Ulrich Spengler

Hepatitis B virus antigen-specific T-cell activation in patients with acute and chronic hepatitis B

Since the hepatitis B virus is noncytopathic, it is generally believed that the individual specific immune response determines the course of infection. The lack of data about hepatitis B virus-specific T-cell reactions in acute infection led us to investigate the specific cellular immune response of infected individuals in terms of proliferation, and gamma-interferon and lymphotoxin production. Our results demonstrate that peripheral blood mononuclear cells (PBMNC) from patients with acute and chronic hepatitis B respond weakly to HBsAg. In contrast, patients with acute hepatitis show a vigorous response to the nucleocapsid antigen (HBcAg) in terms of proliferation and lymphokine production, while only few chronic virus carriers gave a proliferative response. Either of the antigens could activate lymphocytes to produce gamma-interferon and lymphotoxin, cytokines which may modulate antiviral immune response.

Hepatic levels of bile acids in end-stage chronic cholestatic liver disease

In chronic cholestatic liver disease hydrophobic and potentially cytotoxic bile acids are assumed to accumulate in the liver. To test this hypothesis we investigated bile acid levels and pattern in livers and serum of patients with, (A) end-stage chronic cholestatic liver disease, and with (B) end-stage cirrhosis of alcoholic/chronic hepatitic origin who underwent liver transplantation. Bile acids were also analyzed in (C) normal liver tissue. Levels of bile acids were 215 +/- 39.1 nmol/g liver (wet weight) in chronic cholestasis and 120 +/- 32.7 and 56.1 +/- 24.2 nmol/g liver in group B and group C (P < 0.01 and P < 0.005), respectively. Cholic acid was the prevailing bile acid in chronic cholestasis (51%) and was elevated eight-fold as compared to group C (P < 0.005). Chenodeoxycholic acid contributed 41% to total bile acids and was elevated four-fold (P < 0.005). Deoxycholic acid contributed only 1.5% to bile acids in chronic cholestasis as compared to 27% in group C (P < 0.01) and was absent in group B. Levels of lithocholic acid tended to be increased in chronic cholestasis as compared to group C and its sulfation was impaired (P < 0.05). The pattern of serum bile acids in chronic cholestasis agreed well with the bile acid pattern in the explanted livers. We conclude that hepatic accumulation of hydrophobic chenodeoxycholic acid and impaired sulfation of lithocholic acid might contribute to tissue degeneration in chronic cholestatic liver disease due to the detergent effects of these bile acids.

Gallbladder motility before and after extracorporeal shock-wave lithotripsy

To determine whether extracorporeal shock-wave lithotripsy of gallbladder stones alters gallbladder motility, gallbladder contraction in response to intravenous cholecystokinin was investigated by ultrasound. Twenty-one patients with symptomatic gallstones were studied before and after shock-wave lithotripsy, 12 with and 9 without concomitant litholytic therapy (combination of ursodeoxycholic acid and chenodeoxycholic acid). Gallbladder emptying was significantly delayed and less complete in both groups of patients before shock-wave treatment (with bile salts: residual volume, 51% +/- 10% and half-ejection time, 40 +/- 5 min; without bile salts: residual volume, 46% +/- 7%; half-ejection time, 30 +/- 4 min) compared with healthy controls (residual volume, 15% +/- 4%; half-ejection time, 18 +/- 2 min). Gallbladder motility was not altered in either group 1 day and 1 yr after lithotripsy. The findings indicate (a) that extracorporeal shock-wave lithotripsy has no immediate or long-term adverse effects on gallbladder motility and (b) that the defect of gallbladder motility associated with gallstone disease is not abolished by removal of the stone.

T lymphocytes from patients with primary biliary cirrhosis produce reduced amounts of lymphotoxin, tumor necrosis factor and interferon-γ upon mitogen stimulation

Primary biliary cirrhosis (PBC) is considered an autoimmune disease characterized by destruction of small intrahepatic bile ducts by lymphocytes. Altered functions of these lymphocytes might reflect an abnormal immune response leading to tissue damage. We investigated lymphokine secretion by mitogen-stimulated T lymphocytes from the liver biopsies of patients with PBC and for comparison also peripheral blood. In PBC, diminished synthesis of lymphotoxin (TNF beta), tumor necrosis factor (TNF alpha) and interferon-gamma (IFN gamma) was found both in T-cell lines from liver tissue and in peripheral blood. The reduction was most prominent for TNF beta in early histological stages of PBC, and appeared to be a stable phenomenon when T cells were tested after long-term tissue culture. Analysis of mRNA levels indicates a possible link between reduced TNF beta production and a defect in interleukin-2 transcription. The data suggest that diminished lymphokine production in patients with PBC may play an important role in the immunopathogenesis of this disease.

Allelic variation in the TNF-beta gene does not explain the low TNF-beta response in patients with primary biliary cirrhosis.

Autoimmune disorders in humans are often associated with particular alleles of major histocompatibility genes. However, the chronic inflammatory liver disease primary biliary cirrhosis (PBC) has not been found to be correlated with certain haplotypes so far.

Deterioration of cholestasis after endoscopic retrograde cholangiography in advanced primary sclerosing cholangitis

Complications of endoscopic retrograde cholangiography specific to patients with primary sclerosing cholangitis have not yet been reported. We observed transient rises of serum bilirubin after diagnostic endoscopic retrograde cholangiography in five of 15 patients and persistent rises in three of 15 patients with primary sclerosing cholangitis examined consecutively by endoscopic retrograde cholangiography from 1985 to 1990. Deterioration of cholestasis was particularly associated with advanced disease. Seven of eight patients with deterioration after endoscopic retrograde cholangiography had septal fibrosis (stage III) or cirrhosis (stage IV) and a priori elevated serum bilirubin levels. In contrast, all patients with no deterioration of cholestasis following endoscopic retrograde cholangiography had early histological changes (stage I-II), and all but one patient had normal serum bilirubin levels. We conclude that the potentially harmful effects on biliary excretion must be taken into account when the use of endoscopic retrograde cholangiography is being considered in patients with advanced primary sclerosing cholangitis.

Gallbladder emptying is an important factor in fragment disappearance after shock wave lithotripsy

The role of gallbladder emptying in fragment disappearance following shock wave lithotripsy of gallstones is poorly understood. We studied gallbladder motility in two groups of patients who had been treated by electrohydraulic shock wave lithotripsy and bile acid dissolution therapy. Group I (n = 20) consisted of patients with fragment disappearance within 18 months after lithotripsy, while patients in group II (n = 20) still harboured fragments in the gallbladder 18 months after lithotripsy. Fasting gallbladder volume was 19 +/- 10 ml (mean +/- S.D.) in group I, and 24 +/- 12 ml in group II (not significant). The residual volume was 8 +/- 9 ml in group I, but 18 +/- 14 ml in group II (p < 0.005). Thus, patients in group I ejected nearly twice as much of the fasting gallbladder volume as patients in group II. This difference in gallbladder emptying was still present if only the patients with single stones were compared in both groups. From the results of this retrospective study we conclude that gallbladder emptying is an important factor for complete fragment disappearance after gallstone disintegration by extracorporeally generated shock waves. Further prospective studies are needed to confirm these observations.

Formation of iso-ursodeoxycholic acid during administration of ursodeoxycholic acid in man

The appearance of iso-ursodeoxycholic acid (isoUDCA; 3 beta,7 beta-dihydroxy-5 beta-cholan-24-oic acid) in serum of patients with chronic cholestatic liver disease and of healthy subjects during administration of ursodeoxycholic acid (UDCA) is reported. Comparison of the mass spectrum of the newly appearing bile acid with that of authentic 3 beta,7 beta-dihydroxy-5 beta-cholan-24-oic acid revealed its identity as the 3 beta-epimer of UDCA. The appearance of 13C-isoUDCA in serum after ingestion of 13C-UDCA proved its product precursor relationship with UDCA. The putative intermediate in the epimerization of UDCA to isoUDCA, 3-oxo-7 beta-hydroxy-5 beta-cholan-24-oic acid, was identified in serum of patients with cholestatic liver disease during treatment with UDCA. Serum concentrations of isoUDCA after 4 weeks of UDCA treatment were 1.37 +/- 0.79 mumol/l (mean +/- S.D.) in eight patients with primary biliary cirrhosis (PBC), 1.25 +/- 0.91 mumol/l in six patients with primary sclerosing cholangitis (PSC) and 3.87 +/- 0.44 mumol/l in four healthy controls. The intestinal bacterial flora as well as microsomal enzymes of the liver may be involved in the epimerization of UDCA to isoUDCA as indicated by decreased serum levels of isoUDCA under antibiotic treatment with doxycycline (100 mg/day) in healthy subjects and a correlation (r = 0.873, p less than 0.001) between the hepatic microsomal function measured by the 14C-aminopyrine breath test and the fractional conversion of applied UDCA to isoUDCA (isoUDCA/UDCA + isoUDCA) in patients with PBC or PSC. Future studies of bile acid metabolism under UDCA treatment should include measurement of isoUDCA to further elucidate its biological role.

Increased frequency of CD8+ CD45R0+ memory T lymphocytes in acute hepatitis B virus infection

CD8+ lymphocytes of the memory subset (= CD45R0+) encompass antigen-specific effector cells, which are believed to be decisive for virus elimination in several viral infections. To determine whether this can be extended to HBV infection naive and memory T cells were studied among CD(4+)- and CD(8+)-lymphocytes and used monoclonal antibodies in two-color flow cytometric analysis to quantitate functional T cell subsets in peripheral blood of patients with acute hepatitis B (n = 11), chronic hepatitis B (n = 24) and healthy individuals (n = 26). Compared to CD4+ populations of healthy individuals the number of total CD4+ lymphocytes in patients with both acute or chronic hepatitis was significantly reduced. In contrast CD8+ cells did not significantly change in either acute and chronic hepatitis. Analysis of naive and memory subsets demonstrated, however, a significant rise in CD45R0+ memory cells from 5 to 15% (70% of all CD8+ cells) in acute hepatitis. These changes within the CD8+ population were, however, restricted to the acute phase of hepatitis in that the frequency of CD8+CD45R0+ decreased within weeks post infection. Furthermore, patients with chronic hepatitis did exhibit normal values of CD8+ memory cells (30% of all CD8+ cells). These findings suggest that enrichment of CD8+CD45R0+ memory cells reflects an accumulation of functional effector cells, which may be specifically activated by viral antigens and determine the outcome of infection.

Crohn's Disease Is Frequently Complicated by Giardiasis

Giardiasis is a common infection, and many of its symptoms are similar to those of Crohns disease. Despite a long discussion on the role of microbiologic agents in Crohns disease, giardiasis has never been investigated. We studied giardiasis as assessed by the occurrence of cysts in 86 patients with Crohns disease, in 82 patients with other gastrointestinal disease, and in 52 patients without gastrointestinal disease. In addition, in 20 patients with Crohns disease the effects of metronidazole on giardiasis and disease activity were studied. Frequency of giardiasis was 61.6% in patients with Crohns disease, 31.7% in patients with other gastrointestinal disease, and 5.8% in the control group (p less than 0.01). Stool frequency, disease activity, and humoral signs of inflammation in patients with Crohns disease showed no relationship to giardiasis. All but two patients treated with metronidazole became free of cysts. Crohns disease activity index decreased in 14 of 20 patients (p less than 0.05). In conclusion, giardiasis is a common finding in patients with Crohns disease. Treatment of giardiasis can, in individual cases of Crohns disease, result in a quick recovery from symptoms of high disease activity.