Peroral cholecystoscopy with electrohydraulic lithotripsy for treatment of symptomatic cholelithiasis in end-stage liver disease (with videos).

BACKGROUND: Patients with end-stage liver disease have an increased risk of symptomatic gallstone disease, as well as complications associated with cholecystectomy. We hypothesized that peroral transpapillary cholecystoscopy with electrohydraulic lithotripsy of gallbladder stones is technically feasible and beneficial in patients who are high operative risks. DESIGN: Observational, descriptive. PATIENTS: Patients with Child's class C cirrhosis and with gallstone symptoms who were awaiting liver transplantation. INTERVENTIONS: Gallbladder stenting, dilation of the cystic duct, cholecystoscopy, electrohydraulic lithotripsy, ursodiol therapy. MAIN OUTCOME MEASUREMENTS: Gallbladder access and visualization, stone clearance, symptom relief, and complications. RESULTS: The gallbladder wall and stones were adequately visualized. Electrohydraulic lithotripsy achieved stone clearance after two sessions. Mild postprocedure pancreatitis occurred after the first treatment. The patient remained symptom free, stent free, and stone free until a liver transplantation, which was performed 25 months later. LIMITATIONS: Proof of concept performed in a single patient. CONCLUSIONS: Peroral transpapillary cholecystoscopy is technically feasible. Electrohydraulic lithotripsy of gallbladder stones under direct vision can achieve stone clearance. Patients with cirrhosis who are awaiting transplantation and other high-risk surgical candidates with symptomatic gallstone disease may benefit from this treatment option. Studies to assess the efficacy and safety of this novel technique are needed before routine clinical use can be recommended.

CXCR2 agonists in ADPKD liver cyst fluids promote cell proliferation.

Autosomal dominant polycystic kidney disease (ADPKD) is a highly prevalent genetic disease that results in cyst formation in kidney and liver. Cytokines and growth factors secreted by the cyst-lining epithelia are positioned to initiate autocrine/paracrine signaling and promote cyst growth. Comparative analyses of human kidney and liver cyst fluids revealed disparate cytokine/growth factor profiles. CXCR2 agonists, including IL-8, epithelial neutrophil-activating peptide (ENA-78), growth-related oncogene-alpha (GRO-alpha), are potent proliferative agents that were found at high levels in liver but not kidney cyst fluids. Liver cysts are lined by epithelial cells derived from the intrahepatic bile duct (i.e., cholangiocytes). In polarized pkd2(WS25/-) mouse liver cyst epithelial monolayers, CXCR2 agonists were released both apically and basally, indicating that they may act both on the endothelial and epithelial cells within or lining the cyst wall. IL-8 and human liver cyst fluid induced cell proliferation of HMEC-1 cells, a human microvascular endothelial cell line, and Mz-ChA1 cells, a human cholangiocyte cell model. IL-8 expression can be regulated by specific stresses. Hypoxia and mechanical stretch, two likely stressors acting on the liver cyst epithelia, significantly increased IL-8 secretion and promoter activity. AP-1, c/EBP, and NF-kappaB were required but not sufficient to drive the stress-induced increase in IL-8 transcription. An upstream element between -272 and -1,481 bp allowed for the stress-induced increase in IL-8 transcription. These studies support the hypothesis that CXCR2 signaling promotes ADPKD liver cyst growth.

Pancreatic imaging: current and emerging technologies.

This review discusses the current imaging modalities for the diagnosis and staging of solid and cystic pancreatic lesions and for the assessment of acute and chronic pancreatitis, and the future role of emerging technologies in the management of pancreatic diseases. Multidetector row spiral computed tomography is superior to conventional single-detector row spiral computed tomography in the detection and staging of pancreatic adenocarcinoma. Positron emission tomography is a sensitive but relatively nonspecific diagnostic modality. Positron emission tomography-computed tomography fusion may improve the staging accuracy for pancreatic cancer. Echo-enhanced ultrasound may have an emerging role in evaluating pancreatic masses. Endoscopic ultrasound with fine needle aspiration for cytology is the single best method for diagnosis and staging of nonmetastatic pancreatic cancer with a high accuracy for determining tumor resectability. In acute pancreatitis, a modification of the standard computed tomography severity index, which places greater emphasis on extrapancreatic complications, has shown superior correlation with various patient outcome measures. Endoscopic retrograde cholangiopancreatography is still the test of choice for morphological evaluation of chronic pancreatitis, whereas magnetic resonance cholangiopancreatography offers a noninvasive alternative in selected patients. Endoscopic ultrasound can be useful for detecting early chronic pancreatitis. Secretin-stimulated imaging techniques may eventually provide a noninvasive method of reliably assessing pancreatic exocrine function.

Protein kinase C regulates the phosphorylation and oligomerization of ERM binding phosphoprotein 50.

Ezrin-Radixin-Moesin (ERM) binding phosphoprotein 50 (EBP50, a.k.a. NHERF-1) is a scaffold protein essential for the localization and coordinated activity of apical transporters, enzymes and receptors in epithelial cells. EBP50 acts via multiple protein binding interactions, including oligomerization through interactions of its PSD95-Dlg-ZO1 (PDZ) domains. EBP50 can be phosphorylated on multiple sites and phosphorylation of specific sites modulates the extent of oligomerization. The aim of the present study was to test the capacity of protein kinase C (PKC) to phosphorylate EBP50 and to regulate its oligomerization. In vitro experiments showed that the catalytic subunit of PKC directly phosphorylates EBP50. In HEK-293 cells transfected with rat EBP50 cDNA, a treatment with 12 myristate 13-acetate (PMA) induced a translocation of PKCalpha and beta isoforms to the membrane and increased 32P incorporation into EBP50. In co-transfection/co-precipitation studies, PMA treatment stimulated EBP50 oligomerization. Mass spectrometry analysis of full-length EBP50 and phosphorylation analyses of specific domains, and of mutated or truncated forms of EBP50, indicated that PKC-induced phosphorylation of EBP50 occurred on the Ser337/Ser338 residue within the carboxyl-tail domain of the protein. Truncation of Ser337/Ser338 also diminished PKC-induced oligomerization of EBP50. These results suggest the PKC signaling pathway can impact EBP50-dependent cellular functions by regulating EBP50 oligomerization.

Secretion of cytokines and growth factors into autosomal dominant polycystic kidney disease liver cyst fluid.

The principal extrarenal manifestation of autosomal dominant polycystic kidney disease (ADPKD) involves formation of liver cysts derived from intrahepatic bile ducts. Autocrine and paracrine factors secreted into the cyst would be positioned to modulate the rate of hepatic cyst growth. The aim of this study was to identify potential growth factors present in human ADPKD liver cyst fluid. Cytokine array and enzyme-linked immunosorbent assay analysis of human ADPKD liver cyst fluid detected epithelial neutrophil attractant 78, interleukin (IL)-6 (503 +/- 121 pg/mL); and IL-8 (4,488 +/- 355 pg/mL); and elevated levels of vascular endothelial growth factor compared with non-ADPKD bile (849 +/- 144 pg/mL vs. 270 pg/mL maximum concentration). ADPKD liver cyst cell cultures also released IL-8 and vascular endothelial growth factor, suggesting that cystic epithelial cells themselves are capable of secreting these factors. Western blotting of cultured cyst cells and immunostaining of intact cysts demonstrate that cysteine-X-cysteine receptor 2, an epithelial neutrophil attractant 78 and IL-8 receptor, is expressed at the apical domain of cyst lining epithelial cells. Suggesting the cystic epithelial cells may exist in hypoxic conditions, electron microscopy of the ADPKD liver cyst epithelium revealed morphological features similar to those observed in ischemic bile ducts. These features include elongation, altered structure, and diminished abundance of apical microvilli. In conclusion, IL-8, epithelial neutrophil attractant 78, IL-6, and vascular endothelial growth factor may serve as autocrine and paracrine factors to direct errant growth of ADPKD liver cyst epithelia. Interruption of these signaling pathways may provide therapeutic targets for inhibiting liver cyst expansion.