Cyclosporin toxicity at therapeutic blood levels and cytochrome P-450 IIIA

A 40-year-old male liver allograft recipient had neurological dysfunction and renal failure while his cyclosporin blood levels were in the therapeutic range; these features recurred on rechallenge. The hypothesis that this toxic effect might have resulted from abnormal metabolism of cyclosporin by liver cytochrome P-450 IIIA was investigated with the [14C]erythromycin breath test, which is a measure of this enzyme's activity. P-450 IIIA activity was decreased compared with that in controls, including other liver transplant recipients. Pretreatment with rifampicin, an inducer of P-450 IIIA, increased enzyme activity. After treatment with rifampicin the patient could be rechallenged with cyclosporin at a dose almost twice that which had previously been toxic. The patient died during a second transplantation and the microsomal content of P-450 IIIA was found to be low in the first transplant.

Relationship between gastric acid and elevated plasma somatostatinlike immunoreactivity after a mixed meal

The aim of this study was to examine whether hydrochloric acid plays a role mediating the post-prandial increase in plasma somatostatinlike immunoreactivity in normal subjects. Intravenous infusion of cimetidine was found to reduce by 45% the postprandial increment in plasma somatostatin-like immunoreactivity. This effect was reversed by concomitant intragastric administration of 0.1 N hydrochloric acid, which in previous studies in fasted subjects had not affected plasma somatostatinlike immunoreactivity. The effects of cimetidine on postprandial plasma gastrin were the inverse of those observed on postprandial somatostatin. There was a greatly enhanced increment in postprandial plasma gastrin during cimetidine infusion, which was reduced significantly toward control levels by concomitant intragastric infusion of hydrochloric acid. To exclude direct inhibition by cimetidine of nutrient-stimulated plasma somatostatinlike immunoreactivity we studied the effect of cimetidine on plasma somatostatinlike immunoreactivity stimulated by an intraduodenal infusion of fat. Cimetidine did not alter the incremental response of somatostatinlike immunoreactivity to intraduodenal fat infusion. These data show that cimetidine does not invariably reduce nutrient-stimulated plasma somatostatinlike immunoreactivity and are consistent with the hypothesis that the action of cimetidine in reducing the plasma somatostatin response to ingestion of a meal is a consequence of reduction of postprandial acid secretion. These data suggest that the postprandial elevation in plasma somatostatin observed in humans is mediated in part through postprandial secretion of gastric acid, which in turn acts to elevate plasma somatostatin.

Biochemistry and physiology of gastrointestinal somatostatin

Somatostatin, a tetradecapeptide initially isolated from the ovine hypothalamus, is widely distributed throughout the gastrointestinal tract where it may act as a hormone, local chemical messenger, or neurotransmitter to elicit many physiological actions. Release of somatostatin from D cells in the gut is regulated by mechanisms that are both dependent on and independent of cAMP. In most cases somatostatin acts to inhibit the function of its target cells. It performs this action in part via pertussis-toxin-sensitive inhibitory guanine nucleotide-binding proteins that regulate adenylate cyclase activity. Other mechanisms may involve sites of action distal to intracellular second messenger systems.

Severe cholestasis associated with methyltestosterone: a case report

We report a 62-yr-old man with severe jaundice and weight loss attributed to methyltestosterone administration. This case is unusual both in the severity of the cholestasis as well as the associated findings that mimicked an underlying malignancy.

Is bran efficacious in irritable bowel syndrome? A double blind placebo controlled crossover study

Twenty eight patients with classical irritable bowel syndrome completed a double blind placebo controlled crossover trial in which they added to their normal diet a daily supplement of either 12 bran biscuits (1 = 1.3 g fibre) or 12 placebo biscuits (1 = 0.23 g fibre). Each biscuit was given for three months in random order with crossover to the alternative biscuit at three months. After the initial three months therapy, there was a significant symptomatic improvement compared with pretreatment in both the bran treated (p less than 0.01) and placebo treated groups (p less than 0.01), but there was no significant difference in symptom scores between these two groups. There was no further improvement in either group after the second three months treatment with the alternative therapy. When crossover data for all 28 subjects were combined, symptoms scores after three months bran therapy and after three months placebo therapy did not differ significantly. Twenty four patients completed three day stool collections in both treatment periods. When the symptomatic response to bran among 15 subjects in whom stool weights rose on bran was compared with that among nine subjects whose stool weights were static or fell on the bran, it was shown that symptomatic improvement was independent of an increase in stool weight. These data suggest that in irritable bowel syndrome, especially that associated with abdominal pain, the beneficial effects of bran are due to a placebo response which is independent of an increase in stool weight.

Primary biliary cirrhosis in men

To determine whether primary biliary cirrhosis differed in men and women we reviewed the presenting features and clinical course of 39 men and 191 women with primary biliary cirrhosis followed at this unit between 1970 and 1984. Age and severity of disease at time of diagnosis were similar in both groups. Pruritus was significantly less common in men than in women both at diagnosis and throughout the period of follow up (p less than 0.01). The difference in incidence of pruritus at diagnosis was most evident when the male group were compared with a group of premenopausal women, an observation which is consistent with involvement of sex steroid metabolism in the origin of pruritus. Skin pigmentation was also less marked in men at diagnosis (p less than 0.05). Autoimmune associated conditions, especially sicca syndrome, were more common in women. Survival was similar among men and women although hepatoma developed significantly more frequently in male patients (p less than 0.01).

Autonomic regulation of postprandial plasma somatostatin, gastrin, and insulin

To evaluate the neural regulation of postprandial somatostatin release we studied the effect of blockade of (a) alpha-adrenergic and beta-adrenergic and (b) cholinergic receptors on the plasma somatostatin, gastrin and insulin responses to a standard meal in two groups of five fasting healthy male volunteers. Thymoxamine (0.1 mg/kg iv over two minutes then 10 mg/hour for two hours) and propranolol (0.15 mg/kg iv over two minutes, then 0.75 mg/kg/hour for two hours) were started just before eating while atropine (0.04 mg/kg/im) was given at 15 minutes on completion of the meal. There was a prompt and sustained rise in plasma somatostatin after a control meal in all experiments. This rise was arrested by atropine but not altered by either thymoxamine or propranolol. The plasma gastrin response to a meal was moderately enhanced by thymoxamine and markedly enhanced by atropine. Postprandial insulin release was not affected by alpha- or beta-adrenergic blockade but was abolished by atropine. The effect of atropine on the postprandial plasma somatostatin rise might have been mediated through reduction in gastric acidity or delay in gastric emptying. Hence we gave five fasting male volunteers and intraduodenal infusion of fat emulsion (25 calories in 30 minutes) on two occasions both alone and after atropine. Plasma somatostatin rose during the fat infusion alone and this rise was abolished by atropine. These data suggest that (a) cholinergic but not adrenergic mechanisms are important modulators of plasma somatostatin release after orally ingested and intraduodenally infused nutrients (b) atropine abolishes plasma somatostatin release independently of its effects on gastric acidity and motility and (c) are consistent with the hypothesis that atropine potentiates postprandial gastrin release through reduction of somatostatin mediated inhibition.

Does gastric acid release plasma somatostatin in man?

Food and insulin hypoglycaemia raise plasma concentrations of somatostatin. Both also stimulate gastric acid secretion but it is not clear whether gastric acid itself has any effect on somatostatin secretion. We, therefore, studied the effect on plasma concentrations of somatostatin of infusion of 0.1 N HC1 into the stomach and duodenum of healthy subjects. Plasma somatostatin did not rise with a small dose of HC1 given intragastrically (15 mmol) or intraduodenally (4 mmol). After an intraduodenal infusion of 60 mmol HC1 over 30 minutes, sufficient to reduce intraluminal pH to 2, plasma somatostatin rose moderately in five subjects from a mean value (+/- SEM) of 32 +/- 3 pg/ml to a peak at 10 minutes of 54 +/- 11 pg/ml. It is concluded that: (a) intragastric acid infusions do not release circulating somatostatin in man; and (b) that intraduodenal acidification albeit at grossly supraphysiological doses is a moderate stimulus of plasma somatostatin release. Therefore, gastric acid is unlikely to be a major factor mediating postprandial plasma somatostatin release in man.

Response of circulating somatostatin, insulin, gastrin and GIP, to intraduodenal infusion of nutrients in normal man

We have studied the effect of direct infusion of nutrients into the duodenum of normal subjects on circulating plasma somatostatin, insulin, gastrin and gastric inhibitory polypeptide (GIP) levels. Six normal subjects were given on four separate occasions 150 ml of isotonic solutions containing 100 calories of carbohydrate, protein, or fat, and a control solution of saline, by infusion into the second part of the duodenum. Plasma somatostatin rose slightly after carbohydrate, mean basal 30 +/- 3 pg/ml, peak 46 +/- 16 pg/ml at 15 min; and more markedly after protein, peak 57 +/- 9 pg/ml at 30 min. However, fat was the most potent intraduodenal stimulus to plasma somatostatin release into circulation, peak 101 +/- 11 pg/ml at 30 min. The plasma insulin rise was greatest after carbohydrate, peak 68 +/- 10 i.u., but there was a significant rise after protein also, peak 34 +/- 6 i.u. Plasma gastrin rose significantly after protein only, peak 70 +/- 22 pg/ml. Plasma GIP rose markedly after carbohydrate, basal 506 +/- 50 pg/ml, peak 1480 +/- 120 pg/ml. Protein was also a potent stimulus of circulating plasma GIP release, peak 1200 +/- 190 pg/ml, while fat was the least potent, peak 730 +/- 190 pg/ml. Thus, calorie for calorie, fat is the most potent intraduodenal nutrient stimulus of circulating somatostatin. We postulate therefore that somatostatin may be an enterogastrone--a circulating hormone released by intraduodenal fat which inhibits gastric acid secretion. Fat is the least potent intraduodenal nutrient stimulus of circulating GIP release. This is evidence against the hypothesis that circulating GIP acts as an enterogastrone.

Is maternal gastrin important in congenital hypertrophic pyloric stenosis?

The birth of a normal infant to a woman with Zollinger-Ellison syndrome is described. The cord blood serum gastrin was very elevated. This suggests that maternal gastrin can cross the placenta, a fact previously in doubt in man. The infant did not develop congenital hypertrophic pyloric stenosis. This is further evidence that raised blood gastrin in utero is not an important causative factor in the development of congenital hypertrophic pyloric stenosis in man.