Sulphated and unsulphated bile acids in serum, bile, and urine of patients with cholestasis.

Samples of serum, bile, and urine were collected simultaneously from patients with cholestasis of varying aetiology and from patients with cirrhosis; their bile acid composition was determined by gas/liquid chromatography and mass spectrometry. In cholestasis, the patterns in all three body fluids differed consistently and strikingly. In serum, cholic acid was the major bile acid and most bile acids (greater than 93%) were unsulphated, whereas, in urine, chenodeoxycholic was the major bile acid, and the majority of bile acids (greater than 60%) were sulphated. Secondary bile acids were virtually absent in bile, serum, and urine. The total amount of bile acids excreted for 24 hours correlated highly with the concentration of serum bile acids; in patients with complete obstruction, urinary excretion averaged 71-6 mg/24 h. In cirrhotic patients, serum bile acids were less raised, and chenodeoxycholic acid was the predominant acid. In healthy controls, serum bile acids were consistently richer in chenodeoxycholic acid than biliary bile acids, and no bile acids were present in urine. No unusual monohydroxy bile acids were present in patients with primary biliary cirrhosis, but, in several patients, there was a considerable amount of hyocholic acid present in the urinary bile acids. The analyses of individual bile acids in serum and urine did not appear to provide helpful information in the differential diagnosis of cholestasis. Thus, in cholestasis, conjugation of chenodeoxycholic acid with sulphate becomes a major biochemical pathway, urine becomes a major route of bile acid excretion, and abnormal bile acids are formed.     

Sulfated bile acids in serum,bile, and urine of cirrhotic patients before and after portacaval anastomosis

Sulfated and unsulfated bile acid composition was studied in serum and bile in 10 patients with alcoholic cirrhosis. Samples, collected before and 2 months after portacaval anastomosis, were analyzed using a gaschromatographic method. Mean total serum bile acid levels rose from 32.0±5.3(SE) mol/liter before to 87.4±13.3 mol/liter after surgery (P<0.005). The increase in serum bile acid levels was significant only with respect to the unsulfated fraction (22.7±3.0 mol/liter to 67.6±8.1 mol/liter,P<0.005). Thus the percent sulfation of total serum bile acid decreased from 24.6% to 19.2%. The sulfated bile acid fraction comprised mainly chenodeoxycholate both before and after surgery. Percent sulfation of individual bile acids was not modified after portacaval anastomosis. Bile acid sulfates were present in bile only in negligible amounts. The daily uninary excretion of bile acids, studied in 6 patients, increased significantly (P<0.05) after surgery, the increase being due only to the unsulfated compounds. Data from this study indicate that in cirrhotic patients no significant changes occur in serum with respect to sulfated bile acids after portacaval anastomosis, despite a definite increase in serum unsulfated bile acid levels. This is likely due to the lack of an efficient enterohepatic circulation of bile acid sulfates.Supported by grant 900.3/0sp.70/206/100, Divisione III, Ministero della Sanità.     

Unconjugated secondary bile acids in the serum of patients with colorectal adenomas.

A positive association between deoxcholic acid (DCA) in the serum and colorectal adenomas, the precursors of colorectal cancer has recently been found, which supported the hypothesis of a pathogenic role of DCA in colonic carcinogenesis. This approach was based on the hypothesis that DCA formed in the colon is absorbed into the portal venous blood and exhibits a constant spillover to the systemic circulation. To further substantiate this hypothesis this study investigated whether in the serum of adenoma patients DCA was higher in the unconjugated fraction, which originates directly from the colon. DCA was found to be 2.8-fold higher in the unconjugated fraction of patients with colorectal adenomas than in controls (0.89 v 0.32 mumol/l, p < 0.0025), 1.9-fold in the total DCA fraction (1.89 v 0.95 mumol/l, p < 0.0001), and 1.4-fold in the conjugated fraction (0.67 v 0.47 mumol/l, p < 0.05). It was further found that the bacterial isomerisation product 3 beta-DCA was twofold higher in the unconjugated fraction of adenoma patients than in controls (0.08 v 0.04 mumol/l, p = 0.27), 1.8-fold in the total iso-DCA fraction (0.11 v 0.06 mumol/l, p < 0.05), and 1.5-fold in the conjugated iso-DCA fraction (0.03 v 0.02 mumol/l, p = 0.68). The data suggest that the positive association between the serum DCA concentration and colorectal adenoma as described previously results from the DCA fraction that is absorbed from the colon. This further supports a pathogenic role of DCA in the carcinogenesis of colorectal cancer.     

Diagnostic value of serum bile acids.

With the development of simplified methods of bile acid analysis, a new era has drawned in the evaluation of hepatobiliary disease. 1. A total serum bile acid particularly in the postprandial periods is more sensitive than either BSP or ICG for the detection of minimal liver disease and will become a useful screening method. 2. The ratio of chenodeoxycholate to cholate in serum together with the total concentration can often distinguish hepatitis and cirrhosis from intrahepatic and extrahepatic cholestasis with normal liver cell parenchyma. However, in practice this is usually of less value than the total serum bile acid level. 3. Changes in serum bile acids throughout a 24 hour cycle reflect the enterohepatic circulation of bile acids and the capacity of the liver to transport them. These patterns are most useful in judging the severity of cholestasis and response to resin therapy. They also provide new insights into the pathophysiology of bile acid metabolism and excretion in different diseases of the liver.     

Relative concentrations of individual nonsulfated bile acids in the serum and bile of patients with cirrhosis

The relative concentrations of individual nonsulfated bile acids were determined in samples of serum and bile obtained simultaneously from 16 patients with biospy-proven alcoholic cirrhosis. A highly significant (P<0.001) correlation was found between the fasting relative concentrations of each of the three major bile acids (cholic, chenodeoxycholic, and deoxycholic) in serum and bile. This relationship persisted after manipulation of bile acid pools produced by feeding of individual bile acids. We conclude that the relative concentrations of individual nonsulfated bile acids in serum accurately reflect those in bile and that measurement of individual serum bile acids may be used for screening and serial determination purposes. In particular, low levels of biliary deoxycholate can be reliably predicted by serum measurements.This work was supported by the Medical Research Service of the Veterans Administration and Grant RR-51 from the General Clinical Research Centers Program of the Division of Research Resources, National Institutes of Health.This work has appeared in part, in abstract form: Mehta SJ, Kaye MD, Struthers JE Jr, Naylor JL: Relation between individual bile acids in serum and bile. Gastroenterology 66:745, 1974.     

Patterns of gold levels in urine, serum, and saliva in patients with rheumatoid arthritis undergoing chrysotherapy.

Twenty patients undergoing treatment with aurothiomalate for rheumatoid arthritis (RA) were studied for the presence of gold in all urine specimens passed over four days and for gold in the serum of blood drawn by venous section at 10.00, 16.00, and 22.00 hours on a single day of the study. Specimens of saliva collected at the same times as the blood specimens were also analysed for (total) gold content. Eighteen patients showed rhythmic urinary gold excretion. Variations were observed in the serum levels for total, free, and protein bound gold at different times of the day and night together with similar variations in the salivary total gold levels. It was established that a possible relation exists between urinary gold, serum gold, and salivary gold such that at times of higher urinary gold excretion the serum gold levels (total, free, and protein bound) and the total salivary gold levels were decreased. Conversely, at times of lower urinary gold excretion serum and salivary gold levels were increased.     

Bile acids in serum and bile of patients with cholesterol gallstone

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Glucuronidated and sulfated bile acids in serum of patients with acute hepatitis

The concentrations of glucuronidated and sulfated bile acids in the serum of 15 patients with acute hepatitis were determined by mass fragmentography. Total serum bile acid levels were 13.79-444.10 mumol/liter, and the percentages of glucuronidated and sulfated bile acids were in the wide ranges of 1.7-33% and 2.4-49%, respectively. In four of the five patients for whom serum bile acids were analyzed serially from the acute to the recovery stages of acute hepatitis, the decrease of the glucuronidated and sulfated bile acids was slower than that of nonglucuronidated, nonsulfated bile acids. Thus, the relative proportion of the glucuronides and sulfates in total bile acids apparently increased during the recovery phase. The mechanism for the relative predominance of bile acid esters in serum during recovery is unknown but might reflect an improved excretion of the nonesterified bile acids into bile after the rapid recovery of intrahepatic cholestasis.     

Diagnostic value of serum primary bile acids in detecting bile acid malabsorption.

Serum cholic and chenodeoxycholic acid conjugates were measured in fasting conditions and after meals in 14 patients with bile acid malabsorption due to ileal resection. Mean serum fasting levels of both primary bile acids did not differ from the controls. After meals, serum cholic acid peaks were lower in patients with ileal resection than in control subjects (p less than 0.001), while chenodeoxycholic acid peaks were reduced in colectomised patients (p less than 0.01). In the sera from patients with ileal resection, the glycine/glycine + taurine ratio for cholic and chenodeoxycholic acid increased (p less than 0.001) from morning to evening, and glycine/glycine + taurine ratio for chenodeoxycholic acid was significantly (p less than 0.01) different from the controls in the sera collected in the evening. The results are consistent with the concept of a better intestinal conservation of chenyl, mainly of the glycine conjugated from, than of cholylconjugates, in patients with ileal resection; this is probably because of passive absorption in the intestine. The postprandial peaks of serum cholic acid conjugates may therefore be regarded as a test of ileal dysfunction, while peaks of chenodeoxycholic acid conjugates suggest colonic impairment.     

Effects of ursodeoxycholic acid on conjugated bile acids and progesterone metabolites in serum and urine of patients with intrahepatic cholestasis of pregnancy

Background/Aims and Methods: The mechanism(s) behind the effects of ursodeoxycholic acid on serum steroid sulphate profiles in patients with intrahepatic cholestasis of pregnancy is not clear. Conjugated progestone metabolites and bile acids have therefore been analyzed in serum and urine of patients with intrahepatic cholestasis of pregnancy before and during treatment with ursodeoxycholic acid using chromatographic and mass spectrometric methods.Results: The concentration of glycine-/taurine-conjugated bile acids decreased from 8.9±3μmol/l (mean± SEM) before treatment to 1.8±0.6 sml/l during treatment with ursodeoxycholic acid. The total bile acid excretion in urine decreased from 56±14 to 32±5.6 μmol/g creatinine. The proportion of cholic acid in serum and urine, and of 1β-, 2β- and 6α-hydroxylated cholic acids in urine decreased markedly during ursodeoxycholic acid while the percentages of 3α, 12α-dihydroxy-3-oxo-4-cholenoic acid and chenodeoxycholic acid were unchanged. The levels in serum and excretion in urine of sulphated steroids decreased during ursodoexycholic acid, by 45–49% for disuphates and 33–35% for monosulphates. The ratios of 3α- to 3β-hydroxysteroid disulphates were lowered by ursodeoxycholic acid from 1.1 (mean) to 0.68 in serum, and from 1.2 to 0.70 in urine. The corresponding ratios for monosulphates before the during ursodeoxycholic acid were 6.9 and 4.5, respectively, in serum, and 21 and 5.2 respectively, in urine. The major monosulphates in urine, dominated by 5α-pregnane-3α, 20α-diol, were also conjugated with N-acetylglucosamine. The excretion of these double conjugates decreased from 27±8.4 to 15±5.3 μmol/g creatinine during ursodoexycholic acid. In contrast to suplhated steroids, the concentrations of glucruronides were unchanged in serum and their excretion in urine tended to increase during ursodeoxycholic acid. The metabolism of ursodeoxycholic acid was similar to that described in nonpregnant subjects. In addition to metabolites hydroxylated in the 1β-, 5β-, 6αβ and 22-positions, a 4-hydroxy-ursodeoxycholic acid was tentatively identified. This occurred predominantly as a double conjugate with glucine/taurine and glucuronic acid, as did other 4-hydroxylated bile acids of probable foetal origin.Conclusions: The results are compatible with the contention that ursodeoxycholic acid stimulates the biliary excretion of sulphated progesterone metabolites, particularly those with a 3α-hydroxy-5α(H) configuration and disulphates. The effects(s) appears to be independent of the stimulation of bile acid secretion. An effect of ursodeoxycholic acid on the reductive metabolism of progesterone cannot be excluded.     

Postprandial serum bile acids in healthy man. Evidence for differences in absorptive pattern between individual bile acids.

The serum concentrations of cholic acid (C), chenodeoxycholic acid (CD), and deoxycholic acid (D) before and after a standardised meal were determined in five healthy female subjects using a highly specific and accurate gas chromatographic-mass spectrometric technique. The C level rose significantly 60 minutes after the meal, reached a peak after 90 minutes, and had returned to the original level after 150 minutes. In contrast, the serum concentrations of CD and D displayed a significant rise by 30 minutes, reached a peak after 90 minutes, but had not returned to fasting levels after 150 minutes. The serum bile acid responses after a meal suggest that there is considerable absorption of dihydroxy bile acids in the proximal small intestine in man.     

Acute hemorrhagic pancreatic necrosis in mice bile acids in gallbladder bile, serum and pancreas

Mice develop acute hemorrhagic pancreatic necrosis with fat necrosis after 4 days of feeding on a choline deficient-ethionine supplemented (CDE) diet. The diameter, weight and histopathology of the gallbladder were determined in mice fed laboratory chow (LC), a choline-supplemented (CS) diet, a choline-deficient (CD) diet, or the CDE diet for 1, 2 or 3 days. A progressive distension of the gallbladder due to accumulation of bile, was observed in mice fed the CS, CD and CDE diets. An analysis of the bile acid composition of the pancreas, serum and gallbladder bile of mice fed the same diets for 3 days was performed. No differences between control and experimental animals were seen in the concentration and distribution of bile acids in the pancreas. It is concluded that: 1) alterations in bile acid constituents are produced by the diets; and, 2) regurgitation of bile into the pancreas of mice fed the CDE diet does not occur. Thus, bile acids do not seem to initiate or participate in the extensive cellular damage that precedes and accompanies the onset of acute hemorrhagic pancreatic necrosis with fat necrosis in mice fed the CDE diet.     

Unusual trihydroxy bile acids in the urine of patients treated with chenodeoxycholate, ursodeoxycholate or rifampicin and those with cirrhosis

Urinary bile acids from 20 patients treated with chenodeoxycholate, 18 treated with ursodeoxycholate, 15 treated with rifampicin and 8 patients with advanced cirrhosis were analyzed by gas-liquid chromatography and gas-liquid chromatography-mass spectrometry. Occurrence rates and amounts of three so-called unusual trihydroxy bile acids, hyocholate, ursocholate and omega-muricholate, were increased in patients treated with chenodeoxycholate, ursodeoxycholate or rifampicin and decreased in cirrhotic patients as compared with those in untreated healthy adults. These data suggest that chenodeoxycholate and ursodeoxycholate are hydroxylated to produce unusual trihydroxy bile acids in bile acid-loaded humans and that this metabolism may be related to the induction of hepatic microsomal enzymes by rifampicin. In contrast, the hydroxylation of chenodeoxycholate and ursodeoxycholate may be impaired by severe hepatic damage. Because the urine is a secretory pathway for internal bile acids, the occurrence of unusual trihydroxy bile acids in the urine may be used as an indicator of hepatic ability to metabolize "hydrophobic" dihydroxy bile acids to their secretory forms.     

A paucity of unusual trihydroxy bile acids in the urine of patients with severe liver diseases

To clarify the relationship between the occurrence of unusual trihydroxy bile acids, namely hyocholic acid, ursocholic acid (UCA), and omega-muricholic acid (omega-MCA) in urine and liver disease severity, urinary bile acids were analyzed by gas-liquid chromatography in acute and late phases of acute hepatitis and before and after ursodeoxycholic acid (UDCA) loading in healthy adults and liver cirrhosis patients. In 11 patients with acute hepatitis, the occurrence rates and amounts of unusual trihydroxy bile acids were increased in the late (recovery) phase, as compared with those in the early phase. In 10 patients with severe acute hepatitis who had prothrombin times exceeding 16 seconds, these bile acids had completely disappeared from the urine in the early phase but reappeared in the late phase in those who had a good outcome, though never in a patient who died. After UDCA administration for a week, the amounts of unusual bile acids, especially UCA and omega-MCA, which are thought to be synthesized through 12 alpha- and 6 alpha-hydroxylations, respectively, from UDCA, were clearly increased in 10 healthy adults but only slightly changed in 10 patients with liver cirrhosis. In conclusion, hepatic hydroxylations of dihydroxy bile acids as a detoxification reaction were impaired in severe liver diseases, which may play a role in the intensification and perpetuation of hepatocellular injuries.