Oral cholelitholysis--cheno versus urso: Japanese experience

Production of Valuable Lipophilic Compounds by Using Three Types of Interface Bioprocesses: Solid-Liquid Interface Bioreactor, Liquid-Liquid Interface Bioreactor, and Extractive Liquid-Surface Immobilization System

Bioconversions such as enzymatic and microbial transformations are attractive alternatives to organic synthesis because of practical advantages such as resource conservation, energy efficiency, and environmentally harmonic properties. In addition, the production of secondary metabolites through microbial fermentation is also useful for manufacturing pharmaceuticals, agricultural chemicals, and aroma compounds. For microbial production of useful chemicals, the authors have developed three unique interfacial bioprocesses: a solid-liquid interface bioreactor (S/L-IBR), a liquid-liquid interface bioreactor (L/L-IBR), and an extractive liquid-surface immobilization (Ext-LSI) system. The S/L-IBR comprises a hydrophobic organic solvent (upper phase), a microbial film (middle phase), and a hydrophilic gel such as an agar plate (lower phase); the L/L-IBR and the Ext-LSI consist of a hydrophobic organic solvent (upper phase), a fungal mat with ballooned microspheres (middle phase), and a liquid medium (lower phase). All three systems have unique and practically important characteristics such as utilization of living cells, high concentration of lipophilic substrates/products in an organic phase, no requirement for aeration and agitation, efficient supply of oxygen, easy recovery of product, high regio- and stereoselectivity, and wide versatility. This paper reviews the principle, construction, characteristics, and application of these interfacial systems for producing lipophilic compounds such as useful aroma compounds, citronellol-related compounds, β-caryophyllene oxide, and 6-penty-α-pyrone.

Therapeutic uses of animal biles in traditional Chinese medicine: An ethnopharmacological, biophysical chemical and medicinal review

Forty-four different animal biles obtained from both invertebrates and vertebrates (including human bile) have been used for centuries for a host of maladies in traditional Chinese medicine (TCM) beginning with dog, ox and common carp biles approximately in the Zhou dynasty (c. 1046-256 BCE). Overall, different animal biles were prescribed principally for the treatment of liver, biliary, skin (including burns), gynecological and heart diseases, as well as diseases of the eyes, ears, nose, mouth and throat. We present an informed opinion of the clinical efficacy of the medicinal uses of the different animal biles based on their presently known principal chemical components which are mostly steroidal detergent-like molecules and the membrane lipids such as unesterified cholesterol and mixed phosphatidylcholines and sometimes sphingomyelin, as well as containing lipopigments derived from heme principally bilirubin glucuronides. All of the available information on the ethnopharmacological uses of biles in TCM were collated from the rich collection of ancient Chinese books on materia medica held in libraries in China and United States and the composition of various animal biles was based on rigorous separatory and advanced chemical identification techniques published since the mid-20^th century collected via library (Harvard’s Countway Library) and electronic searches (PubMed and Google Scholar). Our analysis of ethnomedical data and information on biliary chemistry shows that specific bile salts, as well as the common bile pigment bilirubin and its glucuronides plus the minor components of bile such as vitamins A, D, E, K, as well as melatonin (N-acetyl-5-methoxytryptamine) are salutary in improving liver function, dissolving gallstones, inhibiting bacterial and viral multiplication, promoting cardiac chronotropsim, as well as exhibiting anti-inflammatory, anti-pyretic, anti-oxidant, sedative, anti-convulsive, anti-allergic, anti-congestive, anti-diabetic and anti-spasmodic effects. Pig, wild boar and human biles diluted with alcohol were shown to form an artificial skin for burns and wounds one thousand years ago in the Tang dynasty (618-907 CE). Although various animal biles exhibit several generic effects in common, a number of biles appear to be advantageous for specific therapeutic indications. We attempt to understand these effects based on the pharmacology of individual components of bile as well as attempting to identify a variety of future research needs.

Chinese medicinal herbs for cholelithiasis

BACKGROUND

Cholelithiasis is a common disease of the biliary tract. Chinese medicinal herbs are being used widely as an alternative treatment in people with cholelithiasis, but their beneficial or harmful effects have not been assessed systematically.

OBJECTIVES

To assess the beneficial and harmful effects of Chinese medicinal herbs in people with cholelithiasis.

SEARCH METHODS

We conducted searches in the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, Chinese Medicine Conference Disc, and Chinese Bio-Medicine Disc to January 2013. We handsearched four Chinese journals. No language or year of publication restrictions were applied.

SELECTION CRITERIA

Randomised clinical trials studying Chinese medicinal herbs for treatment of cholelithiasis.

DATA COLLECTION AND ANALYSIS

Two review authors (SJ, TG) independently extracted data. For dichotomous data, we estimated the risk ratio (RR), and for continuous data, we calculated the mean difference. We also calculated 95% confidence intervals (CI).

MAIN RESULTS

Eleven randomised trials with 1205 participants with asymptomatic or mild-to-moderate cholelithiasis were included. None of the randomised clinical trials compared a single Chinese medicinal herb with a Western medicine or with surgery. No placebo-controlled trials were identified. In the trials comparing one Chinese herbal medicine (Gandanxiaoshi tablet) versus another (Aihuodantong tablet), there was no significant difference in the improvement of upper abdominal pain after the end of treatment (RR 1.21; 95% CI 0.71 to 2.05), and the heterogeneity among trials was not substantial. No other outcomes could be assessed. The remaining trials of Chinese medicinal herbs (Qingdan capsule, Danshu capsule, Paishi capsule, Rongdanpaishi capsule), did not offer specific data on symptoms, signs, or change in gallstones that would permit assessment of significant differences in curative effects between the treatment and control groups. No serious adverse events were reported.

AUTHORS' CONCLUSIONS

This review reveals no strong evidence that the analysed Chinese medicinal herbs have any beneficial effects on asymptomatic or mild-to-moderate cholelithiasis. Definitive conclusions will require much better designed randomised trials to reduce risk of bias and allow detailed assessment of clinical outcomes.

Preparation of Methyl Ursodeoxycholate via Microbial Reduction of Methyl 7-Ketolithocholate in an Anaerobic Interface Bioreactor

An interface bioreactor, which is a device for the microbial transformation of water-insoluble substrates, was applied to an anaerobic bioconversion for the first time. Methyl 7-ketolithocholate [Me-7KLCA] was reduced with the human intestinal bacterium Eubacterium aerofaciens JCM 7790 in a convenient anaerobic interface bioreactor using a nutrient agar plate placed in a GasPak pouch. The resulting methyl ursodeoxycholate [Me-UDCA] is a precursor of ursodeoxycholic acid, which is used as a cholesterol gallstone-dissolving agent. The reaction conditions were optimized, and ABCM medium and dihexyl ether were selected as the best carrier and reaction solvent, respectively. The toxicity of the bile acid esters toward the human intestinal bacterium was effectively alleviated in the interface bioreactor, in which the maximal concentrations of Me-7KLCA and Me-UDCA in the dihexyl ether layer respectively reached to 12.0 and 6.1 g/l.

Preparation of Methyl Ursodeoxycholate in an Interface Bioreactor: Use of a Mixed Solvent System to Increase the Solubilities of Substrate and Product

A mixed solvent system was used as the reaction solvent of an interface bioreactor for the first time. The solvent, dodecane/2-ethylhexyl acetate (4:6), exhibited excellent efficiency in the preparation of methyl ursodeoxycholate with Eubacterium aerofaciens JCM 7790.

Efficacy of bile acid therapy for gallstone dissolution: a meta-analysis of randomized trials

To define better the efficacy of bile acid therapy for dissolution of radiolucent gallstones, we performed a meta-analysis of published trials from January 1966 to September 1992. Studies were identified using a MEDLINE computer search followed by an extensive manual search. The inclusion criteria used were: randomized trial, radiolucent gallstones in a visualizing gallbladder on oral cholecystography, and complete stone dissolution confirmed by oral cholecystography or ultrasound. Study results were pooled into 6 groups: placebo: high- and low-dose chenodeoxycholic acid (CDCA) (> or = 10 mg.kg/day and < 10 mg.kg/day); high- and low-dose ursodeoxycholic acid (UDCA) (> or = 7 mg.kg/day and < 7 mg.kg/day) and combined CDCA plus UDCA. Homogeneity calculations were performed and the percentage of complete stone dissolution calculated for each group with 95% confidence intervals. Of 66 trials identified, 23 comprising 1949 patients met the inclusion criteria. A total of 1062 patients were treated with CDCA, 819 with UDCA and 78 combination therapy. In studies > 6 months' duration, high-dose UDCA completely dissolved stones in 37.3% of patients (95% C.I. 33-42%), low-dose UDCA in 20.6%) and high-dose CDCA 18.2% (95% C.I. 15-21%). Based on only two studies, combination therapy achieved dissolution in 62.8% (95% C.I. 51-74%) of patients. Stones less than 10 mm dissolved significantly more frequently than stones larger than 10 mm. This analysis shows that UDCA in doses greater than 7 mg.kg/day taken for greater than 6 months will dissolve radiolucent gallstones in 38% of patients. The combination of UDCA and CDCA may be more efficacious but this observation is based upon only 78 patients and requires confirmation in further randomized trials.

Agents for gallstone dissolution

Numerous methods are presently available for gallstone dissolution, including oral bile salts; cholesterol solvents such as mono-octanoin and methyl tert-butyl ether; calcium or pigment solvents such as EDTA and polysorbate; mechanical extraction techniques through a T-tube tract or after endoscopic sphincterotomy; or fragmentation methods such as ultrasonography or electrohydraulic lithotripsy, lasers, and extracorporeal shock waves. Which, if any, of these methods will be appropriate for an individual patient depends on the type of stones, whether they are in the gallbladder or bile ducts, whether access to the biliary tree is available, the patient's age and general medical condition, and the availability of expert radiologists, endoscopists, and newer equipment. In the United States, the only available oral bile salt for cholesterol gallstone dissolution is chenodeoxycholate. Ursodeoxycholate, which is more rapid and less toxic, has not been approved by the Federal Drug Administration. These agents are most effective in thin women with small, floating, radiolucent cholesterol gallstones in a functioning gallbladder. Only about half of this small subset of patients, however, will experience partial or complete dissolution of stones in 6 to 12 months. Moreover, recurrence is very likely, and the potential toxicity of long-term therapy is unknown. Thus, for most patients, cholecystectomy remains the most cost-effective and, perhaps, safest option. Intragallbladder instillation of methyl tert-butyl ether and extracorporeal shock wave therapy are also likely to be applicable to only small subsets of patients and to be associated with high recurrence rates. In patients with retained ductal cholesterol stones and access to the biliary tree, mono-octanoin therapy is advantageous in that it can be begun as soon as cholangiography demonstrates no extravasation. In properly selected patients, a 90 percent success rate with mono-octanoin infusion can be expected within a week. Radiologic or endoscopic extraction techniques require maturation of a relatively straight T-tube tract but are not dependent on the type of stone. In the hands of experts, these techniques are highly successful. In postcholecystectomy patients without access to the biliary tree, endoscopic sphincterotomy has become the preferred method of management and can be expected to succeed in more than 90 percent of patients. At this point, the exact role for ultrasonic or electrohydraulic lithotripsy and lasers is unknown. However, these techniques may be applicable in the future in patients with retained bile duct stones in whom extraction and infusion techniques have failed.

Utility of biliary microscopy for the prediction of the chemical composition of gallstones and the outcome of dissolution therapy with ursodeoxycholic acid

To learn whether microcrystalline solids in bile could predict gallstone composition, the findings determined by polarizing microscopy of gallbladder bile were related to stone type at cholecystectomy in 53 patients. Cholesterol crystals were present in 36 of 39 cholesterol stone bile and absent in 12 of 14 bile from non-cholesterol stones. Fifteen cholesterol stones (eight radiopaque) contained calcium carbonate, and characteristic vaterite microspheroliths were observed in 53% of their bile. In another study, crystals in basal duodenal bile were related to the outcome of gallstone dissolution treatment with ursodeoxycholic acid, 10 mg/kg X day. In 39 patients treated for 1 yr, efficacy (complete gallstone dissolution) was 41% overall and 52% in patients with stones less than or equal to 10 mm in diameter. In connection with the findings of biliary microscopy, efficacy was 93% in 14 patients with cholesterol crystals in bile, and 27% in 11 patients with microspheroliths in bile. Cholecystectomies in 9 patients with dissolution failure revealed 4 cases of non-cholesterol stones and 5 cases (including 3 with on-therapy calcification) of calcium carbonate-rich cholesterol stones with a surface/interior mineral ratio greater than 3. The results confirm that cholesterol crystals in bile are a sensitive measure of cholesterol gallstones. They also show that vaterite microspheroliths in bile indicate the presence of calcium carbonate in gallstones. Both findings suggest that biliary crystals reflect gallstone composition, and it is demonstrated that this information is useful in predicting the success or failure of cholelitholysis with ursodeoxycholic acid. Finally, the data show that radiologically undetectable stone calcification reduces the probability of dissolution, and that the calcified structures appearing in some stones during treatment are composed of calcium carbonate.

The Sunnybrook Gallstone Study: a double-blind controlled trial of chenodeoxycholic acid for gallstone dissolution

The Sunnybrook Gallstone Study was a randomized, double-blind, controlled trial of chenodeoxycholic acid treatment over 2 years in 160 patients with radiolucent gallstones. Sixty-four patients received 750 mg daily, 53 received 375 mg daily and 43 received placebo. Total dissolution of gallstones occurred in 10.9% of patients on 750 mg daily, 13.2% of those on 375 mg daily and in no patient on placebo. The drug was tolerated well. Diarrhea severe enough to cause withdrawal from the study occurred in two patients. No patient developed clinically significant hepatotoxicity. Serum cholesterol rose 10% or more above baseline after 2 years in 33% of patients treated with chenodeoxycholic acid and in 30% of those on placebo. Cholecystectomy was performed in 10.9% of patients on 750 mg daily, 17% on 375 mg daily and 13.6% on placebo. Chenodeoxycholic acid given at these doses dissolved radiolucent gallstones safely but the efficacy was limited.

Effect of chenodeoxycholic and ursodeoxycholic acids on isolated adult human hepatocytes

Chenodeoxycholic and ursodeoxycholic are effective cholelitholytic agents, but differ in their side effects. Chenodeoxycholic acid administration induces diarrhea and a transient rise of GOT, which are virtually nonexistent with ursodeoxycholic acid treatment. Lithocholic acid, a bacterial metabolite of chenodeoxycholic acid, has been implicated as a possible hepatotoxin. In the present investigation, the effect of chenodeoxycholic acid or ursodeoxycholic acid and their glycine and taurine conjugates on isolated human hypatocytes was directly assessed. Chenodeoxycholic acid had drastic effects on isolated human hepatocytes by reducing the number of microvilli and disrupting cell membranes. Pronounced release of GOT was observed. In contrast, ursodeoxycholic acid produced only slight morphological changes and enzyme release. Conjugation of each respective bile acids had a moderating effect.

Estimation of ursodeoxycholic acid in human and bear biles using Clostridium absonum 7 beta-hydroxysteroid dehydrogenase

Ursodeoxycholic acid was estimated in bile samples from humans and wild North American black bears using 7 beta-hydroxysteroid dehydrogenase purified from Clostridium absonum by Procion Red affinity chromatography. The percentage ursodeoxycholic acid was calculated by two methods: (a) 7 beta-hydroxyl groups were quantified using 7 beta-hydroxysteroid dehydrogenase and 3 alpha-hydroxyl groups (total bile acids) were quantified using 3 alpha-hydroxysteroid dehydrogenase. The percentage ursodeoxycholic acid was calculated on the basis of [7 beta-hydroxyl groups]/[3 alpha-hydroxyl groups] X 100. (b) Bile was hydrolyzed with sodium hydroxide and subjected to thin-layer chromatography. Bands corresponding to cholic acid, chenodeoxycholic acid plus deoxycholic acid, and ursodeoxycholic acid were identified by the use of standards and Komarowsky's spray reagent. Total bile acids and total ursodeoxycholic acid were measured by elution of silica gel in unsprayed areas corresponding to the bile acid standards and quantification of the total bile acid in each eluate. Direct comparison of these methods validated the use of 7 beta-hydroxysteroid dehydrogenase in the estimation of ursodeoxycholic acid in the biles of black bears and of patients fed ursodeoxycholic acid for cholesterol gallstone dissolution. Relative percentages of ursodeoxycholic acid were 8-24% in four bears and 22 and 27% in the patients ingesting 500 and 750 mg ursodeoxycholic acid per day for 3 months, respectively. Predictably lower values were obtained in two control subjects and one patient ingesting 750 mg chenodeoxycholic acid per day for 3 months.

The preparation of bile acid amides and oxazolines. II. The synthesis of the amides and oxazolines of ursodeoxycholic acid, deoxycholic acid, hyodeoxycholic acid and cholic acid

Bile acid amides and oxazolines were synthesized by a sequence of steps involving the reaction of the free bile acid with formic acid to yield the formyloxy derivative, preparation of the formyloxy acid chloride, condensation of the acid chloride with 2-amino-2-methyl-1-propanol to give the amide and, finally, cyclization of the amide with thionyl chloride to give the oxazoline. The oxazolines were characterized by physical constants, thin layer and gas-liquid chromatography and identified by elemental analysis and gas-liquid chromatography-mass spectrometry. Some of the bile acid oxazoline derivatives alter the activity of bacterial 7-dehydroxylases in vitro, and inhibit the growth of certain anaerobic bacteria in pure culture.

Ursodeoxycholic acid vs. chenodeoxycholic acid as cholesterol gallstone-dissolving agents: a comparative randomized study

Cholesterol gallstones are dissolved in man by chenodeoxycholic acid (CDCA) and ursodeoxycholic acid (UDCA). To test the comparative efficacy of these two cholelitholytic bile acids, 223 gallstones patients were randomly treated with either UDCA or CDCA at two different doses: 7 to 8 mg per kg per day and 14 to 15 mg per kg per day. Efficacy and factors influencing dissolution (dose, size of the stones, and time) were evaluated after 3, 6, and 12 months of treatment. UDCA was significantly more efficacious than was CDCA after 3 and 6 months of treatment, whereas after 12 months, no significant differences were observed. UDCA was equally effective at high and low doses, both on small and large stones. CDCA was significantly more effective at high doses and on small stones. Seventy-four per cent of the total dissolutions with UDCA and 42% with CDCA occurred within the first 6 months of treatment. Diarrhea and hypertransaminasemia occurred only in the CDCA-treated patients. We conclude that UDCA seems to be the bile acid of choice in dissolving cholesterol gallstones.

Epimerization versus dehydroxylation of the 7 alpha-hydroxyl- group of primary bile acids: competitive studies with Clostridium absonum and 7 alpha-dehydroxylating bacteria (Eubacterium sp.)

Primary bile acids, chenodeoxycholic (3 alpha,7 alpha-dihydroxy-5 beta-cholan-24-oic) and cholic (3 alpha,7 alpha,12 alpha-trihydroxy-5 beta-cholan-24-oic) were included in cultures of (a) Clostridium absonum alone (b) a mixture of C. absonum and a 7-dehydroxylating organism, Eubacterium sp. (c) a mixture of C. absonum and fecal bacteria, and (d) fecal bacteria alone. C. absonum, when added to Eubacterium sp. cultures totally prevented lithocholic acid formation when the substrate was chenodeoxycholic acid and halved deoxycholic acid formation when the substrate was cholic acid. As expected, formation of 7 beta-hydroxy- and 7-keto-bile acids took precedence over formation of 7 alpha-dehydroxylated bile acids. However, the addition of C. absonum to mixed fecal cultures containing chenodeoxycholic acid did not alter production of lithocholic (3 alpha-hydroxy-5 beta-cholan-24-oic) acid; instead it enhanced formation of ursodeoxycholic acid (3 alpha,7 beta-dihydroxy-5 beta-cholan-24-oic acid) at the expense of 7-keto-lithocholic acid (3 alpha-hydroxyl-7-oxo-5 beta-cholan-24-oic acid). Similarly, the addition of C. absonum to mixed fecal cultures containing cholic acid promoted production of ursocholic acid (3 alpha,7 beta,12 alpha-trihydroxy-5 beta-cholan-24-oic acid) which did not take place when C. absonum was not added. Surprisingly, deoxycholic acid formation was somewhat enhanced when C. absonum was added to fecal cultures. These studies suggest that successful introduction of "foreign" 7 alpha-epimerizing organisms into animal or human intestines may influence bile acid metabolism in vivo.

Discrepancy between ultrasound and oral cholecystography in the assessment of gallstone dissolution

The Sunnybrook Medical Centre Gallstone Study is a randomized, controlled, double-blind study of chenodeoxycholic acid for dissolution of radiolucent gallstones. Of the first 22 patients whose stones were apparently totally dissolved on oral cholecystography, seven were found to have residual small stone fragments on ultrasound examination of the gallbladder. Continuing chenotherapy was unsuccessful in dissolving these fragments. The possibility that the residual stones represent insoluble nuclei of the original calculi must be considered. Responses to choleitholytic therapy and subsequent stone recurrences need to be reevaluated using ultrasound.

Retrospective comparison of 'Cheno' and 'Urso' in the medical treatment of gallstones

In two groups of gallstone patients ideally suited for medical treatment, the effect of six to 18 months' therapy was compared retrospectively in 52 given chenodeoxycholic acid (CDCA) and 46 given ursodeoxycholic acid (UDCA). The minimum dose (mg kg-1 day-1) required to desaturate bile consistently was 10.1 for UDCA and 14.3 for CDCA. In patients completing six months' treatment, 23 of 35 (66%) taking a mean of 7.7 (+/- SEM 0.5) mg UDCA and 34 of 42 (81%) taking 14.7 +/- 0.2 mg CDCA showed partial or complete dissolution of gallstones. The mean dose in the UDCA-treated patients, however, was artefactually lowered by previous dose-response studies: in those who had not taken multiple doses, the mean UDCA intake in the 'responders' at six months was 9.1 +/- 0.3 mg kg-1 day-1. At six months, more UDCA (five of 35 or 14.3%) than CDCA (four of 42 or 9.5%)-treated patients showed complete dissolution of gallstones, but, by one year, the situation was reversed, 20 of 41 (49%) CDCA-treated and eight of 30 (27%) UDCA-treated patients showing complete dissolution of gallstones. Cumulative efficacy at one year had risen to 76% for UDCA and 89% for CDCA. Both treatments reduced the frequency of dyspepsia and biliary colic; 37% of CDCA and 2.6% of UDCA-treated patients showed hypertransaminasaemia; diarrhoea developed in 60% of the CDCA group but in none of the UDCA group.

The enzymic and chemical synthesis of ursodeoxycholic and chenodeoxycholic acid from cholic acid

Three approaches to the synthesis of ursodeoxycholic acid (UDC) from cholic acid have been investigated: (i) oxidation of cholic acid to 3 alpha, 7 alpha-dihydroxy-12 keto-5 beta-cholanoic acid (12K-CDC) with Clostridium group P 12 alpha-hydroxysteroid dehydrogenase (HSDH), isomerization of 12K-CDC to 3 alpha, 7 beta-dihydroxy-12 keto-5 beta-cholanoic acid (12K-UDC) with Clostridium absonum 7 alpha- and 7 beta-HSDH and reduction of 12K-UDC by Wolff-Kishner to UDC; (ii) isomerization of cholic acid to ursocholic acid (UC) by C. absonum 7 alpha- and 7 beta-HSDH, oxidation of UC to 12K-UDC with Clostridium group P 12 alpha-HSDH and Wolff-Kishner reduction of 12K-UDC to UDC; (iii) oxidation of cholic acid to 12K-CDC by Clostridium group P 12 alpha-HSDH, Wolff-Kishner reduction of 12K-CDC to chenodeoxycholic acid (CDC) and isomerization of CDC to UDC using whole cell cultures of C. absonum. In the first two approaches (using cell free systems) the yields of desired product were relatively low primarily due to the formation of various side products. The third method proved the most successful giving an overall yield of 37% (UDC) whose structure was verified by mass spectroscopy of the methyl ester.