Mechanism by which bile salt disrupts the gastric mucosal barrier in the dog

Cholecystokinin-Induced Duodenogastric Bile Reflux Increases the Severity of Indomethacin-Induced Gastric Antral Ulcers in Re-fed Mice

BACKGROUND/AIMS

We examined the involvement of cholecystokinin (CCK) in the exacerbation of indomethacin (IND)-induced gastric antral ulcers by gastroparesis caused by atropine or dopamine in mice.

METHODS

Male mice were fed for 2 h (re-feeding) following a 22-h fast. Indomethacin (IND; 10 mg/kg, s.c.) was administered after re-feeding; gastric lesions were examined 24 h after IND treatment. In another experiment, mice were fed for 2 h after a 22-h fast, after which the stomachs were removed 1.5 h after the end of the feeding period. Antral lesions, the amount of gastric contents, and the gastric luminal bile acids concentration were measured with or without the administration of the pro- and antimotility drugs CCK-octapeptide (CCK-8), atropine, dopamine, SR57227 (5-HT3 receptor agonist), apomorphine, lorglumide (CCK1 receptor antagonist), ondansetron, and haloperidol alone and in combination.

RESULTS

IND produced severe lesions only in the gastric antrum in re-fed mice. CCK-8, atropine, dopamine, SR57227 and apomorphine administered just after re-feeding increased bile reflux and worsened IND-induced antral lesions. These effects were significantly prevented by pretreatment with lorglumide. Although atropine and dopamine also increased the amount of gastric content, lorglumide had no effect on the delayed gastric emptying provoked by atropine and dopamine. Both ondansetron and haloperidol significantly inhibited the increase of bile reflux and the exacerbation of antral lesions induced by atropine and dopamine, respectively, but did not affect the effects of CCK-8.

CONCLUSIONS

These results suggest that CCK-CCK1 receptor signal increases bile reflux during gastroparesis induced by atropine and dopamine, exacerbating IND-induced antral ulcers.

Gastroparesis Worsens Indomethacin-Induced Gastric Antral Ulcers by Bile Reflux via Activation of 5-HT3 and Dopamine D2 Receptors in Mice

BACKGROUND/AIMS

We examined the contributions of gastric emptying and duodenogastric bile reflux in the formation of gastric antral ulcers induced by NSAIDs in mice.

METHODS

We used the murine re-fed indomethacin (IND) experimental ulcer model. Outcome measures included the appearance of gastric lesions 24 h after IND treatment and the assessment of gastric contents and the concentration of bile acids 1.5 h after re-feeding. The effects of atropine, dopamine, SR57227 (5-HT3 receptor agonist), apomorphine, ondansetron, haloperidol, and dietary taurocholate and cholestyramine were also examined.

RESULTS

IND (10 mg/kg, s.c.) induced severe lesions only in the gastric antrum in the re-fed model. The antral lesion index and the amount of food intake during the 2-h refeeding period were positively correlated. Atropine and dopamine delayed gastric emptying, increased bile reflux, and worsened IND-induced antral lesions. SR57227 and apomorphine worsened antral lesions with increased bile reflux. These effects were prevented by the anti-emetic drugs ondansetron and haloperidol, respectively. The anti-emetic drugs markedly decreased the severity of antral lesions and the increase of bile reflux induced by atropine or dopamine without affecting delayed gastric emptying. Antral lesions induced by IND were increased by dietary taurocholate but decreased by the addition of the bile acid sequestrant cholestyramine.

CONCLUSIONS

These results suggest that gastroparesis induced by atropine or dopamine worsens NSAID-induced gastric antral ulcers by increasing duodenogastric bile reflux via activation of 5-HT3 and dopamine D2 receptors.

Drug Disposition in the Lower Gastrointestinal Tract: Targeting and Monitoring

The increasing prevalence of colonic diseases calls for a better understanding of the various colonic drug absorption barriers of colon-targeted formulations, and for reliable in vitro tools that accurately predict local drug disposition. In vivo relevant incubation conditions have been shown to better capture the composition of the limited colonic fluid and have resulted in relevant degradation and dissolution kinetics of drugs and formulations. Furthermore, drug hurdles such as efflux transporters and metabolising enzymes, and the presence of mucus and microbiome are slowly integrated into drug stability- and permeation assays. Traditionally, the well characterized Caco-2 cell line and the Ussing chamber technique are used to assess the absorption characteristics of small drug molecules. Recently, various stem cell-derived intestinal systems have emerged, closely mimicking epithelial physiology. Models that can assess microbiome-mediated drug metabolism or enable coculturing of gut microbiome with epithelial cells are also increasingly explored. Here we provide a comprehensive overview of the colonic physiology in relation to drug absorption, and review colon-targeting formulation strategies and in vitro tools to characterize colonic drug disposition.

Bilious Vomiting Syndrome in Dogs: Retrospective Study of 20 Cases (2002-2012)

Bilious vomiting syndrome (BVS) is a condition historically associated with early morning vomiting of bile, but it is otherwise poorly characterized. The vomiting is thought to result from a reflux of duodenal fluid into the gastric lumen causing mucosal irritation. Medical records from Colorado State University Veterinary Teaching Hospital (CSUVTH) were searched for "canine" and "bilious vomiting syndrome" between 2002 and 2012. Visual inspection confirmed a diagnosis of BVS during the case history. The diagnosis remained BVS for the duration of the dog's contact with the hospital in 17 cases. Therapy involved frequent feedings, late evening meals, gastric acid reducers, prokinetics, and gastroprotectants. Twelve dogs improved with therapy. Five dogs did not improve or were lost to follow-up. The diagnosis of BVS was supplanted in three cases with gastric adenocarcinoma, dietary indiscretion, and hepatopathy. The patient most likely given a diagnosis of BVS would be a young, mixed-breed, castrated male dog with a chronic history of vomiting bile. Response to therapy suggests abnormal gastrointestinal motility, local gastritis, gastric pH, or stimulation of the emetic center may be important factors in BVS. Dogs diagnosed with BVS rarely received a diagnostic evaluation sufficient to qualify it as a diagnosis of exclusion.

Protective effects of nonionic triblock copolymers on bile acid-mediated epithelial barrier disruption

Translocation of bacteria and other luminal factors from the intestine following surgical injury can be a major driver of critical illness. Bile acids have been shown to play a key role in the loss of intestinal epithelial barrier function during states of host stress. Experiments to study the ability of nonionic block copolymers to abrogate barrier failure in response to bile acid exposure are described. In vitro experiments were performed with the bile salt sodium deoxycholate on Caco-2 enterocyte monolayers using transepithelial electrical resistance to assay barrier function. A bisphenol A coupled triblock polyethylene glycol (PEG), PEG 15-20, was shown to prevent sodium deoxycholate-induced barrier failure. Enzyme-linked immunosorbent assay, lactate dehydrogenase, and caspase 3-based cell death detection assays demonstrated that bile acid-induced apoptosis and necrosis were prevented with PEG 15-20. Immunofluorescence microscopic visualization of the tight junctional protein zonula occludens 1 (ZO-1) demonstrated that PEG 15-20 prevented significant changes in tight junction organization induced by bile acid exposure. Preliminary transepithelial electrical resistance-based studies examining structure-function correlates of polymer protection against bile acid damage were performed with a small library of PEG-based copolymers. Polymer properties associated with optimal protection against bile acid-induced barrier disruption were PEG-based compounds with a molecular weight greater than 10 kd and amphiphilicity. The data demonstrate that PEG-based copolymer architecture is an important determinant that confers protection against bile acid injury of intestinal epithelia.

High serum bile acids cause hyperthyroidism and goiter

BACKGROUND/AIMS

In the duodenal content reflux model of rats, we noted an elevation of serum bile acid and swelling of the thyroid gland. This study was designed to elucidate whether bile acids (BAs) also enhance thyroid function.

METHODS

In varying lengths of period after esophago-jejunostomy without gastrectomy, which causes duodenal content reflux, rats were sacrificed and blood samples were taken from the heart for analyses of BAs and triiodothyronine (T3), thyroxine (T4), free T3 (fT3), free T4 (fT4), and thyroid-stimulating hormone (TSH) in the serum.

RESULTS

Macroscopically, at 10 and 30 weeks after operation, thyroid glands in the reflux model showed a symmetric enlargement because of the presence of diffuse hypertrophy of the thyroid follicular epithelium. At both time points, no significant differences were detected in T3, T4, fT3, and fT4 levels between the reflux model and the control group, whereas, at 10 weeks after operation, the animals with the reflux showed significantly lower serum TSH levels and greater thyroid weight than those in the control group. An inverse correlation between serum BAs and TSH levels was noted in the reflux model but not in the control group. Microscopically, thyroid follicles were greater in size and number, with paler colloids in the reflux model than the control group.

CONCLUSIONS

The present results suggest that high serum BAs cause hyperplasia of the thyroid follicles and the reduction of TSH. The effects of BAs on thyroid hormones, thus, include the induction of overall hyperthyroidism. Therefore, the strict monitoring of serum TSH levels is of vital importance if BAs are used for the treatment of obesity.

Role of phosphatidylcholine saturation in preventing bile salt toxicity to gastrointestinal epithelia and membranes

BACKGROUND AND AIM

The mechanism which protects the biliary and intestinal mucosa from the detergent properties of bile acids is not fully understood. We employed three contrasting in vitro model systems (human red blood cells, polarized intestinal [Caco-2] cells, and synthetic liposomes), to compare the efficacy of saturated and unsaturated phosphatidylcholine (PC) to protect cells and membranes from bile salt injury.

METHODS

Hemolysis of red blood cells, electrical resistance across confluent monolayers of Caco-2 cells, and disruption of synthetic PC liposomes were assessed after incubation with varying concentrations of bile salt (sodium deoxycholate) alone or in the presence of saturated or unsaturated PC.

RESULTS

The hemolytic activity of deoxycholate on red blood cells was observed at > or =2 mM, and could be blocked by equimolar concentration or greater of both saturated or unsaturated PC. In contrast, exposure of Caco-2 cells to deoxycholate at > or =0.8 mM induced a maximal decrease in resistance, which was reversed by > or =0.8 mM unsaturated PC or 5 mM saturated PC. Similarly, synthetic liposomes were permeabilized by 0.8 mM deoxycholate and were protected by a lower concentration of unsaturated PC (2 mM) than saturated (5 mM).

CONCLUSIONS

Cells can show variable resistance to bile salt toxicity. Extracellular PC, especially in the unsaturated state, can directly protect cell and artificial membranes from bile salt injury. These findings support a role for biliary PC in the formation of mixed micelles that have low cytotoxic properties.

Preoperative versus postoperative Helicobacter pylori eradication therapy in gastric cancer patients: a randomized trial

OBJECTIVES

Helicobacter pylori (H. pylori) eradication is strongly recommended for gastric cancer patients who undergo subtotal gastrectomy. The efficacy of proton pump inhibitor-based triple therapy for H. pylori eradication has not been adequately assessed in the gastric remnant. The aim of this study was to compare the efficacy of postoperative versus preoperative H. pylori eradication therapy.

METHODS

A total of 138 distal gastric cancer patients with H. pylori infection were randomized to receive either preoperative (preop, N = 68) or postoperative (postop, N = 70) proton pump inhibitor-based triple therapy for H. pylori eradication. The regimen consisted of rabeprazole 10 mg, clarithromycin 500 mg, and amoxicillin 1,000 mg, all twice daily for 7 days. Eradication was assessed by rapid urease test and histology 12 wk after surgery.

RESULTS

By intention-to-treat (ITT) analysis, H. pylori eradication rates were 84.6% (95% CI 73.5-92.4) in the preop group and 83.1% (95% CI 71.7-91.2) in the postop group (P= 0.99). By per protocol (PP) analysis, the rates were 87.3% (95% CI 76.5-94.4) in the preop group and 86.9% (95% CI 75.8-94.2) in the postop group (P= 0.99). In the postop group, eradication rates did not differ with reconstruction method (Billroth I vs II, 80.4%[95% CI 66.1-90.6]vs 89.5%[95% CI 66.9-98.7] by ITT analysis (P= 0.49), and 85.7%[95% CI 71.5-94.6]vs 89.5% (95% CI 66.9-98.7) by PP analysis, P= 0.99).

CONCLUSIONS

In distal gastric cancer patients, the effect of proton pump inhibitor-based triple therapy for H. pylori eradication was not different whether given postoperatively or preoperatively.

Canine gastritis

Gastritis--inflammation of the stomach--is a frequently cited differential yet rarely characterized diagnosis in cases of canine anorexia and vomiting. Although the list of rule-outs for acute or chronic gastritis is extensive, a review of the veterinary literature reveals fewer than 15 articles that have focused on clinical cases of canine gastritis over the last 25 years. The dog frequently appears in the human literature as an experimentally manipulated model for the study of endoscopic techniques or the effect of medications on gastric mucosa. In the veterinary patient, cases of acute gastritis are rarely pursued with the complete diagnostic armamentarium, and cases of chronic gastritis are rarely found to occur as an entity isolated from the rest of the gastrointestinal tract. This article focuses on those findings most clinically relevant to cases of canine gastritis in veterinary medicine.

Duodenogastric reflux increases the penetration of N-3H-methyl-N-nitro-N-nitrosoguanidine into the antral mucosa of rats: a possible role for mucosal erosions and increased cell proliferation in gastric carcinogenesis

Duodenogastric reflux is a risk factor for gastric carcinogenesis, but the pathogenesis is not fully understood. We studied the risk of N-methyl-N-nitro-N-nitrosoguanidine (MNNG)-induced carcinogenesis in the antrum of rats with duodenogastric reflux. Duodenal fluid was directed into the stomach through the pylorus (pyloric reflux group) or through a gastrojejunostomy (jejunal reflux group). After twenty-four weeks, 5-bromo-2-deoxyuridine (BrdU) was injected intravenously and the stomach was exposed to N-(3)H-methyl-N-nitro-N-nitrosoguanidine ((3)H-MNNG). The antral mucosa was examined with immunohistochemistry and autoradiography for identification of proliferating cells (BrdU labelled) and cells at risk of MNNG-induced carcinogenesis ((3)H-MNNG and BrdU-labelled cells). Duodenogastric reflux increased the number of double-labelled cells in the antral mucosa from 4.8 +/- 0.6 per mm in the control group to 11.3 +/- 1.9 in the jejunal reflux group (P < 0.05) and 12.7 +/- 0.9 in the pyloric reflux group (P < 0.05). Mucosal erosions were observed in 15 of 28 animals with pyloric reflux and the number of double-labelled cells in the erosion area (4.3 +/- 0.7) was higher than in the same area of animals without erosion (1.4 +/- 0.5) (P < 0.05). Duodeno-gastric reflux increased the cell proliferation and significantly changed the distance between the surface epithelial lining and the proliferating cells when compared to the controls. These results indicate that duodenogastric reflux increases the penetration of (3)H-MNNG into the antrum mucosa of rats. Increased cell proliferation and erosions increase the number of cells at risk of an initiation process from a penetrating gastric carcinogen.

Role of biliary phosphatidylcholine in bile acid protection and NSAID injury of the ileal mucosa in rats

BACKGROUND & AIMS

We explored the role of biliary phosphatidylcholine (PC) in protection of the intestinal mucosa against bile salt (BS)-induced intestinal injury and how this property may be blocked by indomethacin (Indo), a nonsteroidal anti-inflammatory drug (NSAID) that is secreted into the bile.

METHODS

We performed in vivo studies in which bile was collected over a 2-hour period after rats were intragastrically administered Indo (25 mg/kg) or an equivalent volume of saline (controls). The bile samples (some of which were supplemented with PC) were then instilled into a loop of distal ileum of anesthetized rats. After a 30-minute exposure period, we measured the hemoglobin concentration of the ileal loop fluid, as an index of bleeding, and mucosal contact angles, as an index of surface hydrophobicity. A similar in vivo experiment was performed in which model bile containing 5 mmol/L each of the BS, sodium deoxycholate, PC, or Indo, alone and in combination, was instilled into ileal loops. In our in vitro test system, human erythrocytes were exposed to the above biliary constituents, and hemolysis was measured spectrophotometrically.

RESULTS

Bile from Indo-pretreated rats decreased the surface hydrophobicity and induced bleeding of ileal loops in comparison with control bile, and both NSAID-induced changes were reversed if PC was added to the bile. Similarly, synthetic BS caused gastrointestinal bleeding, decreased ileal contact angles, and induced erythrocyte hemolysis, all of which were reversed by addition of equimolar PC. This protective role of PC in both the in vivo and in vitro systems was partially blocked by Indo, although the NSAID had no effect on these properties on its own.

CONCLUSIONS

These findings support the hypothesis that PC protects the intestinal mucosa against injurious actions of BS, possibly by forming less toxic mixed micelles. Indo and perhaps other NSAIDs that enter the bile may damage the mucosa, not by a direct action, but by competing for the available protective PC molecules.

Topical prostaglandin E2 protects isolated gastric mucosa against acidified taurocholate-, but not ethanol- or aspirin-induced injury

This study investigates whether topical prostaglandins protect isolated gastric mucosa against injury provoked by acidified "barrier-breaking" agents. Intracellular pH (pHi), apical cell membrane potential (Vcm) and intraepithelial resistances in isolated Necturus antral mucosa were measured using double-barreled liquid sensor microelectrodes. Topical PGE, treatment protected the antral mucosa against acidified taurocholate-induced injury, reducing significantly (P<0.05) intracellular acidification (pHi from 7.39+/-0.05 to 7.08+/-0.08 vs. from 7.30+/-0.02 to 6.62+/-0.15), and opposing significantly the changes in Vcm (hyperpolarization followed by depolarization), and completely abolishing the decrease in transmembrane resistance (Rt from 702+/-37 to 723+/-39 Ohms x cm2 vs. from 721+/-34 to 270+/-105 Ohms x cm2). Also the ratio of apical and basolateral membrane resistances (Ra/Rb) remained at a significantly higher level in PGE2-treated tissues. In contrast, PGE2 treatment had no protective influence on the changes of the respective parameters in acidified ethanol or acetylsalicylic acid injured mucosas. Topical prostaglandin E2 protects isolated gastric mucosa against acidified taurocholate, but not against ethanol- or acetylsalicylic acid-induced injury.

Variability in the composition of physiologic duodenogastric reflux

Duodenogastric reflux has long been associated with various diseases of the foregut. Even though bile is often used as a marker, duodenogastric reflux consists of other components such as pancreatic juice and duodenal secretions. The aim of this study was to investigate the occurrence of duodenogastric reflux, its components, and the variability of its composition in normal subjects. Twenty healthy volunteers (7 men and 13 women) whose median age was 24 years underwent combined 24-hour bilirubin and gastric pH monitoring and intraluminal gastric aspiration. All probes were placed at 5 cm below the lower border of the lower esophageal sphincter. Aspiration was performed hourly and at any time when bilirubin and/or pH monitoring showed signs of duodenogastric reflux. Elastase and amylase were measured in the aspirate. All volunteers had episodes of physiologic duodenogastric reflux. A total of 70 episodes of duodenogastric reflux were registered with a median of three episodes (range 1 to 8) per subject. Most bile reflux occurred separately from pancreatic enzyme reflux. Pancreatic enzyme aspirate was significantly more often associated with a rise in pH in comparison to bile reflux (P <0.01). Duodenogastric reflux is a physiologic event with varying composition. Both bile and pancreatic enzyme reflux frequently occur separately. These findings could explain the disagreement regarding assessment and interpretation of duodenogastric reflux in the past. Thus monitoring of duodenogastric reflux requires more than the detection of just one component.

Cholesterol enhances membrane-damaging properties of model bile by increasing the intervesicular-intermixed micellar concentration of hydrophobic bile salts

Bile salts are potent detergents that, at concentrations attained in bile and intestine, can disrupt cell membranes. Hepatic secretion of vesicles containing lecithin and cholesterol appears to be critical in preventing bile salt damage to hepatobiliary epithelia. We hypothesize that the protective effect of biliary lipids results from lowering of the bile salt intervesicular intermixed micellar bile salt concentration (IMMC) to which epithelial membranes are exposed. We further hypothesize that increases in biliary cholesterol, by reducing association of bile salts with vesicles and mixed micelles, may increase bile toxicity by raising the bile salt IMMC.

METHOD

Large unilamellar lecithin vesicles (100 nm) with varying cholesterol:lecithin molar ratios (C:L) of 0, 0.5, and 1 were added to taurochenodeoxycholate (TCDCA), taurocholate (TCA), or taurodeoxycholate (TDCA) in Tris-buffered saline, pH 7.4. Human erythrocyte ghosts (model target membrane), prepared by osmotic hemolysis and resealed with [14C]inulin trapped inside, were added and incubated at 37 degrees C for 30 min and 4 h. Plasma membrane disruption was quantified by [14C]inulin release and bile salt IMMC was determined by ultrafiltration.

RESULTS

Membrane disruption started at a concentration of 0.5 mM for TDCA, 1 mM for TCDCA, and 2 mM for TCA and was complete within 4 h at concentrations of 1, 2, and 4 mM, respectively. Addition of 2 mM lecithin to 2 mM TDCA, 4 mM TCDCA, or 5 mM TCA reduced or eliminated membrane leakage and lowered the IMMC. For TDCA and TCDCA, the protective effect of vesicles was entirely attributable to reduction in IMMC; in contrast for TCA, the protective effect exceeded that which would have been expected based solely on reduction of the IMMC. Inclusion of cholesterol attenuated the binding of bile salts to vesicles and raised the IMMC, thereby reducing the protective effect of lecithin over the time course of these studies. Although there was loss of phospholipid and cholesterol from the erythrocyte membranes on addition of bile acids even in the presence of vesicles, the ratio of cholesterol to phospholipid in the erythrocyte membrane did not change.

CONCLUSION

Lecithin protects against membrane disruption by hydrophobic bile salts by lowering the IMMC. Cholesterol added to lecithin raises the bile salt IMMC and reduces or eliminates this protective effect. This mechanism of potentiation of bile salt toxicity by cholesterol may be an important contributor to the pathogenesis of gallbladder disease in cholesterol cholelithiasis.

Bile reflux due to disturbed gastric movement is a cause of spontaneous gastric ulcer in W/Wv mice

c-Kit is a receptor tyrosine kinase, and it is encoded by the mouse W locus. Mutant W/Wv mice develop spontaneous gastric antral ulcers. The aim of the present study was to investigate the pathogenesis of these gastric ulcers and to examine the effects of two antiulcer drugs; a proton pump inhibitor (2{[4-(3-methoxypropoxy)-3-methylpyridine-2-yl]methyl-sulfinyl}-1H -benzimidazole sodium salt, rabeprazole) and a mucosal protective drug (geranylgeranylacetone, GGA), on the gastric ulcers. The inhibition of the gastric acid secretion by rabeprazole (30 mg/kg body weight, subcutaneous injection once a day for six weeks) significantly increased the gastric ulcer formation compared to the controls. In contrast, the GGA treatment (100 mg/kg body weight, oral administration for six weeks) significantly inhibited the ulcer formation. Bile reflux was seen in these mutant mice, and they showed no cyclic intense contractions in the gastric antrum. These results suggest that bile reflux due to the disturbance of gastric antral movement is a cause of the spontaneous gastric ulcers in W/Wv mice.

Lecithin protects against plasma membrane disruption by bile salts

INTRODUCTION

Detergent disruption of epithelial plasma membranes by bile salts may contribute to pathogenesis of cholestasis and gastroesophageal reflux disease. Bile, despite containing high concentrations of bile salts, normally is not toxic to biliary or intestinal epithelia. We hypothesize that lecithin in bile may protect cell membranes from disruption by bile salts.

METHODS

We studied the interactions of taurine conjugates of ursodeoxycholate (TUDCA), cholate (TCA), chenodeoxycholate (TCDCA), and deoxycholate (TDCA) with erythrocyte plasma membranes with or without large unilamellar egg lecithin vesicles for various times at 23 degreesC. Release of hemoglobin was quantified spectrophotometrically. The concentration of bile salt monomers and simple micelles in the intermixed micellar aqueous phase (IMMC) was determined by centrifugal ultrafiltration.

RESULTS

The degree of hemolysis depended on the hydrophobicity of the bile salts and was progressive over time. Addition of lecithin reduced the hemolytic effects of 20 mM TCA or 2 mM TDCA in a concentration-dependent manner at both 30 min and 4 h. Increasing the concentration of lecithin progressively reduced the IMMC of TDCA. Hemolysis following addition of lecithin to 2 mM TDCA was comparable to hemolysis produced by lecithin-free TDCA solutions when diluted to similar IMMC values.

CONCLUSION

We conclude that lecithin reduces plasma membrane disruption by hydrophobic bile salts. This protection may be attributable to association of bile salts with vesicles and mixed micelles, reducing the concentration of bile salt monomers and simple micelles available to interact with cell membranes. Lecithin may play a key role in preventing bile salt injury of biliary and gastrointestinal epithelia.

Abnormal duodenal bile composition in patients with acalculous chronic cholecystitis

OBJECTIVE

Our goal was to characterize biliary lipid composition in patients with the syndrome of chronic biliary pain, absence of gallstones, and inflammation of the gallbladder mucosa (acalculous chronic cholecystitis).

METHODS

Duodenal bile, obtained from 27 patients with a history of right upper quadrant pain and with negative imaging studies of the biliary tract, was analyzed enzymatically for bile acids, phospholipids, and cholesterol. Fifteen patients were found to have inflammation and/or fibrosis of the gallbladder at cholecystectomy.

RESULTS

The 15 patients with abnormal gallbladder histology had more dilute duodenal bile, as indicated by a low bile acid concentration and a lower proportion of phospholipids (p < 0.01) when values were compared with those of duodenal bile samples from postmenopausal women without gallbladder disease or from radiolucent gallstone subjects participating in the National Cooperative Gallstone Study. Cholecystectomy relieved pain in 9 of 14 patients.

CONCLUSIONS

Some patients with acalculous chronic cholecystitis have duodenal bile samples characterized by a decreased bile acid concentration and a decreased proportion of biliary phospholipids. The low biliary bile acid concentration may result from impaired gallbladder contraction and/or secretion by the biliary tract epithelium. The low proportion of phospholipid may result from posthepatic hydrolysis of luminal phosphatidylcholine followed by absorption of the hydrolysis products. The latter process could be caused by and/or contribute to mucosal inflammation and would also elevate the cholesterol saturation of bile, increasing the risk for cholesterol gallstone formation.

Effects of bile acids on iodide uptake and deoxyribonucleic acid synthesis in porcine thyroid cells in primary culture

The effects of bile acids on iodide uptake and DNA synthesis were studied in cultured porcine thyroid cells. All five bile acids, which are commonly found in serum, chenodeoxycholic acid (CDCA), cholic acid (CA), deoxycholic acid (DCA), lithocholic acid (LCA), and ursodeoxycholic acid (UDCA) dose-dependently inhibited both basal and TSH-induced iodide uptake at concentrations of 25-250 microM. Since CDCA is one of the two major primary endogenous bile acids, were studied mainly the effects of CDCA. The inhibitory effect of CDCA was detected after 24 h treatment of thyroid cells, and was dependent on the time of exposure up to 72 h. Treatment of thyroid cells with CDCA for 72 h inhibited cAMP production stimulated by 50 mU/L TSH or 0.5 mg/L forskolin and also inhibited iodide uptake induced by 0.5 mM 8-bromo cAMP or 0.5 mg/L forskolin. These results suggest that CDCA inhibits iodide uptake by decreasing cAMP production as well as post-cAMP generation. Bile acids except LCA stimulated [3H]thymidine incorporation into the thyroid cells by itself, indicating that the inhibitory effect of bile acids on iodide uptake is not due to cytotoxic effect. In conclusion, these findings suggest that the direct inhibition of thyroid function by bile acids might cause hypothyroidism in chronic liver disease.

Bile acid-induced depolarization of mitochondrial membrane potential preceding cell injury in cultured gastric mucosal cells

Changes in energy metabolism elicited by sodium taurocholate and their relation to cell viability were determined in gastric mucosal cells. Cultured mucosal cells were labelled with rhodamine-123, a mitochondrial energization-sensitive fluorescence probe, or by propidium iodide, a fluorochrome which labels the nuclei of non-viable cells. The cells were observed under a fluorescence microscope with a laser scanning confocal imaging system. After the addition of sodium taurocholate at concentrations > 5 mol/L, mucosal cells showed a rapid and significant decrease in rhodamine-123 fluorescence. A decrease to 40% of the pretreated values at 30 min was seen with a concentration of sodium taurocholate of 7.5mmol/L. A marked increase in the percentage of propidium iodide-positive cells was noted when the concentration of sodium taurocholate exceeded 5mmol/L. However, the extent of the decrease in rhodamine-123 fluorescence was always greater than the increase in the percentage of propidium iodide-positive cells, suggesting that most of these gastric mucosal cells remained viable. It is therefore suggested that the decrease in rhodamine-123 fluorescence is largely due to the disturbed oxidative phosphorylation of mitochondria. Pretreatment of gastric mucosal cells with low concentrations of ethanol resulted in a significant cytoprotective effect against sodium taurocholate injury with significant prevention of a decrease in rhodamine-123 fluorescence. It is concluded that sodium taurocholate induces a depolarization of the mitochondrial membrane potential preceding cell injury and that the cytoprotective effect of ethanol relates to its attenuation of the uncoupling effect.

Role of acid and duodenogastric reflux in esophageal mucosal injury: a review of animal and human studies

The role of acid and duodenogastric reflux (DGR) in the development of esophageal mucosal injury has been extensively investigated using both animal and human models. In this report, clinical and experimental data are reviewed. The mechanisms by which gastric and duodenal contents produce esophageal mucosal injury are also discussed. Acid and pepsin are unquestionably important in causing mucosal damage at low pH values in both animal and human models. Animal models suggest synergistic damaging potential for conjugated bile acids and HCI as well as that of unconjugated bile acids and trypsin in more neutral pH values. Human evidence for the involvement of bile and its constituents has been controversial; however, the advent of better technology to detect DGR is beginning to clarify the role of these constituents. The contribution of each methodology in clarifying the extent of involvement of DGR in esophageal mucosal injury is reviewed. Despite some conflicting results, preliminary human studies support the results from the animal data suggesting synergistic damaging effects for both bile and acid in esophageal mucosal injury. The implication of these studies in treating gastroesophageal reflux disease are discussed.

Effects of dibutyryl cyclic AMP and papaverine on intrahepatocytic bile acid transport. Role of vesicle transport

The secondary messenger cyclic AMP plays an important role in regulating biliary excretory function by stimulating the transcytotic vesicle transport system, whereas papaverine exerts an inhibitory effect on this system. We therefore investigated their effects on bile acid-induced cytotoxicity and intrahepatocytic content of bile acid in primary cultured rat hepatocytes. Simultaneous addition of 1 mM dibutyryl cyclic AMP (DBcAMP), an analogue of cAMP, with 1 mM taurochenodeoxycholic acid (TCDCA) significantly decreased the release of lactate dehydrogenase (LDH) as compared with the case with 1 mM TCDCA alone (7.1 +/- 0.13% of total versus 10.7 +/- 0.3%). In contrast, 0.1 mM papaverine approximately doubled the amount of LDH (22.0 +/- 0.6% of total versus 10.7 +/- 0.3%; P < 0.01). The intracellular content of TCDCA 180 min after the administration of 1 mM TCDCA alone was 20.8 +/- 0.7 nmol/mg protein, that after simultaneous administration of 1 mM DBcAMP, 16.2 +/- 1.0 nmol/mg protein, and that after the simultaneous administration of 0.1 mM papaverine, 38.5 +/- 1.9 nmol/mg protein. A clear correlation between the release of LDH from hepatocytes and the intracellular content of TCDCA was thus observed. When given together with 1 mM taurocholic acid (TCA) or 1 mM tauroursodeoxycholic acid (TUDCA), papaverine exerted little effect on cytotoxicity or intrahepatocytic bile acid content. When cells were bathed in a medium free of bile acid after pretreatment with 1 mM TCDCA and 1 mM DBcAMP, additional exposure to DBcAMP for 30 min significantly stimulated reduction of intracellular TCDCA content (30.2 +/- 0.4% of total versus 44.0 +/- 1.4%).(ABSTRACT TRUNCATED AT 250 WORDS)

Ornithine decarboxylase activity during gastric ulcer healing in dogs

Ornithine decarboxylase (ODC) activity has been associated with mucosal growth and injury, yet, little information is available on ODC activity during gastric ulcer healing. We measured ODC activity in the ulcer base submucosa and the surrounding mucosa at 1 cm and 2 cm and assessed ulcer surface healing and a histologic score in experimentally induced ulcers (Quinton ulcer-maker) at 0 and 5 hr and at one, two, three, four, and seven days. A total of 26 dogs were studied, eight of which received 2% difluoromethylornithine (DFMO, a specific inhibitor of ODC) in drinking water. Ulcer healing was assessed by digitizing initial (plug size), and final ulcer surface area and was expressed as percent ulcer surface reduction. A histologic score was assessed by two independent pathologists unaware of the treatment. ODC induction was observed in the submucosa of the ulcer base but not in the surrounding mucosa. The baseline submucosal ODC activity was measured at 0.2 +/- 0.1 pmol (14CO2)/mg protein/hr, and at one day the ODC activity increased to 4.0 +/- 0.7, at three days to 15.2 +/- 5.5, and at seven days to 2.6 +/- 1.0 (P less than 0.001). DFMO treatment delayed GU healing significantly up to three days, but no difference was noted at seven days. The assessed histologic parameters did not correlate with ODC activity, and DFMO treatment did not alter the histologic score. These data suggest that polyamine biosynthesis occurs in the ulcer base submucosa during the first seven days of experimentally placed gastric ulcers.(ABSTRACT TRUNCATED AT 250 WORDS)

Protective effect of tauroursodeoxycholate against chenodeoxycholate-induced damage to cultured rabbit gastric cells

Ursodeoxycholate (UDC) and tauroursodeoxycholate (TUDC) have been reported to be protective against liver injury induced by other bile salts. UDC also has been shown to be effective against refluxed bile-induced gastritis after gastric surgery. However the mechanism of the therapeutic effect of UDC on gastric mucosa has not been known. In the present study, cytoprotective actions of UDC and TUDC against chenodeoxycholate (CDC)-induced gastric injury were investigated using rabbit gastric cell cultures without systemic factors. Rabbit gastric mucosal cells were cultured after the isolation of rabbit gastric cells with collagenase and ethylenediaminetetraacetic acid. Cytotoxicity was quantified by measuring 51Cr release from prelabeled cells and MTT assay. Prostaglandin (PG) E2 was assayed by radioimmunoassay. Concentrations of CDC greater than 0.5 mM or UDC greater than 5 mM caused cellular damage and increased 51Cr release in a dose-dependent and time-dependent fashion, while TUDC up to 10 mM did not. TUDC, but not UDC, showed a significant decrease of CDC (1.5 mM)-induced 51Cr release dose dependently. The protective effect of TUDC against CDC-induced damage was confirmed by MTT assay. On phase-contrast microscopy, disruption of monolayers induced by CDC (1.5 mM) was clearly protected by TUDC (10 mM). Free radical scavengers (500 units/ml of superoxide dismutase, 300 units/ml of catalase, and 100 mM of dimethyl sulfoxide) or a calcium blocker (10(-7)-10(-5) M verapamil) did not show significant protection against CDC-induced damage. Deprivation of Ca2+ in the media did not affect CDC-induced damage. Thus free radicals or Ca2+ might not be involved in the cell toxicity of CDC.(ABSTRACT TRUNCATED AT 250 WORDS)

Conjugates of ursodeoxycholate protect against cholestasis and hepatocellular necrosis caused by more hydrophobic bile salts. In vivo studies in the rat

The protective effect of ursodeoxycholate conjugates against bile salt hepatotoxicity was studied in chronic bile fistula rats. Taurochenodeoxycholate or taurodeoxycholate, infused intraduodenally at 24 or 16 mumols/100 g rat per hour, respectively, caused cholestasis and severe hepatocellular necrosis within 8 hours. In contrast, tauroursodeoxycholate or taurocholate at 48 mumols/100 g rat per hour were choleretic. Tauroursodeoxycholate was not hepatotoxic, whereas taurocholate produced moderate hepatocellular necrosis. Simultaneous infusion of tauroursodeoxycholate to rats receiving taurochenoxycholate or taurodeoxycholate preserved bile flow and ameliorated hepatic injury in a dose-dependent manner. Tauroursodeoxycholate protected equally by intravenous and intraduodenal routes. Intravenous glycoursodeoxycholate also was protective. The hydrophobicity index of infused bile salts correlated well with their toxicity. Concurrent administration of ursodeoxycholate conjugates did not reduce biliary recovery of intraduodenally infused [24-14C]-taurocholate. Biliary alkaline phosphatase secretion was stimulated by infusion of taurocholate, taurodeoxycholate, or taurochenodeoxycholate; simultaneous infusion of ursodeoxycholate conjugates failed to prevent this increase. We conclude that ursodeoxycholate counteracts hepatoxicity of more hydrophobic bile salts via a direct effect at the level of the liver.

Bile salt-induced increases in duodenal brush-border membrane proton permeability, fluidity, and fragility

Rabbit duodenal brush-border membrane vesicles were treated in vitro with deoxycholate, glycodeoxycholate, or taurodeoxycholate. Intravesicular [14C]glucose space at equilibrium, 0.54 microliters/mg protein, was reduced by exposure to the three bile salts in a concentration (0.1-5.0 mM)-dependent manner, equatable with increased membrane fragility. Net proton permeability (Pnet), determined by acridine orange fluorescence quenching, was increased from 6.3 x 10(-4) cm/sec in untreated vesicles, by approximately 120, 150, and 170%, by treatment with bile salts at 0.1, 0.5 and 1.0 mM, respectively. The three bile salts were equipotent. The increases in membrane fragility and Pnet were not accompanied by significant increases in membrane fluidity, as assessed from steady-state and time-resolved diphenylhexatriene fluorescence anisotropy. The data demonstrate direct effects of bile salts on duodenal apical membrane fragility and proton permeability that are likely to be early events in bile salt-induced mucosal damage.

Effect of barrier-breaking agents on intracellular pH and epithelial membrane resistances: studies in isolated Necturus antral mucosa exposed to luminal acid

Features of "H+ back-diffusion" after disruption of the gastric mucosal barrier were investigated by assessing, with a microelectrode technique, the influence of three barrier-breaking agents, taurocholate (10 mM), ethanol (20% vol/vol), and acetylsalicylic acid (10 mM) on intracellular pH and epithelial membrane potentials and resistances in isolated Necturus antral mucosa exposed to luminal acid (pH 3). Exposure of the mucosa to each of the three agents induced intracellular acidification of surface epithelial cells, but the pattern of pHi behavior was different for each agent: taurocholate induced immediate acidification of pHi, ethanol acidified pHi after a delay of 4-6 min, whereas acetylsalicylic acid initially alkalinized pHi, whereafter a rapid acidification of pHi occurred. Assessment of intraepithelial membrane resistances indicated that taurocholate primarily increases cellular conductance, decreasing in particular Ra. In contrast, ethanol mainly increased paracellular conductance, but also decreased cellular resistance, in particular Ra. Acetylsalicylic acid initially increased cell membrane resistances and Ra/Rb, whereafter a rapid decrease of Ra/Rb and Rt occurred. In each instance, the decrease of Ra/Rb preceded acidification of pHi. The data suggest that all three agents induce intracellular acidification by increasing the conductance of the apical cell membrane to H+, but in ethanol-treated tissues paracellular conductance primarily contributes to H+ back-diffusion.

Healthy controls have as much bile reflux as gastric ulcer patients

Data on duodenogastric reflux of bile in gastric ulcer are conflicting. We therefore measured intragastric bile acid concentration and its composition from individual bile acids, duodenogastric bile acid reflux rate, gastric emptying rate, and secretion rates of volume and acid in 30 patients with gastric ulcer and in 66 healthy controls, both in the fasting state and after feeding a liquid meal. Patients had higher gastric bile acid concentrations (p less than 0.05) than controls in the fasting state, but the overlap between the groups was considerable. In fasting patients with corpus ulcer, gastric secretion rates were significantly decreased when compared with controls. There was no difference between patients and controls with respect to gastric emptying rate, bile acid reflux rate, intragastric amount of bile acids, and bile acid composition in the fasting state. Postprandially, all parameters tested were similar in patients and controls. Controls showed high reflux rates with similar frequency as did ulcer patients. We conclude that increased gastric bile acid concentrations in the fasting stomach of patients with gastric ulcer are the result of gastric hyposecretion and not of increased reflux. They probably are pathogenetically irrelevant.

Gastric carcinogenesis: a model for the identification of risk factors

In a series of extensive studies on gastric carcinogenesis, we have used Sprague-Dawley rats to examine the morphologic, histochemical, and biochemical effects of risk and protective factors on N-methyl-N'-nitro-N-nitroso guanidine (MNNG)-induced tumors in an attempt to link early observations with the end-point lesion, gastric cancer. We have observed that the putative risk factors sodium chloride (NaCl); a mixture of bile acids; aspirin; alcohol; and nitrite enhance MNNG-induced neoplasia of the gastric mucosa. On the other hand butylated hydroxyanisol (BHA), Se and difluromethylornithine (DFMO) were protective and inhibited the induction of gastric mucosal neoplasia. In most cases, early changes detected by a number of criteria correlated with the end-point, gastric neoplasia. This model appears to be useful in screening and evaluating chemicals for risk for or protection against gastric cancer.

Lysophosphatidylcholine and taurodeoxycholate increase stomach permeability to different-sized molecules

The influence of lysophosphatidylcholine (LPC), taurocholate (TC), and taurodeoxycholate (TDC) on gastric mucosal permeability was studied in a rat experimental model, with different-sized polyethylene glycols (PEGs) in the 722-1206-dalton range as permeability markers. Gastric mucosal morphology was also studied by transmission electron microscopy. We found that 2.5 mM and 5 mM LPC and TDC, but not TC, caused an increase in the passage of PEGs across the gastric mucosa. LPC altered the permeability significantly more than did TDC. Morphologically damaged intercellular microvillous structures could be seen after LPC treatment, whereas no obvious changes could be seen after TC or TDC treatment. These findings indicate that LPC and TDC may damage the gastric mucosa and enable permeation of molecules in the 722-1206-dalton range. Molecules within this range could potentially be toxic or antigenic, and this therefore represents an aspect of interest in the pathology of enterogastric reflux. Furthermore, the results indicate that dihydroxy secondary bile acids (TDC) have a more pronounced effect on gastric mucosal permeability than trihydroxy primary bile acids (TC).

Role of the unstirred layer in protecting the murine gastric mucosa from bile salt

Bile salts disrupt a functional gastric mucosal barrier which normally minimizes back-diffusion of H+ into mucosa. Our previous studies have shown that ionized bile salts disrupt the barrier to H+ by dissolving membrane lipids. The presence of an unstirred water layer on the surface of the gastric mucosa could protect against bile salt injury either by creating a concentration gradient of bile salt from lumen to mucosal surface or by slowing diffusion of lipid-laden mixed micelles away from the mucosal surface. In the present study we investigated this possibility in the anesthetized rat. Measurements of H+ back-diffusion and Na+ forward-diffusion across the gastric mucosa were made before and after exposure to a bile salt solution that was either unmixed or mixed by continuous withdrawal and injection. Using carbon monoxide diffusion, we observed this method of mixing to decrease the unstirred layer thickness from 880 to 448 micron (p less than 0.02). Mixing increased mean H+ back-diffusion induced by a 10 mM mixture of six conjugated bile salts from -2.58 to -4.11 microEq/min (p less than 0.01) and increased mean forward-diffusion of Na+ from 1.81 to 3.27 microEq/min (p less than 0.01). Mixing also increased efflux of mucosal phospholipid (32.7 to 52.2 nmol/min, p less than 0.05) and of cholesterol (4.89 to 8.87 nmol/min, p less than 0.05) into the bile salt solution. Addition of saturation amounts of lecithin and cholesterol to the bile salt solution completely prevented disruption of the barrier whether the solution was mixed or not. Mixing also increased mucosal uptake of bile salt from 74.6 to 221.3 nmol/min (p less than 0.01) when no lipids were added. In the presence of lecithin and cholesterol, mixing increased absorption of bile salt from 63.5 to 165.6 (p less than 0.02). These findings further support the hypothesis that bile salts disrupt the gastric mucosal barrier by dissolution of mucosal membrane lipids, and provide evidence that the unstirred water layer helps protect the gastric mucosa from bile salt injury.

Bile acid accumulation by rabbit esophageal mucosa

Bile acids are one of the noxious components of the gastroduodenal contents which may injure the esophageal mucosa in clinical reflux esophagitis. Animal models of esophagitis have shown that exposure to low luminal bile acid concentrations can cause increased mucosal permeability to a variety of ions and molecules without causing dramatic gross morphologic damage. In order to explore the mechanism by which bile acids alter mucosal permeability, we measured the esophageal mucosal concentration of taurocholic acid and chenodeoxycholic acid after exposure to these bile acids in anesthetized New Zealand white rabbits. We found that bile acids can accumulate in the esophageal mucosa to levels as high as seven times the initial luminal concentration. Thin-layer chromatography showed that this accumulation was not due to bile acid degradation in the mucosa. Since butyric acid also showed some mucosal accumulation, and is a weak acid like taurocholic acid, intracellular ionization may account for some of the accumulation. Mucosal accumulation of these molecules is not a nonspecific phenomenon, since the four-carbon polyol erythritol did not accumulate at all. Bile acid accumulation occurred under the same conditions and in a parallel temporal relationship to the bile-induced permeability changes. It is hypothesized, therefore, that the presence of high concentrations of bile acids in the esophageal mucosa may be pathophysiologically related to the alterations in mucosal permeability which occur after exposure to bile acids.

Gastric and oesophageal carcinogenesis: models for the identification of risk and protective factors

Male weanling rats of the Charles River Sprague-Dawley strain were exposed to N-methyl-N'-nitro-N-nitrosoguanidine (MNNG) in the water for 3 months at the concentration of 75 ml/litre. Other real or potential risk factors were administered, alone or in combination with MNNG. When MNNG was administered in combination with NaCl, bile acids, aspirin or BHA, forestomach tumours were enhanced. MNNG-induced tumours were inhibited by selenium or by difluoromethylornithine, an ornithine decarboxylase inhibitor. BHA alone caused forestomach tumours. When BHA was administered by dietary means or by gavage, alone or in combination with MNNG, the gavage method resulted in greater tumorigenesis than dietary exposure. This increase was associated with increased [3H]thymidine labelling of forestomach epithelium and increased hyperplasia. Oesophageal carcinogenesis induced by methylbenzylnitrosamine (MBN) was enhanced by zinc deficiency, alcohol and 13-cis-retinoic acid. Zinc deficiency also resulted in oesophageal tumours in rats exposed to the hepatocarcinogen dimethylnitrosamine. Riboflavin deficiency injured oral and oesophageal epithelium and increased sensitivity to MBN-induced oesophageal tumours.

The ability of antacids and cholestyramine to bind bile acids: effect of pH

Reflux of bile into the stomach may be injurious to the gastric mucosa. The ability of antacids and cholestyramine to bind bile acids is therefore potentially valuable in the treatment of reflux gastritis. The ability of antacids and cholestyramine to remove bile acids from gastric juice, hepatic bile, and solutions of commercially available bile acids was investigated in vitro over a pH range likely to occur in the stomach. The percentage of bile acids removed by antacids decreased with decreasing initial bile acid concentration and usually decreased as the incubation pH was increased from 3.6 to 7.0. Glycine-conjugated bile acids were bound to a greater extent than taurine-conjugated bile acids and dihydroxy to a greater extent than trihydroxy bile acids. Cholestyramine bound 97-100% of all bile acids in solution at pH 3.6 and pH 7.0. The effect of pH on adsorption should therefore be considered when antacids are used to treat gastritis.

The gastric mucosal barrier. Component control

The 'gastric mucosal barrier' is a descriptive term for the ability of the gastric epithelium to hold a large (10(5)) H+ concentration gradient from lumen to mucosa under physiological conditions. Compounds which classically have been used to describe the functional integrity of the 'barrier', in addition to very low H+ diffusion from lumen to mucosa, include low diffusion of Na+ and K+ from mucosa to lumen and maintenance of a lumen-negative transmucosal potential difference (PD). Na+ appearance in the luminal fluid is a function of active transport and diffusion. Fixed charges within diffusion channels with pK values greater than or equal to 9, may contribute to maintenance of H+ gradients. Luminal application of aspirin, bile salts, and ethanol increases net cationic flux and reduces PD. When acidified, these luminal agents produce histological and visible damage, yet damage can be produced by parenteral agents without concomitant change in these components. Although no anatomical 'barrier' has been described, it has been suggested that the gel mucus and epithelial phospholipids are constituents. Exogenous administration of a variety of prostanoids attenuate the change in cationic flux and PD produced by those agents in both animals and humans. The role of endogenous prostaglandins in barrier integrity has been questioned since it has been shown that salicylic acid produces permeability changes which are equal to aspirin, yet the former does not inhibit cyclooxygenase while the latter does. The gastric mucosal barrier is physiologically important because, by whatever mechanism, H+ back-diffusion is kept to a minimum under physiological conditions.

Protection by dietary proteins against the effects of bile acids on rat jejunum and stomach

Because bile acids bind to certain proteins we examined whether the effect of dihydroxy bile acids on jejunal water transport and gastric mucosal function could be blocked by the presence of protein. In the rat jejunum 2.5% bovine serum albumin blocked the secretion of water and electrolytes induced by 2 mM deoxycholate, whereas 5% ovalbumin, which does not bind bile acids, had no effect. Bovine serum albumin protected large unilamellar liposomes from damage by taurodeoxycholate and reduced the monomer concentration of taurodeoxycholate, whereas ovalbumin afforded no protection. In equilibrium dialysis studies whey protein and bovine serum albumin reduced the free taurodeoxycholate concentration (150 mM HCl enhanced this effect). In the rat stomach taurodeoxycholate (2.5 or 10 mM) in the presence of 150 mM HCl reduced potential difference and enhanced sodium secretion and hydrogen ion loss. These effects were reduced in the presence of whey protein. We conclude that proteins that bind bile acids have the potential to protect mucosal membranes from the adverse effects of bile acids.

The cytoprotective effect of prostaglandin E2 on taurocholate-induced erosions in gastric mucosa of the rat. Light microscopic, morphometric and scanning electron microscopic investigations

The morphological changes associated with the cytoprotective effect of prostaglandin E2 (PGE2) following sodium-taurocholate (NaTC) erosive injury in the gastric mucosa were investigated in male rats. A single topic application of NaTC (80 mMol) induced multiple gastric erosions in all animals. Application of 200 micrograms PGE2/kg body weight prior to NaTC treatment led to a significant 90% decrease in the lesion-score in PGE2-protected animals. Light microscopic morphometric studies of the mucus-producing cells in the fundus mucosa were carried out. Within the PGE2-protected animals a significant increase was observed in the length of zones of the mucus-producing cells at the surface and in the foveolae (both PAS-positive and alcian-blue-positive cells). Compared to the NaTC-injured animals, this increase amounted to 8.1% for the PAS-positive, and 6.1% for the alcian-blue-positive zone. Compared to the untreated controls, these values were 4.7% and 3.2% respectively. In the scanning electron microscope we observed a characteristic explosive release of mucus and damage of the cell's surface membranes in the NaTC-treated animals. The PGE2-protected rats showed a predominance of exocytosis of mucus vesicles which formed a characteristic mucus network at the surface membrane. Our investigations suggest that the cytoprotective effect of PGE2 may, in part, be due to an increase in mucus production and to a modification of mucus adherence at the cell membrane.

Correlations between changes in indicators of gastric mucosal barrier integrity at time of exposure to "barrier breakers" and extent of hemorrhagic erosions one hour later

We have examined the effects of seven different "barrier breakers" (including ethanol, aspirin, salicylic acid, isobutyric acid, Na taurocholate, thermal injury, and hyperosmotic glucose) on chambered gastric mucosae of rats in an attempt to identify variations in accepted indicators of mucosal barrier integrity which would accurately predict the extent of subsequent hemorrhagic erosion. When results from all experimental groups were considered, only the initial decrease in transmucosal potential difference (PD) showed significant correlation with final damage (lesion area). When the results were analyzed as separate subgroups, significant correlations were also found between net K+ efflux during the first 10 min after luminal infusion and final lesion area. Only in the subgroup containing ethanol, salicylates, and thermal injury was there a correlation between net loss of luminal H+ (back-diffusion) and lesion area. These results are considered in terms of their implications for the ulcerogenic actions of each group of agents.

Action of ethanol on gastrin release in the dog

In conscious dogs with gastric and duodenal Thomas fistulas, we studied the effect of ethanol on plasma concentrations of gastrin. Ethanol was given either as an infusion into a peripheral vein (1.95 M, 200 ml/hr) or into the duodenum (0.95 M, 400 ml/hr) or as an intragastric bolus injection. The effect of the intragastric bolus injection of 200 ml of different concentrations (0.3 M, 1.7 M, 6.85 M) of ethanol was compared with that of equimolar solutions of urea and sucrose (0.3 M, 1.56 M), and with that of sodium taurocholate (0.06 M) and distilled water. The gastrin responses to an oral mixed-meat meal (35 g/kg) were also investigated. Intragastric bolus injection of isoosmolar (0.3 M) ethanol, but not of equimolar solutions of urea and sucrose or H2O, significantly (P less than 0.05) increased plasma gastrin levels above basal. Hyperosmolar solutions of ethanol, urea, and sucrose as well as hypoosmolar sodium taurocholate produced a pronounced increase of plasma gastrin concentrations above basal. The comparison of the mean 2-hr integrated plasma gastrin responses (IRG) showed that ethanol (6.85 M), urea (6.85 M), and sodium taurocholate (0.06 M) are at least as potent stimuli of release of gastrin as the test meal used. Intraduodenal and intravenous infusion of ethanol did not significantly alter mean plasma gastrin concentrations. We conclude that in the dog ethanol, but not urea and sucrose, given in a concentration (0.3 M) which is known not to disrupt the gastric mucosal barrier, increases plasma gastrin levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Gastrointestinal bleeding in the pediatric patient

Gastrointestinal hemorrhage in infants and children is a catastrophic event but is not associated with significant mortality except in those with a severe primary illness. Upper gastrointestinal bleeding in infants and young children is most often associated with stress ulcers or erosions, but in older children it may also be caused by duodenal ulcer, esophagitis, and esophageal varices. Lower gastrointestinal bleeding may be caused by a variety of lesions among which are infectious colitides, Meckel's diverticulum, bleeding disorders, gastrointestinal allergy, and inflammatory bowel disease. Techniques of diagnosis and management are discussed.

Bile absorption occurs during disruption of the esophageal mucosal barrier

The role of bile salt absorption in bile-induced disruption of the esophageal mucosal barrier was determined using the continuously perfused rabbit esophagus model. Mucosal barrier disruption was determined by measuring net flux of hydrogen ion, potassium, and glucose. Bile salt absorption was measured by determining net flux of radiolabeled bile salt solution using liquid scintillation counting. Bile salt-containing solutions were prepared with varying concentrations of two bile salts, taurocholate and deoxycholate. The pH of the bile salt exposure also was varied to vary the extent of mucosal injury. The results show that changes in bile salt concentration and in pH of exposure were associated with significant differences in both extent of mucosal barrier disruption and bile salt absorption. Bile salt absorption was associated by direct linear correlation with each index of mucosal barrier function studied. These findings suggest that bile salt absorption plays a role in bile-induced disruption of the esophageal mucosal barrier.

Morphological alterations in experimental esophagitis. Light microscopic and scanning and transmission electron microscopic study

The morphology of esophagitis, both in the presence and absence of acid, was studied by light microscopy and transmission and scanning electron microscopy. For this purpose the rabbit esophagus was isolated in situ and perfused with agents known to cause esophageal mucosal damage (HCl, pepsin, taurocholate, and deoxycholate). In addition, changes in the permeability of the plasma membrane of the esophageal epithelial cells were assessed by staining the esophageal epithelium with trypan blue and antinuclear antibodies. The results indicate that HCl alone causes relatively few changes in the esophageal epithelium. However, when combined with pepsin or taurocholate, severe ulcerative changes were caused within an hour. Deoxycholate, which is formed in the upper gastrointestinal tract under nonacidic conditions, also causes severe damage. Further, it was shown that the esophagitis caused by pepsin and bile salts are clearly morphologically different. Bile salts affect primarily the cell membrane and intracellular organelles, while pepsin seems to affect the intercellular substance causing the epithelial cells to be shed. In contrast, the presence or absence of acid per se does not seem to influence the nature of the epithelial damage, since the lesions caused by the two bile salts (deoxycholate vs taurocholate + HCl) were morphologically similar.

Tauroursodeoxycholic acid is less damaging than taurochenodeoxycholic acid to the gastric and esophageal mucosa

Bile acids are capable of disrupting the gastric and esophageal mucosal barriers and are known to differ in their ability to injure these mucosae. Two bile acids, chenodeoxycholic and its 7-B epimer, ursodeoxycholic, that are being used to dissolve gallbladder stones were evaluated for their damaging effects on experimental preparations of the esophageal (rabbit) and gastric (dog) mucosa. Damage was assessed by measuring indices of mucosal barrier function, including net acid flux, potential difference, and tissue resistance, before and after exposure to the taurine conjugates of these bile acids. In both the esophageal and gastric mucosa, tauroursodeoxycholic acid caused significantly less disruption of barrier function than taurochenodeoxycholic acid. These results demonstrate that minor differences in conjugated bile acid structure can cause major changes in the effects of bile acids on the upper gastrointestinal mucosa and that ursodeoxycholic acid may be the preferred bile acid for oral ingestion to dissolve gallbladder stones.