- Email: [email protected]
Carbonic anhydrase and primary chronic pancreatitis
1054 CORRESPONDENCE
3.
4.
5. 6.
7.
GASTROENTEROLOGY Vol. 112, No. 3
ative primary biliary cirrhosis: a distinct syndrome of autoimmune cholangitis. Gut 1994;35:260–265. Goodman ZD, McNally PR, Davis DR, Ishak KG. Autoimmune cholangitis: a variant of primary biliary cirrhosis. Dig Dis Sci 1995;40: 1232–1242. Gordon SC, Quattrociocchi-Longe TM, Khan BA, Kodali VP, Chen J Silverman AL, Kiechle LK. Antibodies to carbonic anhydrase in patients with immune cholangiopathies. Gastroenterology 1995; 108:1802–1809. Johnson PJ, McFarlane IG. Meeting report: international autoimmune hepatitis group. Hepatology 1993;18:998–1005. Itoh Y, Reichlin M. Antibodies to carbonic anhydrase in systemic lupus erythematosus and other rheumatic diseases. Arthritis Rheum 1992;35:73–82. Kiechle FL, Quattrociocchi-Longe TM, Brinton DA. Carbonic anhydrase antibody in sera from patients with endometriosis. Am J Clin Pathol 1994;101:611–615.
Reply. Muratori et al.1 used two immunoblotting techniques to show a high prevalence of reactivity to CA II in the sera of patients with suspected autoimmune cholangitis, PBC, AIH, and healthy blood donors. The first method, described as ‘‘standard,’’ uses 3% skimmed milk for a blocking reagent, Tween 20, 47C incubation, and horse radish peroxidase–conjugated rabbit anti-human IgG and 4-chloro-1-naphthol for detection. The investigators then modified some, but not all, steps in the first procedure to reflect the method originally published by our laboratory,2 – 4 including using 4% gelatin as a blocking reagent, eliminating Tween 20, and 377C incubation. These modifications resulted in a higher frequency of positive results in all four patient subgroups. This modified method does not specify the source of anti-human IgG (rabbit vs. goat2 – 4) and does not use avidin-biotin detection system.2 – 4 The criteria used for positive and negative results are never defined for either method. The Western blot method as originally published has repeatedly yielded a low frequency of reactivity to CA II in a variety of control patients (0 of 8 patients with Gilbert’s syndrome,3 2 of 17 patients,2 and 0 of 17 fertile controls4). Others have used an enzyme-linked immunosorbent technique and reported reactivity to CA II in 1 of 205 and 1 of 216 sera of control patients. Muratori et al.1 concluded that their high frequency of reactivity to CA II is attributed to higher concentration of patient sera used by our method,2 – 4 a 1:40 dilution vs. the 1:100 dilution they used. However, nonspecific protein binding introduced by rabbit vs. goat anti-human IgG or other unidentified factors must also be considered as an explanation for their high frequency of reactivity. These differences support the conclusion that Western blotting is an art.7 Muratori et al.1 remind us that other autoimmune diseases have been associated with CA II autoantibodies including endometriosis,2,4,5 idiopathic chronic pancreatitis,6 and Sjo¨gren’s syndrome.6 Therefore, it is imperative to carefully evaluate the medical history of any individual included in a ‘‘control’’ group. We do not know if the healthy blood donors1 are men or women or if any had a disease already associated with anti–CA II. Certainly, the association of CA II autoantibodies and disease is an area that requires further investigation. However, it is premature to conclude that there is reason to doubt the high frequency of anti–CA II reported in patients with autoimmune cholangitis and not observed in PBC, AIH, and controls as originally reported.3 In a rat model, in fact, the injection of cholangiocytes induces cholangitis and anti–CA II production as measured by Western blot.8 Therefore, the role of CAII autoantibodies in the etiology and/or diagnosis of autoimmune cholangitis remains to be elucidated similar to other autoantibodies reactive to specific en-
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zymes.9 During the course of these investigations, variations in methodological approaches may confound the interpretation and subsequent conclusions. FREDERICK L. KIECHLE, M.D., Ph.D. THERESE M. QUATTROCIOCCHI–LONGE, M.S.
Department of Clinical Pathology STUART A. GORDON, M.D.
Department of Gastroenterology-Hepatology 3601 West 13 Mile Road Royal Oak, Michigan 48073 1. Muratori P, Muratori L, Lenzi M, Bianchi FB. Antibodies to carbonic anhydrase are not specific to autoimmune cholangiopathy. Gastroenterology (in press). 2. Kiechle FL, Quattrociocchi-Longe TM, Brinton DA. Carbonic anhydrase antibody in sera from patients with endometriosis. Am J Clin Pathol 1994;101:611–615. 3. Gordon SC, Quattrociocchi-Longe TM, Khan BA, Kodali VP, Chen J, Silverman AL, Kiechle FL. Antibodies to carbonic anhydrase in patients with immune cholangiopathies. Gastroenterology 1995; 108:1802–1808. 4. Brinton DA, Quattrociocchi-Longe TM, Kiechle FL. Endometriosis: identification by carbonic anhydrase autoantibodies and clinical features. Ann Clin Lab Sci 1996;26:409–420. 5. D’Cruz OJ, Wild RA, Haas GG Jr, Reichlin M. Antibodies to carbonic anhydrase in endometriosis: prevalence, specificity, and relationship to clinical and laboratory parameters. Fertil Steril 1996;66: 547–556. 6. Kino-Ohsaki J, Nishimori I, Morita M, Okazaki K, Yamamato Y, Onishi S, Hollingsworth MA. Serum antibodies to carbonic anhydrase I and II in patients with idiopathic chronic pancreatitis and Sjo¨gren’s syndrome. Gastroenterology 1996;110:1579–1586. 7. Dunbar BS, ed. Protein blotting: a practical approach. Oxford: IRL, 1994:20. 8. Ueno Y, Phillips JO, Ludwig J, Lichtman SN, LaRusso NF. Development and characterization of a rodent model of immune-mediated cholangitis. Proc Natl Acad Sci USA 1996;93:216–220. 9. Kiechle FL, Quattrociocchi-Longe TM, Brinton DA, Gordon SC, Sykes E, Elkhalifa MY. Autoantibodies to specific enzymes: a review. Ann Clin Lab Sci 1996;26:195–207.
Carbonic Anhydrase and Primary Chronic Pancreatitis Dear Sir: We read with great interest the article by Kino-Ohsaki et al.1 on the presence of serum antibodies to carbonic anhydrase (CA) I and II in patients with chronic pancreatitis (CP) and Sjo¨gren’s syndrome (SS). The study results show the presence of serum anti–CA II antibodies in 62% of patients with SS and in 33% of those with idiopathic CP, whereas lower percentages were observed in primary biliary cirrhosis (9%) and chronic alcoholic pancreatitis (15%). The conclusion of the study was that an immune sensitization against CA II is probably implicated in the pathogenesis of idiopathic CP. Worthy of note is that patients with CP and the presence of serum anti–CA II antibodies showed a pathological endoscopic retrograde pancreatography with an irregular configuration of the main pancreatic duct and branch, which were narrowed and shaped, and only a mild dilatation of Wirsung’s duct. In patients with idiopathic CP and absence of anti–CA II antibodies, the investigators rarely observed these findings, whereas the marked dilatation of the Wirsung’s duct was more common. The authors explain the radiological images in CP with positive anti–CA II antibodies as an autoimmune reaction
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CORRESPONDENCE 1055
against an antigen expressed in the pancreatic ducts, with CA II normally localized in the ductal epithelium of the pancreas.2 These data support our pathogenic hypothesis for CP,3,4 which we believe to be initially caused by a periductal inflammatory infiltrates of the main and/or secondary pancreatic ducts followed by an obliterating periductal fibrosis. The first step in the disease may be an antigenic alteration on the ductal epithelium, possibly alcohol-induced, such as an aberrant expression of HLA-DR,6,8 but it may also involve CA II. The presence of CA II also in the serous acinar and ductal structures of the human salivary glands2,8 may account for the association between CP and SS.9 – 13 In our experience, about 30% of the patients with CP had a pathological sialogram of the parotid glands (unpublished work in progress). This association cannot be casual and must imply a common pathogenesis. The lithostatin hypothesis14 and necrosis-fibrosis hypothesis15 do not justify these findings because we do not observe salivary calcifications and recurrent episodes of salivary gland pain in our patients with CP. We suggest an autoimmune mechanism against common pancreatic and salivary target antigens in CP and SS, as postulated by the authors. Furthermore, CA II has been detected in the mucosal epithelium of the gastrointestinal tract and in the biliary ductal epithelium.2 These data may explain the clinical association between CP and primary sclerosing cholangitis,9 – 11,16 – 19 primary biliary cirrhosis,16 – 18,20,21 ulcerative colitis,20 – 25 and Crohn’s disease.26 – 30 In our opinion an immune pathogenesis is therefore involved in some patients with CP. In clinical practice we would prefer to divide patients into those with primary CP (postulated autoimmune disease) and secondary CP (obstructive disease). Because succeeding in identifying primary CP is an important clinical goal in terms of therapeutic implications, we use instrumental tools (endoscopic retrograde cholangiopancreatography and parotid sialography) and clinical and laboratory data for this pupose. The presence of serum anti–CA II antibodies probably also enhances our knowledge of this poorly understood disease.
7.
8.
9.
10.
11.
12.
13.
14. 15. 16.
17.
18.
19. GIORGIO CAVALLINI LUCA FRULLONI PAOLO BOVO VINCENZO DI FRANCESCO MARCO FILIPPINI
20.
Cattedra di Gastroenterologia Universita` di Verona Policlinico BorgoRoma via delle Menegone 37134 Verona, Italy
21.
22.
1. Kino-Ohsaki J, Nishimori I, Morita M, Okazaki K, Yamamoto Y, Onishi S, Hollingsworth MA. Serum antibodies to carbonic anhydrase I and II in patients with idiopathic chronic pancreatitis and Sjo¨gren’s syndrome. Gastroenterology 1996;110:1579–1586. 2. Parkkila S, Parkkila A-K, Juvonen T, Rajaniemi H. Distribution of the carbonic anhydrase isoenzyme I, II and IV in the human alimentary tract. Gut 1994;35:646–650. 3. Cavallini G. Is chronic pancreatitis a primary disease of the pancreatic ducts? A new pathogenetic hypothesis. Ital J Gastroenterol 1993;25:400–407. 4. Cavallini G, Frulloni L, Di Francesco V, Bovo P, Vaona B, Filippini M. Autoimmunity and chronic pancreatitis (letter). Gut 1995;36: 799. 5. Bovo P, Mirachian R, Merigo F, et al. HLA molecule expression on chronic pancreatitis specimens. Is there a role for autoimmunity? A preliminary study. Pancreas 1987;2:350–356. 6. Bedossa P, Bacci J, Lemaigre G, Martin E. Lymphocyte subsets
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23. 24. 25. 26.
27.
28. 29.
and HLA-DR expression in normal pancreas and in chronic pancreatitis. Pancreas 1990;5:415–420. Jalleh RP, Gilbertson JA, Williamson RCN, et al. Expression of major histocompatibility antigens in human chronic pancreatitis. Gut, 1993;34:1452–1457. Kumpulainen T, Jalovaara P. Immunohistochemical localisation of carbonic anhydrase isoenzymes VI, II and I in human parotid and submandibular glands. J Histochem Cytochem 1990;38: 941–947. Waldram R, Kopelman H, Tsantoulas D, Williams R. Chronic pancreatitis, sclerosing cholangitis and sicca complex in two siblings. Lancet 1975;1:550–552. Sjo¨gren I, Wengle B, Korsgren M. Primary sclerosing cholangitis associated with fibrosis of the submandibular glands and the pancreas. Acta Med Scand 1979;205:139–141. Montefusco PP, Geiss AC, Bronza RL, et al. Sclerosing cholangitis, chronic pancreatitis and Sjo¨gren’s syndrome: a syndrome complex. Am J Surg 1984;147:822–826. Lindstrom E, Lindstrom F, von Schenck H, Ihse I. Pancreatic ductal morphology and function in primary Sjo¨gren’s syndrome. Int J Pancreatol 1991;8:141–149. Nishimori I, Morita M, Kino J, et al. Pancreatic involvement in patients with Sjo¨gren’s syndrome and primary biliary cirrhosis. Int J Pancreatol 1995;17:47–54. Sarles H. Etiopathogenesis and definition of chronic pancreatitis. Dig Dis Sci 1986;31:91S–107S. Kloppel G, Maillet B. Pathology of acute and chronic pancreatitis. Pancreas 1993;8:659–670. Epstein O, Chapman RWG, Lake-Bakaar G, et al. The pancreas in primary biliary cirrhosis and primary sclerosing cholangitis. Gastroenterology 1982;83:1177–1182. Hamilton I, Lintott DJ, Ruddell WSJ, Axon TR. The endoscopic retrograde cholangiogram and pancreatogram in chronic liver disease. Clin Radiol 1983;34:417–422. Fausa O, Kolmannskog F, Ritland S. The pancreatic ducts in primary biliary cirrhosis and sclerosing cholangitis. Scand J Gastroenterol, 1985;20(Suppl 107):32–35. Børkje B, Vetvik K, O / degaard S, et al. Chronic pancreatitis in patients with sclerosing cholangitis and ulcerative colitis. Scand J Gastroenterol 1985;20:539–542. Tavarela Veloso F, Dias LM, Carvalho J, et al. Ulcerative colitis, primary biliary cirrhosis and chronic pancreatitis: coincident or coexistent? J Clin Gastroenterol 1993;7:55–57. Ball PW, Baggenstoss AH, Bargen JA. Pancreatic lesions associated with chronic ulcerative colitis. Arch Pathol 1950;50:347– 358. Kato J, Morimoto H, Unoura M, et al. Primary biliary cirrhosis and chronic pancreatitis in a patient with ulcerative colitis. J Clin Gastroenterol 1985;7:425–427. Axon ATR, Ashton MG, Lintott DJ. Chronic pancreatitis and inflammatory bowel disease. Clin Radiol 1979;30:179–182. Gurian LE, Keefe EB. Pancreatic insufficiency associated with ulcerative colitis. Gastroenterology 1982;82:581–585. Lysy J, Goldin E. Pancreatitis in ulcerative colitis. J Clin Gastroenterol 1992;15:336–339. Legge DA, Hoffman HN, Carlson HC. Pancreatitis as a complication of regional enteritis of the duodenum. Gastroenterology 1971;61:834–837. Altman HS, Phillips G, Bank S, Klotz H. Pancreatitis associated with duodenal Crohn’s disease. Am J Gastroenterol 1983;78: 174–177. Seyrig J-A, Jian R, Modigliani R, et al. Idiopathic pancreatitis with inflammatory bowel disease. Dig Dis Sci 1985;30:1121–1126. Spiess SE, Braun M, Vogelsang RL, et al. Crohn’s disease of the duodenum complicated by pancreatitis and common bile duct obstruction. Am J Gastroenterol 1992;87:1033–1036.
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30. Gschwantler M, Kogelbauer G, Klose W, et al. The pancreas as a site of granulomatous inflammation in Crohn’s disease. Gastroenterology 1995;108:1246–1249.
Reply. We thank Dr. Cavallini and colleagues for their comments and interest in our study. The cause and pathogenesis of the disease known as chronic pancreatitis is undoubtedly multifactorial and heterogeneous, and we strongly agree with the correspondents that autoimmune reactions are important factors that contribute to the initiation or acceleration of the disease. Autoimmune reactivity may extend to cases in which alcohol is the suspected cause of CP because alcohol may not be the sole injurious factor involved in the disease process.1 Moreover, alcohol intake probably induces alterations in antigen expression by the pancreatic ductal cells including enhanced or aberrant expression of major histocompatibility class I and II molecules, which probably contributes to these autoimmune reactions.2,3 Cavallini et al. propose dividing patients with CP into two groups: primary CP (postulated autoimmune disease) and secondary CP (obstructive disease). We support this proposal in principle and believe that it is appropriate to begin careful prospective and retrospective studies into the utility and accuracy of new classifications of CP. Ideally, this project should be undertaken by a multinational consortium of investigators and should include a discussion of other parameters (e.g., genetics) that may be useful for improving the differential diagnosis and treatment of the disease. It is time to consider moving beyond the classical classification of CP as alcoholic and nonalcoholic, but only in a systematic and careful manner. ISAO NISHIMORI, M.D.
First Department of Internal Medicine Kochi Medical School Nankoku, Kochi 783, Japan 1. Jalleh RP, Gilbertson JA, Williamson RCN, Foster CS. A morphological and immunohistochemical analysis of the human liver in chronic pancreatitis. Gut 1991;32:1386–1391. 2. Cavallini G, Frulloni L, Di Francesco V, Bovo P, Filippini M, Vaona B. Autoimmunity and chronic pancreatitis (letter). Gut 1995;36: 799. 3. Jalleh RP, Gilbertson JA, Williamson RCN, Slater SD, Foster CS. Expression of major histocompatibility antigens in human chronic pancreatitis. Gut 1993;34:1452–1457.
H. pylori and Gastric Phospholipids of Peptic Ulcer Dear Sir: We read the paper by Nardone et al.1 regarding alternation of phospholipid concentration in the gastric mucosa in the presence of Helicobacter pylori with interest. The investigators showed that H. pylori infection markedly reduced absolute amounts of total phospholipids, phosphatidylcholine, and phosphatidylethanolamine, which were reduced most significantly in subjects with chronic gastritis. They advocate that lipolytic activity due to phospholipase A2 and phospholipase C, which H. pylori produced, may be related to the decrease in total phosphatidylcholine and phosphatidylethanolamine concentrations. We measured the composition of gastric phospholipids in endoscopic biopsy specimens of patients with peptic ulcer, because Nardone et al. did not show data regarding peptic ulcer. The population in our study consisted of 7 patients without H. pylori infection or gastroduodenal mucosal lesions (controls) and 38 patients with gastric
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and/or duodenal ulcer. The endoscopic biopsy specimens of antral and corporal mucosa were taken from the greater curvature of the subjects to identify H. pylori infection and for phospholipid analysis. Phospholipids were measured quantitatively in the lipid extract from the biopsy specimens according to thin-layer chromatography and flame ionization detection method by Iatroscan TLC/FID analyzer (Iatron Inc., Tokyo, Japan). Phosphatidylethanolamine levels significantly decreased in the gastric mucosa of patients with gastric and duodenal ulcers compared with normal controls (gastric ulcer group, 2.3 { 0.2 mg/mg; duodenal ulcer group, 2.0 { 0.5 mg/mg; normal control group, 3.2 { 0.2 mg/mg; P õ 0.01 and 0.05, respectively). However, phosphatidylethanolamine levels in the mucosa of patients with peptic ulcer did not differ with reference to H. pylori infection (patients with H. pylori infection, 2.7 { 0.3 mg/mg; patients without H. pylori infection, 2.1 { 0.2 mg/mg). Cellular density of the inflammatory cells infiltrated in the mucosa may affect the amount of phospholipids because the polymorphonuclear leukocytes that are recruited to sites of gastric injury during inflammatory process are another potential source of phospholipase.2 The discrepancy in the alteration of phospholipids between Nardone et al.1 and the present study may be partly related to the difference in quantity of inflammatory leukocytes. Phospholipids in gastric mucosa play an important role in the protective barrier of the gastroduodenal epithelium, mainly by way of their hydrophobicity.3 As shown by Nardone et al.,1 H. pylori infection is an important factor in altering gastric mucosal phospholipids. However, as shown in the present study, H. pylori may not be the only factor in decreasing mucosal phospholipid levels in patients with peptic ulcer, whereas phosphatidylethanolamine was reduced in the gastric mucosa of patients with peptic ulcer. TAKANORI KOYAMA SEIJI KAWASAKI HIROYUKI SAKATA RYUICHI IWAKIRI KAZUMA FUJIMOTO
Department of Internal Medicine JUTAROU TADANO
Clinical Laboratory Saga Medical School Saga 849, Japan 1. Nardone G, D’Armiento F, Corso G, Coscione P, Esposito M, Budillon G. Lipids of human gastric mucosa: effect of Helicobacter pylori infection and nonalcoholic cirrhosis. Gastroenterology 1994;107: 362–368. 2. Traynor JR, Authi KS. Phospholipase A2 activity of lysosomal origin secreted by polymorphonuclear leukocytes during phagocytosis or in treatment with calcium. Biochem Biophys Acta 1981;665:571– 577. 3. Lichtenberger LM, Graziani LA, Dial EJ, Butler DB, Hills BA. Role of surface-active phospholipids in gastric cytoprotection. Science 1983;219:1327–1329.
Reply. We read with interest the letter by Dr. Koyama and coworkers reporting a significant decrease of phosphatidylethanolamine level in the gastric mucosa (antral and corporal sites) of patients with gastric and duodenal ulcer compared with control subjects but no significant difference in H. pylori infection. Their findings seem to be at variance with our report of a dramatic variation of the phospholipid profile in patients with nonulcer chronic gastritis affected by H. pylori
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3.
4.
5. 6.
7.
GASTROENTEROLOGY Vol. 112, No. 3
ative primary biliary cirrhosis: a distinct syndrome of autoimmune cholangitis. Gut 1994;35:260–265. Goodman ZD, McNally PR, Davis DR, Ishak KG. Autoimmune cholangitis: a variant of primary biliary cirrhosis. Dig Dis Sci 1995;40: 1232–1242. Gordon SC, Quattrociocchi-Longe TM, Khan BA, Kodali VP, Chen J Silverman AL, Kiechle LK. Antibodies to carbonic anhydrase in patients with immune cholangiopathies. Gastroenterology 1995; 108:1802–1809. Johnson PJ, McFarlane IG. Meeting report: international autoimmune hepatitis group. Hepatology 1993;18:998–1005. Itoh Y, Reichlin M. Antibodies to carbonic anhydrase in systemic lupus erythematosus and other rheumatic diseases. Arthritis Rheum 1992;35:73–82. Kiechle FL, Quattrociocchi-Longe TM, Brinton DA. Carbonic anhydrase antibody in sera from patients with endometriosis. Am J Clin Pathol 1994;101:611–615.
Reply. Muratori et al.1 used two immunoblotting techniques to show a high prevalence of reactivity to CA II in the sera of patients with suspected autoimmune cholangitis, PBC, AIH, and healthy blood donors. The first method, described as ‘‘standard,’’ uses 3% skimmed milk for a blocking reagent, Tween 20, 47C incubation, and horse radish peroxidase–conjugated rabbit anti-human IgG and 4-chloro-1-naphthol for detection. The investigators then modified some, but not all, steps in the first procedure to reflect the method originally published by our laboratory,2 – 4 including using 4% gelatin as a blocking reagent, eliminating Tween 20, and 377C incubation. These modifications resulted in a higher frequency of positive results in all four patient subgroups. This modified method does not specify the source of anti-human IgG (rabbit vs. goat2 – 4) and does not use avidin-biotin detection system.2 – 4 The criteria used for positive and negative results are never defined for either method. The Western blot method as originally published has repeatedly yielded a low frequency of reactivity to CA II in a variety of control patients (0 of 8 patients with Gilbert’s syndrome,3 2 of 17 patients,2 and 0 of 17 fertile controls4). Others have used an enzyme-linked immunosorbent technique and reported reactivity to CA II in 1 of 205 and 1 of 216 sera of control patients. Muratori et al.1 concluded that their high frequency of reactivity to CA II is attributed to higher concentration of patient sera used by our method,2 – 4 a 1:40 dilution vs. the 1:100 dilution they used. However, nonspecific protein binding introduced by rabbit vs. goat anti-human IgG or other unidentified factors must also be considered as an explanation for their high frequency of reactivity. These differences support the conclusion that Western blotting is an art.7 Muratori et al.1 remind us that other autoimmune diseases have been associated with CA II autoantibodies including endometriosis,2,4,5 idiopathic chronic pancreatitis,6 and Sjo¨gren’s syndrome.6 Therefore, it is imperative to carefully evaluate the medical history of any individual included in a ‘‘control’’ group. We do not know if the healthy blood donors1 are men or women or if any had a disease already associated with anti–CA II. Certainly, the association of CA II autoantibodies and disease is an area that requires further investigation. However, it is premature to conclude that there is reason to doubt the high frequency of anti–CA II reported in patients with autoimmune cholangitis and not observed in PBC, AIH, and controls as originally reported.3 In a rat model, in fact, the injection of cholangiocytes induces cholangitis and anti–CA II production as measured by Western blot.8 Therefore, the role of CAII autoantibodies in the etiology and/or diagnosis of autoimmune cholangitis remains to be elucidated similar to other autoantibodies reactive to specific en-
/ 5e19$$0063
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zymes.9 During the course of these investigations, variations in methodological approaches may confound the interpretation and subsequent conclusions. FREDERICK L. KIECHLE, M.D., Ph.D. THERESE M. QUATTROCIOCCHI–LONGE, M.S.
Department of Clinical Pathology STUART A. GORDON, M.D.
Department of Gastroenterology-Hepatology 3601 West 13 Mile Road Royal Oak, Michigan 48073 1. Muratori P, Muratori L, Lenzi M, Bianchi FB. Antibodies to carbonic anhydrase are not specific to autoimmune cholangiopathy. Gastroenterology (in press). 2. Kiechle FL, Quattrociocchi-Longe TM, Brinton DA. Carbonic anhydrase antibody in sera from patients with endometriosis. Am J Clin Pathol 1994;101:611–615. 3. Gordon SC, Quattrociocchi-Longe TM, Khan BA, Kodali VP, Chen J, Silverman AL, Kiechle FL. Antibodies to carbonic anhydrase in patients with immune cholangiopathies. Gastroenterology 1995; 108:1802–1808. 4. Brinton DA, Quattrociocchi-Longe TM, Kiechle FL. Endometriosis: identification by carbonic anhydrase autoantibodies and clinical features. Ann Clin Lab Sci 1996;26:409–420. 5. D’Cruz OJ, Wild RA, Haas GG Jr, Reichlin M. Antibodies to carbonic anhydrase in endometriosis: prevalence, specificity, and relationship to clinical and laboratory parameters. Fertil Steril 1996;66: 547–556. 6. Kino-Ohsaki J, Nishimori I, Morita M, Okazaki K, Yamamato Y, Onishi S, Hollingsworth MA. Serum antibodies to carbonic anhydrase I and II in patients with idiopathic chronic pancreatitis and Sjo¨gren’s syndrome. Gastroenterology 1996;110:1579–1586. 7. Dunbar BS, ed. Protein blotting: a practical approach. Oxford: IRL, 1994:20. 8. Ueno Y, Phillips JO, Ludwig J, Lichtman SN, LaRusso NF. Development and characterization of a rodent model of immune-mediated cholangitis. Proc Natl Acad Sci USA 1996;93:216–220. 9. Kiechle FL, Quattrociocchi-Longe TM, Brinton DA, Gordon SC, Sykes E, Elkhalifa MY. Autoantibodies to specific enzymes: a review. Ann Clin Lab Sci 1996;26:195–207.
Carbonic Anhydrase and Primary Chronic Pancreatitis Dear Sir: We read with great interest the article by Kino-Ohsaki et al.1 on the presence of serum antibodies to carbonic anhydrase (CA) I and II in patients with chronic pancreatitis (CP) and Sjo¨gren’s syndrome (SS). The study results show the presence of serum anti–CA II antibodies in 62% of patients with SS and in 33% of those with idiopathic CP, whereas lower percentages were observed in primary biliary cirrhosis (9%) and chronic alcoholic pancreatitis (15%). The conclusion of the study was that an immune sensitization against CA II is probably implicated in the pathogenesis of idiopathic CP. Worthy of note is that patients with CP and the presence of serum anti–CA II antibodies showed a pathological endoscopic retrograde pancreatography with an irregular configuration of the main pancreatic duct and branch, which were narrowed and shaped, and only a mild dilatation of Wirsung’s duct. In patients with idiopathic CP and absence of anti–CA II antibodies, the investigators rarely observed these findings, whereas the marked dilatation of the Wirsung’s duct was more common. The authors explain the radiological images in CP with positive anti–CA II antibodies as an autoimmune reaction
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CORRESPONDENCE 1055
against an antigen expressed in the pancreatic ducts, with CA II normally localized in the ductal epithelium of the pancreas.2 These data support our pathogenic hypothesis for CP,3,4 which we believe to be initially caused by a periductal inflammatory infiltrates of the main and/or secondary pancreatic ducts followed by an obliterating periductal fibrosis. The first step in the disease may be an antigenic alteration on the ductal epithelium, possibly alcohol-induced, such as an aberrant expression of HLA-DR,6,8 but it may also involve CA II. The presence of CA II also in the serous acinar and ductal structures of the human salivary glands2,8 may account for the association between CP and SS.9 – 13 In our experience, about 30% of the patients with CP had a pathological sialogram of the parotid glands (unpublished work in progress). This association cannot be casual and must imply a common pathogenesis. The lithostatin hypothesis14 and necrosis-fibrosis hypothesis15 do not justify these findings because we do not observe salivary calcifications and recurrent episodes of salivary gland pain in our patients with CP. We suggest an autoimmune mechanism against common pancreatic and salivary target antigens in CP and SS, as postulated by the authors. Furthermore, CA II has been detected in the mucosal epithelium of the gastrointestinal tract and in the biliary ductal epithelium.2 These data may explain the clinical association between CP and primary sclerosing cholangitis,9 – 11,16 – 19 primary biliary cirrhosis,16 – 18,20,21 ulcerative colitis,20 – 25 and Crohn’s disease.26 – 30 In our opinion an immune pathogenesis is therefore involved in some patients with CP. In clinical practice we would prefer to divide patients into those with primary CP (postulated autoimmune disease) and secondary CP (obstructive disease). Because succeeding in identifying primary CP is an important clinical goal in terms of therapeutic implications, we use instrumental tools (endoscopic retrograde cholangiopancreatography and parotid sialography) and clinical and laboratory data for this pupose. The presence of serum anti–CA II antibodies probably also enhances our knowledge of this poorly understood disease.
7.
8.
9.
10.
11.
12.
13.
14. 15. 16.
17.
18.
19. GIORGIO CAVALLINI LUCA FRULLONI PAOLO BOVO VINCENZO DI FRANCESCO MARCO FILIPPINI
20.
Cattedra di Gastroenterologia Universita` di Verona Policlinico BorgoRoma via delle Menegone 37134 Verona, Italy
21.
22.
1. Kino-Ohsaki J, Nishimori I, Morita M, Okazaki K, Yamamoto Y, Onishi S, Hollingsworth MA. Serum antibodies to carbonic anhydrase I and II in patients with idiopathic chronic pancreatitis and Sjo¨gren’s syndrome. Gastroenterology 1996;110:1579–1586. 2. Parkkila S, Parkkila A-K, Juvonen T, Rajaniemi H. Distribution of the carbonic anhydrase isoenzyme I, II and IV in the human alimentary tract. Gut 1994;35:646–650. 3. Cavallini G. Is chronic pancreatitis a primary disease of the pancreatic ducts? A new pathogenetic hypothesis. Ital J Gastroenterol 1993;25:400–407. 4. Cavallini G, Frulloni L, Di Francesco V, Bovo P, Vaona B, Filippini M. Autoimmunity and chronic pancreatitis (letter). Gut 1995;36: 799. 5. Bovo P, Mirachian R, Merigo F, et al. HLA molecule expression on chronic pancreatitis specimens. Is there a role for autoimmunity? A preliminary study. Pancreas 1987;2:350–356. 6. Bedossa P, Bacci J, Lemaigre G, Martin E. Lymphocyte subsets
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23. 24. 25. 26.
27.
28. 29.
and HLA-DR expression in normal pancreas and in chronic pancreatitis. Pancreas 1990;5:415–420. Jalleh RP, Gilbertson JA, Williamson RCN, et al. Expression of major histocompatibility antigens in human chronic pancreatitis. Gut, 1993;34:1452–1457. Kumpulainen T, Jalovaara P. Immunohistochemical localisation of carbonic anhydrase isoenzymes VI, II and I in human parotid and submandibular glands. J Histochem Cytochem 1990;38: 941–947. Waldram R, Kopelman H, Tsantoulas D, Williams R. Chronic pancreatitis, sclerosing cholangitis and sicca complex in two siblings. Lancet 1975;1:550–552. Sjo¨gren I, Wengle B, Korsgren M. Primary sclerosing cholangitis associated with fibrosis of the submandibular glands and the pancreas. Acta Med Scand 1979;205:139–141. Montefusco PP, Geiss AC, Bronza RL, et al. Sclerosing cholangitis, chronic pancreatitis and Sjo¨gren’s syndrome: a syndrome complex. Am J Surg 1984;147:822–826. Lindstrom E, Lindstrom F, von Schenck H, Ihse I. Pancreatic ductal morphology and function in primary Sjo¨gren’s syndrome. Int J Pancreatol 1991;8:141–149. Nishimori I, Morita M, Kino J, et al. Pancreatic involvement in patients with Sjo¨gren’s syndrome and primary biliary cirrhosis. Int J Pancreatol 1995;17:47–54. Sarles H. Etiopathogenesis and definition of chronic pancreatitis. Dig Dis Sci 1986;31:91S–107S. Kloppel G, Maillet B. Pathology of acute and chronic pancreatitis. Pancreas 1993;8:659–670. Epstein O, Chapman RWG, Lake-Bakaar G, et al. The pancreas in primary biliary cirrhosis and primary sclerosing cholangitis. Gastroenterology 1982;83:1177–1182. Hamilton I, Lintott DJ, Ruddell WSJ, Axon TR. The endoscopic retrograde cholangiogram and pancreatogram in chronic liver disease. Clin Radiol 1983;34:417–422. Fausa O, Kolmannskog F, Ritland S. The pancreatic ducts in primary biliary cirrhosis and sclerosing cholangitis. Scand J Gastroenterol, 1985;20(Suppl 107):32–35. Børkje B, Vetvik K, O / degaard S, et al. Chronic pancreatitis in patients with sclerosing cholangitis and ulcerative colitis. Scand J Gastroenterol 1985;20:539–542. Tavarela Veloso F, Dias LM, Carvalho J, et al. Ulcerative colitis, primary biliary cirrhosis and chronic pancreatitis: coincident or coexistent? J Clin Gastroenterol 1993;7:55–57. Ball PW, Baggenstoss AH, Bargen JA. Pancreatic lesions associated with chronic ulcerative colitis. Arch Pathol 1950;50:347– 358. Kato J, Morimoto H, Unoura M, et al. Primary biliary cirrhosis and chronic pancreatitis in a patient with ulcerative colitis. J Clin Gastroenterol 1985;7:425–427. Axon ATR, Ashton MG, Lintott DJ. Chronic pancreatitis and inflammatory bowel disease. Clin Radiol 1979;30:179–182. Gurian LE, Keefe EB. Pancreatic insufficiency associated with ulcerative colitis. Gastroenterology 1982;82:581–585. Lysy J, Goldin E. Pancreatitis in ulcerative colitis. J Clin Gastroenterol 1992;15:336–339. Legge DA, Hoffman HN, Carlson HC. Pancreatitis as a complication of regional enteritis of the duodenum. Gastroenterology 1971;61:834–837. Altman HS, Phillips G, Bank S, Klotz H. Pancreatitis associated with duodenal Crohn’s disease. Am J Gastroenterol 1983;78: 174–177. Seyrig J-A, Jian R, Modigliani R, et al. Idiopathic pancreatitis with inflammatory bowel disease. Dig Dis Sci 1985;30:1121–1126. Spiess SE, Braun M, Vogelsang RL, et al. Crohn’s disease of the duodenum complicated by pancreatitis and common bile duct obstruction. Am J Gastroenterol 1992;87:1033–1036.
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30. Gschwantler M, Kogelbauer G, Klose W, et al. The pancreas as a site of granulomatous inflammation in Crohn’s disease. Gastroenterology 1995;108:1246–1249.
Reply. We thank Dr. Cavallini and colleagues for their comments and interest in our study. The cause and pathogenesis of the disease known as chronic pancreatitis is undoubtedly multifactorial and heterogeneous, and we strongly agree with the correspondents that autoimmune reactions are important factors that contribute to the initiation or acceleration of the disease. Autoimmune reactivity may extend to cases in which alcohol is the suspected cause of CP because alcohol may not be the sole injurious factor involved in the disease process.1 Moreover, alcohol intake probably induces alterations in antigen expression by the pancreatic ductal cells including enhanced or aberrant expression of major histocompatibility class I and II molecules, which probably contributes to these autoimmune reactions.2,3 Cavallini et al. propose dividing patients with CP into two groups: primary CP (postulated autoimmune disease) and secondary CP (obstructive disease). We support this proposal in principle and believe that it is appropriate to begin careful prospective and retrospective studies into the utility and accuracy of new classifications of CP. Ideally, this project should be undertaken by a multinational consortium of investigators and should include a discussion of other parameters (e.g., genetics) that may be useful for improving the differential diagnosis and treatment of the disease. It is time to consider moving beyond the classical classification of CP as alcoholic and nonalcoholic, but only in a systematic and careful manner. ISAO NISHIMORI, M.D.
First Department of Internal Medicine Kochi Medical School Nankoku, Kochi 783, Japan 1. Jalleh RP, Gilbertson JA, Williamson RCN, Foster CS. A morphological and immunohistochemical analysis of the human liver in chronic pancreatitis. Gut 1991;32:1386–1391. 2. Cavallini G, Frulloni L, Di Francesco V, Bovo P, Filippini M, Vaona B. Autoimmunity and chronic pancreatitis (letter). Gut 1995;36: 799. 3. Jalleh RP, Gilbertson JA, Williamson RCN, Slater SD, Foster CS. Expression of major histocompatibility antigens in human chronic pancreatitis. Gut 1993;34:1452–1457.
H. pylori and Gastric Phospholipids of Peptic Ulcer Dear Sir: We read the paper by Nardone et al.1 regarding alternation of phospholipid concentration in the gastric mucosa in the presence of Helicobacter pylori with interest. The investigators showed that H. pylori infection markedly reduced absolute amounts of total phospholipids, phosphatidylcholine, and phosphatidylethanolamine, which were reduced most significantly in subjects with chronic gastritis. They advocate that lipolytic activity due to phospholipase A2 and phospholipase C, which H. pylori produced, may be related to the decrease in total phosphatidylcholine and phosphatidylethanolamine concentrations. We measured the composition of gastric phospholipids in endoscopic biopsy specimens of patients with peptic ulcer, because Nardone et al. did not show data regarding peptic ulcer. The population in our study consisted of 7 patients without H. pylori infection or gastroduodenal mucosal lesions (controls) and 38 patients with gastric
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and/or duodenal ulcer. The endoscopic biopsy specimens of antral and corporal mucosa were taken from the greater curvature of the subjects to identify H. pylori infection and for phospholipid analysis. Phospholipids were measured quantitatively in the lipid extract from the biopsy specimens according to thin-layer chromatography and flame ionization detection method by Iatroscan TLC/FID analyzer (Iatron Inc., Tokyo, Japan). Phosphatidylethanolamine levels significantly decreased in the gastric mucosa of patients with gastric and duodenal ulcers compared with normal controls (gastric ulcer group, 2.3 { 0.2 mg/mg; duodenal ulcer group, 2.0 { 0.5 mg/mg; normal control group, 3.2 { 0.2 mg/mg; P õ 0.01 and 0.05, respectively). However, phosphatidylethanolamine levels in the mucosa of patients with peptic ulcer did not differ with reference to H. pylori infection (patients with H. pylori infection, 2.7 { 0.3 mg/mg; patients without H. pylori infection, 2.1 { 0.2 mg/mg). Cellular density of the inflammatory cells infiltrated in the mucosa may affect the amount of phospholipids because the polymorphonuclear leukocytes that are recruited to sites of gastric injury during inflammatory process are another potential source of phospholipase.2 The discrepancy in the alteration of phospholipids between Nardone et al.1 and the present study may be partly related to the difference in quantity of inflammatory leukocytes. Phospholipids in gastric mucosa play an important role in the protective barrier of the gastroduodenal epithelium, mainly by way of their hydrophobicity.3 As shown by Nardone et al.,1 H. pylori infection is an important factor in altering gastric mucosal phospholipids. However, as shown in the present study, H. pylori may not be the only factor in decreasing mucosal phospholipid levels in patients with peptic ulcer, whereas phosphatidylethanolamine was reduced in the gastric mucosa of patients with peptic ulcer. TAKANORI KOYAMA SEIJI KAWASAKI HIROYUKI SAKATA RYUICHI IWAKIRI KAZUMA FUJIMOTO
Department of Internal Medicine JUTAROU TADANO
Clinical Laboratory Saga Medical School Saga 849, Japan 1. Nardone G, D’Armiento F, Corso G, Coscione P, Esposito M, Budillon G. Lipids of human gastric mucosa: effect of Helicobacter pylori infection and nonalcoholic cirrhosis. Gastroenterology 1994;107: 362–368. 2. Traynor JR, Authi KS. Phospholipase A2 activity of lysosomal origin secreted by polymorphonuclear leukocytes during phagocytosis or in treatment with calcium. Biochem Biophys Acta 1981;665:571– 577. 3. Lichtenberger LM, Graziani LA, Dial EJ, Butler DB, Hills BA. Role of surface-active phospholipids in gastric cytoprotection. Science 1983;219:1327–1329.
Reply. We read with interest the letter by Dr. Koyama and coworkers reporting a significant decrease of phosphatidylethanolamine level in the gastric mucosa (antral and corporal sites) of patients with gastric and duodenal ulcer compared with control subjects but no significant difference in H. pylori infection. Their findings seem to be at variance with our report of a dramatic variation of the phospholipid profile in patients with nonulcer chronic gastritis affected by H. pylori
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