T. Poralla

Intravascular oesophageal variceal pressure (IOVP) assessed by endoscopic fine needle puncture under basal conditions, Valsalva's manoeuvre and after glyceryltrinitrate application.

A simple and safe procedure providing sensitive and reproducible direct measurement of intravascular oesophageal variceal pressure (IOVP) during routine oesophagoscopy is described. The method requires only commercially available equipment. First results were obtained in 16 patients with oesophageal varices caused by liver cirrhosis (Childs A) can be summarised as follows: intravascular oesophageal variceal pressure was nearly identical in different varices of the single patient. Varices grade III exhibited a significantly higher intravascular oesophageal variceal pressure than varices grade II (22.7 +/- 2.5 vs 15.7 +/- 0.6 mmHg, p less than 0.05). After Valsalvas manoeuvre there was a remarkable increase in intravascular oesophageal variceal pressure by 13.6 +/- 1.0 mmHg irrespective of the variceal size. The high intravascular oesophageal variceal pressure values observed in grade III varices during the rise of the intraabdominal pressure may indicate an important risk factor for variceal haemorrhage. Glyceryltrinitrate (1.2 mg sprayed onto the tongues of 14 patients) very effectively lowered the intravascular oesophageal variceal pressure from 22.8 +/- 2.0 to 12.0 +/- 0.4 mmHg in grade III varices, and from 16.3 +/- 0.4 to 10.0 +/- 0.4 mmHg in grade II varices (p less than 0.005 in both groups). We conclude that this method provides a suitable tool to study the effect of drugs with presumed influence on the oesophageal variceal pressure and that the impressive effect of glyceryltrinitrate in lowering intravascular oesophageal variceal pressure warrants further study on the effect of longer acting nitrates on intravascular oesophageal variceal pressure, and the rebleeding rate after oesophageal variceal haemorrhage.

Effect of glyceryl trinitrate on the sphincter of Oddi motility and baseline pressure.

It is widely accepted that glyceryl trinitrate (GTN) effectively dilates the smooth muscles of blood vessels. A similar effect has been postulated on the smooth muscles in the gastrointestinal tract. In this study the motility of the sphincter of Oddi and the common bile duct pressure as determined by endoscopic manometry was investigated in nine patients before and after sublingual application of 1.2 mg GTN (nitro group). Eight untreated patients served as controls. Three minutes after application of GTN the papillary contraction amplitude decreased from 69.3 +/- 4.3 mmHg to 36.8 +/- 5.1 mmHg (p less than 0.005) and the papillary baseline pressure fell from 8.9 +/- 0.6 mmHg to 2.9 +/- 0.2 mmHg (p less than 0.005) respectively. The contraction frequency in the nitro group and all motility parameters in the control group remained unchanged. These results indicate that GTN does not influence the sphincter of Oddi motility, but it relaxes very effectively the sphincter of Oddi muscle. Thus, GTN should be taken into account for the treatment of biliary colic. In our endoscopic unit GTN proved to be useful as premedication for endoscopic examinations, particularly for the removal of small and medium size common bile duct stones through the intact papilla.

Effect of modern analgesic drugs (tramadol, pentazocine, and buprenorphine) on the bile duct sphincter in man.

Modern narcotic analgesic drugs, such as tramadol, pentazocine, and buprenorphine share similarities of molecular structure with morphine which is widely believed to cause spasm of the bile duct sphincter and so impede bile flow. This study assessed the effects of intravenously administered analgesics on bile duct sphincter motor activity measured by ERCP manometry. Ten minutes after pentazocine injection the duration of contractions and baseline pressure of the bile duct sphincter rose from 6.2 +/- 0.2 to 8.2 +/- 0.27 s and from 5.1 +/- 0.6 to 8.8 +/- 0.4 mmHg respectively. Tramadol, buprenorphine and saline showed no such effect. These data indicated that the effects of such drugs on bile duct sphincter function can be safely assessed by ERCP manometry and that pentazocine adversely affects the bile duct sphincter, whilst tramadol and buprenorphine do not. We consider therefore that pentazocine is not the premedication of first choice for endoscopic procedures involving the sphincter of Oddi and should also be avoided in patients with pancreatic and biliary disorders.

Autoantibodies against the human asialoglycoprotein receptor: Effects of therapy in autoimmune and virus-induced chronic active hepatitis

The hepatic asialoglycoprotein receptor (ASGPR) was recently identified as a target antigen for both humoral and cellular immune response in inflammatory liver diseases. Thereby anti-ASGPR autoantibodies directed against human substrate were closely associated with autoimmune chronic active hepatitis. The present study compares the occurrence, titer and immunoglobulin classification of anti-human(h-)-ASGPR antibodies in 23 patients with newly diagnosed autoimmune chronic hepatitis before and after initiation of immunosuppressive therapy to 22 patients with autoimmune hepatitis in remission. Additionally, 1-year follow-up examinations of 42 patients with HBsAg-positive chronic hepatitis and of 32 patients with chronic hepatitis C receiving recombinant interferon-alpha were included. Nineteen of 23 patients with newly diagnosed and 9/22 with autoimmune hepatitis in remission, 5/42 with untreated chronic hepatitis B and 5/32 patients with chronic hepatitis C exhibited anti-h-ASGPR at the beginning of the study. In autoimmune hepatitis anti-h-ASGPR were found in higher titers (median > 1:1000) than in viral hepatitis (maximum 1:400). After initiation of immunosuppressive therapy in autoimmune hepatitis anti-h-ASGPR decreased sharply. Eight of 19 patients eliminated anti-h-ASGPR within 18 months in contrast to 11 patients with persistent anti-h-ASGPR titer over 18 months and longer. Anti-h-ASGPR with maximum titer of 1:600 were detected in 5 patients with chronic hepatitis B (transiently in 4/5 patients) and in 2 patients with chronic hepatitis C during interferon-alpha. Anti-h-ASGPR were from immunoglobulin classes IgG and IgM in cases with untreated autoimmune hepatitis and chronic hepatitis B and C exhibiting mainly IgG2-subclass in autoimmune and IgG4 in viral hepatitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Liver-infiltrating T helper cells in autoimmune chronic active hepatitis stimulate the production of autoantibodies against the human asialoglycoprotein receptor in vitro.

Autoantibodies against the human asialoglycoprotein receptor (ASGPR) occur in the sera orpaticnts with autoimmune liver disorders. Live‐nfiltrating T cell clones that specifically recognize the ASGPR have been described in patients with autoimmune chronic active hepatitis (A‐AH) and primary biliary cirrhosis (PBC). Recently, we have shown that peripheral blood mononuclcar cells (PBMC) from patients with A‐AH or PBC but not chronic viral hepatitis secreted ant‐SGPR antibodies in vitro. In this study we characterized the influence of live‐nfiltrating T cells on the secretion of ASGP‐pecific autoantibodies by autologous B cells in cell culture supernatants. T cell clones from liver biopsies of three patients with chronic autoimmune liver disorders (one with A‐AH, two with PBC) were isolated and investigated for their proliferative response to soluble ASGPR and their helper function provided to autoantibod‐ecrcting B lymphocytes. PBMC from these patients secreted autoantibodies spontaneously in their cell culture supematants and showed a proliferative response to ASGPR. T cel‐epleted PBMC, however, lacked spontaneous antibody secretion. Four CD4+ CD8− live‐nfiltrating T cell clones showed a proliferative response to ASGPR and also induced spontaneous ant‐SGPR antibody production in cell culture supernatants when added to autologous T cell depleted PBMC. Activated supernatants of these T cell clones failed to induce antibody production. None of seven CD4+CD8− and two CD4−CD8+ T cell clones no‐esponding to ASGPR provided this help for antibody secretion. Ant‐SGPR secretion in vitro could not be inhibited by the addition of MoAbs raised against monomorphic determinants on HLA class II molecules. The addition of purified ASGPR or polyclona‐ctivating pokeweed mitogen showed no influence on the production of autoantibodies in these cultures. These data show that B lymphocytes require T cell help for the production of ASGP‐pecific antibodies. This help can be provided by ASGP‐esponsive T helper cells via cellular interactions.

Stimulation of synovial fluid mononuclear cells with the human 65-kD heat shock protein or with live enterobacteria leads to preferential expansion of TCR-γδ+ lymphocytes

T lymphocyte responses to heterologous or self 65‐kD heat shock protein (hsp) have been implicated in the pathogenesis of various forms of arthritis. To delineate the relationship of 65‐kD hsp to different synovial fluid (SF) T cell subsets, we stimulated synovial fluid (SFMC) and peripheral blood mononuclear cells (PBMC) from patients with different inflammatory rheumatic diseases and from healthy controls with human or mycobacterial 65‐kD hsp, tetanus toxoid (TT), heat‐killed or live Yersinia enterocotitica. Phenotyping of the resulting T cell lines revealed an increase of up to 97% TCR‐γδ+ lymphocytes in the 65‐kD hsp‐stimulatcd SF‐derived lines. This expansion of TCR‐γδ+ cells was less pronounced with cultures of PBMC. A preferential expansion of TCR‐γδ+ cells was also shown after SFMC stimulation with live, but not with heat‐killed Yersinia or with TT. We conclude that a common mechanism is involved in the selective expansion of TCR‐γδ+ lymphocytes upon SFMC infection with live Yersinia or upon contact with 65‐kD hsp. Out of a panel of TCR‐γδ+ T lymphocyte clones (TLC) derived from a human 65‐kD hsp‐stimulated line, only a minority of TLC proliferated weakly upon restimulation with this antigen in the presence of autologous monocytes, whereas TCR‐αβ+ TLC responded vigorously to the human 65‐kD hsp and in some cases also cross‐recognized the mycobacterial hsp homologue and/or heat‐killed Yersinia. This implies that additional factors or cells may be present in the milieu of SFMC cultures that propagate the expansion of TCR‐γδ+ cells in response to 65‐kD hsp or live bacteria.

Liver membrane autoantibodies in chronic active hepatitis: Studies on mechanically and enzymatically isolated rabbit hepatocytes

Target antigens relevant for immune reactions in inflammatory liver diseases should be expressed on the hepatocellular membrane. Using mechanically or enzymatically isolated rabbit hepatocytes, we evaluated the influence of cell integrity on the detection of membrane-expressed antigens by sera from patients with chronic hepatitis and by murine monoclonal antibodies. Our results provide evidence that target antigens of liver membrane autoantibodies (LMA) as well as liver kidney microsomal antibodies (LKM) are not expressed on the hepatocellular membrane of viable and intact isolated rabbit hepatocytes. However, LMA were detected in the sera of 56% of patients with autoimmune chronic active hepatitis using mechanically isolated hepatocytes. These findings underline the diagnostic relevance of the autoantibodies. It is suggested that LMA are directed against constituents of the cytoskeleton. Therefore, it seems to be unlikely that this antibody is causally involved in the pathogenesis of autoimmune liver diseases.

Hepatitis C virus associated primary hepatocellular carcinoma in a noncirrhotic liver

SummaryThe case of a 71-year-old man with a primary hepatocellular carcinoma in a non-cirrhotic liver is reported. There were no risk factors of hepatocellular carcinoma (HCC)-like liver cirrhosis, alcohol drinking, tobacco smoking, exposure to vinyl chloride, thorotrast, aflatoxin or α1-antitrypsin deficiency. Serologically, the patient was positive for antibodies to the hepatitis B virus (anti-HBc, anti-HBs) and for anti-hepatitis C virus (HCV) antibodies. Virologically, positive and negative strands of HCV RNA could be detected in the patients serum and tumorous liver tissue by reverse transcription polymerase chain reaction as a sign of persistent HCV replication. Histologically, the HCC was completely surrounded by liver tissue which showed the signs of nodular regenerative hyperplasia. Indeed, the mechanism of hepatocarcinogenesis remains to be clarified. However, this case supports the observation that HCC may also develop in patients with HCV infection without preexisting liver cirrhosis.

Cellular cytotoxicity against autologous hepatocytes in acute and chronic non-A, non-B hepatitis.

In a microcytotoxicity assay we tested lymphocyte cytotoxicity against autologous hepatocytes. The following cytotoxicity values were found (given mean +/- SEM): acute non-A, non-B (NANB) hepatitis 45.7 +/- 4.3% (n = 7), chronic NANB hepatitis 32.8 +/- 5.1% (n = 11), chronic active hepatitis B (CAH-B) 27.7 +/- 6.7% (n = 10), toxic lesions 18.1 +/- 4.2% (n = 18), controls with normal liver histology or minimal changes 4.9 +/- 2.5% (n = 8). Thus our study shows enhanced cellular cytotoxicity in acute and chronic NANB hepatitis and indicates that T cells as well as non-T cells have cytotoxic effector functions. These findings are similar to those obtained in CAH-B and suggest that cellular immune reactions play an important role in the course of NANB hepatitis. For comparison we tested cytotoxic reactions in toxic lesions. They were only moderate and well distinguishable from those observed in NANB hepatitis and CAH-B; they even may be unspecific. No correlation was seen between cytotoxicity and aminotransferase concentrations.

Antibodies to cathepsin G in Crohn's disease.

Abstract. Antibodies directed against antigens in human neutrophils have proved to be of great diagnostic value in certain systemic vasculitides. Recent reports have focused the attention on these antigens as targets of antibodies in sera of patients with inflammatory bowel disease. We investigated the sera drawn from 60 patients suffering from biopsy proven Crohns disease and 15 patients with active ulcerative colitis. Using sensitive enzyme‐linked immunosorbent assays with purified antigens and Western blotting the following antibodies could be demonstrated: cathepsin G (cat‐G) antibodies IgG 38.3%, IgM 13.3%, IgA 23.3% and antibodies against human leucocyte elastase (HLE) IgG, IgA, IgM 3.3%. Low but significant correlations could be found for cat‐G antibodies (IgG) and the van HEES index of activity. 73.9% of the cat‐G (IgG) positive patients had colon involvement. In the sera of patients with ulcerative colitis no antibodies to cat‐G or HLE were detectable. Only 8.3% of the patients with Crohns disease had antibodies against proteinase 3 (C‐ANCA). Our data indicate that cat‐G among other myeloid lysosomal enzymes seems to be an important target antigen of antibodies in sera of patients with Crohns disease. Cat‐G antibodies might be helpful to distinguish Crohns disease from ulcerative colitis.