Endoscopy, extracorporeal shockwave lithotripsy (ESWL) and local lysis with alkaline solution of EDTA and bile salts in water were applied in combination in four patients with extra- and intrahepatic pigment stones as well as calcium bilirubinate covered concrements of the biliary tract. In the first patient (a man aged 80 years) a giant concrement of the bile duct was broken up after ESWL by three weeks of local chemical lysis and the fragments were removed by endoscopy. In the second case (man, aged 72), a nonextractable pigment stone was at first reduced in size by four-day local lysis and then removed endoscopically. Intrahepatic pigment stones were completely removed in the other two patients (boy of 12, man of 62) by local lysis only in 3 and 15 weeks, respectively. Even long-term use of the alkaline solution may not cause any serious side effects. Breaking up of stones after size reduction with ESWL of giant stones, size reduction of intact stones and contact lysis of intrahepatic stones are three important indications for chemical dissolution of biliary tract stones, respectively.

In 15 patients (13 women and two men) with cholesterol stones in the gall-bladder a special (Thistle) catheter was introduced into the gall-bladder under local anaesthesia by percutaneous transhepatic puncture. Methyl-tert-butyl ether, 2-15 ml, was injected via the catheter and removed again after 2 min. The number of stones per gall-bladder averaged 6.3 (1-20), size of stones 1.7 cm (0.5-2.8 cm), and duration of treatment 11.9 h (5-24 h). The stones dissolved in 13 patients (87%). In three patients stone débris remained: in one it was ultimately sucked out after reduction of the amount of débris with an EDTA-containing solution. The side effects of treatment--nausea and vomiting--were minor. In one patient there was a leak of bile from the gall-bladder after the procedure; a cholecystectomy was uneventfully performed. Another patient developed haemobilia which responded to conservative treatment. MTBE treatment has thus proved to be a successful and cheap method, low in side effects, in the treatment of patients with gall-stones.

Objective:To investigate whether enzyme release caused by chenodeoxycholic acid (CDCA) can be prevented by ursodeoxycholic acid (UDCA),and to study the effects of bile acids on bile secretion, glutamate dehydrogenase (GLDH) release and mitochondrial membrane structure. Methods: Totally 0.1-0.5 mmol/L bile acids were perfused into rat livers for 120 min. The bile duct was cannulated for collection of bile flow and GLDH was determined. Intact mitochondria were isolated and mitochondrial suspension was detected with electron paramagnetic resonance spectroscopy (EPR) for membrane mobility and polarity values. Results: Compared with control, CDCA at 0.1,0.3, 0.5 mmol/L decreased the bile flow by 12%, 77.25% and 78.98%, and enhanced GLDH release by 3, 9 and 21 times, respectively. It also increased the mobility of 4-maleimido-TEMPO spin label and the polarity of hydrophobic membrane interior. UDCA increased bile flow by 1.8 times at 0.3 mmol/L and 1.9 times at 0.5 mmol/L. It did not influence enzyme release and membrane structure. Prior infusion with UDCA (0.1 mmol/L) for 30 min followed by combination of UDCA and CDCA improved bile secretion, delayed enzyme release and partly prevented the membrane lesion caused by CDCA compared with CDCA alone. Conclusion:CDCA can damage mitochondrial membrane structure and result in liver dysfunction. UDCA improves secretion of bile and partly prevents liver mitochondrial lesion against CDCA. Low concentration of CDCA does not damage the liver function.

Intact mitochondria were incubated with and without calcium in solutions of chenodeoxycholate, ursodeoxycholate, or their conjugates. Glutamate dehydrogenase, protein and phospholipid release were measured. Alterations in membrane and organelle structure were investigated by electron paramagnetic resonance spectroscopy. Chenodeoxycholate enhanced enzyme liberation, solubilized protein and phospholipid, and increased protein spin label mobility and the polarity of the hydrophobic membrane interior, whereas ursodeoxycholate and its conjugates did not damage mitochondria. Preincubation with ursodeoxycholate or its conjugate tauroursodeoxycholate for 20 min partially prevented damage by chenodeoxycholate. Extended preincubation even with 1 mM ursodeoxycholate could no longer prevent structural damage. Calcium (from 0.01 mM upward) augmented the damaging effect of chenodeoxycholate (0.15–0.5 mM). The combined action of 0.01 mM calcium and 0.15 mM chenodeoxycholate was reversed by ursodeoxycholate only, not by its conjugates tauroursodeoxycholate and glycoursodeoxycholate. In conclusion, ursodeoxycholate partially prevents chenodeoxycholate-induced glutamate dehydrogenase release from liver cell mitochondria by membrane stabilization. This holds for shorter times and at concentrations below 0.5 mM only, indicating that the different constitution of protein-rich mitochondrial membranes does not allow optimal stabilization such as has been seen in phospholipid- and cholesterol-rich hepatocyte cell membranes, investigated previously.

Background: PBC without antimitochondrial antibodies (AMA) is called autoimmune cholangitis.PBC without or with AMA plus antinuclear antibodies (ANA) or smooth muscle antibodies (SMA) and the histological features of PBC and chronic autoimmune hepatitis is called overlap syndrome.Patients and Methods: Because it has been shown that patients with AMA-positive OS respond differently to UDCA therapy from patients without OS, we investigated whether AMA-positive OS is different from PBC with respect to biochemical, serological and morphological criteria.Results: From a collective of 103 PBC-patients the data of 70 patients have been evaluated.45 (64%) had an AMA-positive overlap syndrome, 25 (36%) a PBC.There were no statistically significant differences between the two groups concerning stages of the disease, histological activity, AMA and AMA-subtypes, IgM, IgG, inflammation-indicating enzymes (GLDH, AST, ALT), cholestasis enzymes and the course of the disease.15/45 (33%) of the patients with OS and 7/25 (28%) with PBC responded rapidly to medical therapy, 30 patients (67%) and 18 (72%) responded but slowly.Conclusions: AMA-positive overlap syndrome is not different from primary biliary cirrhosis with respect to biochemical, serological and morphological data.Although there were no differences between patients with OS and PBC concerning response to medical therapy, this needs to be confirmed in a larger study.

Ursodeoxycholate is used to treat primary biliary cirrhosis and is incorporated into hepatocyte plasma membranes. Its steroid nucleus binds to the apolar domain of the membrane, in a similar position to cholesterol. Therefore the question arises whether ursodeoxycholate has a similar effect on membrane structure and stability as cholesterol. Using differential scanning calorimetry the thermotropic behavior of egg phosphatidylcholine and dimyristoylphosphatidylcholine were studied after incubation with cholesterol or ursodeoxycholate. Large unilamellar vesicles were prepared with cholesterol contents of 0-50%. Following incubation of these vesicles with different amounts of ursodeoxycholate, vesicle stability in a gravitational field was investigated by measuring the phospholipid and cholesterol release. Vesicle size was studied by laser light scattering after incubation with cheno- and ursodeoxycholate, and the release of entrapped carboxyfluorescein was measured by means of fluorescence spectroscopy. Increasing cholesterol diminished the enthalpy of the phase transition in the membrane. Ursodeoxycholate decreased the enthalpy of the phase transition at even lower concentrations. Lipid release from vesicles in a high gravitational field diminished with increasing cholesterol content of the vesicles. Ursodeoxycholate had a comparable effect, which increased as the cholesterol content of the vesicles was decreased. Chenodeoxycholate damaged vesicles, whereas ursodeoxycholate did not. Cholesterol and ursodeoxycholate (below its critical micellar concentration) decreased the carboxyfluorescein release from vesicles induced by chenodeoxycholate. Thus like cholesterol, ursodeoxycholate is incorporated into phospholipid model membranes and reduces the change in enthalpy of the gel to liquid-crystalline phase transition. Like cholesterol ursodeoxycholate also maintains membrane stability and prevents membrane damage induced by mechanical and chemical stress.

BACKGROUND:Ursodeoxycholic acid probably is not able to cure primary biliary cirrhosis. Therefore in this study ursodeoxycholic acid was administered together with prednisolone, since monotherapy with glucocorticoids has been shown to have some positive effects.METHODS:Thirty patients with primary biliary cirrhosis (stages I-III) were entered into the study. Fifteen were treated with ursodeoxycholic acid 10 mg.kg-1.day-1 and placebo (group A), 15 with ursodeoxycholic acid and 10 mg prednisolone (group B) for 9 months. Apart from the usual laboratory examinations, liver biopsies were taken from 29 patients before and after therapy.RESULTS:Liver enzymes decreased significantly compared to the initial values in both groups (p < 0.001), but in group B cholestasis-indicating enzymes and the immunoglobulins G and A improved more rapidly. Between both groups the differences for AP, GGT, IgG, IgA and gamma-globulins were significant (p < 0.05), but only for short terms. In group B, liver histology improved significantly (p < 0.003), which correlated with the decrease of IgG. Ursodeoxycholic acid became the predominant bile acid in the serum. Toxic bile acids did not increase. Bone densitometry revealed a slight deterioration of preexisting osteoporosis in one patient.CONCLUSIONS:Although combination therapy with ursodeoxycholic acid and prednisolone was not superior to monotherapy with ursodeoxycholic acid with regard to liver function tests, it had a highly beneficial influence on liver histology. In our previous trials with monotherapy histology remained unchanged. An early decrease in IgG during combination therapy seems to be an indicator of an amelioration of liver histology.

The aim of this paper is to point out that: 1) CDCA and DCA increase the polarity of cell membranes and cause the release of cholesterol and phospholipid from the membranes; 2) the extent of this damage is inversely correlated with the cholesterol content of the membrane investigated; 3) UDCA, TUDCA and GUDCA decrease membrane polarity; 4) they prevent membrane damage when added prior to CDCA or DCA; 5) UDCA appears to be incorporated into the apolar domain of the membrane, TUDCA, GUDCA into the interface; 6) UDCA decreases HLA class I expression on hepatocyte membranes; 7) CDCA induces GLDH-release from liver mitochondria and increases mitochondrial membrane polarity and mobility; and 8) UDCA reduces the release of GLDH from mitochondria caused by CDCA.

The inheritance of Crigler-Najjar syndrome type II (CNS II) is still unclear. Both autosomal dominant transmission with variable penetrance and autosomal recessive transmission have been reported. We describe the diagnosis of CNS II in an adult patient with unconjugated serum bilirubin levels up to 19.6 mg/dl and no detectable activity of bilirubin UDP-glucuronosyltransferase in the liver biopsy. Serum bilirubin levels decreased markedly on phenobarbital treatment. The parents of our patient are first cousins. The mother and three of the patient's five sibs were jaundiced within a few days of birth. Our patient and her jaundiced siblings have 11 children, all healthy and anicteric. We conclude from these data that the inheritance of this very rare disease follows an autosomal recessive pattern, with pseudodominance in this family.

Monocytes appear to play a role in immunological abnormalities observed in primary biliary cirrhosis (PBC). Monocytes not only produce fibroproliferative factors, such as IL-1, TNF, and PDGF but also produce superoxide anion which can directly damage tissues, and thus may lead to fibrosis. The aim of this study was to compare the superoxide production in monocytes obtained from 12 control persons, 9 patients with non biliary cirrhosis, 6 untreated PBC patients, 6 patients with gallstones under urso- and chenodeoxycholicacid (Lithofalk) treatment and 32 PBC patients under ursodeoxycholicacid (UDCA) therapy. Monocytes were isolated and the production of superoxide anions with and without phorbol-myristate-acetate (PMA) stimulation was determined. In two occasion, the monocytes from control patients were preincubated with 10, 50, 100 microM UDCA. Unstimulated monocytes from PBC patients under UDCA therapy produce an average 43% more and the PMA stimulated monocytes an average 42% more superoxide than monocytes from the control or from the other cirrhotic patients. The UDCA preincubation did not influence the superoxide production of monocytes obtained from control patients. These findings suggest that the increased activity of monocytes may also play a role in liver damage and fibrosis in PBC.