Mechanism of bile acid facilitation of biliary protoporphyrin excretion in rat liver.

The mechanism(s) by which bile acids increase biliary protoporphyrin excretion was characterized using perfused rat livers. We determined 1) relationships between biliary bile acids, phospholipid, and protoporphyrin, using rapid kinetic analyses; 2) protoporphyrin excretion in livers with defective canalicular multispecific organic anion transport; 3) effects of intracellular vesicular transport inhibition with colchicine and monensin; and 4) the role of luminal bile acids, using retrograde intrabiliary taurocholate injections. Biliary protoporphyrin excretion peaked with phospholipid excretion 14-18 min after loading. Protoporphyrin excretion induced by taurocholate was not related to effects on intracellular transport, including colchicine- and monensin-inhibitable vesicular systems. Eisai hyperbilirubinemic rat livers excreted protoporphyrin similarly to controls. Retrograde intrabiliary taurocholate injections increased protoporphyrin output. Collectively, these data suggest that 1) intracellular protoporphyrin transport is mediated by nonvesicular carriers targeted to the canalicular membrane, and 2) bile acid facilitates protoporphyrin translocation into bile in the same manner it effects phospholipid excretion.

Randomized, placebo-controlled comparison of famotidine 20 mg b.d. or 40 mg b.d. in patients with erosive oesophagitis.

METHODS: This US multicentre, randomized, double-blind, placebo-controlled, parallel group study determined the effects of two twice daily oral famotidine regimens on symptom relief and healing of erosive oesophagitis in patients with gastro-oesophageal reflux disease. Three hundred and eighteen patients were enrolled: 66 received placebo, 125 received famotidine 20 mg b.d., and 127 received famotidine 40 mg b.d. Patients maintained diaries of their symptoms. Endoscopy was performed at weeks 0 and 6, and again at week 12 if healing had not occurred. RESULTS: Healing at 6 and 12 weeks was (respectively) 48% (P < or = 0.01 vs. placebo) and 69% (P < or = 0.01 vs. placebo) for famotidine 40 mg b.d.; 32% and 54% (P < or = 0.01 vs. placebo) for famotidine 20 mg b.d., and 18% and 29% for placebo. At both 6 and 12 weeks the healing rates of famotidine 40 mg b.d. were significantly greater than placebo and famotidine 20 mg b.d. Compared to placebo, famotidine produced more frequent global symptom improvement and more rapid heartburn relief. There were no significant differences among treatment groups in the incidence of clinical or laboratory adverse events. CONCLUSIONS: Famotidine 40 mg b.d. was a better regimen than famotidine 20 mg b.d. or placebo. The clinical efficacy paralleled the previously documented effect of the famotidine regimens on decrease of oesophageal acid exposure.

Restoration of squamous mucosa after ablation of Barrett's esophageal epithelium.

BACKGROUND: Antireflux therapy has generally failed to induce regression of Barrett's epithelium. It was hypothesized that squamous epithelium could be restored if the columnar tissue was ablated while gastric acid secretion was suppressed. METHODS: Ten white men with Barrett's esophagus received 40 mg of omeprazole daily. Thereafter, every 2-5 weeks they underwent videotaped endoscopies to argon laser photoablate columnar tissue, obtain biopsy specimens, and assess results. Squamous re-epithelialization was assessed by correlation of videotapes and directed biopsies. RESULTS: Patients had one to eight areas ablated, totaling 0.5-12.0 cm2. Videotape assessments were corroborated by biopsy in all but one instance. Thirty-eight of 40 treatment locations partially or completely re-epithelialized with squamous tissue. Squamous regrowth appeared to occur by spread from contiguous squamous borders and de novo from glandular tissue. Regrowth was influenced by the extent of squamous borders and completeness of ablations. Nonablated glandular tissue persisted beneath squamous epithelium. CONCLUSIONS: Ablation of Barrett's epithelium and suppression of acid secretion facilitated squamous re-epithelialization. A progenitor cell within the metaplastic tissue has the potential to differentiate normally.

Protoporphyrin overload in unrestrained rats: biochemical and histopathologic characterization of a new model of protoporphyric hepatopathy.

We determined the feasibility of producing protoporphyric hepatopathy in unrestrained rats by infusing protoporphyrin into their portal circulation via chronic indwelling catheters. Sprague-Dawley rats, 200-300 g, received single (8.5-27.8 mumol) or multiple (64.1-208.7 mumol) infusions of protoporphyrin over 3-240 h. Single protoporphyrin infusions increased the hepatic protoporphyrin concentration from < 1 nmol/g up to 1368 nmol/g; multiple infusions up to 3908 nmol/g. The maximal non-hepatic tissue concentrations averaged 243 nmol/g in the spleen. Hepatocanalicular and ductular birefringent pigmented deposits were found in all livers, generally proportional to the protoporphyrin load. Aggregates of crystalline protoporphyrin were detected in biliary ductules, canaliculi, hepatocytes, Kupffer cells and fat-storage cells by electron microscopy. Laboratory abnormalities included elevations of the transaminases, LDH, GGTP and bilirubin and a modest fall in the haematocrit suggesting a mixture of red blood cell and hepatic injury. Thus, protoporphyric hepatopathy was produced by infusions of protoporphyrin into the portal circulation. This model may aid in understanding the pathogenesis and pathophysiology of liver disease in protoporphyria.

Two doses of omeprazole versus placebo in symptomatic erosive esophagitis: the U.S. Multicenter Study.

Two hundred thirty patients with reflux symptoms and endoscopically proven erosive esophagitis were enrolled from 15 U.S. centers into a randomized, double-blind, dose-ranging study comparing placebo with omeprazole, 20 or 40 mg given once daily in the morning. Esophagitis grade 2 was present in 44% of patients, grade 3 in 37% of patients, and grade 4 in 19% of patients. Endpoints, defined as complete relief of heartburn and complete esophageal mucosal healing, were assessed after 4 and 8 weeks of treatment. Both omeprazole doses were significantly superior to placebo in complete endoscopic healing. After 8 weeks of treatment, 73.5% of patients in the 20-mg omeprazole group and 74.7% in the 40-mg omeprazole group, compared with 14.0% in the placebo group, had complete healing of the esophageal mucosa. At the end of the study, complete relief of daytime heartburn was obtained in 79.5% of patients in the 20-mg omeprazole group, 81.6% in the 40-mg omeprazole group, and 37.2% in the placebo group (P less than or equal to 0.05). Complete relief of nighttime heartburn was noted by 79.5% of patients in the 20-mg omeprazole group, 85.1% in the 40-mg omeprazole group, and 34.9% in the placebo group (P less than or equal to 0.05). The median time to complete relief of daytime and nighttime heartburn occurred earlier in the 40-mg group than in the 20-mg group (9 vs. 17 days and 9 vs. 20 days, respectively); however, these differences were not statistically significant. Relief of acid regurgitation and dysphagia also occurred earlier in the 40-mg group. Omeprazole was well tolerated in this group of patients. No unexpected adverse experiences occurred. The results of this study confirm those of six multicenter, international trials in which omeprazole in doses of 20-60 mg provided a degree of esophageal mucosal healing and complete relief of reflux symptoms superior to any other medical treatment.

Methamphetamine-induced ischemic colitis.

A 50-year-old woman with acute onset of right lower quadrant pain and hematochezia proved to have segmental ischemic colitis associated with methamphetamine abuse. The diagnosis was established by colonoscopy with biopsy, and abdominal angiography revealed no thrombosis, vasculitis, or vasospasm. The condition resolved within 10 days. Since methamphetamine abuse is increasing, physicians should be aware of its potential to produce intestinal ischemia.

Importance of bile acid structure in amelioration of griseofulvin-induced murine protoporphyric hepatopathy.

This study investigated the effects of bile acid structure on griseofulvin-induced murine hepatopathy and explored the mechanism(s) of cholestasis in this model of protoporphyria. Mice were fed pulverized chow with cholate, chenodeoxycholate, or ursodeoxycholate, with or without griseofulvin. After 1 to 4 weeks, bile flow, bile acid excretion and composition, biliary protoporphyrin excretion, hepatic protoporphyrin contents, liver histology, and griseofulvin plasma concentrations were determined. Additionally, bile acid absorption was measured. Griseofulvin induced a progressive increase in liver weight, hepatic protoporphyrin content, and histopathologic evidence of cholestasis. Biliary protoporphyrin excretion increased and pigmented gallbladder microliths developed. Bile flow and bile acid excretion fell in relation to liver weight but not in relation to body weight. Cholic acid augmented biliary protoporphyrin excretion, markedly reduced hepatic protoporphyrin content, and obviated the development of intrahepatic biliary thrombi. Ursodeoxycholate and chenodeoxycholate both reduced biliary protoporphyrin excretion. This was associated with bile acid compositional changes, particularly a fall in cholic acid. Although histopathologic abnormalities were not altered, these bile acids reduced hepatic protoporphyrin contents. Bile acid treatments with griseofulvin all increased bile flow and bile acid excretion relative to controls, but differences in the relationship of bile flow to bile acid structure on protoporphyrin disposition. They document biliary excretion as the principal mode of cholic acid amelioration of griseofulvin-induced hepatopathy. They also suggest distinctive roles for griseofulvin and protoporphyrin in the generation of the cholestasis.

Formation of biliary thrombi in protoporphyrin-induced cholestasis in perfused rat liver.

The effect of bile acids on the formation of biliary thrombi in protoporphyrin-induced cholestasis was determined by perfusing isolated rat livers with taurocholate, chenodeoxycholate and ursodeoxycholate with and without protoporphyrin. Protoporphyrin-induced reduction of bile flow was similar in the presence of each bile acid. The cholestasis was greater at high doses (2,000 to 10,885 nmol) than at low doses (1,500 nmol) of protoporphyrin, unrelated to the amount of lactate dehydrogenase released into the perfusate, and it was not altered by increasing bile acid infusions. Bile acid excretion was inhibited by high protoporphyrin doses. Periportal birefringent pigment deposits were seen in canaliculi and ductules when the biliary protoporphyrin concentration exceeded 161 nmol/ml, 345 nmol/ml and 1,036 nmol/ml for ursodeoxycholate, chenodeoxycholate and taurocholate, respectively; or, when the protoporphyrin (nanomole) to bile acid (micromole) ratio exceeded 3.23, 7.03 and 23.43, respectively. The maximal ratio of ductular deposits to portal tract deposits examined was 0.9. Electron microscopy showed these deposits were associated with canalicular thrombi. Thus, biliary thrombi were produced by infusion of bile acids and protoporphyrin. The occurrence of thrombi varied with bile acid structure. Explanations for this finding are speculative. The presence of periportal thrombi, however, did not influence the degree of functional cholestasis.

Protoporphyrin IX-induced impairment of biliary lipid secretion in the rat.

1. In order to gain information on the effect of protoporphyrin IX on changes in the properties of the canalicular plasma membrane, we studied the release of canalicular membrane constituents, namely phospholipids, cholesterol and 5'-nucleotidase, into bile in anaesthetized rats receiving saline or taurocholate (0.5 mumol min-1 100 g-1 body weight) with or without protoporphyrin IX infusion (10 or 20 micrograms min-1 100 g-1 body weight). 2. Protoporphyrin IX induced an impairment of spontaneous bile flow and of biliary secretion of cholesterol, phospholipids and bile acids. The taurocholate-induced increase in bile acid output was not significantly reduced by protoporphyrin IX at either of the doses used. However, when a cholestatic dose of protoporphyrin IX was infused, the taurocholate-induced bile flow and secretion of lecithin and cholesterol were significantly reduced. 3. Biliary output of phospholipid species other than lecithin did not counterbalance the protoporphyrin IX-induced reduction in biliary lecithin secretion. Biliary outputs of both total phospholipid and lecithin were inhibited by protoporphyrin IX to similar extents. 4. Protoporphyrin IX alone had no effect on the biliary release of 5'-nucleotidase, whereas when it was given with taurocholate, it increased the bile acid-induced biliary output of this enzyme markedly. 5. In summary, these results indicate that protoporphyrin IX impairs the biliary secretion of phospholipids and cholesterol but not that of bile acid. The release of canalicular membrane constituents other than lipids was also modified by protoporphyrin IX.

Effect of protoporphyrin IX on ursodeoxycholate-induced hypercholeresis in the rat.

1. It is known that the perfusion of rat livers with solutions containing protoporphyrin IX induces a decrease in bile flow which is not due to inhibition of bile acid secretion but rather to decreased electrolyte transport into bile. By contrast, ursodeoxycholate induces hypercholeresis, partly due to a marked stimulation of biliary bicarbonate secretion. The aim of the present work was to investigate the effect of protoporphyrin IX on ursodeoxycholate-induced choleresis in anesthetized male Wistar rats. 2. Protoporphyrin IX infusion at rates of 10, 20 and 40 micrograms min-1 100 g-1 body weight into the jugular vein induced a dose-dependent inhibitory effect on bile flow as well as on bile acid and electrolyte secretion. The lowest infused rate only induced slight and non-significant changes in spontaneous bile formation and functional variables such as glycaemia, packed cell volume, blood pH, PCO2, PO2 and bicarbonate concentration, and in hepatic carbonic anhydrase activity. It was thus considered as a subtoxic dose. 3. Sodium taurocholate was infused (0.5 mumol min-1 100 g-1 body weight) over the second hour of the lowest dose of protoporphyrin IX infusion. In these rats, no significant changes in bile flow or bile acid and electrolyte secretion were observed as compared with animals receiving sodium taurocholate plus saline solution. 4. Bile acid secretion induced by ursodeoxycholate infusion (1 mumol min-1 100 g-1 body weight) was similar both in rats receiving ursodeoxycholate plus saline solution and in animals infused with this bile acid over the second hour of the lowest dose of protoporphyrin IX infusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of bile acid hydroxylation on biliary protoporphyrin excretion in rat liver.

The relationships between bile acid structure, protoporphyrin load, and biliary protoporphyrin excretion were studied in rat livers perfused with 0 or 0.7 mumol/min taurocholate and protoporphyrin loads between 350 and 35,525 nmol. Bile acid treatment increased the excretion of extracted protoporphyrin from 0.4 to 28%, the maximal biliary protoporphyrin concentration 32-fold, the protoporphyrin excretion rate approximately 150-fold, and the coupling of excreted protoporphyrin to bile acid. Infusions (0.7 mumol/min) of bile acids differing in structure with 1,500 nmol protoporphyrin all significantly increased protoporphyrin excretion but ursodeoxycholate and tauroursodeoxycholate did so less than others. Infusions (0.175-1.4 mumol/min) of taurocholate, deoxycholate, ursodeoxycholate, and chenodeoxycholate confirmed that protoporphyrin excretion increased significantly more with taurocholate or deoxycholate than chenodeoxycholate and chenodeoxycholate more than ursodeoxycholate. The relative ineffectiveness of dihydroxylated bile acids with a hydroxy group at the seven position (alpha- or beta-configuration) was not correlated with physicochemical parameters of the bile acids and remains unexplained. The findings suggest that ursodeoxycholate is the least acceptable bile acid to consider as a potential treatment for protoporphyria.

Effect of bile acids on hepatic protoporphyrin metabolism in perfused rat liver.

To determine the effect of bile acids on hepatic protoporphyrin metabolism, balance studies were performed in isolated perfused rat livers. Hepatic protoporphyrin metabolism was found to increase linearly as a function of protoporphyrin dose in livers infused with and without taurocholate (0.7 mumol/min), but their rates differed significantly. Employing a standard 1500-nmol protoporphyrin bolus dose, infusions (0.7 mumol/min) of taurocholate, glycocholate, deoxycholate, and chenodeoxycholate, but not tauroursodeoxycholate or ursodeoxycholate, increased protoporphyrin metabolism 1.7- to 2.7-fold over control (0 bile acid) values. Bile acid infusion ranging from 0.175 to 1.4 mumol/min confirmed that both taurocholate and chenodeoxycholate increased protoporphyrin disposal significantly more than ursodeoxycholate. For all bile acids, the increase of protoporphyrin metabolism was most pronounced between biliary bile acid excretion rates of 10-50 nmol/min.g liver. These data indicate that (a) bile acids facilitated protoporphyrin metabolism, (b) bile acid structure influenced the effect, and (c) ursodeoxycholate may not be a prime candidate to study the role of bile acids in the treatment of protoporphyria.

Effect of smoking in a controlled study of ranitidine treatment in gastroesophageal reflux disease.

Smoking has been shown to be a factor in acid peptic disease. A recent U.S. multicenter trial investigating use of ranitidine in the treatment of gastroesophageal reflux disease provided an opportunity to compare smokers and nonsmokers with regard to demographic features, manifestations of disease, and symptomatic response to treatment. A comparison of characteristics of smokers and nonsmokers revealed similar pretrial clinical findings. No significant differences between groups were found with regard to previous complications or recent symptoms of gastroesophageal reflux disease. There were also no significant differences in the way smokers and nonsmokers responded to treatment. Subjects on ranitidine, regardless of their smoking status, showed significantly greater improvement in heartburn symptoms and consumed less antacid than subjects who received placebo. Results of these analyses indicate that smoking as an independent variable was not related to symptomatic response or esophageal healing and that ranitidine was similarly effective in decreasing heartburn symptoms in smokers and nonsmokers.

A multicenter study of ranitidine treatment of duodenal ulcers in the United States.

Treatment of duodenal ulcer with the histamine H2-receptor antagonist, ranitidine, was assessed in a double-blind, randomized, multicenter trial in which patients were treated for two consecutive 4-week periods with ranitidine 150 mg b.i.d. or a placebo. All patients were allowed to take antacids as necessary for symptoms. Three hundred eighty-two patients were entered and 355 completed the first 4-week trial period. Ranitidine significantly improved healing at 2 weeks (37 versus 19%, p less than 0.01) and at 4 weeks (73 versus 45%, p less than 0.01), with better relief of pain and lower use of antacids. In the second 4-week trial period, 124 unhealed patients from the first 4 weeks were re-randomized. Ranitidine treatment resulted in a greater healing rate regardless of previous treatment (p less than 0.05). In this trial, side effects were uncommon and not different between placebo and the tested drug. One case of hepatitis in the ranitidine treated group was presumed on the evidence to be non-A non-B. Ranitidine is effective and appears to be safe in the treatment of duodenal ulcer and its symptoms.

Lactic acidosis associated with cirrhosis, hepatoma, hemoperitoneum, and hyperphosphatemia.

A patient with cirrhosis developed hemoperitoneum, lactic acidosis, and hyperphosphatemia in the absence of shock. At post-mortem examination occult multicentric hepatocellular carcinoma eroding the liver capsule was present. The case emphasizes the central role of the liver in lactic acidosis, indicates that hemoperitoneum may precipitate this complication, and documents the association of lactic acidosis and hyperphosphatemia.

Calcium accelerates cholesterol phase transitions in analog bile.

Analog bile supersaturated with cholesterol was constituted, filtered and divided into equal portions containing no calcium or calcium, 2.5-15 mM. Aliquots were removed over the next 48 h and filtrates analyzed for cholesterol, bile acid and lecithin. Calcium accelerated cholesterol loss from solution in a dose-related fashion.

Structure-function relationships of protoporphyrin-induced liver injury.

To further define the pathogenesis of protoporphyric liver disease, perfused rat livers received varying doses of protoporphyrin, and aberrations of hepatic ultrastructure and function were correlated. Results indicated that the relative canalicular volume was equally increased in all protoporphyrin-perfused livers; however, bile flow was only minimally diminished at the smallest protoporphyrin dose employed. Protoporphyrin injured microvilli at the sinusoidal pole and reduced the surface density of the endoplasmic reticulum in a dose-related fashion. No crystalline or amorphous material was detectable, and only slight mitochondrial distortions occurred. Thus, cholestasis did not correlate with canalicular dilatation, the presence of crystalline material, or mitochondrial changes. Liver plasma membrane abnormalities appeared to correlate with functional defects and support a direct hepatotoxicity. Long-term protoporphyrin overload studies are needed to assess differences between hepatic and erythroid (parenteral) sources of protoporphyrin overproduction.

Acceleration of cholesterol phase transitions in analog bile by chlorpromazine, pentobarbital and ethinyl estradiol.

The effects of incorporation of chlorpromazine, pentobarbital and ethinyl estradiol on the maintenance of cholesterol supersaturation was studied in bile analogs. Bile solutions were initially supersaturated and microscopically clear. Chlorpromazine and pentobarbital were almost totally solubilized; ethinyl estradiol was poorly solubilized. Chlorpromazine and pentobarbital in concentrations of 5 and 10 mg/ml rapidly (less than 3-5 h) diminished cholesterol in bile filtrates compared to controls; ethinyl estradiol did so at a concentration of 1 mg/ml but less rapidly (24 h). Bile acid and lecithin concentrations, over time, did not differ significantly between groups. The results indicate that drug interactions with bile constituents, without causing their precipitation, can alter the maintenance of cholesterol supersaturation and phase transitions in bile.