Bacteria closely resembling Helicobacter pylori detected immunohistologically and genetically in resected gallbladder mucosa

A microorganism with close immunohistological and genetic resemblance to Helicobacter pylori was found in the resected gallbladder mucosa of a 41-year-old woman. The woman was admitted to hospital complaining of fever and right hypochondrial pain. Cholecystectomy was carried out under the diagnosis of gallstones and cholecystitis. A microorganism resembling H. pylori (stained with H&E, Giemsa, and Wartin-Starry) was detected incidentally on pathological examination. The microorganism was also positive for immunohistochemical staining. An amplification reaction was seen on genetic examination by the polymerase chain reaction (PCR) method (urease beta-genes). Our findings suggest that H. pylori may be present in tissues other than gastric mucosa.

Autoimmunity in chronic active Helicobacter hepatitis of mice. Serum antibodies and expression of heat shock protein 70 in liver

Male A/JCr mice with naturally occurring Helicobacter hepaticus infection develop a progressive chronic active hepatitis and liver tumors, despite the presence of serum antibodies to Helicobacter proteins. A rabbit antiserum prepared against the bacterial proteins immunoreacted with hepatocytes present in liver sections from infected mice with progressive lesions. We found that sera from these mice contained IgG antibodies that reacted in immunoblots with recombinant heat shock protein 70 (DmaK from Escherichia coli) but not with heat shock protein 60 (GroEL) or heat shock protein 10 (GroES). A rabbit antibody to heat shock protein 70 reacted with H. hepaticus in tissue sections and to a H. hepaticus protein (70 kd) in Western blots. Immunohistochemistry and in situ hybridization for heat shock protein 70 revealed that individual hepatocytes and other cells expressed the protein in livers with hepatitis but not usually in normal livers. Liver tumors and preneoplastic lesions in infected mice did not usually express heat shock protein 70 except focally in a few tumors. In situ hybridization for H. hepaticus 16S rRNA showed that the bacteria was found throughout the liver associated with hepatitis but not within tumors. CD3+ T lymphocytes were found in close association with hepatic lesions. These data suggest a role for autoimmunity in progressive hepatitis and carcinogenesis in livers infected with H. hepaticus.

Occurrence of Salmonella in cold-blooded animals in Gran Canaria, Canary Islands, Spain

The occurrence of Salmonella in endemic and subendemic species of lizard and frog of Gran Canaria, Gallotia stehlini and Rana perezi, as well as captive reptiles from other regions of the world was investigated. The occurrence of Salmonella was statistically higher in endemic and subendemic species than in captive animals (p < 0.001). Seventy strains of Salmonella were isolated. S. berta and S. gran canaria were the most frequently isolated serotypes. The study of Salmonella in gall-bladder contents showed a high parasitation (85%), being higher in Gallotia stehlini (100%) than in Rana perezi (60%). None of the isolated salmonellae were resistant to tested antibiotics.

Emphysematous pyelonephritis with resultant emphysematous cholecystitis secondary to hematogenous dissemination

Both emphysematous pyelonephritis and emphysematous cholecystitis are uncommon, but potentially fatal, clinical entities. The simultaneous diagnosis of these two entities in the same patient has not previously been reported. In this paper, we describe a 68-year-old diabetic male who presented acutely with emphysematous pyelonephritis and emphysematous cholecystitis. This case demonstrates several important diagnostic and treatment considerations. Additionally, the unique circumstances of this case offer support for the proposal that emphysematous cholecystitis may often be secondary to hematogenous seeding/embolic phenomena rather than obstruction of the cystic duct. Prompt diagnosis is essential, as prompt intervention can minimize mortality and morbidity.

Sources of pancreatic pathogens in acute pancreatitis in cats

The source(s) of pancreatic pathogens is uncertain, although the colon is usually implicated. We studied whether pathogens may spread from different sites in a feline model of the disease. Acute pancreatitis was induced using a standard technique and a distinctive clinical strain of Escherichia coli as the marker bacterium. E. coli were placed in the colon, gall bladder, main pancreatic duct, or obstructed renal pelvis of control cats (no pancreatitis) and acute pancreatitis cats. Pancreases were colonized from each source, whether or not pancreatitis was present. The pancreatic colonization rate was greater in acute pancreatitis only when E. coli had been placed in the colon. In conclusion, E. coli may spread to the pancreas from different sources. The high rate of pancreatic colonization in both control and inflamed glands suggested that, clinically, bacteria may spread to the pancreas more frequently than is currently thought.

Bacteriological studies of bile from the gallbladder in patients with carcinoma of the gallbladder, cholelithiasis, common bile duct stones and no gallstones disease

OBJECTIVE

To compare the presence of bacteria of bile from the gallbladder in control subjects, patients with gallstones, and patients with carcinoma of the gallbladder.

DESIGN

Prospective open study.

SETTING

University department of surgery.

SUBJECTS

372 patients of whom 36 had no signs of gallbladder disease; 211 underwent cholecystectomy for either symptomatic gallstone disease (n = 165) or acute cholecystitis (n = 46); 67 had common bile duct stones and 58 were operated on for carcinoma of the gallbladder.

INTERVENTIONS

Aspiration of bile from the gallbladder.

MAIN OUTCOME MEASURES

Prevalence of pathogenic bacteria in bile from the gallbladder and correlations between the presence of bacteria, the presence of cancer, and age.

RESULTS

No pathogenic bacteria were grown from the bile of the patients who had no signs of gallstones disease. Among the 165 with symptomatic gallstone disease 52 (32%) had pathogens in their bile, and among the 46 with acute cholecystitis the corresponding figure was 19 (41%) while among patients with common bile duct stones this figure was 39 (58%). Among the 58 patients with carcinoma of the gallbladder the bile grew organism in 47 (81%). Patients over the age of 60 years tended to be more likely to have organism in their bile than patients aged 60 or less, and the difference was significant for symptomatic gallstone disease (p < 0.003). Significant differences were also found between patients with symptomatic gallstone disease and those with carcinoma of the gallbladder in both age groups (p < 0.002 in each case). Most of the organism were aerobic or anaerobic Gram negative species, irrespective of type of disease or age.

CONCLUSION

Bacteria may have a role in the development of carcinoma of the gallbladder.

[Antimicrobial prophylaxis with cefamandole in biliary tract surgery]

The authors present their experience with antimicrobial prophylaxis using cephalosporin of the second generation--cefamandole--in biliary surgery. Cefamandole was administered to 28 patients operated for a biliary affection and hospitalized at the Surgical Clinic of the Third Medical Faculty in Prague. Cefamandole was administered after 8-hour intervals in 1 g doses up to 48 hours after the first dose. For antimicrobial prophylaxis patients were selected, included after previous investigations in the high risk group. In the patients in addition to microbiological examination of bile the cefamandole levels in bile and serum were compared. The presented results proved that cefamandole administration is justified in the prevention of infectious complications after operations of the gallbladder and biliary pathways because of its antibacterial and pharmacokinetic properties.

Isolation of Escherichia fergusonii from four different sites in a patient with pancreatic carcinoma and cholangiosepsis

Escherichia fergusonii was isolated from a 69-year-old male with pancreatic carcinoma and cholangiosepsis from gallbladder fluid, three blood cultures, feces, and a superficial wound of the abdomen. Biochemical reactions, antimicrobial susceptibility patterns, susceptibility to polyvalent phage 0-1, and rRNA gene restriction analysis suggested that the four strains were of clonal origin. Our data indicate that E. fergusonii possesses a pathogenic potential in humans.

Piperacillin versus cefazolin given perioperatively to high-risk patients who undergo open cholecystectomy: a double-blind, randomized trial

OBJECTIVE

To study the efficacy, microbiologic features and toxicity of prophylactic cefazolin versus prophylactic piperacillin in high-risk patients who undergo open cholecystectomy.

DESIGN

Double-blind randomized trial with follow-up for 6 weeks postoperatively.

SETTING

An 850-bed community hospital, located in a major Canadian city. Patients admitted to hospital who satisfied published criteria for being at high-risk for infection after open cholecystectomy were entered into the protocol, and those who satisfied the criteria and provided consent were entered into the study. Eighty-one patients were randomly assigned by computer to receive either piperacillin or cefazolin as the prophylactic agent.

INTERVENTIONS

Open cholecystectomy.

MAIN OUTCOME

Provides detailed information on the organisms found in the biliary tree in patients with acute cholecystitis, assesses the in-vitro activity of cefazolin versus piperacillin against the isolated organisms, expecting that piperacillin would be much more active against isolated anaerobes and gram-negative bacteria.

RESULTS

Bactobilia was documented in 42% of patients in the cefazolin group and 29% of patients in the piperacillin group. Piperacillin was active in vitro against 94% of all isolates versus 56% for cefazolin (p < 0.005, McNemar's test). Adverse effects and toxicities in both the piperacillin and cefazolin group were low and were not serious.

CONCLUSIONS

Both piperacillin and cefazolin are safe and effective prophylactic antimicrobials for high-risk patients who undergo open cholecystectomy. However, piperacillin had a much wider spectrum of in-vitro activity against the isolated pathogens, especially Enterococcus sp., Enterobacter cloacae and the anaerobes.

[A microbiological validation and criteria for the efficacy of the use of CO2 and YAG lasers in the surgical treatment of cholecystitis]

A considerable frequency of infected bed of the gallbladder in different forms of cholecystitis was established, the anaerobic microflora being inoculated more often. A direct dependence of the frequency of infecting the bile and gallbladder bed on the patient's age and duration of having chronic cholecystitis was shown. The sterilization and prevention of reinfection of the gallbladder bed after the removal of it can be achieved by the laser irradiation of the total bed surface inspite of the absence of clear symptoms of acute inflammation of the bladder and the surrounding tissues, and the cleansing should be performed after the manipulations on extrahepatic bile ducts are completed.

Systemic dissemination by a newly recognized intestinal microsporidia species in AIDS

OBJECTIVE

Primarily to determine whether an intestinal microsporidian recently identified in AIDS patients disseminates from the bowel to infect other organs.

DESIGN

Disseminated microsporidiosis has been reported in immunocompromised humans, but never due to Enterocytozoon bieneusi, the most common species in AIDS patients and one that evidently infects only enterocytes. In animals, dissemination follows ingestion of Encephalitozoon cuniculi spores, apparently via macrophages, and pathology occurs in, for example, kidneys and brain. A second, un-named Encephalitozoon-like intestinal microsporidia has been identified in five AIDS patients with chronic diarrhea; because it infects lamina propria macrophages, it was logical to investigate its dissemination.

METHODS

Light and transmission electron microscopy were used to study urine sediment from four out of five patients with biopsy-documented small intestinal infection due to the second intestinal microsporidian. The gall bladder from one patient and autopsy specimens from an E. bieneusi-infected patient were similarly studied.

RESULTS

Systemic dissemination was documented by detecting abundant spores, both free and within renal tubular and transitional cells, in the urine of two patients. Many of the lamina propria macrophages in these two patients' intestinal biopsies contained microsporidia, while those of the two negative patients either contained only Mycobacterium avium complex or only occasional parasites. The gall bladder was co-infected with this microspordian and with cytomegalovirus. At autopsy, the patient with documented enteritis due to E. bieneusi 2 years before death had disseminated microsporidiosis, not of E. bieneusi, but apparently of the second intestinal species. The microsporidian had caused severe tubulointerstitial nephritis. Parasites were also observed in non-parenchymal cells of the liver and bronchial epithelium.

CONCLUSION

A newly described Encephalitozoon-like intestinal microsporidian, which causes chronic diarrhea in AIDS patients, can disseminate and cause renal pathology.

[An experimental study on development of gallstone disease after curative gastrectomy for cancer--postoperative alteration of the composition of canine gallbladder bile after subtotal gastrectomy with truncal vagotomy]

In connection with gallstone (GS) formation after gastrectomy for cancer, we examined alteration of the composition of gallbladder bile after subtotal gastrectomy with truncal vagotomy. Of 11 mongrel dogs with cholecystostomy, 3 underwent B-I and 4 B-II gastrectomy. Four dogs without gastrectomy were served as controls. Bile was collected for 12 months. Bile acids were quantified by GLC. The bile was cultured for bacteriology. TBA did not significantly differ among the three groups of the dogs. In the two gastrectomized groups, CDA (a secondary bile acid) kept a higher level and CA (a primary bile acid) maintained a lower concentration compared with those in the controls. A remarkable increase of non-conjugated bile acids was recognized in both gastrectomized groups. Lithogenicity was low for all of the 3 groups. All but 1 control dog incurred bile infection that persisted long. Black pigment stones containing calcium bilirubinate developed in 1 of the 3 B-I and 2 of the 4 B-II dogs but none in the controls. The bile infection seemed to be involved in the development of GS. As the alteration of bile composition and GS occurred solely in the gastrectomized dogs, subtotal gastrectomy with truncal vagotomy might precipitate the GS formation.

Ascending infection of the biliary tract after surgical sphincterotomy and biliary stenting

It has been widely accepted that there is an ascending route of bacterial infection of the biliary tract but there is a lack of direct evidence. This hypothesis was tested in an animal experiment using the cat as an animal model. The implantation of biliary stents and surgical sphincterotomy were performed in these animals, with sham controls. Stents bypassing the sphincter of Oddi with the tip in the duodenal micro-organisms and the biliary tract was heavily contaminated. Blockage of these stents resulted in biliary obstruction. Stents implanted within the common bile duct, proximal to the sphincter were largely unaffected by biofilm formation. After surgical sphincterotomy the biliary tract was also contaminated but, in the absence of obstruction, the animals did not develop any symptoms. It was concluded that ascending infection by duodenal biliary reflux, via the sphincter of Oddi, is an important route of infection in the biliary system.

Single dose cephalosporin prophylaxis in high-risk patients undergoing surgical treatment of the biliary tract

During June 1985 through October 1986, 292 patients considered to be at high risk for having postoperative complications develop underwent cholecystectomy and were evaluated in a multicenter, randomized, prospective, double-blind study. Risk factors included age greater than 70 years, acute cholecystitis within the previous six months, obstructive jaundice, obesity and diabetes mellitus. One gram of cefamandole was administered intravenously to 144 patients and 148 patients received 1 gram of cefotaxime intravenously 30 minutes prior to skin incision. Culture-proved bactibilia was found in 55 patients and 11 of the patients had choledocholithiasis. Of the risk factors considered to place patients at high risk for postoperative infectious complications, obesity and acute cholecystitis proved to be the more common. However, age greater than 70 years, diabetes mellitus and obstructive jaundice were more significant risk factors predisposing to bactibilia. The most common organisms isolated from the bile and gallbladder intraoperatively were Staphylococcus, Streptococcus and Klebsiella species along with enterococcus, Escherichia coli and diphtheroids. Clinically significant postoperative infections occurred in eight patients, including six patients in the cefamandole group and two patients in the cefotaxime group. Antibiotic concentrations were measured in the serum, muscle, subcutaneous fat, gallbladder and bile, with cefamandole showing statistically significant greater concentrations in bile, gallbladder and muscle tissue. There was no statistical significance between the postoperative infection rates, total period of hospitalization or total hospital charges for each group. Therefore, there is no significant advantage between a single prophylactic dose of cefamandole versus cefotaxime for high-risk patients undergoing biliary tract operation.

Bile secretory immunoglobulin A in biliary infection and cholelithiasis

Bile samples from 71 patients with cholelithiasis and a control group of 10 subjects without hepatobiliary diseases were cultured for bacteria and measured for secretory immunoglobulin A (SIgA) using enzyme immunoassay specific for SIgA. The results of bile bacterial culture were all positive in patients with primary bile duct pigment stones, and significantly lower bile SIgA levels were observed than in normal controls (P less than 0.005). It was also shown that the constitutent ratios of SIgA to total bile immunoglobulin and the bile-serum ratio of SIgA were markedly lower in these patients than in normal controls (P less than 0.001, P less than 0.001). In patients with cholecystolithiasis, bile SIgA concentrations of patients with biliary infections were remarkably lower than those of patients without biliary infection (P less than 0.01) and those of normal controls (P less than 0.01). These results suggest a close relationship between biliary tract infection and low concentrations of bile SIgA.

Occult gallbladder perforation: an unusual complication of gallstone lithotripsy

Three days following extracorporeal shock-wave lithotripsy of a solitary, calcified gallstone, a 69-year-old white male patient was re-admitted with E. coli sepsis and fever of up to 39.4 degrees C. Ultrasound and CT both revealed a smooth-rimmed hypodense paravasate in the middle portion of the left liver lobe adjacent to the gallbladder, with a density identical to gallbladder fluid. The evidence for perforation was based on CT scanning, and a diagnosis of occult gallbladder perforation was made. Conservative treatment was performed successfully. Following elective cholecystectomy two months thereafter, gallbladder histology showed signs of chronic cholecystitis and E. coli was isolated in bile cultures. The paravasate had granulated and finally cicatrized. By combining ESWL and chemical dissolution, treatment of multiple, calcified and pigment gallstones is possible and this approach has become an attractive alternative therapy modality for a selected group of gallstone patients. Further assessments of the efficacy and safety of this technique are necessary. Conservative treatment of occult gallbladder perforation is possible and should be performed in high-risk patients.

Bacterial adherence to human gallbladder epithelium

The adherence of Escherichia coli and Pseudomonas aeruginosa to the epithelium of the gallbladders obtained from 32 patients with negative bile culture was quantified by a scanning electron microscope. Of the gallbladders, 5 were histologically normal (group A), 21 had chronic calculus cholecystitis (group B), and 6 had acute calculus cholecystitis (group C). The data were expressed as the mean +/- S.D. of the numbers of adherent bacteria to 1,000 microns2 of the gallbladder epithelium. The number of adherent E. coli were 0.1 +/- 0.2 in group A, 4.2 +/- 2.8 in group B, and 9.2 +/- 3.3 in group C. A similar result was also observed with P. aeruginosa. The number of adherent bacteria, both of E. coli and P. aeruginosa were significantly higher in group C than in groups A and B, and were also significantly higher in group B compared to group A. The amount of bacterial adherence paralleled that of the degree of epithelial damage, and the normal epithelium proved to have an inhibiting ability. Thus, a secondary bacterial infection is more likely to happen in patients with contaminated bile, and therefore, the treatment for acute cholecystitis should be based either on the results of a bile culture or according to predictive factors for bactibilia.

Liver disease in rhesus monkeys infected with simian immunodeficiency virus

Rhesus monkeys infected with simian immunodeficiency virus (SIV) develop a syndrome very similar to patients with acquired immune deficiency (AIDS), including liver disease. This prospective study was undertaken to define the pathology, course, and pathogenesis of liver disease in 20 rhesus monkeys (Macaca mulatta) after intravenous inoculation with the standardized isolate SIV/DeltaB670. Tissue samples from liver and gallbladder between 2 and 24 weeks after inoculation were examined histologically and immunohistochemically for SIV gag protein p26, and by in situ hybridization with an SIV riboprobe. Histologically there was infiltration of portal tracts and around hepatic veins and venules by mononuclear inflammatory cells, focal bile duct damage, proliferation of bile ductules, and focal lobular inflammation as early as 2 weeks after infection. The severity and extent of these lesions were graded semiquantitatively and showed that bile duct damage and hepatic venulitis were the most significant changes. Simian immunodeficiency virus gag protein p26 and SIV RNA were detected in scattered mononuclear cells in portal tracts and sinusoids, but not in hepatocytes or bile duct epithelial cells. The data indicate that the liver is involved early during the course of SIV infection, followed by persistent changes until the terminal stage of the disease. Our findings suggest that the liver damage in SIV-infected rhesus monkeys is similar to the changes observed previously in AIDS patients.

[Bacteriological study of bile from the gallbladder and bile ducts of patients surgically treated for biliary pathology]

We have evaluated the results of a bacteriological study of bile in 115 patients undergoing biliary surgery in the Valdivia Hospital (Chile). 35.6% of the positive bile cultures corresponded to patients with acute cholecystitis and only 22.5% to chronic disease. The culture was positive in 56.3% of cases of common bile duct stones and in 86.7% of cholangitis. Most positive bile cultures were monomicrobial, corresponding to patients with chronic cholecystitis. Most isolates were from Enterobacteriaceae, 49% of which corresponding to Escherichia coli. The in vitro sensitivity study showed that, as a rule, the strains were sensitive to the used antimicrobials.

[The binding of microorganisms isolated from patients with complicated forms of acute cholecystitis with immobilized proteins in the bacterial sorption reaction]

57 strains of different microbial species, isolated from patients having complicated forms of acute cholecystitis, were studied with the use of the reaction of bacteriosorption on immobilized proteins: fibrinogen, fibronectin, gamma globulin, ovalbumin, etc. The reaction of bacteriosorption was positive with all 4 Staphylococcus aureus strains: they were adsorbed on fibrinogen, fibronectin and gamma globulin. Besides, 4 out of 18 Staphylococcus epidermidis strains were selectively adsorbed on fibronectin and 1 of these strains was adsorbed on ovalbumin, while 2 out of 15 Escherichia coli strains were adsorbed on ovalbumin. S. epidermidis strains studied in this work differed from 15 strains of the same species, isolated from the urine of patients and studied earlier, by their adsorption properties.

Public health implications of the microbial pesticide Bacillus thuringiensis: an epidemiological study, Oregon, 1985-86

Bacillus thuringiensis var. kurstaki (B.t.-k) is a microbial pesticide which has been widely used for over 30 years. Its safety for a human population living in sprayed areas has never been tested. Surveillance for human infections caused by B.t.-k among Lane County, Oregon residents was conducted during two seasons of aerial B.t.-k spraying for gypsy moth control. Bacillus isolates from cultures obtained for routine clinical purposes were tested for presence of Bacillus thuringiensis (B.t.). Detailed clinical information was obtained for all B.t.-positive patients. About 80,000 people lived in the first year's spray area, and 40,000 in the second year's area. A total of 55 B.t.-positive cultures were identified. The cultures had been taken from 18 different body sites or fluids. Fifty-two (95 percent) of the B.t. isolates were assessed to be probable contaminants and not the cause of clinical illness. For three patients, B.t. could neither be ruled in nor out as a pathogen. Each of these three B.t.-positive patients had preexisting medical problems. The level of risk for B.t.-k and other existing or future microbial pesticides in immunocompromised hosts deserves further study.

Predictive factors for bactibilia in acute cholecystitis

Acute cholecystitis is well established as one of the high-risk factors bactibilla and wound infection. However, many patients with acute cholecystitis do not have bactibillia. Therefore, we analyzed 20 clinical and laboratory parameters in 49 patients with acute cholecystitis to determine which factor(s) predicted bactibilla. Twenty-one (42.9%) of 49 patients with pathologically proved acute cholecystitis had positive bile and/or gallbladder wall cultures. Univariate analysis suggested that a preoperative temperature greater than 37.3 degrees C, a total serum bilirubin level greater than 8.6 mumol/L, and a white blood cell count greater than 14.1 x 10(9)/L were the best predictors of bactibilia. Multifactorial analysis demonstrated that the 17 patients with zero or one predictive factor had a significantly lower chance of having bactibilia than the 32 patients with two or three predictive factors (6% vs 63%). We concluded that the culture status of patients with acute cholecystitis can be predicted preoperatively. We propose that patients with acute cholecystitis and zero or one of the predictive factors receive a single preoperative antibiotic dose. In patients with two or three predictive factors, antibiotics should be continued until culture data are available.

Occurrence and character of a putative causative virus of enterically-transmitted non-A, non-B hepatitis in bile

The present investigation confirms the possibility that the etiological agent of enterically-transmitted non-A, non-B (ET-NANB) hepatitis (type E hepatitis), multiplied in hepatocytes, is excreted into the feces via bile. The fecal extract was inoculated into 7 cynomolgus monkeys. Bile juice was collected directly from the gallbladder by needle puncture after abdominal operation 3 to 6 times during the experimental course. All 7 monkeys developed elevated serum aminotransferases, which began gradually approximately 2 weeks postinoculation and reached a peak at 3 to 5 weeks. In parallel with this elevation, both in time and magnitude, necroinflammation was observed in the livers. The virus-like particles (VLPs) were found in the bile juice of all 7 monkeys and the serial occurrence of VLPs was typified as follows: the VLPs were negative on day 7, appeared on day 10 after inoculation, and were present until the 3rd week when the subjects were sacrificed. While the particles were individually dispersed on day 10, they started to exhibit spontaneous aggregation on and after week 2. Also, empty particles were very rare at first, but increased in ratio compared to full ones over time. Thus, the putative causative virus of ET-NANB hepatitis was demonstrated to be excreted through bile. The spontaneous aggregation of VLPs might be due to the specific antibody secreted into the bile juice and was closely correlated with hepatitis activity. The increase in empty particles might indicate an increase in disorganized assembly of the nucleic acid and protein during virus proliferation.