Natural history of alcoholic hepatitis. IV. Glycosaminoglycuronans and collagen in the hepatic connective tissue.

The extractable and nonextractable collagen and glycosaminoglycuronans (GAG) were estimated and characterized in 32 dried, defatted human livers obtained at necropsy. 10 had normal livers. 22 of the 32 livers were from patients who drank in excess: 5 had fatty livers, 7 had alcholic hepatitis, and 10 had cirrhosis. Livers with alcoholic hepatitis or cirrhosis had significantly increased total and 1 N NaCl-extractable collagen. Only alcoholic hepatitis livers had significantly increased Tris-buffer-extractable GAG, but the amino acid composition of these GAG (proteoglycans) was no different from that of normal livers. The major fraction of these GAG had isoelectric pH (pI)

Maximal rates of excretion and synthesis of urea in normal and cirrhotic subjects.

When normal individuals eat 0.33 g protein N/kg body weight (BW)((3/4)) per day, they excrete 10-15 mg urea N/h per kg BW((3/4)). If they now ingest (at 0 h) 0.27 (dose A), 0.40 (dose B), 0.53 (dose C), 0.94 (dose D), or 1.33 (dose E) g protein N/kg BW((3/4)) (in the form of casein, ovalbumin, or lactalbumin), the rate of urea N excretion accelerates within 4 h. At dose C a maximal rate of urinary urea N excretion (MRUE) is reached, which averages 55 mg urea N/h per kg BW((3/4)) and which persists for 16 h. Higher doses of protein do not further accelerate urea excretion, but prolong the duration of MRUE to 28 h (after dose E). Blood urea N (BUN) rises by 7-20 mg/100 ml during the first 8 h after dose C to E, and remains stable within +/-5 mg/100 ml during the ensuing 8-28 h of MRUE. Each increment of protein above dose C causes a further increment in plasma alpha-amino N. During infusion of free amino acids at a rate of 110 or 165 mg amino acid N/h per kg BW((3/4)) for 12 h, rate of urea excretion increases to the MRUE value produced by dose C-E of oral protein.These findings indicate that MRUE corresponds to a period of maximal rate of urea synthesis (MRUS). MRUS is greater than MRUE because one fraction of newly formed urea is hydrolyzed in the gastrointestinal tract, and another fraction may accumulate temporarily in body water during the MRUE period. Oral neomycin reduces the proportion of urea hydrolyzed in the gut to less than 20%; its extent is measured by recovery in the urine of a tracer dose of [(14)C]urea injected intramuscularly during determination of MRUE. Accumulation of urea in body water is estimated from increment in BUN during the period of MRUE measurement (8-24 h after dose E of casein) and from body water measured with (3)H(2)O. Then MRUS is calculated as: ([mg urea N excreted between 8 and 24 h after dose E] + [BUN at 24 h - BUN at 8 h] x [body water]) x (100/% recovery [(14)C]urea) x (1/kg BW((3/4))) x (1/16 h).MRUS in 10 normal subjects averaged 65 mg urea N/h per kg BW((3/4)) (range 55-76), and in 34 cirrhotics 27 mg urea N/h per kg BW((3/4)) (range 6-64). Among 19 cirrhotic patients fed 40, 60, 80, or 100 g protein daily for successive 10 day periods, the occurrences of hyperammonemia, hyperaminoacidemia, and encephalopathy at each level of protein intake were inversely related to MRUS value.

The rate of synthesis of glycosaminoglycans and collagen by fibroblasts cultured from adult human liver biopsies.

Adult human liver biopsies were cultured from normal, alcoholic hepatitis, chronic active hepatitis, fibrosis plus alcoholic hepatitis (active cirrhosis), inactive cirrhosis, and drug hepatitis. The synthesis of collagen was estimated in cultures from 58 livers by measuring the conversion of [(14)C]proline to the [(14)C]hydroxyproline of collagen; that of glycosaminoglycans in cultures from 57 livers by the incorporation of [(3)H]acetate and (35)SO(4) into glycosaminoglycans (GAG). The synthesis of procollagen was increased only in cultures from alcoholic hepatitis, both in the pulse medium (P < 0.05) and in the chase medium (P < 0.02). The synthesis of insoluble collagen was increased in cultures from chronic (active) hepatitis (P < 0.01), fibrosis plus alcoholic hepatitis (active cirrhosis) (P < 0.001), and inactive cirrhosis (P < 0.05). Essentially all radioactive GAG was soluble in culture media. The predominant GAG were chondroitin-4 or -6-SO(4). The synthesis of GAG was increased only in cultures from fibrosis plus alcoholic hepatitis (active cirrhosis) both in the pulse medium (P < 0.01) and chase medium (P < 0.001). The data indicate that in the absence of immuno-competent cells or their secretory products, tissue cultures from livers showing biopsy evidence of active fibrosis in vivo may demonstrate increased synthesis of collagen and GAG in vitro. Increased (soluble) procollagen synthesis in cultures from alcoholic hepatitis was not associated with histologically demonstrable overt hepatic fibrosis in vivo, nor was it associated with increased GAG synthesis in vitro. No significant difference was demonstrable in collagen or GAG synthesis in paired cultures which contained either 300 mg/dl ethanol or 3.75 mg/dl methylprednisolone compared to their respective controls.

Biochemistry and pharmacology of S-adenosyl-L-methionine and rationale for its use in liver disease.

The major biological functions of S-adenosyl-L-methionine (SAMe) include methylation of various molecules (transmethylation) and synthesis of cysteine (trans-sulphuration). A stable double salt of SAMe has been found to be effective in intrahepatic cholestasis. The mechanism of its therapeutic effect is not fully understood but presumably involves methylation of phospholipids. Methylation of plasma membrane lipids may affect membrane fluidity and viscosity, which modulate the activities of a number of membrane-associated enzymes, for example, the activity of enzymes involved in Na+/Ca++ exchange (e.g. sarcolemmal vesicles), Na+/K+ adenosine triphosphatase (ATPase) [e.g. hepatocyte plasma membranes], and Na+/H+ exchange (e.g. plasma membranes of colonic cells). Recently, patients with cirrhosis were shown to have an acquired metabolic block in the hepatic conversion of methionine to SAMe. These patients, when administered conventional elemental diets, develop abnormally low plasma concentrations of cysteine and choline, 2 nonessential nutrients present in low concentrations in most elemental diets. These low concentrations probably reflect systemic deficiencies attributable to reduced endogenous syntheses of cysteine and choline caused by limited availability of hepatic SAMe. Such cirrhotic patients are often in negative nitrogen balance and have abnormal hepatic functions, which are corrected by cysteine and choline supplements. Noncirrhotic patients on parenteral elemental diets also become deficient in cysteine and choline. Consequently, these patients may require SAMe as an essential nutrient to normalise their overall hepatic transmethylation and trans-sulphuration activities.

Ethanol: relative fuel value and metabolic effects in vivo.

A nasogastric formula infusion method was used to evaluate the steady-state fuel value of ethanol relative to that of glucose in eight chronically alcoholic men undergoing a 4- or 5-week balance experiment. Each subject received a maintenance infusion of the formula diet throughout the study. When control formula glucose (week 1) was isocalorically replaced with ethanol [week 2, 30% of kcal; week 3 or 4 (5-week experiment) 40% to 60% of kcal], the following was observed: weight loss; zero energy balance and reduced or negative balances of N, K, P, Mg, and Na; increased urinary urea N and 3-methylhistidine; lowered urinary C-peptide; no change in indirectly or directly measured thermal energy losses; and a blood level related rise in breath and urinary ethanol losses. All of these changes promptly reversed during the middle (week 3 in 5-week experiment) and final control weeks. Accounting for all diet-related energy losses (urine, breath, thermal), the fuel value of the ethanol-containing diet relative to the glucose control formula varied between 0.95 and 0.99, depending upon the blood alcohol level. Hence weight loss during short-term (seven-day) ethanol infusion is unrelated to overall negative energy balance, stems primarily from decrements in protein, minerals, and fluid, and may in part be mediated by the reduction in insulin secretion that accompanies switching from dietary glucose to ethanol.

Serum calcium responses to exogenous secretin.

Increasing attention is being focused on the relationship between gastrointestinal hormones and calcium metabolism. While it is apparent that some relationship does exist, the exact nature and significance is as yet undefined. Information regarding the effect of secretin on serum calcium has been both sparse and contradictory. Boot's secretin, 3 units/kg, was given to a group of 44 patients consisting of normal controls and patients with duodenal, gastric, and marginal ulcers; primary hyperparathyroidism; and pernicious anemia. Six serial serum specimens were obtained from each patient at ten-minute intervals for calcium determination by atomic absorption spectrophotometry. Using two-way analysis of variance, no significant changes in postsecretin serum calcium values were observed. It is unlikely that physiologic levels of secretin exert any effect on serum calcium.

Peritoneovenous shunts. Lessons learned from an eight-year experience with 70 patients.

The peritoneovenous shunt (PVS) is preferred over other treatment modalities in the treatment of the cirrhotic patient who has intractable ascites. The favorable effects on nutrition, pulmonary, and renal function, in addition to prompt control of ascites, frequently overshadow potentially life-threatening complications. We summarized our experience with the PVS in 70 patients with portal hypertension at Emory University, Atlanta, and identified the perioperative complications and operative mortalities. Late complications of sepsis and variceal hemorrhage were frequent and often were fatal. Of the multiple preoperative clinical and laboratory determinants, only the serum bilirubin level (greater than or equal to 3 mg/dL) was predictive of the operative mortality and longevity of survivors. The PVS should be reserved for patients with disabling, truly refractory ascites.

Evaluation of patients with portal hypertension.

In order to select the most suitable management of portal hypertension, a full evaluation of the patient is desirable. The aspects studied should include the possible causes of portal hypertension and the disease and function of the liver, as well as the psychosocial aspects of this condition. The usual reason to investigate the presence and causes of portal hypertension is the detection of gastroesophageal varices. The estimated probability of bleeding from the varices and the cause of the varices should be investigated. If cirrhosis is detected, then its cause or mechanism should be clarified and the activity of the process estimated in semiquantitative terms. If therapy is available, it should be initiated. The evaluation of liver function is based on quantitative measurements of hepatocellular metabolic function (such as the galactose elimination capacity or antipyrine clearance), liver volume (weight), liver blood flow, and systemic hemodynamics (cardiac output index).

The mortality of bleeding esophageal varices in a private university hospital.

The mortality of patients with bleeding esophageal varices was studied in a private hospital where the modalities of treatment are considered optimal. Of the sixty-two patients in the study, twenty (32 per cent) died. Mortality was higher (p is less than 0.02) for those who had ascites or bilirubin more than 5 mg/dl, albumin less than 3 gm/dl, prothrombin time more than 4 seconds of control, or blood transfusions of more than 5 liters. The lower mortality in this study as compared with other studies among indigent population is the result of either private patients having less severe liver disease or having more effective care of both.

Radionuclide angiography of the liver and spleen. Noninvasive method for assessing the ratio of portal venous to total hepatic blood flow and portasystemic shunt patency.

Radioactivity verus time curves were generated for the first pass of technetium-99m pertechnetate through the left ventricle, kidneys, spleen and liver, after a 20 mCi peripheral intravenous bolus injection. The rate of change of radioactivity in these organs before recirculation is proportional to blood flow through the organ. The hepatic perfusion index, defined as the ratio of portal flow to total hepatic blood flow, was correlated with the angiographic grade of portal perfusion. The hepatic perfusion index in seven normal subjects was 66.0 +/- 3.4 percent (mean +/- standard error of the mean), and in 22 cirrhotic patients with decreasing angiographic perfusion of grades 1 to 4 the index was 54 +/- 4.6, 37 +/- 2.6, 17 +/- 4.7 and 3 +/- 1.1 percent, respectively. The correlation between the calculated perfusion index and the angiographic grade of portal flow was highly significant (p less than 0.001). The passage of radionuclide through the spleen differed before and after shunt surgery in patients with portal hypertension. The slope to height ratio, based on the downslope of the splenic curve, was significantly greater (p less than 0.01) in the shunted patients and provided a simple index for assessing shunt patency.

Approach to the spectrum of Budd-Chiari syndrome: which patients require portal decompression?

Budd-Chiari syndrome (occlusion of the hepatic veins) represents a spectrum disorder. From 1974 to 1984, 20 patients with the syndrome were managed. Eleven required shunt surgery (Group 1) and 5 were managed with nonshunt therapy (Groups 2 and 3). Results have been good. Retrospective review of the liver biopsy specimens showed that Group 1 patients had a greater degree of zone 3 necrosis than Group 2 and 3 patients. We submit that presence of zone 3 necrosis on an initial liver biopsy specimen may define the failing liver of Budd-Chiari syndrome that requires conversion of the portal vein to an outflow tract by shunting.

Jejunoileal bypass and nutritional liver injury.

Jejunoileal bypass operation may be an experimental model of nutritional liver injury in man. The similarity of the bypass-induced hepatic histopathologic features to those of alchoholic liver disease raises the question of a common pathway in alcoholic and in postoperative (bypass) liver diseases.

Importance of terminal hepatic venule thickening.

Thickening around the terminal hepatic venule (THV) in alcoholics has been implicated as a marker for fibrosis and cirrhosis. To test this hypothesis, we evaluated 107 liver biopsy specimens from patients with normal liver histologic features (12), fatty livers (30), mild alcoholic hepatitis (15), and florid alcoholic hepatitis (29). Twenty-one follow-up liver biopsy specimens from patients with fatty liver and alcoholic hapatitis were also available for this study. Two observers (S.M.N., V.H.N.) graded 18 histologic features on a scale of 0 to 3. There was no significant difference in the prevalence of THV thickening in normal biopsy specimens and in various forms for alcoholic liver injury. There was also no correlation between the degree of THV thickening and steatosis, necrosis, or inflammation. Thickening of the THV was most common in the presence of lobular and subsinusoidal fibrosis. Cirrhosis developed in nine of ten alcoholic patients who had subsinusoidal and lobular fibrosis. These findings illustrate that the marker for progressive fibrosis and development of cirrhosis is lobular and subsinusoidal fibrosis and not the isolated thickening of the THV.

Use of colchicine and steroids in the treatment of alcoholic liver disease.

To date, only one group has reported its clinical experience with colchicine therapy. This study included a randomized clinical trial of 22 patients and an open study of 53 patients. The beneficial effect of 1 mg colchicine daily for five days a week has been promising but not convincing. Corticosteroid therapy for the treatment of alcoholic hepatitis was evaluated in nine short-term randomized clinical trials that included 150 treated and 161 control patients with a mortality rate of 37 and 44%, respectively. In these studies, encephalopathy was present in 80 treated and 76 control patients with a mortality rate of 59 and 74%, respectively. None of these differences is significant. The studies did document that patients with mild disease require no specific therapy besides abstinence and general supportive measures; those with severe disease showed a trend toward better survival on corticosteroid therapy. This trend was strong in the earlier publications, but was absent in the most recent studies, which included the largest numbers of patients.