Effector role of neonatal hepatic CD8+ lymphocytes in epithelial injury and autoimmunity in experimental biliary atresia

BACKGROUND & AIMS: Lymphocytes populate the livers of infants with biliary atresia, but it is unknown whether neonatal lymphocytes regulate pathogenesis of disease. Here, we investigate this question by examining the role of T lymphocytes in the destruction of extrahepatic bile ducts of neonatal mice using an experimental model of biliary atresia. METHODS: Inoculation of neonatal mice with rhesus rotavirus followed by multistaining flow cytometry to quantify expression of interferon-gamma by hepatic lymphocytes, and real-time polymerase chain reaction for mRNA expression of pro-inflammatory cytokines. This was followed by determining the consequences of antibody-mediated depletion of lymphocyte subtypes on the development of biliary obstruction, and coculture and cell transfer experiments to investigate the effector role of lymphocyte subtypes on neonatal biliary disease. RESULTS: Rotavirus infection results in overexpression of interferon-gamma by neonatal hepatic T cells. Among these cells, depletion of CD4(+) cells did not change the course of inflammatory injury and obstruction of neonatal bile ducts. In contrast, loss of CD8(+) cells remarkably suppressed duct injury, prevented luminal obstruction, and restored bile flow. Coculture experiments showed that rotavirus-primed, but not na?ve, CD8(+) cells were cytotoxic to cholangiocytes. In adoptive transfer experiments, we found that primed CD8(+) cells preferentially homed to extrahepatic bile ducts of neonatal mice and invaded their epithelial lining. CONCLUSIONS: Primed neonatal CD8(+) cells can activate a pro-inflammatory program, target diseased and healthy duct epithelium, and drive the phenotypic expression of biliary atresia, thus constituting a potential therapeutic target to halt disease progression.     

Antioxidant Enzyme Activities in Hepatic Tissue from Children with Chronic Cholestatic Liver Disease

Background/Aim:

To study the oxidative stress status in children with cholestatic chronic liver disease by determining activities of glutathione peroxidase (GPx), superoxide dismutase (SOD) and catalase (CAT) in liver tissue.

Materials and Methods:

A total of 34 children suffering from cholestatic chronic liver disease were studied. They were selected from the Hepatology Clinic, Cairo University, and compared with seven children who happened to have incidental normal liver biopsy. The patients were divided into three groups: extrahepatic biliary atresia (n=13), neonatal hepatitis (n=15) and paucity of intrahepatic bile ducts (n=6); GPx, SOD and CAT levels were measured in fresh liver tissue using ELISA.

Results:

In the cholestatic patients, a significant increase was found in mean levels of SOD, GPx and CAT in hepatic tissue compared to control children. The three enzymes significantly increased in the extrahepatic biliary atresia group, whereas in the groups of neonatal hepatitis and paucity of intrahepatic bile ducts, only GPx and CAT enzymes were significantly increased.

Conclusion:

Oxidative stress could play a role in the pathogenesis of cholestatic chronic liver diseases. These preliminary results are encouraging to conduct more extensive clinical studies using adjuvant antioxidant therapy.     

Innervation of intrahepatic bile ducts and peribiliary glands in normal human livers, extrahepatic biliary obstruction and hepatolithiasis. An immunohistochemical study

Innervation of the intrahepatic biliary tree was examined in human normal livers, extrahepatic biliary obstruction and hepatolithiasis. Nerve fibers were immunohistochemically identified on formalin-fixed and paraffin-embedded sections by antibodies to S-100 protein (S-100) and neuron specific enolase (NSE). S-100 and NSE-immunoreactive nerve fibers were present in the walls of intrahepatic large, medium-sized and septal bile ducts as well as in peribiliary glands. Some nerve fibers were in close contact with epithelia of bile ducts and peribiliary glands. Serial section observations showed that the nerve fibers arising from nerve bundles approached, and came to lie in close contact with epithelia of the bile ducts and peribiliary glands. Nerve fibers were sparse around the interlobular bile ducts and bile ductules. These immunoreactive nerve fibers of the intrahepatic biliary tree were rather sparse in normal livers, intermediate in extrahepatic biliary obstruction and dense in hepatolithiasis. These findings suggest that intrahepatic bile ducts and peribiliary glands are innervated and biliary functions are regulated in part by these nerve fibers. Increased nerve fibers may have altered effects on biliary functions in hepatolithiasis.     

Biliary complications after right lobe living donor liver transplantation: a single-centre experience

Background

Biliary complications that developed after right lobe liver transplantation from living donors were studied in a single centre.

Methods

From 2004 to 2010, 200 consecutive living donor right lobe liver transplantations were performed. The database was evaluated retrospectively. Biliary complications were diagnosed according to clinical, biochemical and radiological tests. The number of biliary ducts in the transplanted graft, the surgical techniques used for anastomosis, biliary strictures and bile leakage rates were analysed.

Results

Of a total of 200 grafts, 117 invloved a single bile duct, 77 had two bile ducts and in six grafts there were three bile ducts. In 166 transplants, the anastomosis was performed as a single duct to duct, in 21 transplants double duct to ducts, in one transplant, three duct to ducts and in 12 transplants as a Roux-en-Y reconstruction. In all, 40 bile leakages (20%) and 17 biliary strictures (8.5%) were observed in 49 patients resulting in a total of 57 biliary complications (28.5%). Seventeen patients were re-operated (12 as a result of bile leakages and five owing to biliary strictures).

Conclusion

Identification of more than one biliary orifice in the graft resulted in an increase in the complication rates. In grafts containing multiple orifices, performing multiple duct-to-duct (DD) or Roux-en-Y anastomoses led to a lower number of complications.     

Serum adiponectin and transient elastography as non-invasive markers for postoperative biliary atresia

Background  

Biliary atresia (BA) is a progressive inflammatory disorder of the extrahepatic bile ducts leading to the obliteration of bile flow. The purpose of this study was to determine serum adiponectin in BA patients and to investigate the relationship of adiponectin with clinical parameters and liver stiffness scores.     

Endoscopic Management of Liver Abscess with Biliary Communication

Background and Study Aims  

The formation of a communication between liver abscesses and intrahepatic bile ducts is an uncommon cause of bile leak. The surgical management of biliary fistulas is associated with high morbidity and mortality. We performed a prospective study of the endoscopic management of liver abscess communicating with bile ducts.     

Expression of IFN-γ and IL-4 in the Esophageal Mucosa of Patients with Reflux Esophagitis and Barrett’s Esophagus and Their Relationship with Endoscopic and Histologic Grading

Introduction  

This study investigated the expression of interferon-γ (IFN-γ) and interleukin-4 (IL-4) in the esophageal biopsies from patients with reflux esophagitis (RE) and Barrett’s esophagus (BE) and their relationships with endoscopic grading and histologic grading.     

Efficacy of vessel sealing system for major Glisson bundles and major bile ducts

Background/Purpose

The efficacies of vessel sealing system (VSS) devices for major Glisson bundles and major bile ducts have not yet been determined.

Methods

Male pigs (n = 6) and a LigaSure V device and an Atlas 20 (Valleylab, Boulder, CO, USA) device were used in this study. After laparotomy, the common bile duct and the right and left first-degree Glisson bundles were sealed by the VSS. The lower and upper parts of the common bile ducts were also sealed. Macro-and microscopic examinations were performed for the analysis of specimens taken just after VSS application. In an analysis of bile duct specimens taken 1 week after the VSS application, both burst pressure tests and histological examinations were performed.

Results

(1) In the analysis of the specimens (Glisson bundles and bile ducts) obtained just after the VSS application, the macroscopic changes included permanent, flattened changes of the Glisson bundles and bile ducts, without showing any blood or bile leakage. Histological examination of the transverse sections of the Glisson bundle after VSS application revealed that not only the blood vessels but also the bile ducts were fused together. (2) In the analysis of the specimens (bile ducts) obtained 1 week after the VSS application, second-look laparotomy showed extrahepatic bile duct obstruction. The mean burst pressure of the sealed bile ducts was 74.4 ± 20.1 mmHg. Histological examination revealed that the lumen of the bile duct was completely sealed and the duct was surrounded by dense connective tissues.

Conclusions

The VSS is useful for the safe sealing of not only the major Glisson bundles but also the major bile ducts.     

Intrahepatic bile duct loss in biliary atresia despite portoenterostomy: a consequence of ongoing obstruction?

The histological and immunohistochemical characteristics of the liver in 44 children (28 boys, 16 girls) with extrahepatic biliary atresia at different stages of the clinical course were studied. Thirty-four wedge liver biopsy specimens taken during Kasai operations (25 specimens) and relaparotomy (9 specimens) and 20 hepatectomy explants taken at the time of transplantation were examined. Routine histological stains and monoclonal antibodies against different molecular weight cytokeratins and HLA-DR were used. The histopathological changes and the pattern of cytokeratin expression observed during the course of the disease were suggestive of persistent or recurrent extrahepatic biliary obstruction that occurred despite the Kasai operation and eventually led to cirrhosis and liver failure. Quantitative studies showed a progressive loss of intrahepatic bile ducts over the time course of the disease. This destruction of bile ducts had a geographic anatomical distribution in hepatectomy specimens, and in two livers it occurred predominantly in only one lobe. This geographic distribution of the vanishing bile ducts probably indicates an unpredictable and uneven obliteration of bile ducts in the porta hepatis during portoenterostomy wound healing and scarring.     

A meta-analysis for the effect of prophylactic GTN on the incidence of post-ERCP pancreatitis and on the successful rate of cannulation of bile ducts

Background  

Glyceryl trinitrate (GTN) has been shown to be able to relax the sphincter of Oddi (SO) both in animals and humans. Theoretically, the use of these compounds during and after endoscopic retrograde cholangiopancreatgraphy (ERCP) could relax the biliary and pancreatic sphincters, facilitating cannulation of common bile duct (CBD) during the procedure, or minimizing potential pancreatic outflow obstruction after the procedure. However, clinical trials evaluating the protective effect of GTN on the post-endoscopic retrograde cholangiopancreatgraphy pancreatitis (PEP) have yielded inconclusive results. This meta-analysis is to systematically assess the effect of prophylactic administration of glyceryl trinitrate (GTN) on the prevention of PEP and the effect on the cannulation of bile ducts.     

Endoscopic retrograde cholangiography in the diagnosis of biliary malformations in infants

The differentiation of infantile biliary malformations from primary parenchymal diseases is difficult. The recent development of a pediatric side-viewing endoscope (PJF Endoscope; Olympus Corporation of America) provided an opportunity to investigate the usefulness of endoscopic retrograde cholangiography (ERC) for precise visualization of the extrahepatic biliary passages in infants with persistent cryptogenic cholestasis. ERC was performed in 12 patients, with visualization of the existing extrahepatic bile ducts in 4. The entire biliary system was visualized in one, excluding extrahepatic biliary atresia and choledochal cyst. The reduced caliber of the intrahepatic bile ducts and histological observations in a percutaneous liver biopsy supported the diagnosis of intrahepatic biliary hypoplasia in this case. An intact hepatic portochole cystostomy was documented in one, although the intrahepatic biliary system was not delineated. Atresia of the hepatic bile ducts proximal to the gallbladder was documented in two. Of the eight patients in whom extrahepatic bile ducts were not visualized by ERC, six had extrahepatic biliary atresia confirmed at exploratory laparotomy. The papilla of Vater could not be located in four of these six infants. The remaining two had neonatal hepatitis. ERC may offer a useful alternative to operative cholangiography in selected infants with persistent cholestasis and acholic stools.     

Portal biliopathy: a study of 39 surgically treated patients

Background

Portal biliopathy (PBP) denotes intra- and extrahepatic biliary duct abnormalities that occur as a result of portal hypertension and is commonly seen in extrahepatic portal vein obstruction (EHPVO). The management of symptomatic PBP is still controversial.

Methods

Prospectively collected data for surgically managed PBP patients from 1996 to 2007 were retrospectively analysed for presentation, clinical features, imaging and the results of surgery. All patients were assessed with a view to performing decompressive shunt surgery as a first-stage procedure and biliary drainage as a second stage-procedure if required, based on evaluation at 6 weeks after shunt surgery.

Results

A total of 39 patients (27 males, mean age 29.56 years) with symptomatic PBP were managed surgically. Jaundice was the most common symptom. Two patients in whom shunt surgery was unsuitable underwent a biliary drainage procedure. A total of 37 patients required a proximal splenorenal shunt as first-stage surgery. Of these, only 13 patients required second-stage surgery. Biliary drainage procedures (hepaticojejunostomy [n = 11], choledochoduodenostomy [n = 1]) were performed in 12 patients with dominant strictures and choledocholithiasis. One patient had successful endoscopic clearance of common bile duct (CBD) stones after first-stage surgery and required only cholecystectomy as a second-stage procedure. The average perioperative blood product transfusion requirement in second-stage surgery was 0.9 units and postoperative complications were minimal with no mortality. Over a mean follow-up of 32.2 months, all patients were asymptomatic. Decompressive shunt surgery alone relieved biliary obstruction in 24 of 37 patients (64.9%) and facilitated a safe second-stage biliary decompressive procedure in the remaining 13 patients (35.1%).

Conclusions

Decompressive shunt surgery alone relieves biliary obstruction in the majority of patients with symptomatic PBP and facilitates endoscopic or surgical management in patients who require second-stage management of biliary obstruction.     

Site-characteristic expression and induction of trefoil factor family 1, 2 and 3 and malignant brain tumor-1 in normal and diseased intrahepatic bile ducts relates to biliary pathophysiology.

BACKGROUND/AIM: Trefoil factor family (TFF)1,2,3 are involved in a homeostasis/repair process of mucosal epithelia. In this study, the significance of TFF family and deleted in the malignant brain tumor-1 (DMBT1), a putative receptor of TFF2, in the intrahepatic biliary tree was investigated in normal and diseased livers. MATERIALS AND METHODS: Expression of TFF1,2,3 and DMBT1 were examined immunohistochemically in primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC), chronic viral hepatitis (CVH), extrahepatic biliary obstruction (EBO), and normal livers. RESULTS: In normal livers, TFF1,3 and DMBT1 were infrequently detectable in large and rarely in small bile ducts, respectively. TFF2 was not detectable in large bile ducts. In large bile duct diseases (PSC and EBO), expression of TFF3 and DMBT1 were increased. In small bile duct diseases (PBC and CVH), expression of TFF2/DMBT1 was induced in moderately to severely damaged ducts irrespective of etiology. CONCLUSION: The intrahepatic biliary tree shows a site-characteristic expression and induction of TFF1,2,3 and DMBT1. In large bile ducts, TFF1,3 were constitutively expressed and increased in pathologic bile ducts. In small bile ducts, TFF2/DMBT1 is induced in damaged ducts irrespective of etiologies. However, the cytoprotective/repair property of TFF2/DMBT1 may not be enough to prevent the following bile duct loss in PBC.     

Temporal-spatial activation of apoptosis and epithelial injury in murine experimental biliary atresia

Biliary atresia is a fibro-inflammatory cholangiopathy that obstructs the extrahepatic bile ducts in young infants. Although the pathogenesis of the disease is undefined, studies in livers from affected children and neonatal mice with experimental biliary atresia have shown increased expression of proapoptosis molecules. Therefore, we hypothesized that apoptosis is a significant mechanism of injury to duct epithelium. To test this hypothesis, we quantified apoptosis using terminal transferase dUTP nick end labeling and active caspase-3 staining in livers and extrahepatic bile ducts from Balb/c mice infected with Rhesus rotavirus (RRV) within 24 hours of birth. RRV induced a significant increase in labeled cells in the portal tracts and in epithelial and subepithelial compartments of extrahepatic bile ducts, with onset within 3 days and peaks at 5-10 days. Exploring mechanisms of injury, we found increased biliary expression of caspases 1 and 4 and of interferon-gamma (IFNgamma)-related and tumor necrosis factor-alpha (TNFalpha)-related genes. Using a cholangiocyte cell line, we found that neither IFNgamma nor TNFalpha alone affected cell viability; however, simultaneous exposure to IFNgamma and TNFalpha activated caspase-3 and decreased cell viability. Inhibition of caspase activity blocked apoptosis and restored viability to cultured cholangiocytes. In vivo, administration of the caspase inhibitor IDN-8050 decreased apoptosis in the duct epithelium and the extent of epithelial injury after RRV challenge. Conclusion: The biliary epithelium undergoes early activation of apoptosis in a mouse model of biliary atresia. The synergistic role of IFNgamma and TNFalpha in activating caspase-3 in cholangiocytes and the decreased apoptosis following pharmacologic inhibition of caspases support a prominent role for apoptosis in the pathogenesis of experimental biliary atresia.     

Ultrasonography in the diagnosis of obstructive jaundice

Forty-seven patients with cholestatic jaundice were evaluated for extrahepatic biliary obstruction by ultrasonic cholangiography and the results verified by contrast cholangiography, celiotomy, or autopsy. Sonograms were evaluated both with ("official" reading) and without ("blind" reading) clinical information. By showing dilated bile ducts, sonography correctly diagnosed extrahepatic obstruction in 26 of 30 patients on "official" reading and 23 of 30 on "blind" reading. In all 17 patients without extrahepatic obstruction, sonography revealed the absence of dilated bile ducts. Among patients with extrahepatic obstruction, those with larger bile ducts had higher bilirubin concentrations, longer duration of jaundice, and were more reliably detected by sonography. In these patients, 94% with total bilirubin concentration greater than 10 mg/dl were detected by sonography, while 47% with total bilirubin concentration less than 10 mg/dl were detected. Although we recognize the limited sensitivity of sonography in early extrahepatic obstruction, we find it to be a valuable screening test in cholestatic jaundice.     

Comparison of clinicopathological characteristics between patients with occupational and non‐occupational intrahepatic cholangiocarcinoma

Background

An outbreak of cholangiocarcinoma has been reported among workers of an offset color proof‐printing department at a printing company in Japan. In this study, we compared the clinicopathological findings of this type of intrahepatic cholangiocarcinoma (occupational ICC) and non‐occupational ICC.

Methods

The clinical records of 51 patients with perihilar‐type ICC who underwent liver resection, including five patients with occupational ICC were retrospectively reviewed. The clinicopathological features were compared.

Results

In the occupational group, the patients were significantly younger (P < 0.01), while serum γ‐glutamyl transpeptidase activity and the proportions of patients with regional dilatation of the bile ducts without tumor‐induced obstruction were significantly higher (P = 0.041 and P < 0.01, respectively); the indocyanine green retention rate at 15 min was significantly lower (P = 0.020). On pathological examinations, precancerous or early cancerous lesions, such as biliary intraepithelial neoplasia and intraductal papillary neoplasm of the bile duct, were observed at various sites of the bile ducts in all occupational ICC patients; such lesions were observed in only six patients in the control group (P < 0.01).

Conclusions

The clinicopathological findings including age, liver function test results, diagnostic imaging findings, and pathological findings differed between the occupational and control groups.     

Intrahepatic versus extrahepatic cholestasis. Discrimination with biliary scintigraphy combined with ultrasound

Biliary scintigraphy and ultrasound imaging were performed in 52 patients with suspected biliary tract pathology. Results were correlated with the findings of direct cholangiography. Several new innovations in scintigraphic technique were used. The combination of ultrasound imaging and scintigraphy correctly identified biliary tract obstruction in 17 of 19 patients, 12 of whom had dilated bile ducts on ultrasonography. Intrahepatic cholestasis was correctly diagnosed in 11 of 13 patients. Accurate discrimination between intrahepatic and extrahepatic cholestasis was achieved in 28 of 32 patients (88%) with the combined studies. Scintigraphy also provided a correct diagnosis of acute cholecystitis in all 9 patients with surgically confirmed disease. Eleven additional patients with gallbladder or pancreatic disease had normal bile ducts at scintigraphy, which was confirmed with cholangiography. When combined with ultrasound imaging, modern biliary scintigraphy can (a) provide excellent discrimination between intrahepatic and extrahepatic cholestasis and (b) help determine the need for subsequent invasive diagnostic studies in selected patients.     

Temporal Expression of Cytokines in Rat Cutaneous,Fascial, and Intestinal Wounds: A Comparative Study

Background  

Previous studies have shown that healing in intestinal wounds is proportionally faster than skin. Cytokines and growth factors play a major role in these coordinated wound-healing events. We hypothesized that this more rapid intestinal healing is due to an early upregulation of proinflammatory cytokines (IL-1β, TNF-α, and IFN-γ), followed by increases in the expression of the anti-inflammatory cytokine IL-10 and growth factor TGF-β.     

Eosinophilic cholangitis with obstructive jaundice mimicking bile duct carcinoma

A 55-year-old male who presented with obstructive jaundice and radiographically documented extrahepatic biliary tract obstruction is reported. Eosinophilic infiltration of the gallbladder, common bile duct, intrahepatic bile ducts, and bone marrow was observed. Eosinophilic cholangitis, a rare inflammatory condition that clinically resembles a biliary malignancy, should be taken into consideration in the differential diagnosis in the evaluation of presumed neoplasm of the bile ducts.