Uncoupling protein 2 deficiency of non-cancerous tissues inhibits the progression of pancreatic cancer in mice

Background: Pancreatic ductal adenocarcinoma(PDAC) is a disease of the elderly mostly because its development from preneoplastic lesions depends on the accumulation of gene mutations and epigenetic alterations over time. How aging of non-cancerous tissues of the host affects tumor progression, however, remains largely unknown. Methods: We took advantage of a model of accelerated aging, uncoupling protein 2-deficient( Ucp2 knockout, Ucp2 KO) mice, to investigate the growth of orthotopically transplanted Ucp2 wild-type(WT) PDAC cells(cell lines Panc02 and 6606PDA) in vivo and to study strain-dependent differences of the PDAC microenvironment. Results: Measurements of tumor weights and quantification of proliferating cells indicated a significant growth advantage of Panc02 and 6606PDA cells in WT mice compared to Ucp2 KO mice. In tumors in the knockout strain, higher levels of interferon-γ m RNA despite similar numbers of tumor-infiltrating T cells were observed. 6606PDA cells triggered a stronger stromal reaction in Ucp2 KO mice than in WT animals. Accordingly, pancreatic stellate cells from Ucp2 KO mice proliferated at a higher rate than cells of the WT strain when they were incubated with conditioned media from PDAC cells. Conclusions: Ucp2 modulates PDAC microenvironment in a way that favors tumor progression and implicates an altered stromal response as one of the underlying mechanisms.

胆汁淤积症的肝外表现

严重的胆汁淤积症主要表现为胆汁淤积肝外症状,最常报道的症状是瘙痒和乏力。约半数慢性胆汁淤积症病人产生骨质减少性骨病,导致严重活动能力丧失。本文将集中讨论慢性胆汁淤积症3个主要肝外表现的发病机理和治疗。瘙痒 瘙痒是惹起病人抓伤的不适感,在一天内胆汁淤积症瘙痒的程度不同,研究胆汁淤积病人抓痒活动的强度,可以用固定在病人手指甲上的抓痒记录器测出。有意义的是抓痒活动在中午和下午的开始达到最高峰,而据胆汁淤积症病人的主诉瘙痒感在夜间最强。

Clinical outcome and predictors of survival after TIPS insertion in patients with liver cirrhosis

AIM:To determine the clinical outcome and predictors of survival after transjugular intrahepatic portosystemic stent shunt (TIPS) implantation in cirrhotic patients. METHODS:Eighty-one patients with liver cirrhosis and consequential portal hypertension had TIPS implantation (bare metal) for either refractory ascites (RA) (n= 27) or variceal bleeding (VB) (n = 54). Endpoints for the study were:technical success, stent occlusion and stent stenosis, rebleeding, RA and mortality. Clinical records of patients were collected and analysed. Baseline characteristics [e.g., age, sex, CHILD score and the model for end-stage liver disease score (MELD score), underlying disease] were retrieved. The Kaplan-Meier method was employed to calculate survival from the time of TIPS implantation and comparisons were made by log rank test. A multivariate analysis of factors influencing survival was carried out using the Cox proportional hazards regression model. Results were expressed as medians and ranges. Comparisons between groups were performed by using the Mann-Whitney Utest and the χ 2 test as appropriate. RESULTS:No difference could be seen in terms of age, sex, underlying disease or degree of portal pressure gradient (PPG) reduction between the ascites and the bleeding group. The PPG significantly decreased from 23.4 ± 5.3 mmHg (VB) vs 22.1 ± 5.5 mmHg (RA) before TIPS to 11.8 ± 4.0 vs 11.7 ± 4.2 after TIPS implantation (P = 0.001 within each group). There was a tendency towards more patients with stage CHILD A in the bleeding group compared to the ascites group (24 vs 6, P = 0.052). The median survival for the ascites group was 29 mo compared to > 60 mo for the bleeding group (P = 0.009). The number of radiological controls for stent patency was 6.3 for bleeders and 3.8 for ascites patients (P = 0.029). Kaplan-Meier calculation indicated that stent occlusion at first control (P = 0.027), ascites prior to TIPS implantation (P = 0.009), CHILD stage (P = 0.013), MELD score (P = 0.001) and those patients not having undergone liver transplantation (P = 0.024) were significant predictors of survival. In the Cox regression model, stent occlusion (P = 0.022), RA (P = 0.043), CHILD stage (P = 0.015) and MELD score (P = 0.004) turned out to be independent prognostic factors of survival. The anticoagulation management (P = 0.097), the porto-systemic pressure gradient (P= 0.460) and rebleeding episodes (P = 0.765) had no significant effect on the overall survival. CONCLUSION:RA, stent occlusion, initial CHILD stage and MELD score are independent predictors of survival in patients with TIPS, speaking for a close follow-up in these circumstances.

Hepatocellular carcinoma: Therapy and prevention

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors worldwide. The major etiologies and risk factors for the development of HCC are well defined and some of the multiple steps involved in hepatocarcinogenesis have been elucidated in recent years. Despite these scientific advances and the implementation of measures for the early detection of HCC in patients at risk, patient survival has not improved during the last three decades. This is due to the advanced stage of the disease at the time of clinical presentation and limited therapeutic options. The therapeutic options fall into five main categories: surgical interventions including tumor resection and liver transplantation, percutaneous interventions including ethanol injection and radiofrequency thermal ablation, transarterial interventions including embolization and chemoembolization, radiation therapy and drugs as well as gene and immune therapies. These therapeutic strategies have been evaluated in part in randomized controlled clinical trials that are the basis for therapeutic recommendations. Though surgery, percutaneous and transarterial interventions are effective in patients with limited disease (1-3 lesions, ＜5 cm in diameter) and compensated underlying liver disease (cirrhosis Child A), at the time of diagnosis more than 80% patients present with multicentric HCC and advanced liver disease or comorbidities that restrict the therapeutic measures to best supportive care. In order to reduce the morbidity and mortality of HCC, early diagnosis and the development of novel systemic therapies for advanced disease, including drugs, gene and immune therapies as well as primary HCC prevention are of paramount importance. Furthermore, secondary HCC prevention after successful therapeutic interventions needs to be improved in order to make an impact on the survival of patients with HCC. New technologies, including gene expression profiling and proteomic analyses, should allow to further elucidate the molecular events underlying HCC development and to identify novel diagnostic markers as well as therapeutic and preventive targets.

Intraductal ultrasound substantiates diagnostics of bile duct strictures of uncertain etiology

AIM:To report the largest patient cohort study investigating the diagnostic yield of intraductal ultrasound (IDUS) in indeterminate strictures of the common bile duct.METHODS:A patient cohort with bile duct strictures of unknown etiology was examined by IDUS.Sensitivity,specificity and accuracy rates of IDUS were calculated relating to the definite diagnoses proved by histopathology or long-term follow-up in those patients who did not undergo surgery.Analysis of the endosonographic report allowed drawing conclusions with respect to the T and N staging in 147 patients.IDUS staging was compared to the postoperative histopathological staging data allowing calculation of sensitivity,specificity and accuracy rates for T and N stages.The endoscopic retrograde cholangio-pancreatography and IDUS procedures were performed under fluoroscopic guidance using a side-viewing duodenoscope (Olympus TJF 160,Olympus,Ltd.,Tokyo,Japan).All procedures were performed under conscious sedation (propofol combined with pethidine) according to the German guidelines.For IDUS,a 6 F or 8 F ultrasound miniprobe was employed with a radial scanner of 15-20 MHz at the tip of the probe (Aloka Co.,Tokyo,Japan).RESULTS:A total of 397 patients (210 males,187 females,mean age 61.43 ± 13 years) with indeterminate bile duct strictures were included.Two hundred and sixty-four patients were referred to the department of surgery for operative exploration,thus surgical histopathological correlation was available for those patients.Out of 264 patients,174 had malignant disease proven by surgery,in 90 patients benign disease was found.In these patients decision for surgical exploration was made due to suspicion for malignant disease in multimodal diagnostics (computed tomography scan,endoscopic ultrasound or magnetic resonance imaging).Twenty benign bile duct strictures were misclassified by IDUS as malignant while 14 patients with malignant strictures were initially misdiagnosed by IDUS as benign resulting in sensitivity,specificity and accuracy ratesof 93.2%,89.5% and 91.4%,respectively.In the subgroup analysis of malignancy prediction,IDUS showed best performance in cholangiocellular carcinoma as underlying disease (sensitivity rate,97.6%) followed by pancreatic carcinoma (93.8%),gallbladder cancer (88.9%) and ampullary cancer (80.8%).A total of 133 patients were not surgically explored.32 patients had palliative therapy due to extended tumor disease in IDUS and other imaging modalities.Ninety-five patients had benign diagnosis by IDUS,forceps biopsy and radiographic imaging and were followed by a surveillance protocol with a follow-up of at least 12 mo;the mean follow-up was 39.7 mo.Tumor localization within the common bile duct did not have a significant influence on prediction of malignancy by IDUS.The accuracy rate for discriminating early T stage tumors (T1) was 84% while for T2 and T3 malignancies the accuracy rates were 73% and 71%,respectively.Relating to N0 and N1 staging,IDUS procedure achieved accuracy rates of 69% for N0 and N1,respectively.Limitations:Pretest likelihood of 52% may not rule out bias and overinterpretation due to the clinical scenario or other prior performed imaging tests.CONCLUSION:IDUS shows good results for accurate diagnostics of bile duct strictures of uncertain etiology thus allowing for adequate further clinical management.

Combined TACE and PEI for palliative treatment of unresectable hepatocellular carcinoma

瞄准：估计是否 transarterial chemoembolization 的联合的有效性(不作声) 并且在 unresectable 肝细胞癌(HCC ) 的治疗的经皮的乙醇注射(PEI ) 是优异的独自不作声使随机化的控制试用是 performed.METHODS：长期的幸存率和住院的持续时间上的联合治疗的效果在 52 以前未经治疗的 HCC 被评估，随机分配了到 TACE-PEI (27 磅) 或独自不作声(25 磅) 。结果：TACE 组的累积幸存率在 6 瞬间是 75.8% ， 62.9% 在 12 瞬间，并且 18.0% 分别地在 24 瞬间并且 TACE-PEI 组织 76.9% ， 61.5% ，和 38.7% 。在两个组的全面幸存的比较统计上不出现了有效差量。关于有 HCC 的病人， Okuda 上演我(n = 26 ) ， TACE-PEI 组的中部的幸存显著地更长(】24 瞬间，还没在学习时期到达的 median ) 与 TACE 组相比(18.4 瞬间[范围 11.6-21.7 瞬间] ；P = 0.04 ) 。TACE-PEI 为死亡把相对风险归结为 0.4 (95%CI 0.15-0.96 ) 独自与接待了的病人相比不作声。在有 HCC Okuda 阶段 II 或 III 的病人的中部的幸存是在 TACE 组的 5.0 瞬间(1.7 瞬间不定义) 与 10.4 相比，在 TACE-PEI 的瞬间组织。结论：联合 TACE-PEI 改进了生存时间与相比独自不作声。我们的学习在 HCC Okuda 舞台揭示了统计上重要的改进幸存我。副作用是次要的，联合治疗没更加延长住院的持续时间。

Overlap syndromes among autoimmune liver diseases

The three major immune disorders of the liver are autoimmune hepatitis(AIH),primary biliary cirrhosis(PBC) and primary sclerosing cholangitis(PSC).Variant forms of these diseases are generally called overlap syndromes,although there has been no standardised definition.Patients with overlap syndromes present with both hepatitic and cholestatic serum liver tests and have histological features of AIH and PBC or PSC.The AIH-PBC overlap syndrome is the most common form,affecting almost 10% of adults with AIH or PBC.Single cases of AIH and autoimmune cholangitis(AMA-negative PBC) overlap syndrome have also been reported.The AIH-PSC overlap syndrome is predominantly found in children,adolescents and young adults with AIH or PSC.Interestingly,transitions from one autoimmune to another have also been reported in a minority of patients,especially transitions from PBC to AIH-PBC overlap syndrome.Overlap syndromes show a progressive course towards liver cirrhosis and liver failure without treatment.Therapy for overlap syndromes is empiric,since controlled trials are not available in these rare disorders.Anticholestatic therapy with ursodeoxycholic acid is usually combined with immunosuppressive therapy with corticosteroids and/or azathioprine in both AIH-PBC and AIH-PSC overlap syndromes.In end-stage disease,liver transplantation is the treatment of choice.

Ursodeoxycholic acid treatment of vanishing bile duct syndromes

消失的胆汁管症候群(VBDS ) 被从肝失败导致长期的胆汁郁积，肝硬化，和早熟的死亡的许多不同疾病引起的小肝内管的进步损失描绘。有 VBDS 的成年病人的多数受不了主要胆汁性肝硬变(PBC ) 和主要致硬化的胆管炎(PSC ) 。Ursodeoxycholic 酸(UDCA ) ，吸水的 dihydroxy 胆汁酸，唯一的药当前被同意因为有 PBC 的病人的治疗，和 anticholestatic 效果为几另外的胆汁郁积的症候群被报导了。UDCA 的行动的几潜在的机制包括肝胆管分泌物的刺激被建议了， apoptosis 的抑制和对恐水病的胆汁酸的有毒的效果的 cholangiocytes 的保护。

Medical treatment of cholestatic liver diseases:From pathobiology to pharmacological targets

胆汁分泌物依赖于很多个肝胆管运输系统的协调函数。胆汁郁积可以被胆汁分泌物，胆汁流动的阻塞或二的联合的一个缺陷引起。胆汁郁积的所有形式的普通后果在导致 hepatocytes 并且最后的 apoptosis 或坏死到长期的胆汁郁积的肝疾病的 hepatocytes 是胆汁酸和另外的潜在地有毒的混合物的保留。在某些胆汁郁积的混乱，也有进仙子的胆汁酸的漏胆汁的空间引起门发炎和纤维变性。为肝内胆汁郁积的处理的下列药理学目标能被识别：身体笔直的胆汁的分泌物的刺激并且后退进为经由肾到的排泄的全身的发行量的胆汁酸和另外的有毒的 cholephils 的分泌物在 hepatocytes 减少他们的保留；到更吸水的、不太有毒的代谢物的恐水病的胆汁酸和另外的有毒的混合物的新陈代谢的刺激；对胆汁的有毒的效果的受伤 cholangiocytes 的保护；apoptosis 的抑制由细胞毒素的胆汁酸的提高的层次引起了；纤维变性的抑制由胆汁酸的漏引起了进仙子胆汁的空间。主要胆汁性肝硬变的 ursodeoxcholic 酸治疗的临床的结果可以被认为是这策略的第一成功。

Computed tomography vs liver stiffness measurement and magnetic resonance imaging in evaluating esophageal varices in cirrhotic patients:A systematic review and meta-analysis

BACKGROUND Computed tomography(CT),liver stiffness measurement(LSM),and magnetic resonance imaging(MRI)are non-invasive diagnostic methods for esophageal varices(EV)and for the prediction of high-bleeding-risk EV(HREV)in cirrhotic patients.However,the clinical use of these methods is controversial.AIM To evaluate the accuracy of LSM,CT,and MRI in diagnosing EV and predicting HREV in cirrhotic patients.METHODS We performed literature searches in multiple databases,including Pub Med,Embase,Cochrane,CNKI,and Wanfang databases,for articles that evaluated the accuracy of LSM,CT,and MRI as candidates for the diagnosis of EV and prediction of HREV in cirrhotic patients.Summary sensitivity and specificity,positive likelihood ratio and negative likelihood ratio,diagnostic odds ratio,and the areas under the summary receiver operating characteristic curves were analyzed.The quality of the articles was assessed using the quality assessment of diagnostic accuracy studies-2 tool.Heterogeneity was examined by Q-statistic test and I2 index,and sources of heterogeneity were explored using metaregression and subgroup analysis.Publication bias was evaluated using Deek’s funnel plot.All statistical analyses were conducted using Stata12.0,Meta Disc1.4,and Rev Man5.3.RESULTS Overall,18,17,and 7 relevant articles on the accuracy of LSM,CT,and MRI in evaluating EV and HREV were retrieved.A significant heterogeneity was observed in all analyses(P<0.05).The areas under the summary receiver operating characteristic curves of LSM,CT,and MRI in diagnosing EV and predicting HREV were 0.86(95%confidence interval[CI]:0.83-0.89),0.91(95%CI:0.88-0.93),and 0.86(95%CI:0.83-0.89),and 0.85(95%CI:0.81-0.88),0.94(95%CI:0.91-0.96),and 0.83(95%CI:0.79-0.86),respectively,with sensitivities of 0.84(95%CI:0.78-0.89),0.91(95%CI:0.87-0.94),and 0.81(95%CI:0.76-0.86),and 0.81(95%CI:0.75-0.86),0.88(95%CI:0.82-0.92),and 0.80(95%CI:0.72-0.86),and specificities of 0.71(95%CI:0.60-0.80),0.75(95%CI:0.68-0.82),and 0.82(95%CI:0.70-0.89),and 0.73(95%CI:0.66-0.80),0.87(95%CI:0.81-0.92),and 0.72(95%CI:0.62-0.80),respectively.The corresponding positive likelihood ratios were 2.91,3.67,and 4.44,and 3.04,6.90,and2.83;the negative likelihood ratios were 0.22,0.12,and 0.23,and 0.26,0.14,and 0.28;the diagnostic odds ratios were 13.01,30.98,and 19.58,and 11.93,49.99,and 10.00.CT scanner is the source of heterogeneity.There was no significant difference in diagnostic threshold effects(P>0.05)or publication bias(P>0.05).CONCLUSION Based on the meta-analysis of observational studies,it is suggested that CT imaging,a non-invasive diagnostic method,is the best choice for the diagnosis of EV and prediction of HREV in cirrhotic patients compared with LSM and MRI.

Sclerosing cholangitis following severe trauma: Description of a remarkable disease entity with emphasis on possible pathophysiologic mechanisms

AIM: Persistent cholestasis is a rare complication of severe trauma or infections, Little is known about the possible pathomechanisms and the clinical course,METHODS: Secondary sclerosing cholangitis was diagnosed in five patients with persistent jaundice after severe trauma (one burn injury, three accidents, one power current injury). Medical charts were retrospectively reviewed with regard to possible trigger mechanisms for cholestasis, and the clinical course was recorded.RESULTS: Diagnosis of secondary sclerosing cholangitis was based in all patients on the primary sclerosing cholangitis (PSC)-like destruction of the intrahepatic bile ducts at cholangiography after exclusion of PSC. In four patients, arterial hypotension with subsequent ischemia may have caused the bile duct damage, whereas in the case of power current injury direct thermal damage was assumed to be the trigger mechanism. The course of secondary liver fibrosis was rapidly progressive and proceeded to liver cirrhosis in all four patients with a follow-up ＞2 years. Therapeutic possibilities were limited.CONCLUSION: Posttraumatic sclerosing cholangitis is a rare but rapidly progressive disease, probably caused by ischemia of the intrahepatic bile ducts via the peribiliary capillary plexus due to arterial hypotension. Gastroenterologists should be aware of this disease in patients with persistent cholestasis after severe trauma.

Regulatory T cells in viral hepatitis

The pathogenesis and outcome of viral infections are significantly influenced by the host immune response. The immune system is able to eliminate many viruses in the acute phase of infection. However, some viruses, like hepatitis C virus (HCV) and hepatitis B virus (HBV), can evade the host immune responses and establish a persistent infection. HCV and HBV persistence is caused by various mechanisms, like subversion of innate immune responses by viral factors, the emergence of T cell escape mutations, or T cell dysfunction and suppression. Recently, it has become evident that regulatory T cells may contribute to the pathogenesis and outcome of viral infections by suppressing antiviral immune responses. Indeed, the control of HCV and HBV specific immune responses mediated by regulatory T cells may be one mechanism that favors viral persistence, but it may also prevent the host from overwhelming T cell activity and liver damage. This review will focus on the role of regulatory T cells in viral hepatitis.

Identification and characterization of a novel bipartite nuclear localization signal in the hepatitis B virus polymerase

AIM:To characterize the nuclear import of hepatitis B virus(HBV)polymerase(P)and its relevance for the viral life cycle.METHODS:Sequence analysis was performed to predict functional motives within P.Phosphorylation of P was analyzed by in vitro phosphorylation.Phosphorylation site and nuclear localization signal(NLS)were destroyed by site directed mutagenesis.Functionality of the identified NLS was analyzed by confocal fluorescence microscopy and characterizing the karyopherin binding.Relevance of the structural motives for viral life cycle was studied by infection of primary Tupaia hepatocytes with HBV.RESULTS:We identified by sequence alignment and functional experiments a conserved bipartite NLS containing a casein kinaseⅡ(CKⅡ)phosphorylation site located within the terminal protein domain(TP)of the HBV polymerase.Inhibition of CKⅡimpairs the functionality of this NLS and thereby prevents the nuclear import of the polymerase.Binding of the import factor karyopherin-α2 to the polymerase depends on its CKⅡ-mediated phosphorylation of the bipartite NLS.In HBV-infected primary Tupaia hepatocytes CKⅡinhibition in the early phase(post entry phase)of the infection process prevents the establishment of the infection.CONCLUSION:Based on these data it is suggested that during HBV infection the final import of the genome complex into the nucleus is mediated by a novel bipartite NLS localized in the TP domain of HBV polymerase.

EGFR and HER2 expression in advanced biliary tract cancer

AIM:To analyze the pathogenetic role and potential clinical usefulness of the epidermal growth factor receptor(EGFR)and the human epidermal growth factor receptor 2(HER2)in patients with advanced biliary tract cancer(BTC). METHODS:EGFR and HER2 expression was studied in biopsy samples from 124 patients(51%women; median age 64.8 years),with advanced BTC diagnosed between 1997 and 2004.Five micrometers sections of paraffin embedded tissue were examined by standard, FDA approved immunohistochemistry.Tumors with scores of 2+or 3+for HER2 expression on immunochemistry were additionally tested for HER2 gene amplification by fluorescence in situ hybridisation(FISH).RESULTS:34/124 patients(27.4%)had gallbladder cancer,47(37.9%)had intrahepatic BTC and 43(34.7%)had extrahepatic or perihilar BTC.EGFR expression was examined in a subset of 56 samples. EGFR expression was absent in 22/56 tumors(39.3%). Of the remaining samples expression was scored as 1+in 12(21.5%),2+in 13(23.2%)and 3+in 9(16%), respectively.HER2 expression was as follows:score 0 73/124(58.8%),score 1+27/124(21.8%),score 2+ 21/124(17%)and score 3+4/124(3.2%).HER2 gene amplification was present in 6/124,resulting in an overall amplification rate of 5%. CONCLUSION:Our data suggest that routine testing and therapeutic targeting of HER2 does not seem to be useful in patients with BTC,while targeting EGFR may be promising.

Comparative analysis of ERCP,IDUS,EUS and CT in predicting malignant bile duct strictures

AIM:To compare endoscopic retrograde cholangio-pancreatography(ERCP),intraductal ultrasound(IDUS),endosonography(EUS),endoscopic transpapillary forceps biopsies(ETP)and computed tomography(CT)with respect to diagnosing malignant bile duct strictures.METHODS:A patient cohort with bile duct strictures of unknown etiology was examined by ERCP and IDUS,ETP,EUS,and CT.The sensitivity,specificity,and accuracy rates of the diagnostic procedures were calculated based on the definite diagnoses proved by histopathology or long-term follow-up in those patients who did not undergo surgery.For each of the diagnostic measures,the sensitivity,specificity,and accuracy rates were calculated.In all cases,the gold standard was the histopathologic staging of specimens or long-term follow-up of at least 12 mo.A comparison of the accuracy rates between the localization of strictures was performed by using the Mann-Whitney U-test and theχ2test as appropriate.A comparison of the accuracy rates between the diagnostic procedures was performed by using the McNemar’s test.Differences were considered statistically significant if P<0.05.RESULTS:A total of 234 patients(127 males,107 females,median age 64,range 20-90 years)with indeterminate bile duct strictures were included.A total of 161patients underwent operative exploration;thus,a surgical histopathological correlation was available for those patients.A total of 113 patients had malignant disease proven by surgery;in 48 patients,benign disease was surgically found.In these patients,the decision for surgical exploration was made due to the suspicion of malignant disease in multimodal diagnostics(ERCP,CT,or EUS).Fifty patients had a benign diagnosis and were followed by a surveillance protocol with a followup of at least 12 mo;the median follow-up was 34 mo.Twenty-three patients had extended malignant disease,and thus were considered palliative.A comparison of the different diagnostic tools for detecting bile duct malignancy resulted in accuracy rates of 91%(ERCP/IDUS),59%(ETP),92%(IDUS+ETP),74%(EUS),and 73%(CT),respectively.In the subgroup analysis,the accuracy rates(%,ERCP+IDUS/ETP/IDUS+ETP;EUS;CT)for each tumor entity were as follows:cholangiocellular carcinoma:92%/74%/92%/70%/79%;pancreatic carcinoma:90%/68%/90%/81%/76%;and ampullary carcinoma:88%/90%/90%/76%/76%.The detection rate of malignancy by ERCP/IDUS was superior to ETP(91%vs 59%,P<0.0001),EUS(91%vs74%,P<0.0001)and CT(91%vs 73%,P<0.0001);EUS was comparable to CT(74%vs 73%,P=0.649).When analyzing accuracy rates with regard to localization of the bile duct stenosis,the accuracy rate of EUS for proximal vs distal stenosis was significantly higher for distal stenosis(79%vs 57%,P<0.0001).CONCLUSION:ERCP/IDUS is superior to EUS and CT in providing accurate diagnoses of bile duct strictures of uncertain etiology.Multimodal diagnostics is recommended.

Stimulation of p38 MAPK by hormal preconditioning with atrial natriuretic peptide

AIM：Stress-activated signaling pathways responsible for hepatic ischemia reperfusion injury and their modulation by protective interventions are widely unknown.Preconditioning of rat livers with Atrial Natriuretic Peptide(ANP)attenuates ischemia reperfusion injury(Gerbes et al.Hepatology1998,18:1309-1317),SinANP has recently been shown to be a regulator of the p38MAPKpathway in endothelial cells(Kiemer et al.CircRes2002,90:874-881).aim of this thudy was to investigate activities of MAPK during ischemia and reperfusion and effects of ANP on MAPK.METHODS:Rat livers were perfused with KH-buffer in the presence or absence of ANP for 20min,kept in cold UWsloution for 24h,and reperfused forupto120min,Activities of p38MAPKand JNKwas determined by in vitro phosphorylation assays using MBP and c-jun as substrates.After SDS/PAGE electrophoresis,gels were quantified by phosphorimaging.RESULTS:Activity of p38MAPKin control organs decreased in the course of ischemia and reperfusion by85%,whereas ANPincreased p38 activity by up to 30-fold.JNKactivation of control livers increased in the course of ischemia and reperfusion by up to three-fold.This increase in JNK activrity was slightly elevated in ANP preconditioned organs.CONCLUSION:This work represents a systematic investigation of MAPK activation during liver ischemia and reperfusion.Employing ANP,for the first time a pharmacological approach to modulate these central signal transduction molecules is presented.

Prospective evaluation of small bowel preparation with bisacodyl and sodium phosphate for capsule endoscopy

AIM: To determine the effect of Prepacol?, a com- bination of sodium phosphate and bisacodyl, on transit and quality of capsule endoscopy (CE). METHODS: Fivety two consecutive patients were included in this prospective study. CE was performed following a 12 h fasting period. Twenty six patients were randomized for additional preparation with Prepacol?. The quality of CE was assessed separately for the proximal and the distal small bowel by 3 experienced endoscopists on the basis of a graduation which was initially developed with 20 previous CE. RESULTS: Preparation with Prepacol? accelerated small bowel transit time (262 ± 55 min vs 287 ± 97 min), but had no effect on the quality of CE. Visibility was significantly reduced in the distal compared to the proximal small bowel. CONCLUSION: The significantly reduced visibility of CE in the distal small bowel allocates the need for a good preparation. Since Prepacol? has no beneficial effect on CE the modality of preparation and the ideal time of application remains unclear. Further standardized examinations are necessary to identify sufficient preparation procedures and to determine the impact of the volume of the preparation solution.

Innovative immunohistochemistry identifies MMP-9 expressing macrophages at the invasive front of murine HCC

AIM:To investigate the proteolytic contribution of tumor-associated macrophages(TAM)in tumor invasion,we analyzed whether TAM at the invasive front of small HCC in Abcb4-/--mice show an enhanced expression of MMP-9. METHODS:Liver cryosections of the hepatocellular carcinoma(HCC)invasive front from 12 mo old Abcb4-/--mice were stained for collagen typeⅠand MMP-9 using Alexa488 and Alexa568 labeled secondary antibodies.Afterwards,the Alexa568 dye was bleached and the macrophage marker F4/80 was visualized using Alexa568 labeled secondary antibodies.Finally, photographs of the invasive tumor front were digitally overlaid and analyzed. RESULTS:After complete bleaching of the primary dye,specific fluorescence staining of a third antigen, here F4/80,was successfully performed on the same histological section.With this method,we were able to identify conglomerates of matrix metalloproteinase (MMP-9)expressing macrophages within the tumor capsule of HCC. CONCLUSION:MMP-9 expressing macrophages are involved in matrix remodelling at the invasive tumor front of HCC.The described staining protocol provides a simple yet powerful extension of conventional immuno-histochemistry,facilitating visualization of at least three different antigens plus nuclei in one single histological section.

Impact of hyperglycemia on autoimmune pancreatitis and regulatory T-cells

AIM To evaluate the influence of hyperglycemia on the progression of autoimmune pancreatitis.METHODS We induced hyperglycemia by repetitive intraperitoneal(ip) injection of 50 mg/kg streptozotocin in MRL/Mp J mice, which develop autoimmune pancreatitis due to a genetic predisposition. We compared the extent of inflammation(histological score, CD3^+ lymphocytes, CD8^+ T-cells, CD4^+ T-cells, Foxp3^+ T-helper cells) in the pancreas of hyperglycemic and normoglycemic mice. We also analyzed the number of leukocytes, lymphocytes, granulocytes and monocytes in the blood. In addition, we determined the percentage of CD3^+ lymphocytes, CD8^+ T-cells, CD4^+ T-cells, Foxp3^+ T-helper cells, Foxp3^+ CD25^+ T-helper and Foxp3^+T-helper cells in the spleen by flow cytometry.RESULTS Treatment with streptozotocin caused a strong induction of hyperglycemia and a reduction in body weight(P < 0.001). Severe hyperglycemia did not, however, lead to an aggravation, but rather to a slight attenuation of autoimmune pancreatitis. In the pancreas, both the histological score of the pancreas as well as the number of CD3+ lymphocytes(P < 0.053) were decreased by hyperglycemia. No major changes in the percentage of CD8^+ T-cells, CD4^+ T-cells, Foxp3^+ T-helper cells were observed between hyperglycemic and normoglycemic mice. Hyperglycemia increased the numbers of leukocytes(P < 0.001), lymphocytes(P = 0.016), granulocytes and monocytes(P = 0.001) in the blood. Hyperglycemia also moderately reduced the percentage of CD3^+ lymphocytes(P = 0.057), significantly increased the percentage of Foxp3^+ T-helper cells(P = 0.018) and Foxp3^+ CD25^+ T-helper cells(P = 0.021) and reduced the percentage of Foxp3^+T-helper cells(P = 0.034) in the spleen. CONCLUSION Hyperglycemia does not aggravate but moderately attenuates autoimmune pancreatitis, possibly by increasing the percentage of regulatory T-cells in the spleen.

Trametinib and dactolisib but not regorafenib exert antiproliferative effects on rat pancreatic stellate cells

BACKGROUND： Modulation of the stroma response is considered a promising approach for the treatment of chronic pancreatitis and pancreatic cancer. The aim of this study was to evaluate the effects of three clinically available small molecule kinase inhibitors, regorafenib, trametinib and dactolisib, on effector functions of activated pancreatic stellate cells （PSCs）, which play a key role in pancreatic fibrosis.