May chronic cough in chronic obstructive pulmonary disease be a contraindication of Percutaneous Endoscopic Gastrostomy placement: a case report

Background

Percutaneous Endoscopic Gastrostomy (PEG) can involve some complications, despite the good safety of its track record. The Buried Bumper Syndrome (BBS) is a rare, late and dangerous complication that consists in the erosion of the internal bumper through the gastric wall.

Case presentation

We report the development of BBS in a man with chronic obstructive pulmonary disease (COPD) who had a persistent chronic cough which was prevalently but not solely in the morning and required placement of a PEG tube for continuous infusion of Levodopa/carbidopa intestinal gel for advanced Parkinson's disease.

Conclusion

We believe that COPD with chronic cough while not representing an absolute contraindication to PEG placement, may potentially cause BBS and therefore an appropriate regimen of tube care by expert personnel is mandatory in this setting.

Role of bisphenol A as environmental factor in the promotion of non-alcoholic fatty liver disease: in vitro and clinical study

BACKGROUND

Bisphenol A is an endocrine disrupting chemical associated with type 2 diabetes mellitus (T2DM), cardiovascular disease and liver enzyme abnormalities.

AIM

To evaluate bisphenol A plasma and urine levels in non-alcoholic fatty liver disease (NAFLD) patients compared to healthy subjects. Furthermore, we evaluated, in human HepG2 cells, the effects of exposure to different concentrations of bisphenol A on both oxidative stress induction and cell proliferation.

METHODS

We enrolled 60 patients with histological diagnosis of NAFLD with or without T2DM and sixty healthy subjects. In vitro, the proliferation of bisphenol A-exposed HepG2 cells at two different concentrations (0.025 and 0.05 μM) was evaluated, both at high (H-HepG2) and at low (L-HepG2) glucose concentrations for 48 h. Lipoperoxidation was assessed by thiobarbituric acid reactive substances (TBARS) assay.

RESULTS

Bisphenol A levels were significantly higher in 60 NAFLD subjects, both in urine and in plasma (P < 0.0001) when compared to controls and, in this group, it appeared to be higher in 30 non-alcoholic steatohepatitis patients compared to 30 simple steatosis subjects (P < 0.05), independently from the presence of T2DM. After a bisphenol A-free diet for 1 month, NAFLD patients showed a significant reduction in bisphenol A circulating levels (P < 0.05), without a significant reduction in urine levels. H-HepG2 cells treated with bisphenol A (0.05 μM) increased proliferation compared to controls at 48 h (P < 0.0001). Bisphenol A increased TBARS levels at 48 h versus controls.

CONCLUSIONS

Our study reveals a possible role of bisphenol A as an environmental factor involved in the promotion of NAFLD, particularly in T2DM patients.

The epidemiology of non-alcoholic fatty liver disease and its connection with cardiovascular disease: role of endothelial dysfunction

The non-alcoholic fatty liver disease is considered a predominant hepatopathy worldwide and a component of metabolic syndrome. It represents a risk factor for the development of cardiovascular diseases, independently of the presence of diabetes mellitus, hypertension and obesity. For this reason, nowadays an epidemiological analysis and a research of the causes that correlate non-alcoholic fatty liver disease and cardiovascular pathologies, are extremely useful. There are important epidemiological variations in relation to various geographical areas, and depending on different population groups, the prevalence of this pathology changes. Epidemiological analysis for non-alcoholic fatty liver disease shows its remarkable relevance and diffusion, especially in Western areas; therefore immediate interventions are necessary for its prevention, diagnosis and therapy. Endothelial dysfunction could be the joining link between non-alcoholic fatty liver diseases and cardiovascular disease risk. Indeed, their correlation should be researched in the alterations that metabolic hepatopathies are able to induce on endothelial function and viceversa. For this reason, the scientific community may research new therapeutic strategies for non-alcoholic fatty liver disease, by intervening on the early stage of the pathology and blocking endothelial dysfunction.

Crohn's disease and skin

Crohn's disease is a chronic inflammatory bowel disease potentially involving any segment of the gastrointestinal tract. Extra-intestinal manifestations may occur in 6%-40% of patients, and disorders of the skin are among the most common. This manuscript will review skin manifestations associated to Crohn's disease, with a particular focus on lesions associated to anti-tumour necrosis factor therapy.

A pilot study on the ability of clinoptilolite to absorb ethanol in vivo in healthy drinkers: effect of gender

Zeolites are microscopic minerals of volcanic origin, and the zeolite most commonly used in medicine is clinoptilolite. Over the years, clinoptilolite has been tested in several ways: as an antioxidant, as an adjuvant in anticancer therapy due to its ability to capture chemotoxins, as an antidiarrhoeal agent and as a chelating agent for heavy metals. The aim of this study was to evaluate the ability of clinoptilolite to absorb ethanol in vivo in healthy drinkers. We enrolled 12 healthy drinkers in this study. The study was conducted as follows: phase 1: consumption of a hydroalcoholic solution containing 25 g of ethanol; phase 2: use of a 16.25 mL medical device containing clinoptilolite (2.5 g of clinoptilolite within a single-dose sachet) + consumption of a hydroalcoholic solution containing 25 g of ethanol; phase 3: use of a 32.5 mL medical device (5 g of clinoptilolite within a single-dose sachet) + consumption of a hydroalcoholic solution containing 25 g of ethanol. At the time of blood sampling, alcohol ingestion was also measured using an Alcolmeter instrument, and the results showed that the two methods overlapped. Reductions of 43%, 35%, 41% and 34% in blood ethanol at 30, 60, 90 and 120 minutes, respectively, were observed after the consumption of 5 g of clinoptilolite + 25 g of ethanol in both males and females, whereas the consumption of 2.5 g of clinoptilolite did not result in a statistically significant reduction in blood ethanol. In particular, the blood ethanol reduction was more significant in males. Our study highlights and confirms the ability of clinoptilolite to decrease the absorption of ingested ethanol by reducing blood alcohol levels. This effect was statistically significant at a dose of 5 g.

The effects of alcohol on gastrointestinal tract, liver and pancreas: evidence-based suggestions for clinical management

Alcohol has a direct impact on the digestive system due to its contact with mucosal lining and interference with digestive functions. Various diseases of the gastrointestinal tract, including tumors, may be related to an excess of alcohol intake and the relationship between alcohol abuse and hepatic and pancreatic damage is well established. According to WHO, alcohol and alcohol-related diseases represent a major health problem and will probably continue to do so in the foreseeable future. In this review, we summarize the present knowledge on clinically relevant alcohol-related problems in order to provide practicing physicians with evidence-based general suggestions which might help in the management of alcohol-related gastrointestinal disorders. A thorough clinical history together with a number of questionnaires are essential for detecting alcohol dependence or abuse. Biochemical tests (nonspecific and specific) have been considered to be less sensitive than questionnaires in screening for alcohol abuse, but they may be useful in identifying relapses. Protracted behavior modification, cognitive behavioral therapy, psychological counseling, and mutual support groups have been considered the most effective long-term treatments. Several drugs have been developed that are able to interfere with the neurotransmitters involved in craving mechanisms, and we summarize the evidence of their efficacy to increase abstinence and to prevent relapse.

Helicobacter pylori infection but not small intestinal bacterial overgrowth may play a pathogenic role in rosacea

BACKGROUND AND AIMS

Recent studies suggest a potential relationship between rosacea and Helicobacter pylori (H. pylori) infection or small intestinal bacterial overgrowth (SIBO), but there is no firm evidence of an association between rosacea and H. pylori infection or SIBO. We performed a prospective study to assess the prevalence of H. pylori infection and/or SIBO in patients with rosacea and evaluated the effect of H. pylori or SIBO eradication on rosacea.

METHODS

We enrolled 90 patients with rosacea from January 2012 to January 2013 and a control group consisting of 90 patients referred to us because of mapping of nevi during the same period. We used the (13)C Urea Breath Test and H. pylori stool antigen (HpSA) test to assess H. pylori infection and the glucose breath test to assess SIBO. Patients infected by H. pylori were treated with clarithromycin-containing sequential therapy. Patients positive for SIBO were treated with rifaximin.

RESULTS

We found that 44/90 (48.9%) patients with rosacea and 24/90 (26.7%) control subjects were infected with H. pylori (p = 0.003). Moreover, 9/90 (10%) patients with rosacea and 7/90 (7.8%) subjects in the control group had SIBO (p = 0.6). Within 10 weeks from the end of antibiotic therapy, the skin lesions of rosacea disappeared or decreased markedly in 35/36 (97.2%) patients after eradication of H. pylori and in 3/8 (37.5%) patients who did not eradicate the infection (p < 0.0001). Rosacea skin lesions decreased markedly in 6/7 (85.7%) after eradication of SIBO whereas of the two patients who did not eradicate SIBO, one (50%) showed an improvement in rosacea (p = 0.284).

CONCLUSIONS

Prevalence of H. pylori infection was significantly higher in patients with rosacea than control group, whereas SIBO prevalence was comparable between the two groups. Eradication of H. pylori infection led to a significant improvement of skin symptoms in rosacea patients.

A facebook survey to obtain alcohol-related information by young people and adolescents. An Italian study

BACKGROUND

Alcohol consumption by adolescents and young adults is an issue of significant public concern. Internet-based Social Networking sites, such as Facebook, are potential avenues to reach young people easily.

OBJECTIVE

to underline the innovation in proposing surveys to collect health-related information regarding young people alcohol consumption and other substances abuse by using Social Networking Websites, particularly Facebook.

METHODS

A questionnaire investigating modalities of alcohol consumption, drinking patterns' risk behaviors and other substances abuse was proposed through a "Facebook event" to young Italian Facebook users aged between 16 and 32. Each Facebook user invited to the event was free to participate, to answer to the questionnaire and to invite his "Facebook friends".

RESULTS

During the 89 days of permanence on the Social Network, 1846 Facebook users participated the event and 732 of them decided spontaneously to answer the questionnaire. The frequency of answering was 8.2 people per day. About 200 users wrote a positive comment to the initiative on the wall of the event. Sixty% of subjects participating the survey were females. Ninety-one% of people answering the questionnaire were alcohol consumers. More than 50% of alcohol consumers were also smokers. Approximately 50% of subjects were binge drinkers. Illegal drugs were used by the 22.2% of the interviewed people.

CONCLUSIONS

Facebook resulted an efficient and rapid tool to reach young people from all over Italy and to propose surveys in order to investigate alcohol consumption and alcohol-related health problems in the youth.

Focus on irritable bowel syndrome

The Irritable bowel syndrome (IBS) is a clinical syndrome characterized by chronic abdominal dis-comfort associated with changes in bowel habits and these symptoms can't be explained by any biochemical or organic abnormalities. The review summarizes the relevant findings that have emerged in recent years on the pathogenesis of this syndrome. The most important mechanisms recently implicated in the genesis of IBS symptoms are the abnormal intestinal motility, the incongruous intestinal gas production and the enhanced intestinal nociception. A lot evidence confirms the presence of dysfunction of the intrinsic enteric nervous system (ENS) as demonstrated by the presence of altered expression of transient receptor potential vanilloid 1 (TRPV1), acid sensing ion channel 3 (ASIC3), putinergic receptor P2X, ligand-gated ion channel 3 (P2X3r), tetrodoxin-sensitive receptor 2 (TTRX2), protease activated receptors (PPARs) and others. There are different assumption that explain these phenomena, and the impairment of the immune system is one of the most reliable. In IBS subjects it was found that the immune system is altered in both the cellular composition and its activation. Many studies have shown that inflammation and immune dysregulation affect the sensitivity of nerve fibers so it is vital to build on this argument for the development of effective therapies to control the symptoms of this syndrome.

Alcoholic beverages and gastric epithelial cell viability: effect on oxidative stress-induced damage

Alcohol is known to cause damage to the gastric epithelium independently of gastric acid secretion. Different alcoholic beverages exert different damaging effects in the stomach. However, this has not been systematically evaluated. Moreover, it is not known whether the non-alcoholic components of alcoholic beverages also play a role in the pathogenesis of gastric epithelial cell damage. Therefore, this study was designed to evaluate whether different alcoholic beverages, at a similar ethanol concentration, exerted different damaging effect in gastric epithelial cells in vitro. Moreover, we evaluated whether pre-treatment of gastric epithelial cells with alcoholic beverages prevented oxidative stress-induced damage to gastric cells. Cell damage was assessed, in MKN-28 gastric epithelial cells, by MTT assay. Oxidative stress was induced by incubating cells with xanthine and xanthine oxidase. Gastric cell viability was assessed following 30, 60, and 120 minutes incubation with ethanol 17.5-125 mg/ml(-1) or different alcoholic beverages (i.e., beer, white wine, red wine, spirits) at comparable ethanol concentration. Finally, we assessed whether pre-incubation with red wine (with or without ethanol) prevented oxidative stress-induced cell damage. Red wine caused less damage to gastric epithelial cells in vitro compared with other alcoholic beverages at comparable ethanol concentration. Pre-treatment with red wine, but not with dealcoholate red wine, significantly and time-dependently prevented oxidative stress-induced cell damage.

CONCLUSIONS

1) red wine is less harmful to gastric epithelial cells than other alcoholic beverages; 2) this seems related to the non-alcoholic components of red wine, because other alcoholic beverages with comparable ethanol concentration exerted more damage than red wine; 3) red wine prevents oxidative stress-induced cell damage and this seems to be related to its ethanol content.

The effect of a new symbiotic formulation on plasma levels and peripheral blood mononuclear cell expression of some pro-inflammatory cytokines in patients with ulcerative colitis: a pilot study

BACKGROUND

During intestinal inflammation white blood cells are recruited from the blood, and they represent the major contributors to tissue perpetuation of inflammation via their production of chemokines and proinflammatory cytokines.

OBJECTIVES

Investigate the effect of a symbiotic formulation containing Lactobacillus Paracasei B 20160 versus placebo, on serum levels of interleukin (IL)-6, tumor necrosis factor (TNF)alpha, IL-8, IL-1beta and IL-10 and on mRNA lymphomonocyte expression of TNFalpha, IL-8 and IL-1beta in patients with ulcerative colitis.

MATERIALS AND METHODS

Eighteen patients entered the study with histologically proven not complicated ulcerative colitis, treated with mesalazine. Patients were treated for 8 weeks (9 with symbiotic and 9 with placebo). Serum levels of IL-6, TNFalpha, IL-8, IL-1beta and IL-10 were measured using a commercially available sandwich ELISA kit. RT-PCR analysis was performed on total RNA isolated from peripheral lymphomonocytes.

RESULTS

In basal condition, there was an increase of serum levels of TNFalpha, IL-6, and IL-8. The treatment with symbiotic significantly decreased serum levels of the last two cytokines (IL-6 and IL-8). In lymphocytes, the treatment with the symbiotic don't significantly reduced the mRNA expression of TNFalpha and IL-1beta, while that of IL-8 was strongly and significantly decreased.

CONCLUSION

Our preliminary results suggest that a symbiotic formulation containing Lactobacillus paracasei significantly improves the plasma and lymphocyte content of some proinflammatory cytokines.

Drinking habits and risk of altered liver enzymes in the general population of a rural area in Southern Italy

PURPOSE

To assess the overall drinking habits (amount and duration of alcohol intake, as well as type of alcoholic drinks consumed) and their potential for alteration of liver enzymes in a random sample of the general population aged > or =18 years of a rural area in Southern Italy.

MATERIALS AND METHODS

Of the 4000 subjects selected, 3306 (82.7%) agreed to take part in the study. Of these, 41% were teetotallers (54.4% females, 26.1% males; p<0.01). A very small proportion of subjects reported > or =4 drinks/day (11.9% males, 0.8% females; p<0.01).

RESULTS

Increased aspartate aminotransferase and/or alanine aminotransferase values were observed in 148 (4.5%) subjects. Hepatitis C virus positivity alone, excessive body mass index alone and alcohol intake alone were observed in 28.6, 23.8 and 18.4% of cases, respectively. After exclusion of subjects with chronic viral hepatitis infections (hepatitis B virus and/or hepatitis C virus) and adjustment for the confounding effect of age (>50 years) and body mass index (> or =25) by multiple logistic regression analysis, subjects who reported consuming >4 drinks/day were 2.4-fold (95%CI=1.1-5.2) more likely than teetotallers to have altered liver enzyme values; subjects reporting intake below this threshold were not at risk of alterations in aspartate aminotransferase/alanine aminotransferase (OR 1.4; 95%CI=0.7-2.6).

CONCLUSIONS

These findings indicate that only a small proportion of the rural population studied (particularly females) can be considered as alcohol misusers. Moreover, a mild alcohol intake (< or =4 drinks/day) is not associated with alterations in aspartate aminotransferase/alanine aminotransferase levels in the absence of other factors such as hepatitis viruses and impaired body mass index.

Platelet aggregation is affected by nitrosothiols in patients with chronic hepatitis: In vivo and in vitro studies

AIM: To investigate the relationship among the number of platelets and plasma levels of S-nitrosothiols (S-NO), nitrite, total non-protein SH (NPSH), glutathione (GSH), cysteine (CYS), malondialdehyde (MDA), 4-hydroxininenal (4HNE), tumor necrosis factor-alpha (TNFα) and interleukin (IL)-6 in patients with chronic hepatitis C (CH).

METHODS: In vitro the aggregation of platelets derived from controls and CH patients was evaluated before and after the addition of adenosine diphosphate (ADP) and collagen, both in basal conditions and after incubation with nitrosoglutathione (GSNO).

RESULTS: In vivo, S-NO plasma levels increased significantly in CH patients and they were significantly directly correlated with platelet numbers. Patients with platelet counts < 150 000/μL, had a smaller increase in S-NO, lower levels of GSH, CYS, NPSH, TNFα, and IL-6, and higher levels of nitrite, MDA, and 4-HNE relative to those of patients with platelet counts > 150 000/μL. In vitro, the ADP and collagen aggregation time was increased in platelets from patients and not from controls; in addition, platelets from CH patients but not from controls also showed a latency time after exposure to collagen.

CONCLUSION: The incubation of platelets with GSNO improved the percentage aggregation and abolished the latency time.

Treatment of patients with non-alcoholic fatty liver disease: current views and perspectives

Non-alcoholic fatty liver disease is considered a component of the metabolic syndrome associated with obesity. Problems still exist concerning non-alcoholic fatty liver disease patients in clinical practice, for example: (a) how to diagnose non-alcoholic fatty liver disease and its type; (b) how to select patients candidate to treatment; (c) how to treat selected patients. Non-alcoholic fatty liver disease includes steatosis and non-alcoholic steatohepatitis, but only non-alcoholic steatohepatitis evolves into cirrhosis and the absolute risk of mortality for non-alcoholic fatty liver disease is low. As yet, no tools, other than liver biopsy, are available to differentiate the various types of non-alcoholic fatty liver disease. Many drugs are, currently, under study to treat non-alcoholic fatty liver disease, even if well-performed trials are until necessary to define the best treatment. At the moment, the entity of the problem and the characteristics of patients frequently put the physician, in clinical practice, to choose the therapeutic approach arbitrarily which is considered more effective for each individual patient. Probably the future will consider the possibility of treating non-alcoholic fatty liver disease with more than one drug, by considering the various aspects and degree of this syndrome. Actually each physician should select the individual treatment on the basis of his/her knowledge and experience, by never forgetting the old saying 'primum non nocere'. However, the epidemiological entity of the problem, the characteristics of the patients, generally young, the frequent lack of clinical evidence of involvement of the liver, are all the factors that require vast well-performed clinical trials in order to define the best therapeutic approach for each individual patient.

Total parenteral nutrition-related gastroenterological complications

Total parenteral nutrition is a life saving therapy for patients with chronic gastrointestinal failure, being an effective method for supplying energy and nutrients when oral or enteral feeding is impossible or contraindicated. Clinical epidemiological data indicate that total parenteral nutrition may be associated with a variety of problems. Herein we reviewed data on the gastroenterological tract regarding: (i) total parenteral nutrition-related hepatobiliary complications; and (ii) total parenteral nutrition-related intestinal complications. In the first group, complications may vary from mildly elevated liver enzyme values to steatosis, steatohepatitis, cholestasis, fibrosis and cirrhosis. In particular, total parenteral nutrition is considered to be an absolute risk factor for the development of biliary sludge and gallstones and is often associated with hepatic steatosis and intrahepatic cholestasis. In general, the incidence of total parenteral nutrition-related hepatobiliary complications has been reported to be very high, ranging from 20 to 75% in adults. All these hepatobiliary complications are more likely to occur after long-term total parenteral nutrition, but they seem to be less frequent, and/or less severe in patients who are also receiving oral feeding. In addition, end-stage liver disease has been described in approximately 15-20% of patients receiving prolonged total parenteral nutrition. Total parenteral nutrition-related intestinal complications have not yet been adequately defined and described. Epidemiological studies intended to define the incidence of these complications, are still ongoing. Recent papers confirm that in both animals and humans, total parenteral nutrition-related intestinal complications are induced by the lack of enteral stimulation and are characterised by changes in the structure and function of the gut. Preventive suggestions and therapies for both these gastroenterological complications are reviewed and reported in the present review.

The treatment of NAFLD

Nonalcoholic fatty liver disease (NAFLD) is becoming an increasing cause of chronic liver damage. The decision of start a medical treatment is based on the documented risk of progression to cirrhosis and liver cancer, when steatohepatitis (NASH) occurs. The therapy of this syndrome requires, as obviously, some considerations on the natural history of the condition, on the efficacy and safety of various therapeutic options, as well as on the costs. Treatment of patients with NAFLD has typically been focused on the management of associated conditions such as obesity, diabetes mellitus and hyperlipemia. Weight loss improves insulin sensitivity, and NASH may resolve with weight reduction. Insulin resistance seems to be the common denominator in many cases of NAFLD. Two classes of drugs have been shown to correct insulin resistance: biguanides (e.g., metformin) and thiazolidinediones (e.g., rosiglitazone and pioglitazone). The last two decades have witnessed a considerable progress in the understanding of the mechanisms respon-sible for the fibrogenic progression of chronic liver diseases. Several drugs believed to be hepatoprotective or antifibrotic agent as UDCA, betaine, vitamin E, lecithin, beta-carotene and selenium have been used in patients with NASH. Silybin is the main component of silymarin that is absorbed when linked whith a phytosome. This substance reduces in rats the lipid-peroxidation and the activaction of hepatic stellate cells. In humans, some non controlled data show that silybin is able to reduce insulin resistance, liver steatosis and plasma markers of liver fibrosis.

Nutritional state and energy balance in cirrhotic patients with or without hypermetabolism. Multicentre prospective study by the 'Nutritional Problems in Gastroenterology' Section of the Italian Society of Gastroenterology (SIGE)

BACKGROUND AND AIMS

A total of 334 stable, compensated cirrhotic patients admitted to 10 Italian Gastroenterology Units were included in a prospective study to evaluate nutritional state and energy balance in liver cirrhosis.

MATERIALS AND METHODS

Nutritional state and calorie intake were examined in the total population, while adequacy of calorie intake versus measured total energy expenditure was evaluated in a comparable subpopulation and in 40 matched controls, by computing the energy balance.

RESULTS

Our data demonstrated that: (i) malnutrition was present in 25% of the total patients and significantly correlated with the Child's group (A=16%; B=25%; C=44%); (ii) the type of malnutrition is influenced by mBEE: normometabolic patients exhibit a significant (p<0.005) reduction of mid-arm fat area while both hypermetabolic and hypometabolic patients show a significant (p<0.005) decline in kg of free fat mass; (iii) normometabolic and hypometabolic patients have a negative energy balance, due to a high level of physical activity (127+/-14 kJ) in the first group and a reduced energy intake/kg body weight (102+/-12 kJ) in the second; (iv) hypermetabolic patients have a positive energy balance due to decreased daily physical activity/kg body weight (108+/-28 kJ); (v) malnourished and normometabolic patients eat a significantly (p<0.05) reduced percentage of protein whereas malnourished and hypermetabolic patients eat a significantly increased percentage of fat (p<0.05).

CONCLUSION

Although multivariate regression analysis confirms that the Child-Pugh's score is a better independent predictor of malnutrition, the measure of REE, TEE, calorie intake and energy balance need to be routinely performed in cirrhotic patients, in order to recognise hypermetabolic and hypometabolic patients (approximately 30%) in whom the nutritional and metabolic parameters are indispensable as a basis for designing and prescribing personalised nutritional strategies that can treat muscle malnutrition and thus improve the morbidity and mortality rates.

Psychological status and depression in patients with liver cirrhosis

BACKGROUND

Previous studies reported an impairment of both the physical and mental dimensions of quality of life in patients with cirrhosis. Very few data are available on the psychological impact of the disease and its relation to liver function.

AIM

To measure the psychological status of patients with cirrhosis in relation to the severity of the liver impairment.

PATIENTS AND METHODS

One hundred and fifty-six patients with cirrhosis were studied. Two questionnaires (the Beck Depression Inventory and the Psychological General Well-Being Index) were self-administered in random order. Clinical and laboratory data were collected using standardised forms.

RESULTS

The global score of Psychological General Well-Being Index was severely reduced compared to Italian population norm. Among individual domains, the more severely affected was General Health, the less compromised was Positive Well-Being. A negative relation was found between Child-Pugh score (a comprehensive measure of disease severity) and global Psychological General Well-Being Index and several individual subscales. The Beck Depression Inventory scores were indicative of a depressed mood in over 50% of patients, in relation to the presence of clinical symptoms.

CONCLUSIONS

Patients with cirrhosis have signs of psychological distress and depression, as assessed by Beck Depression Inventory and Psychological General Well-Being Index, in relation to the severity of liver disease. Accordingly, a non-negligible number of patients warrant treatment.

[Effects of a new pharmacological complex (silybin + vitamin-E + phospholipids) on some markers of the metabolic syndrome and of liver fibrosis in patients with hepatic steatosis. Preliminary study]

AIM

This open preliminary pilot study was aimed to evaluate the effect of a new pharmaceutical complex (silybin+vitamin E+phospholipids - RealSIL-IBI-Lorenzini Pharmaceutical, Italy) on some parameters of metabolic syndrome and of liver fibrosis in patients with non alcoholic fatty liver disease (NAFLD) with or without the contemporaneous presence of hepatitis C virus (HCV)-related chronic hepatitis.

METHODS

Eighty five patients were consecutively enrolled in the study and divided in 2 groups; the first group was represented by 59 patients affected by NAFLD, negative for other known causes of chronic liver damage (M/F= 39/20; median age and range: 44 years, 22-76, group A); the second group was represented by 26 patients (M/F=19/7; median age and range 51 years, 20-75, group B) with HCV-related chronic hepatitis associated to NAFLD. Adverse events and drop-outs were absent in all group and compliance at the study was absolute.

RESULTS

This open preliminary study shows that the new compound silybin+vitamin E+ phospholipids is active, in vivo, and produces some therapeutic effects in patients with different forms of chronic liver damage. In particular, it improves insulin resistance and plasma levels of markers of liver fibrosis in patients in whom these parameters are particularly altered.

CONCLUSIONS

Our data have a role of suggestion to further evaluate, through a controlled trial, a possible therapeutic use of this new compound in the management of patients with NAFLD.

Apple polyphenol extracts prevent damage to human gastric epithelial cells in vitro and to rat gastric mucosa in vivo

BACKGROUND

Fresh fruit and vegetables exert multiple biological effects on the gastrointestinal mucosa.

AIM

To assess whether apple extracts counteract oxidative or indomethacin induced damage to gastric epithelial cells in vitro and to rat gastric mucosa in vivo.

METHODS

Apple extracts were obtained from freeze dried apple flesh of the "Annurca" variety. Cell damage was induced by incubating MKN 28 cells with xanthine-xanthine oxidase or indomethacin and quantitated by MTT. In vivo gastric damage was induced by indomethacin 35 mg/kg. Intracellular antioxidant activity was determined using the (2,2'-azinobis (3-ethylbenzothiazolin-6-sulfonate) method. Malondialdehyde intracellular concentration, an index of lipid peroxidation, was determined by high pressure liquid chromatography with fluorometric detection.

RESULTS

(1) Apple extracts decreased xanthine-xanthine oxidase or indomethacin induced injury to gastric epithelial cells by 50%; (2) catechin or chlorogenic acid (the main phenolic components of apple extracts) were equally effective as apple extracts in preventing oxidative injury to gastric cells; and (3) apple extracts (i) caused a fourfold increase in intracellular antioxidant activity, (ii) prevented its decrease induced by xanthine-xanthine oxidase, (iii) counteracted xanthine-xanthine oxidase induced lipid peroxidation, and (iv) decreased indomethacin injury to the rat gastric mucosa by 40%.

CONCLUSIONS

Apple extracts prevent exogenous damage to human gastric epithelial cells in vitro and to the rat gastric mucosa in vivo. This effect seems to be associated with the antioxidant activity of apple phenolic compounds. A diet rich in apple antioxidants might exert a beneficial effect in the prevention of gastric diseases related to generation of reactive oxygen species.

Non-alcoholic fatty liver disease: a multicentre clinical study by the Italian Association for the Study of the Liver

AIM

To define the characteristics of the Italian patient presenting non-alcoholic fatty liver disease.

PATIENTS AND METHODS

A total of 305 patients with abnormally high plasma aminotransferase and/or gamma-glutamyl-transpeptidase levels for at least 12 months, with no known cause of chronic liver damage, were consecutively enrolled in the study. Clinical, routine biochemical and liver histology investigations were carried out in all patients. Also evaluated were: (a) oral glucose load; (b) insulinaemia and insulin-resistance using the HOMA test model; and (c) plasma endotoxaemia, total antioxidant plasma capability, tumour necrosis factor-alpha, plasma interleukin-6 and -10 levels. Malondialdehyde and 4-hydroxynonenal content were determined on liver samples from 120 patients.

RESULTS

The majority of patients were young overweight or obese males, with dyslipidaemia (20-60%), diabetes (10.5%), hyperinsulinaemia (40%), hyperferritinaemia (35%). Endotoxaemia was negative in all patients and cytokines were only sporadically altered. Total antioxidant plasma capability was decreased in 38.4% of the patients. Eighty percent of the cases had histological steatosis with a mild degree of inflammation and fibrosis. Seven patients had cirrhosis. Lipid peroxidation markers were increased in 90% of the cases, inversely correlated with fibrosis. Even if at univariate analysis, age, ferritin and tissue 4-hydroxynonenal were independent factors of steatosis (P < 0.01), and insulin, HOMA and ferritin of inflammation and fibrosis (P < 0.01), at multivariate analysis no single factor was found to be an independent predictor of hepatic lesions.

CONCLUSIONS

The typical Italian patient with non-alcoholic fatty liver disease is a young male, obese, not diabetic, with a variable incidence of dyslipidaemia and hyperinsulinaemia. Only liver biopsy may define the type of liver damage.

Glutathione supplementation improves oxidative damage in experimental colitis

BACKGROUND

The pathogenesis of inflammatory bowel disease is due, in part, to enhanced free-radical production and reduced antioxidant potential in mucosa cells.

AIM

We evaluated in a rat model of trinitrobenzensulphonic acid (TNBS) colitis to see whether parenteral administration of glutathione is able to improve mucosal oxidative damage at onset (study A) and during chronic phases of colitis (study B).

METHODS

In study A, the rats were injected with a single dose of glutathione (200 mg/kg, i.p.) or saline (0,2 ml, i.p.) 1 h before colitis induction and killed 1 h later. In study B, rats with induced colitis were treated with daily injection of glutathione (50 mg/kg, i.p.) or saline (0,2 ml, i.p.), and killed at 1, 2, 4 and 8 weeks. We evaluated on mucosal samples the macroscopic and histological damage and the oxidative stress assessed by the mucosal levels of lipoperoxides, malonyldialdehyde, glutathione and cysteine.

RESULTS

In study A, colitis induction caused a significant increase to the total histological score (p<0.05), lipoperoxide and malonyldialdehyde levels (p<0.001), but did not affect glutathione and cysteine content. Glutathione pre-treatment decreased both total histological score (p<0.05) and lipoperoxide and malonyldialdehyde values (p<0.001). In study B, the extensive macroscopic and histological colonic damage induced by TNBS was accompanied by a reduction of glutathione and cysteine mucosal levels (p<0.01) and increased lipid peroxidation. Glutathione supplementation significantly improved colonic damage (p<0.01), restored glutathione and cysteine levels, and decreased, and even, if not totally, abolished lipid peroxidation (p<0.001).

CONCLUSION

This paper further supports the pathogenic role of the imbalance in oxidant/antioxidant content in inducing mucosal colonic damage.

Liver p53 expression in patients with HCV-related chronic hepatitis

Mutated p53 acts as a dominant oncogene and alterations in the p53 gene are described in a large number of patients with hepatocellular carcinoma (HCC). It has been demonstrated that hepatitis C virus (HCV)-core protein regulates transcriptionally cellular genes, as well as cell growth and apoptosis. This study was undertaken to evaluate whether p53 may be expressed also in a precocious stage of HCV-related liver damage. We studied p53 expression by immunoluminometric assay on liver samples from 40 patients (M/F 18/ 22, median age 44 years, range 13-64 years) with biopsy-proven HCV-related chronic hepatitis. We considered the following factors: degree of liver damage, liver iron content and HCV-RNA titre. We also evaluated as possible co-factors alcohol and food intake in the last 3 years. p53 was over-expressed in seven of 40 (17.5%) patients. Liver histology documented the presence of unexpected cirrhosis in two patients among the p53 positive subjects. The p53 positive group had a daily ethanol intake significantly higher in respect to that of the p53 negative group (P < 0.05). Alimentary history documented that patients with a p53 over-expression had a lower intake of total calories, monounsaturated fatty acids, vitamin C and riboflavin. Data indicate that p53 over-expression can occur even in initial stages of HCV-related liver disease.

Cyclic treatment of chronic hepatic encephalopathy with rifaximin. Results of a double-blind clinical study

BACKGROUND

Chronic hepatic encephalopathy (HE) represents a frequent and serious complication of chronic liver disease. Aim of the study is to comparatively evaluate the effect of rifaximin, lactitol and their combination in treating chronic HE.

METHODS

Forty out-patients (29 males, 11 females, mean age: 59 years, range 40-70), with viral liver cirrhosis and chronic HE (1st-2nd degree) were studied. HE was assessed by considering: mental state, asterixis, number connection test (NCT), arterial blood ammonia levels. Patients were randomly assigned to the following treatments: rifaximin (plus sorbitol as placebo) (group R); lactitol (group L); rifaximin plus lactitol (group RL). All treatments were continued for 15 days for 3 cycles, intervalled by 15 days of washout.

RESULTS

The 3 treatments reduced HE, but with different efficacy: patients of group R and RL significantly (p<0.05) documented a faster improvement in HE degree, a higher percentage of patients which normalized mental state and NCT, a faster improvement of asterixis and a longer persistence of normal ammonia levels than patients of group L.

CONCLUSIONS

Rifaximin in combination with lactitol or sorbitol represents an effective and safe treatment of chronic HE.

Reduced quality of life of patients with hepatocellular carcinoma

BACKGROUND

It has been shown that health-related quality of life is reduced in patients with cirrhosis and with chronic hepatitis in relation to antiviral therapy. No data are available on patients with hepatocellular carcinoma.

AIM

To assess health-related quality of life in cirrhotic patients with hepatocellular carcinoma.

PATIENTS AND METHODS

Health-related quality of life was assessed in 101 hepatocellular carcinoma patients by means of Short Form-36 and Nottingham Health Profile questionnaires. Final scores of domains for individual patients were compared to age-adjusted normative Italian values, using Z-score and with values obtained in 202 matched patients with cirrhosis, without hepatocellular carcinoma.

RESULTS

All Short Form-36 domains and 4 out of 6 Nottingham Health Profile domains were altered. When hepatocellular carcinoma patients were compared with matched cirrhotics, differences were present for Bodily Pain, Role Limitation-Physical, and the Physical Component Summary of Short Form-36, as well as Pain of Nottingham Health Profile. Perceived health status had changed significantly in the year prior to assessment. Health-related quality of life was not primarily related to tumour mass or hepatocellular failure, whereas sleep disorders were selected by logistic regression as strongly associated with poor health-related quality of life.

CONCLUSIONS

The present data stress the relevance of pain in poor perceived health status of hepatocellular carcinoma patients, and the importance of minor symptoms, such as sleep disorders.

Non-alcoholic fatty liver disease in an area of southern Italy: main clinical, histological, and pathophysiological aspects

BACKGROUND/AIMS

Studies on non-alcoholic fatty liver disease (NAFLD) have included chronic liver damage attributed to various causes. Our investigation was held to observe the main clinical, histological, and pathophysiological aspects of NAFLD in patients not exposed to any known cause of chronic liver disease.

METHODS

We evaluated, in 84 in-patients (male/female, 66/18; median age, 36 years), the clinical and biochemical characteristics of NAFLD, and particularly its association with diabetes, dyslipidemia, hyperinsulinemia and/or with the increase of parameters of oxidative stress (blood levels of malonyldialdehyde, 4-hydroxynonenal and total plasma antioxidant capacity).

RESULTS

Ninety percent of patients had an increased body mass index (BMI), 35% had dyslipidemia, 40% had sub-clinical diabetes (only 3% had overt diabetes), 60% had hyperinsulinemia, and more than 90% had enhanced levels of lipid peroxidation markers. In 48 patients who had consented to liver biopsy, we found: 14 with simple steatosis, 32 with steatohepatitis, and two with cirrhosis.

CONCLUSIONS

Our data indicate that in our country, NAFLD may occur in young males with an increased BMI, with or without hyperinsulinemia, dyslipidemia and diabetes, generally associated with disorders of redox status, and that it may be differentiated from steatosis to steatohepatitis or cirrhosis only with a liver biopsy.

Relationship of blood trace elements to liver damage, nutritional status, and oxidative stress in chronic nonalcoholic liver disease

Trace elements are involved in chronic liver diseases because these elements may have a direct hepatic toxicity or may be decreased as a consequence of the impaired liver function, particularly in patients with alcoholic cirrhosis and/or malnutrition. In this study, we determined plasma and erythrocytes trace elements in 50 inpatients with nonalcoholic chronic liver disease (11 with biopsy-proven chronic hepatitis, 39 with cirrhosis [16 in stage A according to Child-Pugh criteria, 23 Child B+C]), and in a control group of 10 healthy subjects by the proton induced x-ray emission method. The relationship between trace element concentration and the extent of liver damage, the nutritional status (by anthropometric evaluations), and various blood markers of oxidative stress--reduced glutathione, total lipoperoxides and malonyldialdehyde--was investigated. We found that cirrhotics had a significant decrease of Fe, Zn, Se, and GSH levels in the plasma and of GSH and Se in the erythrocytes with respect to the control and chronic hepatitis groups. GSH levels were related to the degree of liver damage; a significant direct correlation was observed among Se, Zn, and GSH plasma values and between GSH and Se in the erythrocytes. The trace element decrease was, on the contrary, independent of the degree of liver function impairment and only partially affected by the nutritional status. Data indicate that liver cirrhosis, even if not alcohol related, induces a decrease of Se and Zn and that, in these patients, an oxidative stress is present, as documented by the significant correlation between Se and GSH. The plasma Br level was higher in cirrhotics with respect to the control and chronic hepatitis groups.

Renal tubular function by lithium clearance in liver cirrhosis

Increased tubule sodium reabsorption has been largely suspected in liver cirrhosis (LC), however studies in humans have produced contrasting results. Therefore to ascertain the entity of renal sodium handling in LC this study was devised. A total of 13 patients with child A LC were studied along with 26 age-sex matched healthy controls (HC). Patients and controls were kept on daily Na-intake of 100 mmol for at last 1 week, by measuring glomerular filtration rate (GFR; inulin) and lithium clearance. We have calculated (1) C(Li); (2) the absolute reabsorption of isotonic fluid in the proximal tubule (APR) as GFR - C(LI); (3) the fractional proximal sodium reabsorption (FPRNa) as 1 - (C(Li)/GFR); (4) the absolute distal reabsorption of sodium (ADRNa) as (C(LI) - C(Na)) x P(Na;) and (5) the fractional distal sodium reabsorption (FDRNa) as (C(LI) - C(Na))/C(Li). GFR was significantly lower in LC (P<.001), C(Li) was significantly higher in LC than in HC (P<.001). APRNa and FPRNa were reduced in LC (P<.0001). ADRNa was higher in LC than in HC (P<.001). No difference was found for FDRNa. In conclusion, lithium clearance discloses an increase sodium reabsorption in distal tubule in humans with LC.

Interactions between metabolic disorders (diabetes, gallstones, and dyslipidaemia) and the progression of chronic hepatitis C virus infection to cirrhosis and hepatocellular carcinoma. A cross-sectional multicentre survey

BACKGROUND

Diabetes, gallstones and dyslipidaemia are widespread, metabolically related, disorders that can affect the liver, often in a clinically silent fashion.

AIM

To investigate whether the presence of these disorders may worsen chronic viral disease by inducing additional liver damage, revealed by variations in serum increases of aminotransferase, alkaline phosphatase and gamma-glutamyl-transpeptidase activities.

PATIENTS AND METHODS

This retrospective, cross-sectional study involved 1,195 patients with chronic hepatitis C virus infection: 47.2% chronic hepatitis, 45.2% cirrhosis, and 7.6% hepatocellular carcinoma. 14.9% of patients had enzymatic cholestasis, defined as combined increase of alkaline phosphatase and gamma-glutamyl-transpeptidase. A Log-linear statistical model was applied to the following variables: stages of liver disease, diabetes, cholelithiasis, hypertriglyceridaemia, hypercholesterolaemia, and enzymatic cholestasis.

RESULTS

Log-linear analysis, applied to categorical variables, revealed, for the first time, a three-way interaction between the stages of chronic liver disease, diabetes, and enzymatic cholestasis. Two-way interactions demonstrated that liver disease stages correlated directly to the prevalence of cholelithiasis and inversely to hypercholesterolaemia. Irrespective of the liver disease stage, hypertriglyceridaemia correlated to hypercholesterolaemia.

CONCLUSIONS

This study discloses a synergistic liver damaging effect of diabetes and hepatitis C virus. The three-way interaction obtained by our analysis suggests that diabetes is a risk factor for the progression of viral liver disease and that it contributes to disease evolution, at least in part, by induction of cholestasis.

Factors associated with poor health-related quality of life of patients with cirrhosis

BACKGROUND & AIMS

Increasing interest is being given to health-related quality of life in chronic diseases. In cirrhosis, both physical functioning and mental well-being may be altered, but no study has investigated factors associated with a poor perceived health status.

METHODS

We measured quality of life by Short Form-36 and Nottingham Health Profile questionnaires in 544 patients with cirrhosis. Data were compared with age- and gender-adjusted values of 2 random samples of the Italian population (more than 2000 subjects). Factors associated with poor perceived health status were identified by logistic regression.

RESULTS

All domains of health-related quality of life, except pain, were altered in cirrhosis (by 9%-42%), mainly in younger patients. There were minor differences in relation to gender, whereas etiology had no effects. Severity of disease (Child-Pugh score) and, above all, muscle cramps were the factors most closely associated with poor health status perception. Self-rating of disease progression was associated with ascites and pruritus, whereas previous variceal sclerotherapy and the use of disaccharides had a protective effect. Most areas of daily life were affected by perceived health problems; this was mainly true for paid employment and sex life in men and home life and social life in women.

CONCLUSIONS

Quality of life is variably impaired in cirrhosis, also in uncomplicated patients. Non-life-threatening symptoms, such as muscle cramps, are of major concern. These data are the basis for longitudinal studies measuring the effects of therapy and procedures on patient-derived health outcomes.

Can dietary intake influence plasma levels of amino acids in liver cirrhosis?

BACKGROUND

Modifications in plasma amino acid patterns in cirrhotics are attributed to impaired liver function, being more evident in alcoholic than in viral cirrhosis.

AIM

To evaluate whether diet influences plasma amino acid concentrations in different aetiological groups of cirrhotics.

PATIENTS

Study population comprised 40 patients with cirrhosis (25 virus- and 15 alcohol-related], all Child A, and 30 healthy subjects (controls).

METHOD

A food frequency and quality questionnaire was utilized to determine dietary history and alcohol intake. Nutritional status was evaluated by anthropometric method. Amino acids were determined, on venous blood samples, using a specific analyzer while cysteine was evaluated by fluorescent high power liquid chromatography

RESULTS

The total daily intake of calories, proteins, lipids, and carbohydrates was similar in all individuals. Food quality distinguished the cirrhotics from the controls, but not the different aetiological groups of cirrhotics. Plasma cysteine levels were significantly lower, while aromatic amino acids and methionine were significantly higher, in all cirrhotics (p<0.001 and p<0.01, respectively, versus controls). The decrease in cysteine and the increase in other amino acids were more marked in alcoholics (p<0.01).

CONCLUSIONS

Ethanol intake, but not diet, further enhances the changes in plasma aromatic amino acids, methionine and cysteine induced by impaired liver function in patients with cirrhosis, suggesting a direct interference of alcohol in their metabolism.

Clinical nutrition practice in Italian Gastroenterology Units

BACKGROUND

Nutritional status affects the course, ensuing complications and prognosis of virtually all diseases.

AIMS

To define the role of nutrition in Gastroenterology Units by means of two investigations that analyse: a) availability of devices for assessing nutritional status; b) nutritional treatment in clinical practice: incidence and frequency of indications for its use, together with type of treatment adopted.

PATIENTS AND METHODS

Two questionnaires were sent to Italian Academic and Hospital Gastroenterology Units, all with clinical wards.

RESULTS

Results refer to 27 Units, 22 of which took part in both parts of the analysis, enrolling 547 patients during the two-week study The first analysis shows that scales and the altimeter are not available everywhere, while more specific tools, such as skinfold calipers are available in 54% of the Units, and caloric intake can be assessed in 22-41%. The second analysis reveals that nutritional treatment was necessary in 50% of patients in the series examined, and that this was taken into account and prescribed in almost all cases (91%). Of the patients treated, 69% received dietetic supplementation and 31% artificial nutrition [12% enteral, 88% parenteral), although supportive parenteral nutrition is often contraindicated in conditions where good bowel function provides the conditions for enteral nutrition.

CONCLUSION

Data emerging from the investigation showed that i) artificial nutrition is commonly used in gastroenterology Units in Italy although 23% of them never consider either enteral or parenteral nutrition as medical treatment of gastrointestinal disease; ii) malnutrition is a very frequent complication (mean 27%; range 4-55%0) in Gastroenterology Unit patients albeit only 42% of malnourished patients received artificial nutrition; iii) indications for enteral and parenteral nutrition are not always respected, as there is an excessive use of parenteral nutrition and an unjustified resistance to the use of enteral nutrition; iv] nutritional treatment is often administered without adequate nutritional assessment and without a complete adherence to the standards recommended for preparation of parenteral bags, supported by suitable technology; v) only two Gastroenterology Units report admitting and following patients in a home parenteral nutrition programme; vi) this investigation probably reflects the response of those Gastroenterology Units most aware of the importance of nutritional problems. Better awareness of correct practices for nutritional support should be promoted, encouraging greater use of diagnostic and monitoring techniques and a more discerning choice of the most suitable type of artificial nutrition to be administered in gastroenterology

Reduced quality of life in patients with chronic hepatitis C: effects of interferon treatment

BACKGROUND

Quality of life is an area of increasing interest in hepatology. Studies, so far, have assessed quality of life in patients with chronic virus C-related hepatitis in relation to antiviral therapy by means of generic questionnaires.

AIM

To measure quality of life in chronic hepatitis patients without cirrhosis by means of the Nottingham Health Profile questionnaire, a measure of "distress" in comparison with the Medical Outcome Survey SF-36, an index of well-being.

PATIENTS

A series of 126 outpatients with chronic hepatitis; 37 on and 89 not on active interferon treatment.

METHODS

The two questionnaires were used in random order. Clinical and laboratory data were also collected. The final score of any domain of the two questionnaires, for any individual patient, was compared to age-adjusted normal values obtained in 2 random samples of Italian population.

RESULTS

Patients showed a significant modification of 3 domains of Nottingham Health Profile (Energy, Social Isolation and Physical Mobility) and 6 domains of SF-36. In relation to interferon treatment, the Nottingham Health Profile questionnaire was able to detect differences in Energy, Physical Mobility and Pain, which were modified only in treated patients. SF-36 did not show any differences in relation to treatment. In addition, the Nottingham Health Profile demonstrated that treated patients had a lower prevalence of concern for family life, possibly due to expectations of treatment itself.

CONCLUSIONS

Active interferon treatment causes considerable distress in chronic hepatitis C patients, adding to the perceived change in health status caused by liver disease.

Drinking habits of subjects with hepatitis C virus-related chronic liver disease: prevalence and effect on clinical, virological and pathological aspects

Alcohol changes the progression of hepatitis C virus (HCV)-related chronic liver disease and may affect the outcome of interferon therapy. The ethanol intake of 245 patients with biopsy-proven chronic hepatitis C with or without cirrhosis, its interaction with laboratory and histological parameters common to alcohol and HCV-mediated liver damage, and its effects on therapy were evaluated. The results show that 60-70% of subjects regularly consumed alcohol (median intake >40 g/day in about 30%). Less than 50% stopped drinking after being diagnosed as having liver disease. Ethanol intake affected: fibrosis, especially in women, HCV RNA levels, which were significantly lower in abstainers than in drinkers (0.6 +/- 0.3 vs 6.9 +/- 5.9 Eq/ml x10(6); P < 0.01), and response to interferon therapy. The number of responders decreased as ethanol intake increased. There were less abstainers than drinkers among non-responders (10.7% vs 63.1% respectively; P < 0.001). Data indicate that alcohol will induce and worsen liver damage and, in subjects with chronic liver disease who continue to drink, adversely affect their response to treatment.

Ethanol consumption, amino acid and glutathione blood levels in patients with and without chronic liver disease

BACKGROUND

Ethanol abuse and liver cirrhosis cause a reduction of glutathione blood levels; liver cirrhosis induces an alteration of the plasma amino acid pattern. We evaluated whether or not ethanol abuse affects amino acid levels, particularly those that are involved in metabolizing glutathione in the plasma and erythrocytes of chronic alcohol abusers with or without liver cirrhosis.

METHODS

We studied 10 chronic alcohol abusers without liver cirrhosis, 10 with alcoholic cirrhosis, 10 affected by hepatitis C virus-related cirrhosis, and 10 healthy subjects. Glutathione, y-glutamyl-cysteine, and cysteine were determined by fluorescent HPLC, glutamic acid, glycine, and other free amino acids by cation exchange chromatography both in the plasma and erythrocytes of all studied subjects.

RESULTS AND CONCLUSIONS

In both alcoholics and cirrhotics, we found a significant increase of plasma-aromatic amino acid and methionine levels, whereas glutathione was significantly reduced. The erythrocytes of these patients showed a significant increase of cysteine, glutamic acid, and glycine; gamma-glutamylcysteine was normal; and glutathione and other free amino acids were significantly decreased. Data suggest that, independent of liver cirrhosis, ethanol abuse affects the metabolism of amino acids and glutathione in both the plasma and the erythrocytes.

The significance of alpha-glutathione S-transferase determination in patients with chronic liver diseases

BACKGROUND

Alpha-glutathione S-transferases (alpha-GST) are the ''basic'' class of a large family of enzymes, ubiquitarly distributed in the cells, particularly in the hepatocytes. Their principal biological function is the detoxification of the cells by conjugating glutathione with various electrophiles and hydroperoxides.

METHODS

We evaluated plasma alpha-GST in comparison to aminotransferase values (ALT) in 234 patients: 18 healthy volunteers, 51 chronic alcohol abusers with (22) or without (29) chronic liver damage and 165 with chronic HCV infection (32 ''apparently'' healthy carriers of HCV infection, 88 with a biopsy-proven chronic hepatitis (CH), 48 treated with interferon, 15 with well compensated and 12 with decompensated liver cirrhosis (LC) and 18 with hepatocellular carcinoma (HCC). Alpha-GST were determined on the venous blood samples after an overnight fast by Hepkit Alpha-Biotech (Biotrin International, Dublin, Ireland).

RESULTS

Control values: <8 ng/ml (range 2.7-6.3). In alcoholics we found a constant increase in 31% of patients without liver disease, in which ALT levels proved constantly normal, and in 13.6% of cirrhotics, without significant correlation among plasma values of alpha-GST, gamma-GT or alcoholemia. In ''healthy'' HCV-carriers, HCV-RNA determination selected 21 subjects positive for viral replication, while 11 were negative. HCV-RNA negative subjects had constant normality of plasma alpha-GST values, while in those HCV-RNA positive alpha-GST increased in 57% of cases. In patients with HCV-related chronic liver disease, alpha-GST proved higher than normal in 80.6% patients with CH, in 40% well-compensated and in 8.3% decompensated cirrhotics and in 33.3% of patients with HCC. No statistically significant correlation was observed between alpha-GST and other liver tests in all groups studied. In patients treated with interferon (6 MU x 3/weekly of alpha-interferon) alpha-GST plasma values were significantly higher in relapsers with respect to responders or not to interferon treatment and during the treatment only in relapsers, while ALT returned to normal values, alpha-GST did not change and, in some cases, increased further. No significant correlation was observed between response to treatment, ALT, alpha-GST and HCV-RNA plasma levels in all groups of CH patients.

CONCLUSIONS

Data indicate that in patients with chronic liver disease with different aetiologies, plasma alpha-GST determination may be useful for discovering a liver involvement also when ALT are normal. In patients with HCV-related CH, plasma alpha-GST values may be utilized as reliable markers in monitoring the response to interferon treatment.

The role of glutathione in the gastrointestinal tract: a review

The primary role of glutathione is to protect cells from oxidative stress. It is abundantly distributed in the mucosal cells of gastrointestinal tract both in animals and man. The highest concentration is found in the duodenum. The amount of glutathione ingested with foods, age and drug or ethanol consumption affect glutathione concentration. The detoxifying capability of glutathione is directly related to its thiol group and to its function as a substrate for enzymatic activity; in fact, glutathione regulates the action of glutathione-peroxidases and glutathione-transferases. It has been documented that a direct relation between glutathione concentration and mucosal damage or between glutathione-related enzymes and cancer occurrence is present in various pathological conditions of the gastrointestinal tract (from oesophagus to rectum). The present review underlines: a) the role of oxidative stress in numerous physiological and pathological conditions in experimental animals and man; b) the need to maintain a normal antioxidant potential in the mucosal cells of the gastrointestinal tract; and c) the possibility to evaluate, through clinical studies, how glutathione concentration, food intake, and gastrointestinal diseases are associated.

Enhancement of fatty acid and cholesterol synthesis accompanied by enhanced biliary but not very-low-density lipoprotein lipid secretion following sustained pravastatin blockade of hydroxymethyl glutaryl coenzyme A reductase in rat liver

A 3-week treatment of rats with pravastatin (PV) augmented biliary cholesterol and phospholipid output 3.6- and 2.2-fold over controls, while bile acid (BA) output and kinetics were unchanged. No major changes were detected in hepatic and serum cholesterol concentrations despite the PV inhibitory property on hydroxymethyl glutaryl coenzyme A (HMG CoA) reductase. To evaluate the mechanisms of this adaptive phenomenon, several parameters of hepatic lipid homeostasis were assessed. Biliary cholesterol changes could not be attributed to an increased influx of lipoprotein cholesterol to the liver and bile. Hepatic low-density lipoprotein (LDL) receptor content, as inferred from Western blot analysis, was unchanged, as was the biliary excretion of labeled cholesterol derived from chylomicron remnants. In vivo 3H2O-incorporation studies showed an 80% increase in hepatic cholesterol synthesis, evidence for bypass of the PV block. Remarkably, fatty acid synthesis was also stimulated twofold, providing substrate for hepatic triglycerides, which were slightly enhanced. However, serum triglycerides decreased 52% associated with a 22% decrease in hepatic very-low-density lipoprotein (VLDL) secretion. Thus, the biochemical adaptation following PV treatment produces complex alterations in hepatic lipid metabolism. An enhanced supply of newly synthesized cholesterol and fatty acids in association with a limited VLDL secretion rate augments the biliary lipid secretion pathway in this experimental model.

Tauroursodeoxycholic acid for the treatment of HCV-related chronic hepatitis: a multicenter placebo-controlled study

BACKGROUND/AIMS

Tauroursodeoxycholic acid is a promising drug for the treatment of chronic cholestatic liver diseases since it has more favourable physicochemical and metabolic properties than ursodeoxycholic acid. Tauroursodeoxycholic acid may be of benefit also for necroinflammatory liver disease, especially for HCV-related chronic hepatitis in which bile duct damage and some degree of cholestasis are frequently seen at histology.

METHODOLOGY

One hundred and fifty patients with chronic hepatitis were randomly assigned to receive tauroursodeoxycholic acid at daily doses of 500 mg or 750 mg, or a placebo for 6 months.

RESULTS

A consistent decrease in aminotransferase serum levels was observed in patients treated with tauroursodeoxycholic acid compared with placebo (p<0.001) and a progressive improvement with time was also found (p<0.05; linear time effect).

CONCLUSIONS

Tauroursodeoxycholic acid improves the biochemical expression of chronic hepatitis. Long-term studies with clinically relevant end-points are warranted.

Determination of plasma alpha-glutathione-S-transferases in chronic alcohol abusers: relationship with alcohol intake and liver involvement

Alpha-gluthathione-S-transferases (alpha-GSTs) are enzymes involved in the cellular detoxifying processes; elevated circulating alpha-GSTs activity is considered to be an early index of liver damage. Glutathione (GSH) is the substrate for alpha-GST action.

THE AIMS OF OUR STUDY WERE

(1) to evaluate plasma GSH levels and alpha-GST activity in chronic alcohol abusers with or without liver cirrhosis; (2) to define the relationship between these two biochemical parameters; (3) to establish their clinical relevance in patients with alcohol abuse and/or liver damage. We studied 69 subjects (18 healthy subjects and 51 chronic alcohol abusers: 29 without liver cirrhosis and 22 with). Plasma alpha-GST activity was determined on baseline samples and every following day for a total of 10 days in five alcoholics by HEPKIT (Alpha-Biotech, Biotrin International, Dublin, Ireland). GSH was determined on all subjects' baseline samples by fluorescent high-performance liquid chromatography. Alcohol intake was evaluated in all patients by determining blood-alcohol concentrations. Significant increases in plasma alpha-GSTs were observed in 9/29 (31%) alcoholics and 3/22 (13.6%) cirrhotics irrespective of their alcohol intake. GSH was significantly lower than normal values (P < 0.001) in all alcoholics with or without cirrhosis (controls 10.4 +/- 4.8; alcoholics without cirrhosis 3.9 +/- 1.4; alcoholics with cirrhosis 3.3 +/- 1.6). No correlation was observed between plasma alpha-GST and GSH levels. Our data indicate that: (1) alpha-GST activity does not correlate with GSH levels in the plasma; (2) alpha-GSTs do not have clinical relevance as markers of recent alcohol intake; (3) in cirrhotics, alpha-GST does not provide more information than other liver function tests. However, plasma alpha-GST determination may be useful in selecting a subgroup of alcoholics in whom routine biochemical markers of liver damage are within reference ranges.

Determination of plasma alpha-glutathione S-transferases in patients with HCV-related chronic infection: its significance and possible clinical relevance

AIMS/BACKGROUND

Alpha-glutathione S-transferases (alpha-GST) are the cytoplasmatic class of enzymes responsible for cellular detoxifying processes. We evaluated the plasma alpha-GST activity in relation to chronic infection caused by hepatitis C virus (HCV).

METHODS

Eighteen anti-HCV-negative healthy subjects (controls), 32 anti-HCV-positive subjects with a constant normality of alanine aminotransferases (ALT) and gamma-glutamyl transpeptidase (gamma-GT) levels ("apparently healthy carriers"), and 85 patients with HCV-related chronic liver disease (40 chronic hepatitis, 27 cirrhosis, and 18 with hepatocellular carcinoma) were studied. We assayed plasma alpha-GST in all subjects upon their entry into the study; and every 6 months for 3 years in the control group and in anti-HCV apparently healthy carriers.

RESULTS

Alpha-GST values were significantly higher than normal values in 57% of the 21 HCV-RNA-positive apparently healthy carriers and in none of 11 persistently HCV-RNA-negative subjects; the highest increment of alpha-GST was documented in patients with chronic hepatitis. We did not observe correlation among HCV-RNA, histological activity, gamma-GT and ALT or alpha-GST values.

CONCLUSIONS

Therefore, the increment of plasma alpha-GST indicates a liver involvement even when ALT levels are normal. This may be clinically relevant to "apparently healthy carriers" whose plasma alpha-GST values, when increased, might need further evaluation.

Alpha-glutathione transferases in HCV-related chronic hepatitis: a new predictive index of response to interferon therapy?

BACKGROUND/AIM

The aim of this study was to evaluate if plasma levels of alpha-glutathione-S-transferases (determined in basal conditions and monthly for 1 year during and 1 year after interferon therapy) could characterize patients who show only a primary response.

METHODS

We studied 48 patients with biopsy-proven, hepatitis C virus ribonucleic acid positive chronic hepatitis treated with interferon: 18 were "Sustained Responders", 12 "Relapsers" and 18 "Non-Responders".

RESULTS

Relapsers showed higher basal levels of alpha-glutathione-S-transferases, which remained higher than normal even when alanine aminotransferases normalized. No correlation was documented between alpha-glutathione-S-transferase levels and all other parameters examined (alanine aminotransferases, gamma-glutamyl-transpeptidase, viremia, and histological activity index).

CONCLUSIONS

These findings suggest that alpha-glutathione-S-transferase levels may be considered a predictive index of response to interferon therapy in chronic hepatitis C patients.

Trace elements and chronic liver diseases

The relationships between chronic liver diseases and trace element (TE) contents are debated. Particularly, no defined data are available about the TE levels in viral liver disease patients with or without malnutrition. In this study we evaluated blood and plasma levels of various trace elements in patients with HCV-related chronic liver disease, at different stages of liver damage (8 patients with chronic hepatitis and 32 with liver cirrhosis) with or without malnutrition. We also studied 10 healthy volunteers as control group. We found that cirrhotic subjects had a significant decrease of blood levels of Zn and Se, independently on the nutritional status, whereas plasma levels of Fe were significantly reduced only in malnourished cirrhotic patients. Our data indicate that liver impairment is the main cause of the blood decrease of Se and Zn levels in patients with non alcoholic liver disease, whereas the malnutrition affects Fe levels only.

Free radicals and not acetaldehyde influence the circulating levels of glutathione after acute or chronic alcohol abuse: in vivo and in vitro studies

BACKGROUND

The oxidation of ethanol and acetaldehyde enhances the production of various free radicals involved in membrane lipoperoxidation, and decreases glutathione levels.

AIMS

We evaluated the effects of acute and chronic ethanol use in vivo, with or without the administration of S-adenosyl-methionine (SAME, 2 g I.v.), and the effects of ethanol and acetaldehyde in vitro, on the erythrocyte levels of malonyldialdehyde and glutathione, and of its principal synthesizing enzymes, gamma-glutamyl-cysteine-synthetase and glutathione-synthetase.

METHODS

Twelve healthy volunteers (age range 26-44 years, median 32 years) and 20 chronic alcohol abusers without liver disease (age range 26-57 years, median 44 years) were studied. Malonyldialdehyde was evaluated by thiobarbituric acid; glutathione and its enzymes by high performance liquid chromatography using a fluorescent detector.

RESULTS

In the healthy subjects, an acute load of ethanol induced a significant decrease in plasma levels of glutathione, which was inhibited by the infusion of S-adenosyl-methionine. In the erythrocytes of alcoholic patients, glutathione and glutathione-synthetase were decreased while malonyldialdehyde was increased. In vitro, acetaldehyde did not affect either the glutathione or the glutathione-related enzyme levels.

CONCLUSIONS

Our data suggest that the alterations in glutathione metabolism in the erythrocytes of alcoholics may be due principally to the production of free radicals, as supported by the high levels of malonyldialdehyde observed.

Focal gastric blood perfusion in relation with the endoscopic signs and liver function in cirrhotic patients

Focal blood perfusion was measured, by means of a laser-Doppler technique, in the gastric upper body of 70 patients with liver cirrhosis and of 33 noncirrhotic controls. Perfusion was found to be lower in patients with pink mosaic-like pattern as compared to controls (p < 0.001). On the contrary, patients with red spots showed a marked increase of the focal gastric blood flow (p < 0.001). No different blood flow values were found between patients with red mosaic-like pattern and controls. Multiple regression showed that focal gastric blood flow perfusion was independently related to the Child score (p < 0.003), suggesting that gastric hemodynamic abnormalities can be favored by functional decompensation of cirrhosis, whereas there was no independent correlation with esophageal varices size, as assessed by their lumen occupancy percentage. Such observations may contribute to the understanding of the pathophysiology of gastric wall lesions in liver cirrhosis

Age affects glutathione content and glutathione-transferase activity in human gastric mucosa

This study was undertaken to evaluate the influence of age on the content of glutathione, and its amino-acid precursor cysteine and on the activity of glutathione-S-transferase of gastric mucosa in man. We examined 44 gastric mucosal samples taken from the body and the antrum of the stomach of 22 healthy subjects, aged between 19 and 65 years. The results were examined in relationship to their distribution in the stomach, to the sex and to the age of the subjects. Glutathione and glutathione-S-transferase were higher in the gastric body than in the antrum, without differences between males and females. The activity of glutathione-S-transferase was directly related to glutathione content and both decreased with age. Cysteine was not influenced by any of the factors considered. These data indicate that the antioxidative and detoxifying capability of gastric mucosa decreases with age in man.