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Duodenal Drainage of Sulfobromophthalein (BSP) in Hepatobiliary Disease
Vol. 51, No.1 Printed in U.S.A.
GASTROENTEROLOGY
Copyright © 1966 by The Williams & Wilkins Co.
DUODENAL DRAINAGE OF SULFOBROMOPHTHALEIN (BSP) IN HEPATOBILIARY DISEASE LESLIE
J.
ScHOENFIELD,
M.D.
Gastrointestinal Research Unit, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
It was suggested by Wirts and Bradford1 that the sulfobromophthalein (BSP) excreted in bile and collected by duodenal drainage be used as a sensitive index of liver function. Caroli and Tanasoglu 2 advocated the use of the initial appearance time of BSP in the bile as a discriminating test of liver function. Other European investigators,3· 4 more recently, have reported that the proportion of BSP conjugates in bile obtained by duodenal drainage in cases of hepatic parenchymal disease was diminished from normal. Recent advances have led to a better understanding of the transport and metabolism of BSP. 5 When injected intravenously, BSP combines with serum albumin and is removed from the blood by the hepatic parenchymal cells primarily. Within the liver, most of the BSP is conjugated with glutathione, although certain amino acids may participate also. BSP accumulates in the liver cells in some fixed gradient with respect to plasma and is then transferred into bile by a rate-limited transport system. In the light of this newer knowledge, and to investigate the diagnostic possibilities, it seemed that further study was warranted of BSP duodenal drainage in patients having well documented diseases of the liver and biliary system. Received January 15, 1966. Accepted March 7, 1966.
Address requests for reprints to : Dr. L. J. Schoenfield, Mayo Clinic, 201 First Street, S.W., Rochester, Minnesota 55901. This investigation was supported in part by Research Grant AM-06908 from the National Institutes of Health, United States Public Health Service.
Procedure
The BSP duodenal drainage tests were done after the subject had fasted for 4 hr or more. Intubation with a double lumen gastroduodenal tube was accomplished under fluoroscopic control. The patient reclined comfortably at rest in bed. The gastric and duodenal tubes were connected to independent intermittent suction apparatuses (Gomco), and then the control period collection of separated gastric and duodenal juices was started. With this method it was not possible to obtain a quantitative collection of duodenal drainage free of gastric juice. The adequacy of placement of the tubes and of separation of the aspirates was determined by estimating the pH of the juices with nitrazine paper and noting the presence or absence of bile pigment. It was required, before the administration of BSP, that the duodenal juice have a pH of 7 or more and that the bile flow average at least 0.2 ml per min; at times further adjustment of the gastroduodenal tube position was necessary. If both the gastric and duodenal juices were alkaline at the same time that bile pigment was not present in the duodenal aspirate, the effectiveness of biliary drainage was particularly open to question; therefore, the results of such tests have been excluded. No special measures were taken to stimulate the flow of bile or the emptying of the gall bladder. Intubation and tube placement were satisfactory in about 80% of all tests attempted, whether the subjects did or did not have hepatobiliary disease. Control blood was drawn from an antecubital vein; the syringe was changed; and, with the same needle in place, BSP (5 mg per kg) was injected intravenously rapidly. The duodenal drainage was collected in separate Erlenmeyer flasks at 5-min intervals until the initial appearance of BSP in the bile was observed. BSP in the bile could usually be detected readily, at 1-min intervals, by dipping an applicator stick into the biliary drainage at a tube con59
60
SCHOEN FIELD
nection and then into a 30% solution of potassium hydroxide in a sepa rate test t ube. The development of a purple color, which was often apparent in biliary drainage containing BSP even without this additional alkalinization, indica ted the presence of the dye in the bile. If BSP did not appear in the duodenal drainage, but normal 60-min serum retention was found, the t ube placement was considered to be unsatisfactory. Appearance times were measured with a stopwatch to t he nearest Y2 min . After the initial appearance of BSP in the bile, t he subsequent 1 hr was divided into three collection periods : (1) the first 10 min after appearance, (2) t he middle period, and (3) the last 10 min of the hour. The color, pH, and volume of duodenal drainage were recorded for each period. Blood was drawn from a vein in t he a rm opposite to that used for the injection at 3 min and at 60 min after the administration of the dye. All of the gastric aspirate was collected into a single flask and event ually discarded. If BSP did not appear in the biliary dra inage by 1 hr, the collection was extended for up to 2 hr. If BSP first appeared during the 2nd hr, an adequate bile sample (at least 1 ml) was collected, and the test was terminated . The colorimetric method for measurement of t he concentration of BSP in the duodenal drainage (usually after a 1:50 dilution) and in the serum samples and t he paper chromatographic method for the separation and estimation of free and conjugated BSP have been described in detail previously.• In t he present study the quantities of the va rious metabolites in each sample were combined to give a single value for conjugated BSP. The sum of the optical densities of each of the metabolites was equal to the optical density of t he combined metabolites from a duplicate paper chromatogram . In 15 determinations, 91.0% ± 4.1% and 85.2% ± 3.6% (mean percentage ± standard deviation) of BSP added in known amounts to serum and bile, respectively, were found in the final colorimetric estimation after paper chromatogra phic analysis. Determinations were done in duplicate, and these agreed within 8% . Since BSP conjugates may have a lower molar extinction coefficient than free BSP, t he proportion of conjugates may be underestimated by the colorimetric technique. The addition of BSP to serum or bile specimens in vitro yielded only free BSP, whereas the metabolites of BSP were found in serum or bile onlv after int ravenous administration of t he dye. i'Vhen a colorimetrically determined amoun t of conjugated BSP obtained from a paper chromatogram was
Vol. 51, No.1
evaporated, dissolved in serum or bile, and rechromatographed, about 85% of the conjugated BSP could be recovered. The following observations were recorded for each subject : (1) duodenal drainage flow rate, the time of maximal concentration of BSP in the bile, and the percentage of administered BSP recovered in the bile during 1 hr after injection; (2) time of initial appearan ce of BSP in t he duodenal drainage; and (3) percentage of BSP that was conjugated in the bile during each of the three duodenal drainage collection periods. Subjects. BSP duodenal drainage tests were done on 12 healthy volunteers; the test was repeated once for 2 of these subjects and t wice for 3 others at intervals of 1 week to 1 month. In addition, 10 hospitalized p atients without clinical or laboratory evidence of liver involvement were studied. None of these subjects had a past history of hepatobiliary disease, and none had recently ingested known potentially hepatotoxic drugs. Sixty-eight patients wit h diseases of t he liYer and biliary system underwent satisfactory BSP duodenal drainage tests. Each of these patients had a positive histological diagnosis obtained from needle biopsy of the liver or from biopsy of the liver at an abdominal operation, except that diagnoses were based on clinical data and eventual recovery in 7 cases of hepatitis and 1 case of jaundice associated with ingestion of erythromycin (Ilosone). Serial tests were done in 3 of the cases of hepatitis. The criterion for intrahepatic cholestasis was, arbit rarily, the presence of at least three of the following four findings: (1) a value for serum alkaline phosphatase of more than 30 King and Armstrong units (normal value, less than 14); (2) a value for serum glutamic oxaloacetic transaminase (SGOT) of less than 15 ,u.moles per hr per ml (normal, 1.43) ; (3) normal values for flocculation tests; and (4) a liver biopsy interpreted as showing bile stasis. Results
In healthy volunteers, in those instances when there seemed t o be good sep ar ation of gastric and duodenal juices, the biliary drainage flow r ate was about I or 2 ml p er min; at times the flow appeared to be intermittent and at times it was continuous. In general, the flow rate varied considerably among control subjects, a mong r epeated test s on the same individual, and amon g patients with hepatobiliary disease. Likewise, the values for the maximal
July 1966
61
DUODENAL DRAINAGE OF ESP
concentration of BSP in the bile and the time at which this maximum was attained, as well as the percentage of injected dye that was recovered in the bile, were not consistent within or among the groups of subjects in this study. The appearance times and the percentages of conjugated BSP in the bile of the ambulatory and hospitalized control subjects showed no significant differences; these two groups, therefore, were combined as a single group for comparisons with the groups of patients with hepatobiliary diseases. There were no differences in the find ings of BSP duodenal drainage whether the test was done in the morning or in the afternoon or related to the number of fasting hours before testing. At the BSP dose of 5 mg per kg, the age, sex, and body weight of the subject did not affect the results. The mean value for the appearance time was 17.3 min, and a range of 8.9 to 25.7 min (including two standard deviations) delineated the 95% confidence limits for this measurement. The mean percentages of conjugated BSP in the bile and standard deviations for the periods follow: period 1, 58.3% ± 9.6% ; period 2, 64.4% ± 8.7%; and period 3, 68.5% ± 11.3%. In normal subjects, during period 2, that period used for subsequent comparisons, all values for percentage of conjugated BSP were greater than 50. In 5 healthy volunteers the initial ap pearance times and the percentages of conjugated BSP in the bile were relatively unchanged on two or three repeated tests at weekly or monthly intervals. Tables 1 and 2 list the findings on BSP duodenal drainage in the cases of hepatobiliary disease. There was a wide range of appearance times, 12 to 102 min, among the patients with cirrhosis and hepatitis; the mean was 30.9 min (sn, 23.9). Although the mean appearance time was significantly greater than that found for normal subjects (P < 0.02), 8 patients with cirrhosis and 4 with hepatitis had normal appearance times. The percentage of conjugated BSP in the bile of all of these patients, even for those with relatively normal standard tests of liver function, was less than 50% and was
1. Sulfobromop'hthalein (ESP) duodenal drainage-cin·hosi s , hepatitis, and intrahepatic cho les tasis
TABLE
BSP in bile Diagnosis
Appearance time
Cirrhosis of liver
Conjugated
min
%
15.5 16.0 17.0 15 .0 26.0 32.5 18.0 16.0 18.0 16.0 102.0 36 .0
40.5 43.1 34.7 32.8 46 .8 25.7 31.3 38.3 26.7 29 .0 42 .6 37.6
82.0 30.0 25 .0 45.0 55 .0• 19.0 21.0• 12.0
35.5 26.7 34.3 25.2 38.2 28.3 20 .7 24.8
9.0 21.0
29.0 38.0
Cirrhosis
34.0 27.0 32.0 17.0
21.6 32.4 26.4 39.6
Primary biliary cirrhosis
24.0 43.0 55 .0 30.0
39.5 38.3 24.7 30.0
46.0
21.7
14.0
31.2
16.0
42.0
Hepa titis
Intrahepatic cholestasis Hepatitis
Drug reaction Chlorpromazine (Thorazine) Methandrostenolone (Dianabol) Erythromycin estol ate (Ilosone)
a Repeated test; BSP did not appear in bile on first test .
significantly diminished from normal (P < 0.001) with a mean of 33.1% ± 7.2%. There were no significant differences in the values for the appearance time and the
62
SCHOEN FIELD
2. Sulfobromophthalein (ESP) duodenal drainage-choledocholithiasis, bile duct strictU?·e, and miscellaneous disorde1·s
TABLE
BSP in bile Diagnosis
Appearance timea
Conjugated
min
%
19.5 30.0 18.0 16.0 21.0
62.4 49.5 56.9 50 .8 65.1
26.0 70.0
60.3 54.7
Bile duc t stricture "·ithout cirrhosis
24.0 21.0
49.9 85.5
with
28.5 30.0
33.1 38.2
13.5 20.0 17 .Ob 21.5b 28.0 20.5 33 .5 19 .5
45.3 27.0 58.8 63.2 65 .0 49.5 55.0 58 .3
Choledocholithiasis
Bile duct stricture cirrhosis
Hepatitis a nd cholelithiasis Cirrhosis and choleli th ias is
Metasta tic tumor of liverc
• D ash(-) indicates that BSP did not appear. b Functioning gall bladder with cholelithiasis. c Hepatocellular metastasis, metastatic bile duct obstruction , or both.
percentage of conjugated BSP in the bile in the cases of cirrhosis as compared to the corresponding values in cases of hepatitis. There were no significant correlations of the values for serum bilirubin, alkaline phosphatase, and SGOT with either the appearance time or the percentage of conjugated BSP in the bile for any of the groups of patients with hepatobiliary disease. During the posticteric convalescent stage in 3 cases of hepatitis, the bile still contained a diminished proportion of conjugated BSP, but in serial studies in each case, these values gradually n~turned to
Vol. 51, No.1
normal. The appearance times (mean, 28.3 ± 13.6) were significantly prolonged in 7 of the 13 cases of intrahepatic cholestasis, but the most striking observation in this group of cases was the uniformly diminished conjugated BSP in the bile (mean, 31.9% ± 7.1 %) compared with normal values (P < 0.001). In figure 1, the appearance times are plotted against the percentages of conjugated BSP in the bile for the control subjects and for all of the patients with hepatic parenchymal disease. There was no significant correlation between the appearance times and the percentages of conjugated BSP found in the bile of normal subj ects and those found in the bile of patients having hepatobiliary disease. BSP did not appear in the duodenal drainage of any of the 12 patients who had an obstruction of the bile duct by a malignant tumor. Of the 8 patients with choledocholithiasis who underwent BSP duodenal drainage, 3 had delayed appearance times; all had normal percentages of conjugated BSP in the bile. BSP did not appear in the duodenal drainage of 1 patient with choledocholithiasis or in 1 of the 3 cases of bile duct stricture without cirrhosis. The results of BSP duodenal drainage in the cases of metastatic tumor of the liver were similar to those obtained in the subjects with choledocholithiasis. Included in the group of patients with miscellaneous disorders were 4 patients having hepatocellular disease associated with bile duct stricture or cholelithiasis. In each instance the finding of diminished conjugated BSP in the bile indicated the presence of associated hepatocellular disease which was confirmed at an abdominal operation or by needle biopsy of the liver. Comment
Some of the variations in the results might have been eliminated by stimulating bile flow, gall bladder contraction, and relaxation of the sphincter of Oddi. Caroli and Tanasoglu, 2 using choleretics as part of their duodenal drainage test, found delayed appearance times in cases of incomplete biliary obstruction, whereas in those of hepatitis or cirrhosis the appear-
63
DUODENAL DRAINAGE OF ESP
July 1966
22 controls 100
~"'
80
~ Q:)
70
...,
~
"' "<:-
50
C>
""' .l?"' <::
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"''-"
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13 intrahepatic cholestasis -Jo:
... .. . :
60
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mean ±2 S D
24 parenchymal disease-a
90
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,p 0
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0 )l!
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lil )l!
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10 5
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15
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25
30
35
40 45
50
55
60
82
102
Appearance time of BSP in bile, minutes
Fra. 1. Results of tests of sulfobromophthalein (ESP) duodenal drainage are shown for 22 normal subjects and 37 patients having parenchymal hepatic disease, including 13 having intrahepatic cholestasis and 4 with associated extrahepatic obstruction. Diminished conjugated BSP in bile of all of patients and delayed appearance time of BSP in bile of half of the patients were found, whether or not intrahepatic cholestasio: was present.
ance times were normal or even more rapid. More recently, however, Tilling7 was unable to correlate the appearance time with the pathophysiological process. In the present study, a delayed appearance time confirmed the presence of an abnormality in the liver or biliary system but did not help determine the etiology. Also, it was found that many of the patients having liver disease or partial bile duct obstruction had normal appearance times. The finding that the proportion of conjugated BSP in the bile was diminished in cases of hepatic parenchymal disease is in agreement with the reports of the European investigators, Hoenig and co-workers 3 and vVernze and Schmidt. 4 This decreased percentage of conjugated BSP in the bile of patients having parenchymal disease probably could result from impaired formation, increased hydrolysis, or impaired excretion of conjugated BSP. The proportion of conjugated BSP is diminished also in the blood of patients having parenchymal disease. 6 Table 3 summarizes the value and limitations of BSP duodenal drainage. The information derived from this test in individual cases usually could have been
3. Sulfobromophthalein (ESP) duodenal drainage-usefulness in diagnosis of hepalobiliary disease
TABLE
BSP in duodenal drainage
Diagnosis suggested
None
Malignant obstruction"
Delayed appearance
Any disease of liver or biliary tract
Diminished percentage of conjugated BSP
Parenchymal disease, including intrahepatic cholestasis
Limitations
ESP may be absent from bile in some cases of parenchymal disease of liver (2 of 33), duct stricture or stone (2 of 12), and metastatic tumor of liver (2 of 6) Does not differentiate between diseases, and appearance is not delayed in 50% of cases Associated extrahepatic obstruction is not excluded
a The presence of ESP in bile probably excludes malignant obstruction.
64
SCHOENFI'ELD
obtained by clinical examination and conventional liver function tests. Choledocholithiasis and metastatic malignancy usually were clearly differentiated from hepatitis and cirrhosis, although common duct stone could not be distinguished from metastatic tumor nor could hepatitis be differentiated from cirrhosis. All patients with intrahepatic cholestasis had a diminished percentage of conjugated BSP in the bile. However, this finding did not always distinguish intrahepatic cholestasis from ext rahepatic obstruction because in some patients with mechanical obstruction there was presumably sufficient secondary parenchymal damage to interfere with the conjugating mechanisms and so bring about a diminished proportion of conjugated BSP in the bile. Summary
Sulfobromophthalein (BSP) duodenal drainage tests were done on 22 control subjects and 68 patients having well documented disorders of the liver and biliary tract. Finding no BSP in the duodenal aspirate after intravenous injection of the dye was suggestive but not diagnostic of malignant obst ruction of the bile duct. The presence of BSP in bile militated against this diagnosis. A delayed appearance t ime of BSP in the bile indicated the presence of an abnormality in the liver or biliary system but did not discriminate further, and normal appearance times occurred in half of the cases of hepatobiliary disease. The percentage of conjugated BSP in the bile was a sensitive indicator of the presence of primary hepatic parenchymal disease. Diminution of conjugated BSP occurred in all cases of hepatocellular disease, even those of intrahepatic cholestasis or associ-
Vol. 51, No.1
ated extrahepatic obstruction of the bile duct. In the presence of intrahepatic cholesta'sis, the proportion of conjugated BSP in the bile was in all instances diminished. However, this finding did not invariably differentiate intrahepatic from extrahepatic cholestasis. The results of BSP duodenal drainage were not sufficiently reliable in the differential diagnosis of hepatobiliary diseases to recommend its routine clinical use. REFERENCES 1. vVirts, C. W ., Jr., and B. K. Bradford. 1948.
2.
3.
4.
5.
6.
7.
The biliary excretion of Bromsulfalein as a test of liver function in a group of patients following hepatitis of serum jaundice. J. Clin. Invest. 27' : 600-608. Caroli, J., and Y. Tanasoglu. 1953. Le temps de'apparition de Ia bromesulfonephtaleine dans Ia bile : Nouveau test pour le diagnostic des icteres incomplets par retention et des blocages anicteriques de Ia vme principale. Sem. Hop. P aris 29: 591-606. Hoenig, V., M. Jirsa, and J. Hoenigova. 1961. Sulfobromophthalein (ESP) metabolism in viral hepatitis, liver cirrhosis and hereditary spherocytosis. Acta Hepatosplen. (Stuttgart) 8: 217-226. Wernze, H., and H. Schmidt. 1961. Uber die Ausscheidung von Bromsulphthalein in die Galle bei Lebergesunden und akuter H epatitis. Klin. Wschr. 39 : 924-925. Schoenfield, L. J . 1965. Sulfobromophthalein transport and metabolism (editorial). Gastroenterology 48: 530-533. Schoenfield, L. J., W. T. Foulk, and H. R. Butt. 1964. Studies of sulfobromophthalein sodium (BSP) metabolism in man. I. In normal subj ects and patients with hepatic disease. J. Clin. Invest. 43: 1409-1418. Tilling, W. 1963. Der Caroli-Test und seine klinische Brauchbarkeit. Med. Klin. 58: 1365-1366.
GASTROENTEROLOGY
Copyright © 1966 by The Williams & Wilkins Co.
DUODENAL DRAINAGE OF SULFOBROMOPHTHALEIN (BSP) IN HEPATOBILIARY DISEASE LESLIE
J.
ScHOENFIELD,
M.D.
Gastrointestinal Research Unit, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
It was suggested by Wirts and Bradford1 that the sulfobromophthalein (BSP) excreted in bile and collected by duodenal drainage be used as a sensitive index of liver function. Caroli and Tanasoglu 2 advocated the use of the initial appearance time of BSP in the bile as a discriminating test of liver function. Other European investigators,3· 4 more recently, have reported that the proportion of BSP conjugates in bile obtained by duodenal drainage in cases of hepatic parenchymal disease was diminished from normal. Recent advances have led to a better understanding of the transport and metabolism of BSP. 5 When injected intravenously, BSP combines with serum albumin and is removed from the blood by the hepatic parenchymal cells primarily. Within the liver, most of the BSP is conjugated with glutathione, although certain amino acids may participate also. BSP accumulates in the liver cells in some fixed gradient with respect to plasma and is then transferred into bile by a rate-limited transport system. In the light of this newer knowledge, and to investigate the diagnostic possibilities, it seemed that further study was warranted of BSP duodenal drainage in patients having well documented diseases of the liver and biliary system. Received January 15, 1966. Accepted March 7, 1966.
Address requests for reprints to : Dr. L. J. Schoenfield, Mayo Clinic, 201 First Street, S.W., Rochester, Minnesota 55901. This investigation was supported in part by Research Grant AM-06908 from the National Institutes of Health, United States Public Health Service.
Procedure
The BSP duodenal drainage tests were done after the subject had fasted for 4 hr or more. Intubation with a double lumen gastroduodenal tube was accomplished under fluoroscopic control. The patient reclined comfortably at rest in bed. The gastric and duodenal tubes were connected to independent intermittent suction apparatuses (Gomco), and then the control period collection of separated gastric and duodenal juices was started. With this method it was not possible to obtain a quantitative collection of duodenal drainage free of gastric juice. The adequacy of placement of the tubes and of separation of the aspirates was determined by estimating the pH of the juices with nitrazine paper and noting the presence or absence of bile pigment. It was required, before the administration of BSP, that the duodenal juice have a pH of 7 or more and that the bile flow average at least 0.2 ml per min; at times further adjustment of the gastroduodenal tube position was necessary. If both the gastric and duodenal juices were alkaline at the same time that bile pigment was not present in the duodenal aspirate, the effectiveness of biliary drainage was particularly open to question; therefore, the results of such tests have been excluded. No special measures were taken to stimulate the flow of bile or the emptying of the gall bladder. Intubation and tube placement were satisfactory in about 80% of all tests attempted, whether the subjects did or did not have hepatobiliary disease. Control blood was drawn from an antecubital vein; the syringe was changed; and, with the same needle in place, BSP (5 mg per kg) was injected intravenously rapidly. The duodenal drainage was collected in separate Erlenmeyer flasks at 5-min intervals until the initial appearance of BSP in the bile was observed. BSP in the bile could usually be detected readily, at 1-min intervals, by dipping an applicator stick into the biliary drainage at a tube con59
60
SCHOEN FIELD
nection and then into a 30% solution of potassium hydroxide in a sepa rate test t ube. The development of a purple color, which was often apparent in biliary drainage containing BSP even without this additional alkalinization, indica ted the presence of the dye in the bile. If BSP did not appear in the duodenal drainage, but normal 60-min serum retention was found, the t ube placement was considered to be unsatisfactory. Appearance times were measured with a stopwatch to t he nearest Y2 min . After the initial appearance of BSP in the bile, t he subsequent 1 hr was divided into three collection periods : (1) the first 10 min after appearance, (2) t he middle period, and (3) the last 10 min of the hour. The color, pH, and volume of duodenal drainage were recorded for each period. Blood was drawn from a vein in t he a rm opposite to that used for the injection at 3 min and at 60 min after the administration of the dye. All of the gastric aspirate was collected into a single flask and event ually discarded. If BSP did not appear in the biliary dra inage by 1 hr, the collection was extended for up to 2 hr. If BSP first appeared during the 2nd hr, an adequate bile sample (at least 1 ml) was collected, and the test was terminated . The colorimetric method for measurement of t he concentration of BSP in the duodenal drainage (usually after a 1:50 dilution) and in the serum samples and t he paper chromatographic method for the separation and estimation of free and conjugated BSP have been described in detail previously.• In t he present study the quantities of the va rious metabolites in each sample were combined to give a single value for conjugated BSP. The sum of the optical densities of each of the metabolites was equal to the optical density of t he combined metabolites from a duplicate paper chromatogram . In 15 determinations, 91.0% ± 4.1% and 85.2% ± 3.6% (mean percentage ± standard deviation) of BSP added in known amounts to serum and bile, respectively, were found in the final colorimetric estimation after paper chromatogra phic analysis. Determinations were done in duplicate, and these agreed within 8% . Since BSP conjugates may have a lower molar extinction coefficient than free BSP, t he proportion of conjugates may be underestimated by the colorimetric technique. The addition of BSP to serum or bile specimens in vitro yielded only free BSP, whereas the metabolites of BSP were found in serum or bile onlv after int ravenous administration of t he dye. i'Vhen a colorimetrically determined amoun t of conjugated BSP obtained from a paper chromatogram was
Vol. 51, No.1
evaporated, dissolved in serum or bile, and rechromatographed, about 85% of the conjugated BSP could be recovered. The following observations were recorded for each subject : (1) duodenal drainage flow rate, the time of maximal concentration of BSP in the bile, and the percentage of administered BSP recovered in the bile during 1 hr after injection; (2) time of initial appearan ce of BSP in t he duodenal drainage; and (3) percentage of BSP that was conjugated in the bile during each of the three duodenal drainage collection periods. Subjects. BSP duodenal drainage tests were done on 12 healthy volunteers; the test was repeated once for 2 of these subjects and t wice for 3 others at intervals of 1 week to 1 month. In addition, 10 hospitalized p atients without clinical or laboratory evidence of liver involvement were studied. None of these subjects had a past history of hepatobiliary disease, and none had recently ingested known potentially hepatotoxic drugs. Sixty-eight patients wit h diseases of t he liYer and biliary system underwent satisfactory BSP duodenal drainage tests. Each of these patients had a positive histological diagnosis obtained from needle biopsy of the liver or from biopsy of the liver at an abdominal operation, except that diagnoses were based on clinical data and eventual recovery in 7 cases of hepatitis and 1 case of jaundice associated with ingestion of erythromycin (Ilosone). Serial tests were done in 3 of the cases of hepatitis. The criterion for intrahepatic cholestasis was, arbit rarily, the presence of at least three of the following four findings: (1) a value for serum alkaline phosphatase of more than 30 King and Armstrong units (normal value, less than 14); (2) a value for serum glutamic oxaloacetic transaminase (SGOT) of less than 15 ,u.moles per hr per ml (normal, 1.43) ; (3) normal values for flocculation tests; and (4) a liver biopsy interpreted as showing bile stasis. Results
In healthy volunteers, in those instances when there seemed t o be good sep ar ation of gastric and duodenal juices, the biliary drainage flow r ate was about I or 2 ml p er min; at times the flow appeared to be intermittent and at times it was continuous. In general, the flow rate varied considerably among control subjects, a mong r epeated test s on the same individual, and amon g patients with hepatobiliary disease. Likewise, the values for the maximal
July 1966
61
DUODENAL DRAINAGE OF ESP
concentration of BSP in the bile and the time at which this maximum was attained, as well as the percentage of injected dye that was recovered in the bile, were not consistent within or among the groups of subjects in this study. The appearance times and the percentages of conjugated BSP in the bile of the ambulatory and hospitalized control subjects showed no significant differences; these two groups, therefore, were combined as a single group for comparisons with the groups of patients with hepatobiliary diseases. There were no differences in the find ings of BSP duodenal drainage whether the test was done in the morning or in the afternoon or related to the number of fasting hours before testing. At the BSP dose of 5 mg per kg, the age, sex, and body weight of the subject did not affect the results. The mean value for the appearance time was 17.3 min, and a range of 8.9 to 25.7 min (including two standard deviations) delineated the 95% confidence limits for this measurement. The mean percentages of conjugated BSP in the bile and standard deviations for the periods follow: period 1, 58.3% ± 9.6% ; period 2, 64.4% ± 8.7%; and period 3, 68.5% ± 11.3%. In normal subjects, during period 2, that period used for subsequent comparisons, all values for percentage of conjugated BSP were greater than 50. In 5 healthy volunteers the initial ap pearance times and the percentages of conjugated BSP in the bile were relatively unchanged on two or three repeated tests at weekly or monthly intervals. Tables 1 and 2 list the findings on BSP duodenal drainage in the cases of hepatobiliary disease. There was a wide range of appearance times, 12 to 102 min, among the patients with cirrhosis and hepatitis; the mean was 30.9 min (sn, 23.9). Although the mean appearance time was significantly greater than that found for normal subjects (P < 0.02), 8 patients with cirrhosis and 4 with hepatitis had normal appearance times. The percentage of conjugated BSP in the bile of all of these patients, even for those with relatively normal standard tests of liver function, was less than 50% and was
1. Sulfobromop'hthalein (ESP) duodenal drainage-cin·hosi s , hepatitis, and intrahepatic cho les tasis
TABLE
BSP in bile Diagnosis
Appearance time
Cirrhosis of liver
Conjugated
min
%
15.5 16.0 17.0 15 .0 26.0 32.5 18.0 16.0 18.0 16.0 102.0 36 .0
40.5 43.1 34.7 32.8 46 .8 25.7 31.3 38.3 26.7 29 .0 42 .6 37.6
82.0 30.0 25 .0 45.0 55 .0• 19.0 21.0• 12.0
35.5 26.7 34.3 25.2 38.2 28.3 20 .7 24.8
9.0 21.0
29.0 38.0
Cirrhosis
34.0 27.0 32.0 17.0
21.6 32.4 26.4 39.6
Primary biliary cirrhosis
24.0 43.0 55 .0 30.0
39.5 38.3 24.7 30.0
46.0
21.7
14.0
31.2
16.0
42.0
Hepa titis
Intrahepatic cholestasis Hepatitis
Drug reaction Chlorpromazine (Thorazine) Methandrostenolone (Dianabol) Erythromycin estol ate (Ilosone)
a Repeated test; BSP did not appear in bile on first test .
significantly diminished from normal (P < 0.001) with a mean of 33.1% ± 7.2%. There were no significant differences in the values for the appearance time and the
62
SCHOEN FIELD
2. Sulfobromophthalein (ESP) duodenal drainage-choledocholithiasis, bile duct strictU?·e, and miscellaneous disorde1·s
TABLE
BSP in bile Diagnosis
Appearance timea
Conjugated
min
%
19.5 30.0 18.0 16.0 21.0
62.4 49.5 56.9 50 .8 65.1
26.0 70.0
60.3 54.7
Bile duc t stricture "·ithout cirrhosis
24.0 21.0
49.9 85.5
with
28.5 30.0
33.1 38.2
13.5 20.0 17 .Ob 21.5b 28.0 20.5 33 .5 19 .5
45.3 27.0 58.8 63.2 65 .0 49.5 55.0 58 .3
Choledocholithiasis
Bile duct stricture cirrhosis
Hepatitis a nd cholelithiasis Cirrhosis and choleli th ias is
Metasta tic tumor of liverc
• D ash(-) indicates that BSP did not appear. b Functioning gall bladder with cholelithiasis. c Hepatocellular metastasis, metastatic bile duct obstruction , or both.
percentage of conjugated BSP in the bile in the cases of cirrhosis as compared to the corresponding values in cases of hepatitis. There were no significant correlations of the values for serum bilirubin, alkaline phosphatase, and SGOT with either the appearance time or the percentage of conjugated BSP in the bile for any of the groups of patients with hepatobiliary disease. During the posticteric convalescent stage in 3 cases of hepatitis, the bile still contained a diminished proportion of conjugated BSP, but in serial studies in each case, these values gradually n~turned to
Vol. 51, No.1
normal. The appearance times (mean, 28.3 ± 13.6) were significantly prolonged in 7 of the 13 cases of intrahepatic cholestasis, but the most striking observation in this group of cases was the uniformly diminished conjugated BSP in the bile (mean, 31.9% ± 7.1 %) compared with normal values (P < 0.001). In figure 1, the appearance times are plotted against the percentages of conjugated BSP in the bile for the control subjects and for all of the patients with hepatic parenchymal disease. There was no significant correlation between the appearance times and the percentages of conjugated BSP found in the bile of normal subj ects and those found in the bile of patients having hepatobiliary disease. BSP did not appear in the duodenal drainage of any of the 12 patients who had an obstruction of the bile duct by a malignant tumor. Of the 8 patients with choledocholithiasis who underwent BSP duodenal drainage, 3 had delayed appearance times; all had normal percentages of conjugated BSP in the bile. BSP did not appear in the duodenal drainage of 1 patient with choledocholithiasis or in 1 of the 3 cases of bile duct stricture without cirrhosis. The results of BSP duodenal drainage in the cases of metastatic tumor of the liver were similar to those obtained in the subjects with choledocholithiasis. Included in the group of patients with miscellaneous disorders were 4 patients having hepatocellular disease associated with bile duct stricture or cholelithiasis. In each instance the finding of diminished conjugated BSP in the bile indicated the presence of associated hepatocellular disease which was confirmed at an abdominal operation or by needle biopsy of the liver. Comment
Some of the variations in the results might have been eliminated by stimulating bile flow, gall bladder contraction, and relaxation of the sphincter of Oddi. Caroli and Tanasoglu, 2 using choleretics as part of their duodenal drainage test, found delayed appearance times in cases of incomplete biliary obstruction, whereas in those of hepatitis or cirrhosis the appear-
63
DUODENAL DRAINAGE OF ESP
July 1966
22 controls 100
~"'
80
~ Q:)
70
...,
~
"' "<:-
50
C>
""' .l?"' <::
40
"''-"
~
13 intrahepatic cholestasis -Jo:
... .. . :
60
""'
mean ±2 S D
24 parenchymal disease-a
90
.<;:
+
... 0
0
cg
,p 0
30
)l!
0 )l!
0
"
OOOQ
OJ!i
0
0 0 0
liil
0
20
lil
0
o l!§oa
0
lil )l!
)l!
10 5
10
15
20
25
30
35
40 45
50
55
60
82
102
Appearance time of BSP in bile, minutes
Fra. 1. Results of tests of sulfobromophthalein (ESP) duodenal drainage are shown for 22 normal subjects and 37 patients having parenchymal hepatic disease, including 13 having intrahepatic cholestasis and 4 with associated extrahepatic obstruction. Diminished conjugated BSP in bile of all of patients and delayed appearance time of BSP in bile of half of the patients were found, whether or not intrahepatic cholestasio: was present.
ance times were normal or even more rapid. More recently, however, Tilling7 was unable to correlate the appearance time with the pathophysiological process. In the present study, a delayed appearance time confirmed the presence of an abnormality in the liver or biliary system but did not help determine the etiology. Also, it was found that many of the patients having liver disease or partial bile duct obstruction had normal appearance times. The finding that the proportion of conjugated BSP in the bile was diminished in cases of hepatic parenchymal disease is in agreement with the reports of the European investigators, Hoenig and co-workers 3 and vVernze and Schmidt. 4 This decreased percentage of conjugated BSP in the bile of patients having parenchymal disease probably could result from impaired formation, increased hydrolysis, or impaired excretion of conjugated BSP. The proportion of conjugated BSP is diminished also in the blood of patients having parenchymal disease. 6 Table 3 summarizes the value and limitations of BSP duodenal drainage. The information derived from this test in individual cases usually could have been
3. Sulfobromophthalein (ESP) duodenal drainage-usefulness in diagnosis of hepalobiliary disease
TABLE
BSP in duodenal drainage
Diagnosis suggested
None
Malignant obstruction"
Delayed appearance
Any disease of liver or biliary tract
Diminished percentage of conjugated BSP
Parenchymal disease, including intrahepatic cholestasis
Limitations
ESP may be absent from bile in some cases of parenchymal disease of liver (2 of 33), duct stricture or stone (2 of 12), and metastatic tumor of liver (2 of 6) Does not differentiate between diseases, and appearance is not delayed in 50% of cases Associated extrahepatic obstruction is not excluded
a The presence of ESP in bile probably excludes malignant obstruction.
64
SCHOENFI'ELD
obtained by clinical examination and conventional liver function tests. Choledocholithiasis and metastatic malignancy usually were clearly differentiated from hepatitis and cirrhosis, although common duct stone could not be distinguished from metastatic tumor nor could hepatitis be differentiated from cirrhosis. All patients with intrahepatic cholestasis had a diminished percentage of conjugated BSP in the bile. However, this finding did not always distinguish intrahepatic cholestasis from ext rahepatic obstruction because in some patients with mechanical obstruction there was presumably sufficient secondary parenchymal damage to interfere with the conjugating mechanisms and so bring about a diminished proportion of conjugated BSP in the bile. Summary
Sulfobromophthalein (BSP) duodenal drainage tests were done on 22 control subjects and 68 patients having well documented disorders of the liver and biliary tract. Finding no BSP in the duodenal aspirate after intravenous injection of the dye was suggestive but not diagnostic of malignant obst ruction of the bile duct. The presence of BSP in bile militated against this diagnosis. A delayed appearance t ime of BSP in the bile indicated the presence of an abnormality in the liver or biliary system but did not discriminate further, and normal appearance times occurred in half of the cases of hepatobiliary disease. The percentage of conjugated BSP in the bile was a sensitive indicator of the presence of primary hepatic parenchymal disease. Diminution of conjugated BSP occurred in all cases of hepatocellular disease, even those of intrahepatic cholestasis or associ-
Vol. 51, No.1
ated extrahepatic obstruction of the bile duct. In the presence of intrahepatic cholesta'sis, the proportion of conjugated BSP in the bile was in all instances diminished. However, this finding did not invariably differentiate intrahepatic from extrahepatic cholestasis. The results of BSP duodenal drainage were not sufficiently reliable in the differential diagnosis of hepatobiliary diseases to recommend its routine clinical use. REFERENCES 1. vVirts, C. W ., Jr., and B. K. Bradford. 1948.
2.
3.
4.
5.
6.
7.
The biliary excretion of Bromsulfalein as a test of liver function in a group of patients following hepatitis of serum jaundice. J. Clin. Invest. 27' : 600-608. Caroli, J., and Y. Tanasoglu. 1953. Le temps de'apparition de Ia bromesulfonephtaleine dans Ia bile : Nouveau test pour le diagnostic des icteres incomplets par retention et des blocages anicteriques de Ia vme principale. Sem. Hop. P aris 29: 591-606. Hoenig, V., M. Jirsa, and J. Hoenigova. 1961. Sulfobromophthalein (ESP) metabolism in viral hepatitis, liver cirrhosis and hereditary spherocytosis. Acta Hepatosplen. (Stuttgart) 8: 217-226. Wernze, H., and H. Schmidt. 1961. Uber die Ausscheidung von Bromsulphthalein in die Galle bei Lebergesunden und akuter H epatitis. Klin. Wschr. 39 : 924-925. Schoenfield, L. J . 1965. Sulfobromophthalein transport and metabolism (editorial). Gastroenterology 48: 530-533. Schoenfield, L. J., W. T. Foulk, and H. R. Butt. 1964. Studies of sulfobromophthalein sodium (BSP) metabolism in man. I. In normal subj ects and patients with hepatic disease. J. Clin. Invest. 43: 1409-1418. Tilling, W. 1963. Der Caroli-Test und seine klinische Brauchbarkeit. Med. Klin. 58: 1365-1366.