Small intestinal neoplasms

Small intestinal neoplasms are uncommonly encountered in clinical practice. They may occur sporadically, in association with genetic diseases (e.g., familial adenomatous polyposis coli or Peutz-Jeghers syndrome), or in association with chronic intestinal inflammatory disorders (e.g., Crohn's disease or celiac sprue). Benign small intestinal tumors (e.g., leiomyoma, lipoma, hamartoma, or desmoid tumor) usually are asymptomatic but may present with intussusception. Primary malignancies of the small intestine-including adenocarcinoma, leiomyosarcoma, carcinoid, and lymphoma-may present with intestinal obstruction, jaundice, bleeding, or pain. Extraintestinal neoplasms may involve the intestine via contiguous spread or peritoneal metastasis. Hematogenous metastases to the intestine from an extraintestinal primary are unusual and are most typical of melanoma. Because the small intestine is relatively inaccessible to routine endoscopy, diagnosis of small intestinal neoplasms is often delayed for months after onset of symptoms. When the diagnosis is suspected, enteroclysis is the most useful imaging study. Small bowel endoscopy (enteroscopy) is increasingly widely available and may permit earlier, nonoperative diagnosis.

When to suspect ischemic colitis. Why is this condition so often missed or misdiagnosed?

Ischemic colitis is one of the most often seen disorders of the large intestine in the elderly. Common predisposing factors are atherosclerosis, shock, and congestive heart failure, but often, elderly patients have no obvious predisposing or precipitating factors. The typical clinical presentation is acute sudden abdominal pain and distention with bloody diarrhea. Common early radiographic signs are bowel-wall thickening with thumbprinting, and later, ulceration and strictures may be found. Endoscopy is valuable in revealing the sharp demarcation between viable and necrotic colonic mucosa that is a strong indicator of ischemia. Within 48 hours, most patients show favorable response to conservative measures consisting of intravenous hydration, bowel rest, antibiotic therapy, and correction of precipitating processes. Vasoconstricting drugs and corticosteroids are contraindicated. When surgical intervention is indicated, it usually consists of resection of the ischemic segment and exteriorization of the remaining ends of the bowel.

Protective effects of zinc in indomethacin-induced gastric mucosal injury: evidence for a dual mechanism involving lipid peroxidation and nitric oxide

BACKGROUND

Indomethacin causes gastric mucosal injury, although the pathogenesis is not fully understood. Zinc, is known to have gastroprotective effects in both humans and experimental animals.

AIM

To determine (i) the protective effects of zinc in indomethacin-induced gastric mucosal injury in rats, and (ii) whether these cytoprotective effects are mediated by changes in gastric lipid peroxidation and/or nitric oxide synthase activity.

METHODS

Gastric lesions were induced in rats by the intragastric administration of indomethacin. Morphological changes, lipid peroxidation (malondialdehyde levels) and nitric oxide synthase activity were determined in animals pre-treated with zinc sulphate and in controls.

RESULTS

Indomethacin significantly increased malondialdehyde levels and decreased NOS activity. These effects were attenuated by pre-treatment with zinc (P < 0.005 and 0.0001, respectively). The protective effects of zinc were readily abolished in animals pre-treated with N-nitro-L-arginine methyl ester (L-NAME). Morphologically, indomethacin induced large areas of mucosal ulcerations, which were completely prevented by zinc pre-treatment.

CONCLUSIONS

Zinc provides protection against indomethacin-induced gastric mucosal injury. These protective effects result from the inhibition of lipid peroxidation and the preservation of mucosal nitric oxide synthase.

Effects of fructose-1,6-diphosphate on the activity of rat liver nitric oxide synthase in vitro

Fructose-1,6-diphosphate (FDP) was found to cause significant stimulation of nitric oxide synthase (NOS) in rat liver homogenates in vitro. This effect was more pronounced for the inducible isoform than its constitutive counterpart. Furthermore, FDP restored rat liver inducible NOS levels following their depletion by carbon tetrachloride (CCl4). This finding may have further practical implications in hepatoprotection from various noxious chemical and biological agents.

Multiple synchronous primaries of the gastrointestinal tract: a molecular case report

Six synchronous gastrointestinal primaries were identified in a 70 year old male with no known cancer predisposition syndrome or recognized risk factors except alcohol abuse. These specimens appeared to be independent and unrelated by gross and histopathological examination. In order to further evaluate the six tumors, we analyzed selected DNA sequences for alterations in the K-ras oncogene and p53 tumor suppressor gene. In addition, three loci were analyzed to determine microsatellite instability. Using the polymerase chain reaction, single stranded conformational polymorphism, and DNA sequencing, we demonstrated that each primary manifests genetic characteristics typical of the tissue of origin. In addition, one primary, a moderately differentiated colon adenocarcinoma, exhibited mutations not detected in the other specimens. This study suggests that these synchronous primaries arose independently and progressed along different carcinogenic pathways.

Gastric cancer and pernicious anemia appearing as pseudoachalasia

An elderly black man was admitted to our institution with macrocytic anemia, dysphagia, and significant weight loss. Results of an esophagogram were suggestive of achalasia. Gastric adenocarcinoma infiltrating the gastric cardia was seen on gastroscopy. The mode of presentation of gastric cancer in this case has not been previously reported in association with pernicious anemia. Patients with pernicious anemia are at higher risk of having gastrointestinal neoplasms than is the general population. We review the current literature and address the controversy concerning the need to subject patients with pernicious anemia to surveillance with upper gastrointestinal endoscopy.

Activity of gastric mucosal nitric oxide synthase in portal hypertensive gastropathy

OBJECTIVE

The importance of portal hypertensive gastropathy, as a potentially bleeding lesion in cirrhotics with portal hypertension, has recently been appreciated. Histologically, dilation of the mucosal and submucosal vessels of the stomach is noted in this entity. The possibility of nitric oxide acting as a mediator for this mucosal vascular dilation has not been explored.

METHODS

We determined, in a group of 10 male cirrhotic patients with esophageal varices and endoscopic changes consistent with severe portal hypertensive gastropathy (Group A), the gastric mucosal nitric oxide synthase activity. This was determined by measuring the rate of conversion of [3H]-arginine to [3H]-citrulline. Serum levels of nitrates and nitrites, the end products of nitric oxide, were also measured. The results were compared with those of a group of 10 male controls with no liver disease (Group B).

RESULTS

Gastric mucosal constitutive and inducible nitric oxide synthase levels were significantly higher in group A (125.4 +/- 4.3 and 259.7 +/- 5.5 pmol/mg protein/minute, respectively) than in group B (88 +/- 8.6 and 130.8 +/- 6.6 pmol/mg protein/minute, respectively) ( p < 0.002 and < 0.0001, respectively). Serum nitrate/nitrite levels were 30.1 +/- 3.2 nmol/ml in group A and 15.5 +/- 0.09 nmol/ml in group B (p < 0.001).

CONCLUSIONS

We conclude that the significantly increased gastric mucosal nitric oxide synthase activity, in patients with portal hypertensive gastropathy, suggests an important role for nitric oxide in the pathogenesis of this mucosal lesion.

Eosinophilic gastro-enteritis associated with protein-losing enteropathy and protein C deficiency

Reported below is a case of eosinophilic gastro-enteritis involving the colon, stomach and duodenum in a patient who was also found to have marked hypoalbuminaemia and protein C deficiency due to severe protein-losing enteropathy. The most recent literature is reviewed and the challenging differential diagnosis of the disease is discussed.

Colonic ganglioneuroma presenting as filiform polyposis

A 74-year-old man had an isolated colonic ganglioneuroma presenting endoscopically as filiform polyposis coli. Extensive workup failed to show either von Recklinghausen's neurofibromatosis or multiple endocrine neoplasia (MEN) 2b. We discuss the clinical implications of this and review the literature.

Biliary complications of Fasciola hepatica: the role of endoscopic retrograde cholangiography in management

The parasite Fasciola hepatica resides in the biliary tree but rarely causes significant clinical sequelae. In this report, we review our experience with four patients in whom F. hepatica infection resulted in biliary complications, especially severe biliary colic and jaundice. The diagnosis was achieved with endoscopic retrograde cholangiography which demonstrated the worms in the extrahepatic bile ducts. Endoscopic sphincterotomy was performed uneventfully in all patients allowing balloon extraction of the parasites and resolution of their symptoms.

Serum gastrin levels in patients with colorectal cancer and adenomatous polyps: a prospective study

Serum gastrin levels were measured by radioimmunoassay in 62 patients with colorectal neoplasms (40 with adenomatous polyps and 22 with cancer) and 40 controls. Fasting serum gastrin in both the polyp (73.93 +/- 6.5 pg/ml) and the cancer (99 +/- 19.7 pg/ml) groups was significantly higher than those of the control group (42.65 +/- 2.2 pg/ml). These findings suggest that hypergastrinemia may be an etiologic factor in colorectal neoplasia.

Case reports: pseudomelanosis duodeni: association with systemic hypertension

Two male patients with mild gastrointestinal bleeding had peculiar dark pigmentation of their duodenum on upper endoscopy. These pigmented lesions were still present 3 months after the original endoscopy and after resolution of all other mucosal lesions. Both patients had other medical problems, including hypertension. They have been on multiple antihypertensive medications for many years. Biopsies of these duodenal lesions showed the pigment to be present inside the macrophages found in the lamina propria and in between the epithelial cells. Electron microscopy revealed a lysosomal localization of this pigment. This melanin-like pigment proved to contain varying amounts of iron, sulfur, and calcium. This pigmentation is closely associated with systemic hypertension, even in the pediatric population.

Syndrome of inappropriate ADH secretion and diplopia: oat cell (small cell) rectal carcinoma metastatic to the central nervous system

Extrapulmonary small cell carcinoma is being increasingly recognized as a distinct clinical entity. We report a patient with small cell carcinoma of the rectum metastatic to the brain, presenting with diplopia and inappropriate antidiuretic hormone syndrome.

Alcoholic hepatitis. Recent advances in pathogenesis and therapy

Although the pathogenesis of alcoholic hepatitis is not fully understood, significant progress has been achieved in recent years. The role of the immune system in initiating and perpetuating the injury is being defined. Abstinence from alcohol is probably the most effective treatment. Nutritional support has not had a consistently beneficial effect on survival rates. There is renewed interest in the use of corticosteroids in patients with severe disease. Orthotopic liver transplantation is appropriate for some patients with end-stage liver disease.

Ethanol enhances desialylation of transferrin by liver endothelial cells in the rat

Desialylated transferrin is emerging as a reliable index of alcoholism, and liver endothelial cells are known to partially desialylate transferrin. The effect of a single intraperitoneal injection of ethanol on the desialylation of transferrin in the rat was studied. In pulse-chase experiments, fully sialylated diferric transferrin labeled with 125I (protein moiety) or 3H (sialyl residues) was incubated with isolated, fractionated liver endothelial cells from rats that were given ethanol. The supernatants then were subjected to column chromatography using RCA120-agarose to separate and quantify the desialylated fraction of transferrin. Saline-treated animals served as controls. Incubation of the endothelial cells derived from the liver of ethanol-treated rats resulted in a 263% increase in desialylation level of transferrin. Our data indicate that administering ethanol in rats enhances the desialylation of transferrin by rat liver endothelial cells.

Spontaneous bacterial peritonitis in cirrhosis: clinical and laboratory features, survival and prognostic indicators

This is a retrospective study of 35 patients with spontaneous bacterial peritonitis and liver cirrhosis identified between 1981 and 1989. The mean age of all patients was 44 years, with a range of 16 to 68. Criteria for spontaneous bacterial peritonitis included either a positive ascites culture with a polymorphonuclear cell concentration greater than 250 cells per mm3 (18 cases) or a negative ascitic fluid culture with a polymorphonuclear cell count greater than 500 cells per mm3 and no evident intra-abdominal source of infection (17 cases). Twenty-one patients were male and 14 female. The most frequent presenting symptoms were abdominal pain and fever, noted in 20 (57%) and 19 (54%) patients, respectively, while 5 patients (14%) were completely asymptomatic. The overall mortality in this series was 54% (19 of 35 patients). The presence of encephalopathy or renal insufficiency was associated with a high mortality rate (73% and 87%, respectively). Encephalopathy was present in 67% of the non-survivors, but in only 25% of the survivors (p < 0.0025); likewise, renal failure was observed in 68% of the non-survivors, but in only 12.5% of those who survived (p < 0.001). The use of newer-generation cephalosporins and penicillins led to a diminished mortality (42%) as compared with that (64%) observed in patients treated with conventional antibiotic regimens.

Gallbladder perforation: preoperative diagnosis by combined imaging techniques

Gallbladder perforation represents the most serious complication of cholecystitis. Rapid preoperative diagnosis is necessary because of the high morbidity and mortality associated with it. The authors present a case of gallbladder perforation in a 64-year-old man who had been on high doses of steroids. This case was diagnosed preoperatively by combined radiologic imaging methods.

Laboratory markers of ethanol intake and abuse: a critical appraisal

Laboratory markers for ethanol intake and abuse and chronic alcoholism currently in use have been critically reviewed. The merits and pitfalls of each test have been evaluated. The clinical use of the new test of carbohydrate-deficient transferrin has been particularly emphasized. Carbohydrate-deficient transferrin currently provides the highest specificity and sensitivity of all commonly used markers of alcoholism.

Prostaglandin E1 cytoprotection against CCl4-induced necrosis in isolated rat liver cells

The role of the prostaglandin E1 (PGE1) analog misoprostol in hepatocellular injury induced by carbon tetrachloride (CCl4) was investigated in isolated rat hepatocytes. Exogenously added PGE1 at nanomolar concentrations attenuated significantly liver cell injury and death induced by CCl4. This cytoprotection, however, was accomplished only when a "crude" liver cell preparation was used. When the small nonparenchymal liver cell fraction (Kupffer and endothelial cells) was eliminated, the beneficial effects of PGE1 could no longer be observed. The results indicate that nonparenchymal liver cells play an important role in the cytoprotection provided by PGE1 at the initial stage of cellular damage in our isolated rat liver cell system.

LSA: a new liver-specific antigen in the rat. I. Purification and characterization

A liver-specific antigen (LSA) was purified to homogeneity from rat liver by conventional methods of protein chemistry. By consecutive 100,000 g centrifugation, ammonium sulfate precipitation, ion-exchange chromatography on DEAE-cellulose, gel filtration on Sephadex G-200, ion-exchange chromatography on CM-cellulose and affinity chromatography on concanavalin-Sepharose, it has been possible to isolate a preparation that migrated as a single band on SDS-PAGE. This preparation gave a complete identity pattern with the original crude rat liver extract when tested by double immunodiffusion. This antigen has a molecular weight of 72.5 kD with an electrophoretic mobility in the region of alpha 2-globulins. The LSA proved to be thermolabile since exposure to 55 degrees C completely destroyed the antigen. Exposure of the LSA to different pH ranging from 4 to 10 had no detrimental effect on its antigenic activity. The amino acid composition of the LSA revealed that the acidic amino acids out-number the basic amino acids, with glutamic acid being the most abundant of them. Failure of beta-mercaptoethanol to split the LSA molecule suggests the absence of sulfhydryl groups related to its antigenic activity. Subcellular fractionation of rat liver revealed most of the antigenic activity in the 100,000 g supernate, i.e. the soluble cytoplasmic fraction of the liver (cytosol). By contrast, the LSA was absent from isolated Kupffer cells from rat liver. The absence of any carbohydrate or lipid from the purified preparation of this antigen, in conjunction with the destructive effects of trypsin suggest that the LSA is a protein or a moiety closely associated with proteins.

Effects of gastrointestinal hormonal peptides on the transformation of human peripheral lymphocytes

The gastrointestinal peptides secretin and cholecystokinin were found to inhibit the incorporation of 3H-thymidine in the lymphocyte transformation reaction in response to phytohemagglutinin. Both peptides inhibited lymphocyte activation in a dose responsive fashion. This inhibition was not due to the toxicity of these substances, as the lymphocytes remained intact and capable of excluding trypan blue. Neither glucagon nor gastrin had any effects of lymphocyte transformation.

The effect of ethanol on the uptake, binding, and desialylation of transferrin by rat liver endothelium: implications in the pathogenesis of alcohol-associated hepatic siderosis

Chronic alcoholism has been reported to be associated with a reduced carbohydrate content of transferrin (TF), particularly, its reduced sialylation state. Low sialylation state of TF now serves as an objective marker of chronic alcohol abuse. To investigate the pathophysiological significance of this finding in relation to hepatic siderosis, also commonly associated with chronic alcoholism, the authors have investigated the effect of ethanol on the uptake, binding, and desialylation of transferrin by isolated rat liver endothelium in vitro. In pulse-chase experiments, transferrin labeled with either 125I (protein-labeled) or 3H (sialic acid-labeled) was incubated with isolated, fractionated liver endothelium with and without ethanol, and the supernates were subjected to column chromatography using RCA120- agarose. Incubation of the endothelium with increasing concentrations of ethanol resulted in a progressive increase in the desialylation rate of transferrin which was maximal when 160 mM concentration of ethanol was used. These data indicate that ethanol significantly promotes the desialylation of transferrin by rat liver endothelium. The implications of these findings in the pathogenesis of hepatic siderosis of the alcoholic are discussed.

Prevention of galactosamine-induced hepatotoxicity in rats with fructose-1,6-diphosphate

Galactosamine (GalN) administration produces hepatitis-like liver injury in animals. The hepatotoxicity of GalN is attenuated by several interventions, including activation of the reticuloendothelial system (RES). Fructose-1,6-diphosphate (FDP) administration significantly increases the phagocytic activity of the RES in animals. Thus, investigations were designed to determine whether FDP affords protection against GalN toxicity. Rats were injected with GalN (375 mg/kg) and treated with 0.9% NaCl (n = 8) or FDP (n = 9). Eight rats were sham-operated. Serum glutamic oxaloacetic transaminase was 40 times higher in the saline group as compared to the FDP-treated rats (p less than 0.0001). Glutamic pyruvic transaminase, gamma-glutamyltranspeptidase and bilirubin were similarly elevated (saline vs. FDP, p less than 0.005, p less than 0.01 and p less than 0.05, respectively). These values were not different between FDP-treated and sham-operated rats. Extensive hepatic necrosis was observed in all saline-treated rats, whereas in the FDP group only isolated foci of hepatocellular necrosis were noted. The hepatoprotective effect of FDP in this model is attributed to its ability to enhance the phagocytic activity of RES and to suppress release of oxyradicals by the leukocytes during the inflammatory phase.

Protective effects of misoprostol on carbon tetrachloride-induced liver damage in the rat

Effects of misoprostol on histologic and biochemical alterations caused by CCl4 were investigated in the rat. Misoprostol protected against CCl4-induced liver injury. A close correlation occurred between biochemical data and morphological changes. This hepatoprotective effect was observed only when misoprostol was given 30 min before CCl4.

Herpes viruses and duodenal ulcer disease

Antibodies to herpes simplex virus and Epstein-Barr virus were sought in the sera of 33 patients with endoscopically proved duodenal ulcer and 33 healthy controls. Neither the prevalence nor the antibody levels to both viruses were significantly different between the two groups. These results suggest that herpes viruses may not play a role in the pathogenesis of duodenal ulcer disease.

Familial nonhemolytic jaundice with free and conjugated hyperbilirubinemia, elevated serum bile acids, and liver pigmentation

We have described an 11-year-old patient with nonhemolytic hyperbilirubinemia, elevated serum bile acids, and liver pigmentation. The Bromsulphalein clearance was not typical of that seen in the Dubin-Johnson syndrome, but there was a secondary rise at 120 min. The abnormalities involving several organic anions and liver histology are compared to those seen in other types of familial nonhemolytic jaundice.

An acid transporting enzyme in human gastric mucosa

Isolation of a microsomal fraction from human gastric mucosa followed by density gradient centrifugation yielded a vesicular membrane preparation free of mitochondrial markers, containing a K+-activated, ouabain-insensitive ATPase with an activity of 20.7 mumol P1 released/mg protein per h. Sodium dodecyl sulfate gel electrophoresis showed that the human gastric membrane vesicles contained a major polypeptide of 110,000 daltons, which accounted for approximately or equal to 30% of the total protein stained and was phosphorylated by [gamma-32P]ATP and dephosphorylated in the presence of K+. Electron microscopy revealed the presence of vesicles with an average size of 0.13 micrometer in diameter. Addition of 0.65 microM ATP to this vesicular preparation resulted in the uptake of 17 nmol H+/mg protein which was dependent on the presence of K+. The gradient was dissipated by a combination of valinomycin and protonophore after consumption of the ATP. Incubation of fixed human fundic sections or human gastric biopsy with monospecific hog gastric membrane antibody followed by fluorescein-conjugated goat anti-rabbit gamma-globulin, showed fluorescent staining in the middle portion of the gastric glands. These data indicate that human stomach contains a H+ transport ATPase with characteristics similar to those established for lower species.

Value of gallium-67 citrate scanning in Crohn's disease: concise communication

A frequent problem in Crohn's disease is the distinction between exacerbated inflammation of the bowel, which can be treated medically, and intra-abdominal abscess, a common complication that requires surgical management. We present evidence that the gallium scan is of value in making this distinction. From a series of 11 studies, negative gallium scans correctly excluded abscess in over half. All patients were symptomatic at the time of the scan. Most patients with active Crohn's disease do not have abnormal gallium uptake and in these patients the gallium scan is useful to exclude the possibility of abscess.

Utilization of a radioiodinated bile salt for kinetic studies and hepatic scintigraphy. Studies in nonhuman mammals

An 125I- or 131I-labeled bile salt derivative, cholylglycyliodohistamine, has been synthesized and purified. The bile salt derivative is rapidly cleared from the circulation when injected intravenously into rats and rabbits. Ten minutes after injection, approximately 50% of the recovered bile salt derivative was in the jejunum and ileum, and 36% was found in the liver. Sixty minutes after injection, 99% of the recovered radioactivity was found in the luminal gastrointestinal tract. The isotope was cleared from the circulation of rabbits with a t1/2 of approximately 2 min. Hepatic scintigraphy using rabbits demonstrated rapid uptake by the liver and excretion into the intestine. Quantitative analysis of scintigraphy showed an uptake rate of 14%/min and a subsequent excretory rate of 4.6/min.

Modification of D-galactosamine-induced liver injury in the rat by spironolactone

Spironolactone, a competitive inhibitor of mineralocorticoid effects on the distal tubule of the kidney, has recently been found to have other metabolic effects. In these studies, spironolactone (200mg/kg intraperitoneally) for 3 days was found to have a marked protective effect against the hepatotoxic effect of D-galactosamine (275 mg/kg) in rats. Further progress in defining the mechanism of protection from D-galactosamine hepatic necrosis by spironolactone will require assessment of effects of spironolactone on uridine nucleotide metabolism.

Sclerosing cholangitis associated with ulcerative colitis. Light and electron microscopy studies

The light and electron microscopy findings of liver biopsies from four patients with sclerosing cholangitis and ulcerative colitis are described. The main histologic feature was mesenchymal proliferation involving phagocytic, fibroblastic and immunocytic cells suggestive of an immunologic type of liver injury which may attack bile duct epithelial cells. Other histologic features, included the presence of myelin fibers in both hepatocytes and bile duct epithelial cells and an abundant amount of lysosome-like structures. The significance of these findings is discussed.

Serum lysozyme activity in inflammatory bowel disease

Serum lysozyme activity was determined in the sera of 70 patients with inflammatory bowel disease by the lysoplate method. Serum lysozyme levels were significantly elevated only in patients with Crohn's disease of the small bowel. Patients with either granulomatous or ulcerative colitis had serum lysozyme values not different from normals, irrespective of activity of their disease.

Immunologic studies on a pancreatic oncofetal protein

Immunization of rabbits with a human fetal pancreas extract produced precipitating antibody against an antigen present only in fetal pancreas and extracts of human pancreatic carcinoma. Pancreatic oncofetal protein (POP) migrated on immunoelectrophoresis in the alpha1-alpha2 region, thus making possible its detection by counterimmunoelectrophoresis. POP was found in the 12,000 X g supernatant of fetal pancreas and could be precipitated with (NH4)2SO4 at concentrations between 30 and 45%. The antigen was partially purified by consecutive centrifugation at 12,000 X g, 40% (NH4)2SO4 precipitation, and ion-exchange chromatography. Treatment of the POP with trypsin completely abolished its antigenic activity; this suggested that the antigen was a protein or a moiety closely associated with protein.

Circumferential web of the upper esophagus

Two patients with circumferential webs of the upper esophagus are presented. Both patients had a long history of intermittent dysphagia, particularly with solid food. The clinical, endoscopic, and radiologic features of these webs are discussed.

Hepatitis B antigen and polymyositis

Concomitant polymyositis diagnosed by muscle biopsy developed in a 51-year-old man with hepatitis B surface antigen (HBsAg) hepatitis. Findings from immunofluorescent studies showed deposits of gamma-globulins and complement in both muscle and liver. The HBsAg and HBsAg-antibody complexes were detected in the liver by immunofluorescence using fluorescein-labeled antibody to hepatitis Bs.