was found in the patient's plasma. Quantitative determination of apo E-rich HDL revealed a striking increase of this lipoprotein in plasma. After choledocho-jejunostomy, a prompt and remarkable decrease of plasma apo E-rich HDL was observed, indicating a direct contribution of cholestasis to the accumulation of apo E-rich HDL in plasma in this patient.

[Effect of extrahepatic cholestasis on amino acid metabolism in the animal experiment]

The knowledge of pathobiochemical processes in extrahepatic cholestasis is one of the prerequisites for the application of infusion solutions adjusted to meet the requirements. Early changes of amino acid metabolism in rats after bile-duct ligation, which indicate disorders in the urea cycle are reported. For this purpose 60 male Wistar rats were laparotomized and the common bile duct was twice ligated under narcosis with pentobarbital. Exsanguination of the animals from the aorta abdominalis occurred after 3, 6, 12, 24, 48 and 72 hours. Analysis of the free amino acids in serum was performed by means of middle pressure liquid column chromatography at fully automatic analytical apparatus (Liquimat III, Kontron).

RESULTS

Of 23 free amino acids investigated in serum only Ornithin and Arginin showed significant changes in their serum concentrations after ligature of the common bile duct. The increase of the serum concentration of Ornithin and the simultaneous decrease of Arginin suggests the inhibition of the urea cycle induced by resorptive jaundice. This might be due to the inhibition of the ATP-dependent, mitochondrial carbamyl phosphate synthetase or to the activation of the cytoplasmatic arginase.

Extra-hepatic cholestasis determines a reversible increase of glycoproteic tumour markers in benign and malignant diseases

This study was performed in order to assess the relative role of cholestasis in increasing some serum glycoproteic markers of malignancy (CA 19-9, TPA, CEA). 30 Patients with benign and 16 with malignant extra-hepatic cholestasis were studied on admission (stage A) and after the operative or spontaneous resolution of the cholestatic picture (stage B). CA 19-9 and TPA were found to be lower in stage B than in stage A benign diseases. A similar behaviour was found in malignant diseases, although findings were significant only for CA 19-9. In neither of the patient groups was CEA found to present a significant trend. Extra-hepatic cholestasis appears able to increase per se serum glycoproteic markers in benign diseases, with variations proportional to the severity of the clinical picture. The same considerations can apply to malignancies, even if in these situations the production of tumour markers by the neoplastic growth should also be considered. We should therefore be cautious in assessing the diagnostic usefulness of new tumour markers when cholestasis is present.

Bile duct varices or "pseudo-cholangiocarcinoma sign" in portal hypertension due to cavernous transformation of the portal vein

A total of 832 patients with portal hypertension resulting from different etiology was studied by ultrasonograph as a screening test. In 17 of the 832 patients, cavernous transformation of the portal vein was detected by means of ultrasonography. We have prospectively studied these 17 patients, and the diagnosis of cavernous transformation was confirmed by portography in all patients. To evaluate how much biliary tract has been affected from cavernous transformation of the portal vein, and to explain the cause of mildly increased alkaline phosphatase and serum bilirubin levels, endoscopic retrograde cholangiopancreatography (ERCP) was performed in 16 of the 17 patients. There were narrowing, irregularity, undulation and nodular extrinsic defects resulting from compression of thrombosis of the portal vein and the collateral vessels, mimicking cholangiocarcinoma spreading along the common bile duct on the extrahepatic biliary tract in all 16 patients who underwent ERCP. Similar ERCP findings were not found in six patients with portal hypertension due to liver cirrhosis. The ultrasonographic, portographic, and ERCP findings corresponded to surgical findings in six patients who had undergone splenectomy for either hypersplenism or bleeding from esophageal varices. The results indicate that cavernous transformation of the portal vein cause the above-mentioned radiographic findings that we propose to call "pseudo-cholangiocarcinoma sign."

Clinical meaning of GGT activity in follow-up of patients with alcohol-related liver injury and cholestasis

The dynamics of GGT was investigated in three groups of patients after removing some primary causes of GGT increase. Group A included 34 patients with alcohol-related liver disease, group B included 16 patients with alcoholic liver injury and cholestasis, caused by concomitant alcoholic pancreatitis and group C included 17 patients with extrahepatic cholestasis, caused by choledocholithiasis. Follow-up assays of GGT were performed on the 7th, 14th and 30th days. Our results showed that the dynamics of GGT was more rapid after removing the cause for cholestasis than in stopping alcohol consumption in patients with chronic liver diseases. On the 14th day more than a 50% decrease in GGT activity was noted in 20% of the patients from groups A and B and in almost all cases from group C. On the 30th day, the reference range of GGT was not attained by any of the patients with liver disease nor in five patients from group C. No significant correlation was found between the severity of liver damage and the extent of GGT increase at the beginning and at the end of the follow-up period.

Alterations in bilirubin metabolism during extra- and intrahepatic cholestasis

This study was performed to investigate modifications in the serum bilirubin forms, hepatobiliary enzymes, and some glycoproteic substances in patients during the course of extrahepatic cholestasis (stage A) and following its clinical resolution (stage B). The series consisted of 16 patients: 11 had main bile duct stones; two, benign stenosis of the main bile duct; and three, main bile duct cancer. Cholestasis resolved spontaneously in one case, under endoscopy in two, and following surgery in 13. Five patients with liver cirrhosis and a picture of intrahepatic cholestasis following anesthesia were also investigated. Serum bilirubin forms were measured using van den Bergh's method and the alkaline methanolysis-HPLC procedure; the mono- and di-conjugated forms were considered together in the overall evaluation of the results. The hepatobiliary enzymes (ALP, GGT, and AST) were increased at stage A and significantly decreased at stage B. Similar patterns were observed in total (TB), unconjugated (UB), and conjugated bilirubin (CB) and in the percentage of CB out of TB (% CB). In the majority of patients, % CB at stage B was lower than at stage A, whereas in subjects with a high initial UB value, a different % CB pattern was observed. The direct bilirubin percentage (% DB), on the other hand, had a different pattern, and the variations between stages A and B were not significant. The pathophysiological bilirubin pattern was similar in patients with intrahepatic cholestasis. At stage A, in a number of patients the levels of glycoproteic substances (CA 19-9, TPA and ferritin) were raised, but at stage B they tended to decrease towards the normal range.(ABSTRACT TRUNCATED AT 250 WORDS)