Molecular pathogenesis of cholangiocarcinoma.

Epidemiological data from the last years show an increasing trend of incidence and mortality of cholangiocarcinoma (CC) worldwide. Many pathophysiologic aspects of this neoplasia are still unknown and need to be fully discovered. However, several progresses were recently made in order to establish the molecular mechanisms involved in the transformation and growth of malignant cholangiocytes. The principal concept that at least seems to be established is that cholangiocarcinogenesis is a multistep cellular process evolving from a normal condition of the epithelial biliary cells through a chronic inflammation status ending with malignant transformation. The bad prognosis related to CC justifies why a better identification of the molecular mechanisms involved in the growth and progression of this cancer is required for the development of effective preventive measures and valid treatment regimens. This Paper describes the scientific progresses made in the last years in defining the molecular pathways implicated in the generation of this devastating disease.

Gastric emptying and intragastric balloon in obese patients.

BACKGROUND: Intragastric balloons have been proposed to induce weight loss in obese subjects. The consequences of the balloon on gastric physiology remain poorly studied. We studied the influence of an intragastric balloon on gastric emptying in obese patients. PATIENTS AND METHODS: 12 patients were included in the study, with BMI (mean +/- SD) of 38.51 +/- 4.32 kg/m2. The balloon was inserted under light anaesthesia and endoscopic control, inflated with 700 ml saline, and removed 6 months later. Body weight and gastric emptying (T1/2 and T lag) using 13C-octanoic acid breath test were monitored before balloon placement, during its permanence and 2 months after removal. RESULTS: Mean weight loss was: 6.2 +/- 2.3 kg after one month; 12.4 +/- 5.8 kg after 3 months; 14.4 +/- 6.6 kg after 6 months and 10.1 +/- 4.3 kg two months after BIB removal. Gastric emptying rates were significantly decreased in the first periods with balloon in place, and returned to pre-implantation values after balloon removal. T1/2 was: 87 +/- 32 min before BIB positioning, 181 +/- 91 min after 1 month, 145 +/- 99 min after 3 months, 104 +/- 50 min after 6 months and 90 +/- 43 min 2 months after removal. T lag was 36 +/- 18 min before BIB positioning, 102 +/- 82 min after 1 month, 77 +/- 53 min after 3 months, 59 +/- 28 min after 6 months and 40 +/- 21 min. 2 months after removal. CONCLUSIONS: BIB in obese patients seems to be a good help in following the hypo caloric diet, especially during the first three months when the gastric emptying is slower and the sense of repletion is higher. After this period gastric emptying starts to return to normal and the stomach adapts to BIB loosing efficacy in weight loss.

Portal hypertensive gastropathy: reproducibility of a classification, prevalence of elementary lesions, sensitivity and specificity in the diagnosis of cirrhosis of the liver. A NIEC multicentre study. New Italian Endoscopic Club.

OBJECTIVE: To classify elementary endoscopic lesions of portal hypertensive gastropathy, assess their reproducibility, prevalences, sensitivity and specificity in the diagnosis of cirrhosis of the liver. METHODS: 1) A classification of portal hypertensive gastropathy elementary lesions was defined. 2) Thirty-two endoscopists evaluated videotapes of endoscopic examinations of patients with liver cirrhosis to assess beyond-chance agreement (kappa). 3) Fifteen centres enrolled consecutive patients with or without cirrhosis of the liver and recorded portal hypertensive gastropathy pattern according to its location. RESULTS: 1) Four elementary lesions (Mosaic-Like Pattern, Red Point Lesions, Cherry Red Spots, Black-Brown Spots) were identified, and graded. 2) A fair to good beyond-chance agreement was obtained for all 4 lesions. 3) portal hypertensive gastropathy prevalence was higher in patients with cirrhosis of the liver (0.63, sensitivity) than in controls (0.17). Mosaic-like pattern was the most prevalent sign (0.54). Specificity of portal hypertensive gastropathy was 0.83. Portal hypertensive gastropathy was tentatively classified as mild or severe when mosaic-like pattern alone or red marks of any kind were present, respectively; this classification led to a further improvement in reproducibility. CONCLUSIONS: Our results suggest that a sufficient degree of agreement can be achieved in recording portal hypertensive gastropathy. Therefore, the New Italian Endoscopic Club classification should be used to evaluate the natural history of this condition.

Sclerotherapy plus octreotide versus sclerotherapy alone in the prevention of early rebleeding from esophageal varices: a randomized, double-blind, placebo-controlled, multicenter trial. New Italian Endoscopic Club.

Because of its ability to decrease portal pressure, azygos blood flow, and postprandial splanchnic hyperemia, octreotide administration could be effective in reducing early rebleeding in patients undergoing endoscopic variceal sclerotherapy (EVS). We report the results of a trial comparing EVS + octreotide versus EVS alone. Consecutive patients with cirrhosis and endoscopically proven variceal hemorrhage were considered eligible for the trial if hemodynamically stable for at least 24 hours after bleeding stopped. Patients with advanced liver cancer or having received EVS treatment in the past were not enrolled. After enrollment patients were submitted to EVS (day 1); all patients were randomized to receive octreotide, 100 micrograms three times a day subcutaneously, or an identical placebo, up to day 29; EVS was repeated at days 8, 15, and 29. Fifty-eight patients were randomized to receive either EVS + octreotide (n = 26) or EVS alone (n = 32). The two groups were evenly balanced for sex, age, Child-Pugh class, history of previous bleeding, endoscopic appearance of varices, or treatment received in emergency. Eight of 26 (31%) patients in the EVS + octreotide group rebled, compared with 11 of 32 (34%) in the EVS group. Four of the eight (50%) patients in the former group and 8 of 11 (73%) in the latter, respectively, bled within day 15. There were 10 (38.5%) deaths in the EVS + octreotide group (seven bleeding-related), compared with seven (21.9%) (five bleeding-related) in the EVS group; these differences did not reach statistical significance. Administration of octreotide, 100 micrograms three times a day, subcutaneously, to patients undergoing EVS for prevention of recurrent variceal bleeding does not decrease the incidence of early rebleeding.

The fate of electron opaque tracers (horseradish peroxidase and lanthanum chloride) during valproic acid-induced choleresis.

Horseradish peroxidase (HRP) and lanthanum chloride (LaCl3) are useful tools for, respectively, the study of vesicular transport through the hepatocyte and the study of the permeability of junctional complexes. These tracers have been used to detect the changes associated with the choleresis independent of bile acids induced by valproic acid (VPA) in rats. The animals were given a single dose of VPA (600 mg/kg, ip). HRP (100 mg/kg) or 5 mM LaCl3 were given intraportally after 1 h, when bile flow had increased twofold. The excretion of HRP in bile was measured colorimetrically up to 2 h after HRP. Ultrastructural morphometry was conducted on liver of intact rats taken from 1 to 40 min after HRP. The volume density (VD) of HRP-containing vesicles and of HRP-containing multivesicular bodies (MVB) was counted. In VPA-treated rats, HRP appeared in bile with a peak showing at 5 min against 20 min in controls, but the total amount of HRP excreted was less than in controls. The intrahepatocytic vesicular transport of HRP was also modified, showing a peak at 3 min in VPA-treated rats compared to 10 min in controls, together with a decreased VD of pericanalicular vesicles. This was accompanied by an increase of HRP-containing MVB, already evident at 5 min.(ABSTRACT TRUNCATED AT 250 WORDS)

Demonstration of a transcellular vesicle pathway for biliary excretion of inulin in rat liver.

We tested the hypothesis that the blood to bile transport of hydrophilic inert nonelectrolytes such as inulin is mediated in part by a transcellular pathway involving endosomelike vesicles (transcytosis). Forty minutes after intravenous injection of [3H]methoxyinulin into renal pedicle ligated rats, 0.8% of the radioactivity was recovered in liver homogenate and 85% +/- 3.6% of this radioactivity was associated with membrane bound vesicles. Subcellular fractionation studies and electron microscopy confirmed this association. If rats were treated with taurochenodeoxycholic acid, 5 mumol/100 g body wt, the hepatocellular uptake of [3H]methoxyinulin increased approximately twofold and [3H]methoxyinulin was again recovered in small subcellular vesicles. Furthermore, taurochenodeoxycholic acid also stimulated the biliary excretion of [3H]methoxyinulin, which peaked in bile at 20 min. Taurochenodeoxycholic acid had similar effects on the biliary excretion of horseradish peroxidase, a protein known to be transported from blood to bile by membrane vesicles. Thus under the conditions of these experiments, the dihydroxy bile acid taurochenodeoxycholic acid can stimulate the rate of vesicle-dependent transcellular transport into bile. If inulin clearance represents a maximal estimate of this process, only 6%-8% of total bile production in the rat under basal conditions would be mediated by vesicle-mediated transcytosis.

Multiple gastric carcinoids and pernicious anemia: report of a case.

A case of pernicious anemia associated with multiple gastric carcinoids is reported. The neoplastic growth was composed of enterochromaffin-like (ECL) cells, and ECL cell hyperplasia was observed also in hyperplastic polyps, inside the fundic glands and in small nests lying in the lamina propria (microcarcinoidosis). The possible relation between pernicious anemia and ECL cell hyperplasia is discussed.

The effects of H2 receptor antagonists on hepatic microsomal drug metabolism and fine morphology of rat liver.

The study is concerned with the effects of cimetidine (C), ranitidine (R) and oxmetidine (O) on rat liver cells, in order to compare the effects of increasing amounts of the drugs on various metabolic pathways and on hepatocyte morphology, and their relationship with the drug structure, namely the presence of an imidazole or furan ring. In vitro, an inhibition of ethylmorphine N-demethylase (E-DM) (60%) and of aniline hydroxylase (A-OH) (20%) was observed when either C or R were added at a concentration higher than 0.5 mM to microsomes from untreated rats. Microsomes from phenobarbital or 3-methylcholanthrene-pretreated animals showed a 30 to 40% inhibition of E-DM (mixed type inhibition). In vivo, administration of a single dose (475 microM/kg) of R was followed by an inhibition of E-DM activity, significantly less pronounced (p less than 0.05) than following an equimolar amount of C, whereas O did not alter the enzymatic activity. The amount of cytochrome P-450 and the activities of NADPH cytochrome c reductase and of A-OH were substantially unaffected. No changes of smooth endoplasmic reticulum or of other liver cell organelles were observed by electron microscopy. These findings demonstrate that both in vivo and in vitro E-DM appears as the more sensitive among the pathways considered. Moreover the data support the view that the mere presence of the imidazole ring does not account for the inhibitory effect of H2 antagonists.

Changes induced in human liver by long-term anticonvulsant therapy. Functional and ultrastructural data.

The study reports functional and morphological findings in eight male subjects undergoing anticonvulsant therapy for periods from 20 days up to 15 years. All subjects showed an increased activity of the hepatic microsomal NADPH cytochrome c reductase and an increased amount of smooth membranes in hepatocytes. The enzymatic activity was higher in the first years of treatment. Quantitative ultrastructural analysis showed that a twofold increase of the smooth membranes of hepatocytes had already been reached after 20 days of therapy, with a modest additional increase occurring thereafter. Both enzymatic and structural changes appear to be related to therapy. In addition, abnormal lipofuscin-related cytoplasmic formations were present in the hepatocytes of five subjects. Such formations are thought to represent an accumulation of abnormal degradation products, possibly related to an interaction of the drug(s) metabolites with cellular components.

Rifampicin-induced elevation of serum bile acids in man.

Fasting and postprandial serum bile acid concentrations were determined by gas-liquid chromatography in 20 consecutive individuals (14 normal subjects, 6 cirrhotics) before and after administration of rifampicin in a single dose of 900 mg, using each individual as his own control. In the normal subjects the 2-hr postprandial level was 2.9 +/- 0.2 microM (mean +/- 1 SEM) prior to drug administration. Following rifampicin, it was 7.7 +/- 0.5 microM (P less than 0.0005). In the patients with liver cirrhosis the 2-hr postprandial level increased from 30.2 +/- 3.5 before, to 105.0 +/- 27.7 microM after rifampicin (P less than 0.025). Twelve hours after drug administration the levels of serum bile acids were not significantly different with respect to the control values. Total serum bilirubin also showed a transient and parallel increase. These findings are compatible with the hypothesis that rifampicin inhibits the hepatic transport of bile acids.

Effect of chenodeoxycholic acid on liver structure and function in man: a stereological and biochemical study.

Chenodeoxycholic acid (CDCA) is an effective treatment for dissolving gallstones but experimental studies have suggested that it might be hepatotoxic. The present study is concerned with a group of patients undergoing medical therapy for gallstones for periods of 30 days up to 14 months with CDCA (15 mg/kg/day). Routine functional tests, determination of some liver microsomal enzymes and stereological studies of the liver tissue have been performed and the data have been compared with those obtained before treatment. No significant changes were observed in the functional tests throughout the study. Also the microsomal mixed function oxidase system seemed unaffected by CDCA therapy. The histological features of the liver biopsies were not appreciably different from those observed prior to treatment. Although there were large interindividual variations, the volume density of parenchymal steatosis and of the lipocytes remained comparable in the ssme individual. The ultrastructural features noted in untreated subjects such as curled mitochondrial cristae, slight intracellular bile retention, increased surface density of the rough endoplasmic reticulum were still evident after 14 months of treatment. No additional changes were noted. These results show that no evidence of hepatotoxicity seems to develop in man under therapy with CDCA at the dose considered. But the structural abnormalities observed before treatment appear to persist even in subjects under long-term therapy.

[Routine double contrast examination of the stomach: results and considerations on personal experience (author's transl)]. / L'esame di routine a doppio contrasto dello stomaco: risultati e considerazioni di un'esperienza.

The results are presented on the double contrast investigation of the stomach performed during routine hospital activity. Purposes of the work are to evaluate the diagnostic accuracy of the method and to suggest the location of the diagnostic investigation. 602 consecutive patients were examined and 188 out of these underwent endoscopy. The diagnostic accuracy of the method was evaluated at gastroscopic control. Moreover the cost of the method was considered, in order to evaluate the possible routine application of the method in the hospitals.

[Multi-institution, multidisciplinary radiology and endoscopy trial of the diagnostic accuracy of the double contrast examination of the stomach surface]. / Trial policentrico multidisciplinare radiologia-endoscopia sul rendimento diagnostico dell'esame a doppio contrasto di superficie dello stomaco.

In 12 X-ray and gastroenterology departments 1570 patients, clinically suspected to have a gastric pathology, have been examined by double contrast (surface) examination of the stomach followed by gastroscopy. Diagnostic accuracy was 93% in respect of endoscopic data, assumed correct by hypothesis. On the basis of a cost and benefit evaluation, made according to the well known criteria, a wider routine use of the double contrast technique is proposed.

A stereological and biochemical study of the human liver in uncomplicated cholelithiasis.

A quantitative analysis of needle liver biopsies of patients with untreated, uncomplicated cholelithiasis has been performed to better evaluate eventual changes occurring under medical therapy of gallstones. With the light microscope, the intensity of parenchymal steatosis was variable among the patients but the mean volume density of lipid droplets was significantly increased as compared to normal subjects. In addition, there was a significant increase in the volume density of lipocytes (fat-storing cells) without an increase in the number per square area, suggesting a hypertrophy of individual cells. The data obtained by ultrastructural morphometry show a significant increase in the surface density of the rough endoplasmic reticulum in the hepatocytes, a significant increase of the mitochondrial volume density together with the presence of curled mitochondrial cristae and a slight, inconstant intracellular and intracanalicular bile retention. No qualitative or quantitative changes were observed at the level of the smooth endoplasmic reticulum. The activity of the microsomal enzyme NADPH-cytochrome c reductase as evaluated on liver biopsy material was in the normal range. Some of the features observed in this group of patients are reminiscent of alterations previously described in human or experimental cholestasis and suggest that they might depend on a common underlying disturbance in cholesterol and bile salt metabolism.