The use of ultrasound in the diagnosis of abdominal wall hernias

BACKGROUND

The diagnosis of abdominal wall hernias is not always straightforward and may require additional investigative modalities. Real-time ultrasound is accurate, non-invasive, relatively inexpensive, and readily available. The value of ultrasound as an adjunctive tool in the diagnosis of abdominal wall hernias in both pre-operative and post-operative patients was studied.

STUDY DESIGN

Retrospective analysis of 200 patients treated at the Hernia Institute of Florida was carried out. In these cases, ultrasound had been used to assist with case management. Patients without previous hernia surgery and those with early and late post-herniorrhaphy complaints were studied. Patients with obvious hernias were excluded. Indications for ultrasound examination included patients with abdominal pain without a palpable hernia, a palpable mass of questionable etiology, and patients with inordinate pain or excessive swelling during the early post-operative period. Patients were treated with surgery or conservative therapy depending on the results of the physical examination and ultrasound studies. Cases in which the ultrasound findings influenced the decision-making process by confirming clinical findings or altering the diagnosis and changing the treatment plan are discussed.

RESULTS

Of the 200 patients, 144 complained of pain alone and on physical exam no hernia or mass was palpable. Of these 144 patients with pain alone, 21 had a hernia identified on the US examination and were referred for surgery. The 108 that had a negative ultrasound were treated conservatively with rest, heat, and anti-inflammatory drugs, most often with excellent results. Of the 56 remaining patients who had a mass, with or without pain, 22 had hernias identified by means of ultrasound examination. In the other 34, the etiology of the mass was not a hernia.

CONCLUSIONS

Abdominal wall ultrasound is a valuable tool in the scheme of management of patients in whom the diagnosis of abdominal wall hernia is unclear. Therapeutic decisions can be influenced by the ultrasound findings that can provide more efficient and economical treatment by expediting their clinical management.

Closer to an ideal solution for inguinal hernia repair: comparison between general surgeons and hernia specialists

BACKGROUND

It is accepted a priori that specialists of hernia surgery have better results than general surgeons who use the same or different techniques as part of their complete surgical repertoire.

METHODS

Results of general surgeons trained in the technique of hernia repair using a bilayer connected mesh device (BCMD) was compared to results of specialists and other general surgeons who used other techniques.

RESULTS

One report from hernia specialists and three additional reports from trained general surgeons showed similar results using a BCMD. These results were better than results of all other mesh repairs.

DISCUSSION

This study shows the value of surgeon-training as well as the value in the design of a particular mesh device for hernia repair. The three components of this device offer three separate, yet connected, barriers to the formation of a recurrent hernia.

CONCLUSION

General surgeons trained to use a bilayer mesh device repeatedly duplicated the results of specialists who used it.

Combined anterior and posterior inguinal hernia repair: Intermediate recurrence rates with three groups of surgeons

BACKGROUND

Use of a bilayer polypropylene mesh device (BPMD) for inguinal hernia repair began in 1998. Intermediate follow-up is now available for patients undergoing repair by three groups of surgeons.

METHODS

Surgeons whose practice is dedicated to hernia repair trained preceptors who, in turn, assisted in the training of other surgeons in this new technique. All three groups provided information regarding their recurrence rates with this technique.

RESULTS

Recurrence rates were similar for all three groups. Hernia specialists reported three recurrences out of 4,801 repairs. Preceptors reported one recurrence in 3,780 repairs. Other surgeons reported one failure in 3,369 repairs.

CONCLUSIONS

Use of the BPMD (Prolene Hernia System) provides reliable results in the hands of hernia specialists, as well as general surgeons whose practices are not concentrated on the management of hernias.

Linoleic acid, but not oleic acid, upregulates the production of interleukin-8 by human intestinal smooth muscle cells isolated from patients with Crohn's disease

BACKGROUND & AIMS

Crohn's disease is a chronic inflammatory bowel disease (IBD) of unknown etiology. In this study, we investigated the hypothesis that dietary fatty acids, linoleic acid (LA) and oleic acid (OA), could be involved in the inflammatory response through stimulation of the neutrophil chemokine, IL-8.

METHODS

Human intestinal smooth muscle (HISM) cells were isolated from normal patients and patients with Crohn's disease and cultured for 24h with LA or OA in the presence or absence of oxidative stress. The concentrations of IL-8 were measured in the media and cellular oxidative stress was quantitated by measurement of thiobarbituric acid reactive substances (TBARSs).

RESULTS

Spontaneous production of IL-8 was significantly higher in HISM cells isolated from Crohn's bowel compared to control bowel. LA caused a marked, nine-fold, increase in IL-8 secretion by Crohn's cells, an effect that could be simulated in normal HISM cells by co-incubation of LA with an oxidizing solution (Ox) composed of hypoxanthine+xanthine oxidase+FeSO(4) (OxLA). These effects were inhibited by vitamins C and E. Treatment of Crohn's cells with OxLA did not further increase IL-8 over that of LA alone. The effect of LA alone was not associated with an increase in cellular oxidative stress as quantitated by TBARSs. In contrast to the results with LA, treatment with OA or OxOA did not increase IL-8 in either normal or Crohn's cells. In addition, OA protected Crohn's cells from the increase in TBARSs induced by Ox. In contrast to IL-8, spontaneous production of monocyte chemotactic protein (MCP-1) was significantly lower in Crohn's HISM cells as compared to normal cells and exposure to OxLA did not increase its production.

CONCLUSIONS

LA, but not OA, increased the production of IL-8 by HISM cells. These results suggest that replacement of LA by OA in the diet of Crohn's patients and increased intake of a diet rich in antioxidants could be beneficial in decreasing inflammatory activity in Crohn's disease.

Intestinal macrophages lack CD14 and CD89 and consequently are down-regulated for LPS- and IgA-mediated activities

The intestinal mucosa normally displays minimal inflammation despite the close proximity between mucosal macrophages and lumenal bacteria. Macrophages interact with bacteria and their products through CD14, a surface receptor involved in the response to LPS, and CD89, the receptor for IgA (FcalphaR). Here we show that resident macrophages isolated from normal human intestine lack CD14 and CD89. The absence of CD14 and CD89 was not due to the isolation procedure or mucosal cell products, but was evident at the transcriptional level, as the macrophages expressed neither CD14- nor CD89-specific mRNAs, but did express Toll-like receptor 2 and 4 transcripts. Consistent with their CD14(-) phenotype, lamina propria macrophages displayed markedly reduced LPS-induced cytokine production and LPS-enhanced phagocytosis. In addition, IgA-enhanced phagocytosis was sharply reduced in lamina propria macrophages. Thus, the absence of CD14 and CD89 on resident intestinal macrophages, due to down-regulated gene transcription, causes down-modulated LPS- and IgA-mediated functions and probably contributes to the low level of inflammation in normal human intestinal mucosa.

Redox imbalance in Crohn's disease intestinal smooth muscle cells causes NF-kappaB-mediated spontaneous interleukin-8 secretion

Interleukin-8 (IL-8), a chemokine secreted by cells at injury sites, has recently been recognized as involved in the pathogenesis of Crohn's disease. However, the pathogenesis of enhanced spontaneous transcription of IL-8 by the bowel in patients with Crohn's disease is undefined. Although IL-8 is secreted primarily by neutrophils, macrophages, and endothelial and epithelial cells, we observed the involvement of mesenchymal cells in the inflammatory process. A smooth muscle cell line isolated from the ileum of a patient with Crohn's disease (CDISM) and maintained in culture exhibited spontaneous transcription and secretion of IL-8 when compared with intestinal smooth muscle cells obtained from a normal subject (NHISM). Furthermore, IL-8 transcription from CDISM cells was associated with remarkable spontaneous activation of the oxidant-sensitive transcription factor NF-kappaB, as assessed by transient transfection assays with an IL-8 promoter reporter construct, Western blot analysis, and electrophoretic mobility shift assays (EMSA). Finally, we report here that CDISM cells exhibit significantly altered redox balance. The antioxidant pyrrolidine dithiocarbamate (PDTC) restored the redox equilibrium by mechanisms that inhibit binding of NF-kappaB to its cognate site on the IL-8 promoter. These findings suggest that restoration of the redox balance could hold promise for therapeutic intervention in Crohn's disease.

Palmitoyl ascorbate: selective augmentation of procollagen mRNA expression compared with L-ascorbate in human intestinal smooth muscle cells

The effect of 6-O-palmitoyl ascorbate on procollagen mRNA levels, collagen synthesis, and collagen secretion was investigated and compared with the effect of L-ascorbate in human intestinal smooth muscle (HISM) cells in vitro. Collagen synthesis, determined by the incorporation of 3H-proline into pepsin-resistant, salt-precipitated collagen, increased in a concentration-dependent manner in response to palmitoyl ascorbate. There was a twofold increase in collagen synthesis at 2.5 and 5 microM. By contrast, L-ascorbate was required at 4-5 times the concentration for the same response. However, at 20 microM, both palmitoyl and L-ascorbate induced similar 2.7-fold increases in collagen synthesis. Palmitoyl ascorbate induced a 1.6- and 3.5-fold increase in steady-state levels of procollagen I and III mRNA levels respectively, whereas L-ascorbate had no effect. Palmitoyl ascorbate and L-ascorbate induced similar increases in the amounts of newly synthesized procollagen secreted into the medium and in the amounts of collagen types I, III and V accumulating in the cell layer. There was no effect of either palmitoyl ascorbate or L-ascorbate on the activity of a procollagen alpha2 (I) promoter construct transiently transfected into HISM cells. Palmitoyl ascorbate augments HISM cell procollagen synthesis and mRNA levels more efficiently than L-ascorbate. This property may be due to the greater resistance of the ascorbate ester to oxidation and suggests that palmitoyl ascorbate could be an important agent for studies of collagen synthesis in vitro.

Intestinal macrophages display reduced permissiveness to human immunodeficiency virus 1 and decreased surface CCR5

BACKGROUND & AIMS

Because the role of intestinal mononuclear cells in the pathogenesis of human immunodeficiency virus 1 (HIV-1) disease has not been elucidated, we determined the biological properties of HIV-1 infection in primary intestinal macrophages.

METHODS

Mucosal macrophages purified from normal human jejunum were infected with well-characterized macrophage-tropic isolates of HIV-1 (ADA, DJV, and Ba-L).

RESULTS

Productive HIV-1 infection of intestinal macrophages was demonstrated by the release of p24 antigen, the presence of proviral DNA, and zidovudine inhibition of infection. Surprisingly, the titer of virus needed to establish infection of intestinal macrophages was 100-1000-fold higher than that required to infect peripheral blood derived macrophages. This marked reduction in the permissiveness of intestinal macrophages to HIV-1 was not caused by the isolation procedure or differences in CD4 expression. Instead, intestinal macrophages expressed almost no CCR5, the principal coreceptor for macrophage-tropic HIV-1, compared with blood-derived macrophages, although both cell types contained comparable levels of CCR5 messenger RNA. Exposure of blood-derived but not intestinal macrophages to HIV-1 or gp120 led to increased surface expression of CCR5.

CONCLUSIONS

Intestinal macrophages express reduced levels of HIV-1, probably because of impaired permissiveness to HIV-1 entry associated with the near absence of cell surface CCR5.

Recombinant Helicobacter pylori urease activates primary mucosal macrophages

Helicobacter pylori urease is absorbed into the gastric mucosa at sites of inflammation, but whether the enzyme activates mucosal macrophages is not known. Because mucosal macrophages differ phenotypically and functionally from blood monocytes, whether recombinant H. pylori urease (rUrease) activated purified lamina propria macrophages in vitro was investigated. rUrease (1-10 microgram/mL) induced primary mucosal macrophages to produce interleukin (IL)-1beta, IL-6, and tumor necrosis factor (TNF)-alpha but not IL-8 proteins in a dose-dependent manner (P<.05 to P<.001). Quantitative reverse transcriptase-polymerase chain reaction using capillary electrophoresis laser-induced fluorescence showed that rUrease (0.1-10 microgram/mL) also induced dose-dependent expression of IL-1beta, IL-6, and TNF-alpha but not IL-8 mRNA (P<.05), suggesting that rUrease-induced production of certain cytokines is regulated at the level of gene transcription. These findings indicate that the ability of H. pylori urease to activate mucosal macrophages, resulting in production of proinflammatory cytokines, may be involved in the pathogenesis of H. pylori-associated mucosal inflammation.

Development of pseudointima and stenosis after transjugular intrahepatic portasystemic shunts: characterization of cell phenotype and function

The clinical utility of transjugular intrahepatic portasystemic shunts (TIPS) is frequently complicated by the ingrowth of tissue into the stent lumen, causing stent stenosis. These studies were undertaken to define the cellular and matrix components of the pseudointima, define the phenotype and function of the mesenchymal cells in the pseudointima and maintain them in culture, and to study the differences between stenotic and nonstenosed stents. A total of 35 stents were evaluated. TIPS pseudointima were examined histologically, by immunohistochemistry and in situ hybridization to determine the cellular and connective tissue constituents. Mesenchymal cells were grown from tissue within the TIPS and around it, and their phenotype was studied and compared with control smooth muscle cells and fibroblasts. Masson's trichrome staining of histological sections demonstrated that TIPS tissue was composed of collagen and palisades of mesenchymal cells and was lined by an endothelium. Immunostaining demonstrated strong and uniform alpha-smooth muscle staining in TIPS mesenchymal cells and peri-TIPS cells. Type I procollagen mRNA expression was demonstrated in mesenchymal cells in and around the stent by in situ hybridization. TIPS mesenchymal cells secreted less radiolabeled fibronectin, and far more type III, relative to type I, collagen compared with peri-TIPS cells. TIPS cells also expressed high levels of type III procollagen mRNA compared with peri-TIPS cells. There was no difference between stenotic stents and nonstenosed stents with respect to clinical features, time from stenting, gross morphology, histology, presence of bile fistulae, and cell phenotype. However, smooth muscle cells (SMC) from stenotic stents demonstrated both greater cell proliferation and collagen I and III secretion compared with those from nonstenosed stents. These data demonstrate that TIPS stenosis results from an accumulation of collagen and proliferation of SMC within the stent lumen.

Corticosteroids repress the interleukin 1 beta-induced secretion of collagenase in human intestinal smooth muscle cells

BACKGROUND & AIMS

The cytokine interleukin (IL)-1 beta induces collagenase expression and inhibits collagen expression in human intestinal smooth muscle (HISM) cells. Corticosteroids cause transrepression of certain genes, including the collagenase gene. The aim of this study was to determine if corticosteroids repress the induction of collagenase expression and the inhibition of collagen secretion by IL-1 beta in HISM cells.

METHODS

HISM cells were exposed to IL-1 beta (1-100 pmol/L) for 24 hours in the presence or absence of dexamethasone (10(-6) mol/L). Collagenase messenger RNA (mRNA) levels were determined by ribonuclease protection assay. Collagenase and tissue inhibitor of metalloproteinase protein secretion were determined by enzyme-linked immunosorbent assay of culture medium. Procollagen and collagen secretion were determined by polyacrylamide slab gel analysis of radiolabeled proteins in culture medium.

RESULTS

A 30-fold induction of collagenase mRNA and collagenase protein secretion by IL-1 beta was completely abrogated by dexamethasone. Dexamethasone at 10(-6) mol/L also reduced basal levels of collagenase mRNA by 50% and blocked the IL-1 beta-induced inhibition of collagen secretion.

CONCLUSIONS

Corticosteroids repress the collagenolytic action of IL-1 beta on HISM cells in vitro and therefore should promote healing in the inflamed intestine.

Sutureless technique: second version

Mesh repairs have revolutionized hernia surgery. When used to patch or plug a musculoaponeurotic abdominal wall defect, the results have been much better than traditional pure tissue repairs. The difference is simple: patch and plug techniques avoid tension on tissues. The improved sutureless repair not only avoids tissue tension, it obviates the need to suture the mesh. Fixation is achieved by intra-abdominal pressure, the same force that caused the hernia. Thorough dissection of the inguinal canal and the indirect sac is essential to avoid early failure. Whereas various repairs can be used with excellent results, there is no substitute for a complete dissection of the peritoneal sac well into the iliac fossa. The improved sutureless repair offers 2 advantages over the original version: (a) type III hernias can now be repaired without opening the canal's posterior wall, and (b) the incidence of clinically evident seroma has been reduced by 90%. Most primary and recurrent groin hernias can be repaired under local or regional anesthesia on an outpatient basis. Immediate ambulation and prompt recovery accompany this technique. Most patients resume full activity and employment by the end of the first week. The procedure is simple to learn, easy to perform and less costly than other techniques.

Cleavage of type I procollagen by human mast cell chymase initiates collagen fibril formation and generates a unique carboxyl-terminal propeptide

The ability of human mast cell chymase and tryptase to process procollagen was examined. Purified human intestinal smooth muscle cell procollagen was incubated with human mast cell tryptase or human mast cell chymase. Purified chymase, but not tryptase, exhibited procollagen proteinase activity in the presence of EDTA. Addition of purified porcine heparin over a range of 0.1-100 microg/ml did not affect either the rate or the products of procollagen chymase cleavage. The cleavage site of chymase on the pro-alpha1(I) collagen carboxyl terminus was found to be in the propeptide region at Leu-1248-Ser-1249. Cleavage at this site suggested that the collagen products would form fibrils and confirmed the production of a unique carboxyl-terminal propeptide. Turbidometric fibril formation assay demonstrated de novo formation of chymase-generated collagen fibrils with characteristic lag, growth, and plateau phases. When observed by dark field microscopy, these fibrils were similar to fibrils formed by the action of procollagen proteinases. Thus, mast cell chymase, but not tryptase, exhibits procollagen peptidase-like activity as evidenced by its ability to process procollagen to fibril-forming collagen with concurrent formation of a unique carboxyl-terminal propeptide. These data demonstrate that mast cell chymase has a potential role in the regulation of collagen biosynthesis and in the pathogenesis of fibrosis.

Isolation and purification of CD14-negative mucosal macrophages from normal human small intestine

Mucosal macrophages play a fundamental role in the regulation of immunological events and inflammation in the small intestine. Because no information is available on normal small intestinal macrophages, we developed a technique for the isolation and purification of jejunal lamina propria macrophages in order to study their phenotype and activity. From sections of normal human jejunum, lamina propria mononuclear cells were isolated by neutral protease digestion and then subjected to counterflow centrifugal elutriation to purify the macrophages. The cells isolated by this procedure contained < 1% CD3+ lymphocytes and displayed the size distribution, morphological features, ultrastructure and phagocytic activity of mononuclear phagocytes. In contrast to blood monocytes, however, mucosal macrophages from the jejunum did not exhibit adherence properties or express CD14, a receptor for the lipopolysaccharide-binding protein. The purification of large numbers of lamina propria macrophages by this procedure offers the opportunity to define the role of this cell in the physiological inflammation characteristic of normal intestinal mucosa and the pathological inflammation associated with small intestinal diseases.

Helicobacter pylori cytotoxin induces vacuolation of primary human mucosal epithelial cells

We investigated whether Helicobacter pylori cytotoxin induces vacuolation in primary epithelial cells from normal human mucosa. Epithelial cells purified by enzyme digestion and elutriation were evaluated for vacuolation in a blinded protocol by light and electron microscopy before and after incubation with culture supernatant (CS) from H. pylori 60190, which has vacuolating activity for HeLa cells (Tox+), and isogenic H. pylori mutant 60190-v1, which lacks this activity (Tox-). Primary epithelial cells (>98% pure) exposed to CS from Tox+ H. pylori exhibited marked vacuolation (52% +/- 5% of cells) compared with epithelial cells exposed to either CS from Tox- H. pylori (23% +/- 3.2%) or uninoculated control broth (23% +/- 3.7%) (P < 0.05) by light microscopy, which was confirmed by electron microscopy and antibody inhibition studies. These are the first data to show that H. pylori cytotoxin causes vacuolation of primary human mucosal epithelial cells.

Interleukin 1 beta down-regulates collagen and augments collagenase expression in human intestinal smooth muscle cells

BACKGROUND & AIMS

Smooth muscle cells resident in the intestinal wall play a significant role in the healing of the injured intestine and in the fibrosis that complicates Crohn's disease. The cytokine interleukin 1 beta (IL-1 beta) is involved in inflammatory bowel disease. The aim of this study was to determine the action of IL-1 beta on proliferation and collagen metabolism in human intestinal smooth muscle cells.

RESULTS

IL-beta caused a three-fold increase in [3H]thymidine uptake at 100 pmol/L. This mitogenic effect was equipotent with that of platelet-derived growth factor when cells were exposed to IL-beta for 48 vs. 24 hours. IL-beta inhibited the secretion of procollagen into culture medium by 70% and the accumulation of newly synthesized procollagen in cells by 55%. In addition, IL-beta caused a concentration-dependent inhibition of steady-state levels of procollagen I and III messenger RNA (85% inhibition at 100 pmol/L) and a 3-5-fold augmentation of collagenase messenger RNA levels.

CONCLUSIONS

IL-beta is mitogenic for human intestinal smooth muscle cells, but this action is associated with a concomitant down-regulation of collagen synthesis and secretion and an augmention of collagenase expression.

Corticosteroids increase procollagen gene expression, synthesis, and secretion by human intestinal smooth muscle cells

BACKGROUND & AIMS

Collagen synthesis by smooth muscle cells plays an important role in intestinal fibrosis. Corticosteroids inhibit collagen synthesis in fibroblasts. The aim of this study was to examine the effect of corticosteroids on the expression of collagen by human intestinal smooth muscle (HISM) cells in vitro.

METHODS

Collagen synthesis was determined by the sensitivity of radiolabeled protein to collagenase. Secretion was determined by polyacrylamide gel electrophoresis of radiolabeled procollagen in the medium. Procollagen messenger RNA was determined by Northern blot analysis.

RESULTS

Collagen synthesis by confluent HISM cells was not affected by corticosteroids at 10(-10) to 10(-5) mol/L but, in subconfluent cultures, was nonspecifically increased 50% at 10(-5) mol/L. Procollagen secretion was nonspecifically increased 60% at 10(-6) mol/L dexamethasone without any effect on the type III/I ratio. Procollagen I and III messenger RNA levels responded in a biphasic manner: a 45%-65% increase at 10(-10) mol/L and a 15% and 30% decrease at 10(-8) and 10(-6) mol/L. In fibroblasts, collagen synthesis was inhibited 85% by dexamethasone, procollagen secretion was decreased 70%, the type III/I ratio decreased from 70:1 to 18:1, and procollagen messenger RNA was inhibited 25% and 60% (types I and III).

CONCLUSIONS

Collagen expression by HISM cells is refractory to corticosteroids and, at certain concentrations, is augmented.

Role of ascorbic acid in procollagen expression and secretion by human intestinal smooth muscle cells

The role of ascorbate in the production and secretion of procollagen by human intestinal smooth muscle cells and the conditions in culture for optimal ascorbate bioefficacy were studied. Procollagen synthesis and secretion were determined by the incubation of cells with L-[5-3H]proline, and the quantitation of radiolabelled procollagen bands in the cell layer and the culture medium by polyacrylamide slab gel electrophoresis and densitometry. When cells were cultured without ascorbate in the culture medium, procollagen secretion into the medium was 75% less than in cells receiving fresh ascorbate daily. In the cell layer, in contrast, procollagen accumulation was fourfold greater in the scorbutic cells than in the ascorbate-replete cells. These findings contrasted with those in a control line of scorbutic human dermal fibroblasts in which a 95% decrease in procollagen secretion was not associated with any procollagen accumulation in the cells. In the intestinal smooth muscle cells, the absence of ascorbate resulted in a 25 and 50% decrease in steady-state levels of procollagen I and III mRNA, respectively, compared to a 40 and 75% decrease in fibroblasts. Heat inactivation of the serum in the culture medium augmented the promotion of procollagen secretion by ascorbate two- to fourfold. L-ascorbate phosphate did not increase the activity of L-ascorbate when replaced in medium either daily or every 4 days, and its efficacy was not augmented by serum heat inactivation. The changing of culture medium induced collagen secretion in the absence of ascorbate, but this process was markedly enhanced by ascorbate and induced a transient decrease in the steady-state levels of both procollagen and nonprocollagen mRNAs. The predominant action of L-ascorbate on HISM cells in vitro is to promote procollagen secretion and not procollagen synthesis. L-ascorbate-phosphate is not an adequate substitute for L-ascorbate in this cell line.

Collagen production by human smooth muscle cells isolated during intestinal organogenesis

The extracellular matrix influences organogenesis by modulating cell behavior. In humans, collagen is the major matrix constituent of the adult intestinal wall and is synthesized by smooth muscle cells. The objective of the current study was to examine collagen production by fetal human intestinal smooth muscle cells isolated during intestinal morphogenesis. Techniques were developed for the isolation and culture of human fetal intestinal smooth muscle cells. The cultured cells were confirmed as muscle by immunohistochemical stains for cytoskeletal filaments and documentation of contractile behavior. In culture, these cells stained for mesenchymal and muscle cytoskeletal proteins: vimentin, actin, and desmin, and did not stain for neural or epithelial markers. The muscle cells contracted in response to acetylcholine, in contrast to human fetal dermal fibroblasts which did not contract appreciably. Collagen production was assayed by the uptake of [3H]-proline into collagenase-digestible protein. Collagen production was greatest at 11 weeks gestation, the youngest age studied. By 20 weeks gestation, collagen production had decreased to adult levels. However, when compared to another matrix-producing fetal mesenchymal cell, the dermal fibroblast, intestinal smooth muscle cells produced twice as much collagen. Collagen types were determined by polyacrylamide slab gel electrophoresis. Smooth muscle cells predominantly produced types I and III collagen alpha chains. Therefore, collagen production is a significant function of human fetal intestinal smooth muscle cells, and probably plays a major role in the development of intestinal structure. The in vitro model presented here provides a means of studying the regulation of this collagen production throughout intestinal organogenesis.

Transforming growth factor beta 1 selectively augments collagen synthesis by human intestinal smooth muscle cells

Intestinal smooth muscle cells play a major role in the stricture formation that complicates chronic intestinal inflammation, by proliferating and producing collagen. Transforming growth factor beta 1 has been identified as an important inflammatory mediator in the fibrotic response of human tissue to inflammation. To determine whether this mediator might be involved in intestinal fibrosis, the effect of transforming growth factor beta 1 on collagen production and proliferation by human intestinal smooth muscle cells was studied in vitro. Cells in the second passage were grown to subconfluence in medium containing 10% Nu-Serum (Collaborative Research Inc., Bedford, MA), after which the concentration of Nu-Serum was decreased. Forty-eight hours later, transforming growth factor beta 1 was added to the culture medium to achieve concentrations of 1-500 pmol/L. After 24 hours exposure to the transforming growth factor beta 1, cellular collagen synthesis was determined by the uptake of [3H]proline into collagenase-sensitive protein. Transforming growth factor beta 1 caused a 100% increase in collagen production and a 40% increase in noncollagen protein production per cell, reflecting an increase in relative collagen synthesis of 58%. This effect was maximal at a concentration of 10 pmol/L. Epidermal growth factor, by comparison, had no significant effect on relative collagen synthesis. Transforming growth factor beta 1 caused a significant increase in the uptake of methylaminoisobutyric acid, a nonmetabolized amino acid analog, into the cells at 10 pmol/L. However, this effect was small (20% increase) compared with the effect on the uptake of proline into collagen (100% increase) at this concentration. When cell proliferation was examined by the uptake of [3H]thymidine, transforming growth factor beta 1 had no effect, whereas epidermal growth factor (1000 pmol/L) caused a 94% increase. Transforming growth factor beta 1 selectively augments collagen production by human intestinal smooth muscle cells in vitro. This effect is potent and is not related to effects on either cell proliferation or amino acid uptake. These data suggest that transforming growth factor beta 1 has an important role as an inflammatory mediator in the pathogenesis of intestinal fibrosis.

A microassay to quantitate collagen synthesis by cells in culture

A method to quantitate collagen synthesis, total protein synthesis, and DNA in 24-well culture plates is presented. Collagen-producing cells such as human intestinal smooth muscle cells and dermal fibroblasts were pulse-labeled with [3H]proline. After incubation, the plates were heated to 90 degrees C to stop isotope incorporation and sonicated to lyse the cells and an aliquot was removed for DNA quantitation. Carrier protein was added, all protein was precipitated by trichloroacetic acid, and unbound isotope was removed by repeated precipitations. After incubation with purified bacterial collagenase, both the soluble 3H-labeled collagen-derived peptides and the remaining insoluble 3H-labeled noncollagen protein were quantified. Results were expressed as the amount of radioactivity incorporated into collagen and noncollagen protein per nanogram DNA and also as the percentage of collagen synthesis per total protein synthesized. The advantage of this technique over previous attempts to scale down the assay is that the entire assay for DNA, collagen, and non-collagen protein can be carried out in the same well without any transfer of material. This technique also provides a significant savings of culture medium, serum, growth factors, and cell material.

Protamine selectively inhibits collagen synthesis by human intestinal smooth muscle cells and other mesenchymal cells

Collagen synthesis is a major function of human intestinal smooth muscle (HISM) cells and contributes to intestinal fibrosis in chronic inflammatory bowel disease. As an extension of previous in vitro studies of the role of heparin in regulating HISM cell proliferation and collagen synthesis, the effect of protamine sulfate was studied. Protamine decreased collagen production by 50% in confluent and proliferating cultures. This effect was concentration-dependent and was selective for collagen in that neither noncollagen production nor DNA accumulation in the culture plates was affected. Other human mesenchymal cells which produce collagen, such as dermal fibroblasts and aortic smooth muscle cells, responded to protamine in a similar fashion. Protamine has a strong cationic charge and is rich in lysine and arginine. To determine which of these properties was important in decreasing collagen production, the effect of protamine was compared to that of other polyionic compounds. Poly-L-lysine decreased collagen production to a lesser degree than protamine. Poly-L-arginine was toxic to the cells. Poly-L-glutamic acid, which has an opposite charge to protamine, had no effect. These findings suggest that both the number and the arrangement of lysyl residues, in addition to positive charge, are important. Binding assays demonstrated that protamine did not inhibit collagen production by binding to ascorbate in the culture medium. Electrophoretic separation and chromatography of collagen types expressed following protamine treatment showed that the ratio of type I to type III collagen remained 2:1. This observation suggests that suppression of collagen production is not specific to a particular collagen type. The selective inhibition of collagen production by protamine provides an important tool to study the regulation of collagen production in human cells and may also provide potential therapy of fibrotic disorders.

Cyclic nucleotides regulate collagen production by human intestinal smooth muscle cells

The effect of cyclic nucleotides on collagen production by human intestinal smooth muscle cells was examined in vitro. Cholera toxin and isobutylmethylxanthine, agents that elevate cyclic adenosine monophosphate, caused selective inhibition of collagen production when cells were exposed to these agents for 24-72 h. Exposure for 6 h inhibited noncollagen protein synthesis without effects on collagen production. Forskolin similarly inhibited collagen production, decreasing relative collagen synthesis 40% at 10 microM and 60% at 100 microM. After 48 h of exposure to cholera toxin and isobutylmethylxanthine, levels of cyclic adenosine monophosphate had increased in a concentration-dependent manner. The effect of cyclic nucleotide analogues was also examined. Dibutyryl cyclic adenosine monophosphate inhibited collagen production, whereas dibutyryl cyclic guanosine monophosphate increased collagen production by 65%. This effect was maximal at a concentration of 10 microM. These observations suggest that cyclic adenosine monophosphate has a significant effect on collagen production by human intestinal smooth muscle cells in vitro and may play a role in the modulation of collagen production by these cells in vivo.

Collagen content and types in the intestinal strictures of Crohn's disease

The collagen content and the relative amount of collagen types were quantitated in control intestine as well as in both inflamed and strictured intestine resected from patients with Crohn's disease. The major collagen type in control intestine was type I (68%), followed by types III (20%) and V (12%). In strictured intestine both collagen content and the relative amount of type V collagen were significantly increased compared with control intestine. Histologic studies demonstrated that in strictured specimens there was a striking proliferation of smooth muscle cells of the muscularis mucosae associated with an accumulation of collagen in the submucosa. The thickness of the muscularis propria was also increased. Immunohistochemical studies demonstrated small amounts of type V collagen in the submucosa of control bowel. In contrast, large amounts of type V collagen were seen in the fibrotic, expanded submucosa of strictured bowel, particularly in the areas where smooth muscle cells of the muscularis mucosae had proliferated. Intestinal strictures in Crohn's disease are therefore characterized by an accumulation of collagen, a proliferation of smooth muscle cells, and an increase in type V collagen, a collagen type produced in relatively large amounts by smooth muscle cells. These changes appear to result in both a loss of the normal compliance of the intestine and a thickening of the intestine wall, resulting ultimately in the intestinal obstruction so frequently seen in patients with Crohn's disease.

Heparin modulates human intestinal smooth muscle cell proliferation, protein synthesis, and lattice contraction

The effect of heparin on human intestinal smooth muscle cell proliferation, collagen and noncollagen protein synthesis, and collagen lattice contraction was studied in vitro. Proliferation of serum-stimulated cells was inhibited in a concentration-related fashion by continuous exposure to heparin. The inhibition of proliferation was reversible when heparin was removed from the culture medium. Collagen synthesis was inhibited by 24-h exposure to heparin, but only during that phase of culture (8-12 days) when collagen synthesis was maximal. Noncollagen protein synthesis was down-regulated by 24-h exposure to heparin at all phases of culture tested (5-21 days). Heparin also abolished the contraction of collagen lattices populated by human intestinal smooth muscle cells. These studies demonstrate that heparin plays a significant role in the modulation of human intestinal smooth muscle cell behavior in vitro and suggest that a similar role is played by heparinlike components of the extracellular matrix in vivo.

Collagen synthesis by human intestinal smooth muscle cells in culture

Growth kinetics and collagen production were determined in smooth muscle cells isolated from human jejunum and maintained in cell culture. Collagen synthesis increased during the first 15 days in culture at a time when the rate of cell proliferation was maximal. When confluent, these cells produced significantly more collagen than human dermal fibroblasts cultured under identical conditions. The smooth muscle cells required daily replenishment of ascorbate for maximal collagen synthesis. The types of collagen produced by human intestinal smooth muscle cells in culture were the same as those collagens extracted from strictured human bowel (types I, III, and V). These findings suggest that collagen production by human intestinal smooth muscle cells has a role in the repair as well as the fibrosis of the gastrointestinal tract.

Heparin induces specific protein release from human intestinal smooth muscle cells

Human intestinal smooth muscle cells have recently been identified as the major cell type responsible for stricture formation in Crohn's disease. Heparin, a sulfated glycosaminoglycan, has been shown to be a key modulator of vascular smooth muscle cell growth both in vivo and in vitro and to affect the release of proteins from these cells. Heparin has also been shown to affect the growth of human intestinal smooth muscle cells. In this report we demonstrate that heparin, in addition to its effects on proliferation, also has very specific effects on proteins released by these cells in vitro. Examination of the culture medium proteins of heparin-treated human intestinal cells revealed an increase in three proteins of molecular weight between 150-250 kd, an increase in a 37 kd protein and a decrease in synthesis of lower molecular weight (less than 20 kd) proteins. In substrate-attached material a transient effect on a 48 kd protein was observed. No effects on intracellular labeled proteins could be demonstrated. The 35S-methionine labeled protein profile of human intestinal smooth muscle cells exposed to heparin is similar to that observed in rat vascular smooth muscle cells yet distinct differences do exist. Extracellular processing does not account for the released proteins nor is de novo protein synthesis required suggesting that altered intracellular protein processing is the mechanism for the heparin-induced protein pattern. The release of specific proteins following exposure to heparin may reflect a significant influence of this glycosaminoglycan on the metabolism of smooth muscle cells in general and particularly in the human intestine.

Ultrasound findings in ectopic gestation

To study the diagnostic accuracy of real-time ultrasonography in the evaluation of ectopic pregnancy, the case records and preoperative sonograms of 57 patients with surgically proven ectopic pregnancy were reviewed. Some 81% of these patients had abnormal sonograms. However, the ultrasonographic findings were often nonspecific and in only 8.7% of the cases was an ectopic fetal heart beat demonstrated. Two patients in this series had coexistent intrauterine and extrauterine gestations. Other findings such as an adnexal mass, an empty uterus, fluid in the cul-de-sac, and a decidual reaction in the uterus are all suggestive of an ectopic pregnancy but can be seen in other conditions. The presence of a normal intrauterine gestation practically rules out the possibility of ectopic pregnancy.

Isolation and culture of human intestinal smooth muscle cells

Intestinal smooth muscle cells were isolated from human bowel and maintained in culture through several passages. These cells were obtained by enzyme digestion of slices taken from the circular layer of the muscularis propria of human jejunum. When subcultured, they initially flattened out and then began proliferating after 3 days. After 3 weeks in culture, they began aggregating into ridges. Fluorohistochemical staining revealed numerous prominent actin stress fibers. When these cells were exposed to the C-terminal octapeptide of cholecystokinin they contracted in a dose-dependent fashion. The availability of human intestinal smooth muscle cells in culture will considerably enhance our ability to study the contractile, proliferative and connective tissue responses of the smooth muscle of the human gastrointestinal tract.

An in vitro model of fibroplasia: simultaneous quantification of fibroblast proliferation, migration, and collagen synthesis

Previous studies of fibroblast proliferation, migration, and collagen synthesis have been limited in their ability to define the interrelationship among these events in response to various inflammatory mediators. We have now defined an in vitro tissue culture model for the synchronous quantification of these parameters of fibroplasia. Biopsies (2 mm) of chicken flexor tendons are embedded in a fibrin matrix and exposed to various factors for 5 days in tissue culture. The availability of the fibrin matrix surrounding the tendon biopsy satisfies the need for a solid support medium for fibroblast migration. Multiple measurements of tendon fibroblast proliferation, migration into the fibrin matrix, and relative collagen synthesis are then made on these preparations. Fetal calf serum stimulated tendon fibroblast proliferation and migration in a dose responsive fashion, whereas the selective expression of collagen synthesis was decreased. Platelet lysate stimulated fibroblast proliferation at low concentration, but migration only at high concentration and was without effect on relative collagen synthesis. This model now provides a means of more clearly defining the influence of various inflammatory factors on the events of fibroplasia.

Inhibition of bile flow in the isolated perfused rat liver by a synthetic parenteral amino acid mixture: associated net amino acid fluxes

To identify a role for amino acids in cholestasis associated with total parenteral nutrition, we measured bile formation by the isolated perfused rat liver in the presence and absence of added amino acids. All livers were infused constantly with sodium [14C]taurocholate (0.28 mumoles per min) for 90 min. At 40 min, a primed-constant infusion of a synthetic L-amino acid mixture (121 + 19.3 mumoles of N per min) was administered for an additional 50 min. Mean bile flow rates during the amino acid infusion were reduced from 15.4 microliter per min per 10 gm liver weight to 10.4 microliter per min per 10 gm (p less than 0.005). There was no significant change during saline infusion of control livers, and there was no significant difference in perfusate osmolalities in the two groups. Although biliary recovery of infused taurocholate was slightly lower in the experimental perfusions than in controls (95.3% vs. 101.7%, p less than 0.05), there was no significant reduction in taurocholate excretion rate during the infusion in either group. Bile flow changes were related to ambient concentrations and net fluxes of individual amino acids in the perfusate. Of the 14 infused amino acids, glycine and arginine achieved levels greater than 3 times greater than reported physiological postprandial portal venous concentrations in the rat, and together constituted about 25% of the 90-min perfusate amino acids (8.3 mM). The highest net hepatic uptake was for glycine (125 mumoles per hr per 10 gm), which was almost 50% of its infusion rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Intrinsic tendon fibroplasia: documentation by in vitro studies

There has been considerable controversy concerning the capacity of tendons to heal intrinsically without adhesion formation. To help clarify this issue, a tissue culture model was developed to study the potential of tendon fibroblasts to proliferate and migrate. Avian flexor tendons, isolated free of sheath and all synovial components, were maintained in sterile culture plates with Dulbecco's Modified Eagle Medium. After 5 days in culture, the 2 mm tendon biopsies were analyzed for DNA synthesis [( 125I])iododeoxyuridine incorporation) and migration of fibroblasts out of the explant (planimeter analysis). DNA synthesis was maximal on day 5 in culture, and tendon fibroblasts were observed migrating from the biopsy within 48 h. Addition of cells from plasma resulted in a significant increase in fibroblast migration, and the presence of fibrin in the plasma clot was an absolute requirement for the migratory process. These findings further support the hypothesis that injured tendons can heal by an intrinsic healing process in addition to healing by adhesion formation.

Abnormal endometrial echoes: sonographic spectrum of endometrial pathology

This report reviews the cases of 12 patients in whom ultrasound examination revealed endometrial cavity echoes that were more prominent than expected. Dilatation and curettage or hysterectomy, or both, in these patients revealed a spectrum of endometrial pathology in 83 per cent of the patients, including carcinoma in 33 per cent and normal findings in 17 per cent.

Intrinsic tendon cell proliferation in tissue culture

This study examines the potential of tendon cells to participate in tendon repair. Explants were prepared from chicken sublimis tendons and studied in tissue culture. Under defined culture conditions, in the absence of tendon sheath, tendon cells were observed to migrate in a limited concentric fashion around the margin of a 2 mm window in the explant. When a plasma clot was present in the window, tendon cell migration and proliferation were accelerated and continued until the window was confluent with cells. Electron micrographs demonstrated that these tendon cells were fibroblasts associated with extracellular collagen fibrils. Specific biochemical analyses confirmed that these tendon fibroblasts were synthesizing collagen. This in vitro study demonstrates that tendons contain active fibroblasts capable of proliferation, migration, and collagen synthesis. These findings support the hypothesis that tendons can heal by intrinsic processes.

Ultrasonographic screening of the common hepatic duct in symptomatic patients after cholecystectomy

This study was undertaken to assess the usefulness of an ultrasonographically enlarged common hepatic duct as an indicator of biliary obstruction after cholecystectomy. The abdominal sonograms of 165 postcholecystectomy patients were reviewed retrospectively, and follow-up was obtained on 56 patients. In 23 of 36 patients who had common hepatic ducts larger than 4 mm, the cause of biliary obstruction was found at surgery. In the remaining 13 patients, no evidence of obstruction was found on subsequent radiographic studies, and none of these patients underwent surgery. Eight patients had common bile ducts that were considered to be dilated (> 1cm) on subsequent intravenous cholangiography. In 20 patients whose common hepatic ducts measured 4 mm or less, 17 had no evidence of dilatation on subsequent radiographic studies, but three had choledocholithiasis.

Endoscopic small bowel biopsy in children with a modified multipurpose biopsy tube

Small bowel biopsy is a difficult procedure in infants and children, and the authors describe a new technique. The Quinton multipurpose suction biopsy instrument is incorporated into an Olympus GIF-P2 fiberoptic endoscope to allow positioning of the biopsy capsule under direct visual control. Fourteen children, 2 months to 4 years of age, have been biopsied, and tissue was successfully obtained in 20 of 21 procedures. Nine of 21 endoscopic examinations of duodenal mucosa were abnormal and gave additional diagnostic information.

The size of the normal common hepatic duct following cholecystectomy: an ultrasonographic study

Sixty-seven asymptomatic patients underwent repeat ultrasonography four to 16 months following cholecystectomy with or without common bile duct exploration. Fifty-six patients (84%) had common hepatic ducts with a normal internal diameter of 4 mm or less. Four patients had common hepatic ducts measuring 5 mm, and seven patients had common hepatic ducts measuring 6 to 10 mm. It is concluded that, although the common hepatic duct generally is not dilated following cholecystectomy, there is a significant minority (16%) of asymptomatic patients who have common hepatic ducts larger than 4 mm, and in these patients the duct may measure up to 10 mm.

The usefulness of transfer factor in asthma associated with frequent infections

Fifteen patients underwent controlled trial with transfer factor for repeated infections and severe asthma. Marked decrease in respiratory infections and striking improvement in asthma resulted. The authors suggest that transfer factor may reconstitute immune function, thus representing a unique approach to severe asthma associated with frequent infections.