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Multiple organ failure in human acute pancreatitis is associated with increased local and systemic inflammatory mediators
April 2000
transgenic mice in which this biosynthetic capacity was blocked because of ectopic expression of arginase I in the enterocytes. In two independent lines, arginine levels were reduced down to 20 % of normal, but levels of other amino acids were not affected. Transgenics suffered from a pronounced retardation of fur- and body-growth, but showed normal enzymatic maturation. Arginine deficiency led to an impaired development of the GALT, as in the transgenics Peyers patches did not develop until adulthood. Row cytometry of intra-epithelial and lamina propria lymphocytes revealed a severe reduction of the B-cell population in the arginine depleted mice, though the T-cell populations were normal, Production of IFN y, IL-4 and IL-6 by in vitro stimulated T-cells, isolated from transgenics was strongly decreased, compared to wild-type. In addition to the immune effects, adult transgenic mice showed behavioural and memory defects. Most phenotypic abnormalities could be reversed by neonatal injection of arginine, but not creatine. Analyses of NOS-deficient mice and mice with severe ornithine transcarbamoylase deficiency indicated that lack of NO synthesis or a state of general malnourishment are not responsible for the observed phenotypes. The results show that intestinal arginine synthesis during the suckling period is important for the normal development of the intestinal immune system and brain function. Our arginine deficient transgenic mice are a promising model to unravel the mechanism of arginine s immunonutrient function.
3684 ALTERATION IN INTESTINAL EPITHELIAL CELL EXPRESSION OF TOLL-LIKE RECEPTORS IN INFLAMMATORY BOWEL DISEASE. Elke Cario, Daniel K. Podolsky, MA Gen Hosp , Gastrointestinal Unit, CSIBD, Boston, MA. Background: Initiation and perpetuation of the inflammatory intestinal responses in inflammatory bowel disease (IBD) may result from an exaggerated host defense reaction of the intestinal epithelium to endogenous lumenal bacterial flora. We have recently shown that intestinal epithelial cell lines constitutively express Toll-like Receptors (TLR2 and 4) (J. Immunol. in press) which appear to be key receptors involved in recognizing various types of lipopolysaccharide and subsequently iniating intracellular signalling. The aim of this study was to characterize the protein expression of TLR2 and TLR4 in primary intestinal epithelial cells from patients with IBD. Material and Methods: Small intestinal and colonic biopsy specimens were collected from patients with IBD (Crohn's Disease (CD); Ulcerative Colitis (UC» and from controls (non-IBD). Diagnosis was confirmed by endoscopy and histology. Specimens were embedded in paraffin and assessed by immunofluorescence histochemistry using antibodies specific for TLR2 and TLR4. Results: TLR4 protein expression was absent or minimally detectable in intestinal epithelial cells of normal, non-diseased mucosa. However, TLR4 was strongly upregulated in acute inflammation of IBD. In active CD, TLR4 was mostly expressed on the apical cytoplasmic side of the intestinal epithelium. In contrast, TLR4 was detected on both the apical and basolateral surfaces of intact intestinal epithelial cells in inflamed Uc. TLR2 was not significantly present in intestinal epithelial cells of patients with either active UC or CD. TLR4 expression was also significantly increased in lamina propria cells from active CD and UC, but was absent in non-inflamed tissue of normal mucosa. Conclusions: These data suggest that immune imbalance in IBD could result from hyperresponsiveness to lumenal bacteria due to an increase in expression of TLR4. This study has been supported by grants from the NIH (DK4I557,DK43351) and from the Deutsche Forschungsgemeinschaft (Ca 22612-1).
3685 CURRENT MANAGEMENT STRATEGIES FOR THE TREAT· MENT OF POST·INFLAMMATORY PANCREATIC PSEUDO· CYSTS. Garth C. Beattie, Alexander Baker, Rowan W. Parks, Ajith K. Siriwardena, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom. Introduction: Internal drainage of post-inflammatory pancreatic pseudocysts at open operation has been replaced by a combination of radiologic and endoscopic techniques. Many of these methods are advocated by enthusiasts in the absence of a strong evidence base. Aims: To examine the multi-modality treatment of pancreatic pseudocysts. Methods: The study
AGAA673
population consists of 21 consecutive pancreatic pseudocysts treated over a 4 year period. There were II males, median age 50(IQR 45-62). Etiologic agents of the index attack of pancreatitis were alcohol in 10 (48%), gallstones in 7, post-ERCP in 2 and idiopathic in a further 2. Median delay to presentation (defined as time from first recalled or recorded symptoms to confirmation of pseudocyst) was 5 months (2-12). Three patients presented with a pseudocyst arising on a background of previously investigated minimal-change chronic pancreatitis (etiology alcohol in all 3). The diagnosis of post-inftammatory pseudocyst ws confirmed by computed tomography in all patients and 15 underwent ERCP in an effort to demonstrate ductal leak. Results: endoscopic trans-gastric drainage was successful in 10 (48%) patients, with II initial (technical) failures. Examining the treatment failures revealed that bleeding occurred as an immediate complication in 3(14%) cases with one patient requiring urgent laparotomy for control of hemorrhage. A further patient developed peritonitis and required laparotomy for perforation. Of the failed procedures 5 went on to have surgical drainage, I died, and 5 were managed conservatively. Of the initially successfully treated patients, 5 required no further intervention. A further 5 developed a recurrent pseudocyst (2 of these resolved with further endoscopic manipulation). Thus endoscopic drainage achieved definitive control of pseudocysts in 7 (33%). During the same 4-year period 17 patients underwent open treatment (8 having failed endoscopic treatment). These were treated either by cyst-gastrostomy [8] or (for pseudocysts with infracolic extension) by roux-en-y pseudocystjejunostomy [9]. There was no significant morbidity associated with surgical drainage and no deaths. No pseudocysts recurred after surgical drainage. CONCLUSIONS: Endoscopic treatment is a reasonable first step but has an appreciable morbidity and treatment failure rate. Surgical treatment will salvage endoscopic failures but appears to be a valid option in its own right. Our evidence justifies a formal prospective comparative trial.
3686 MULTIPLE ORGAN FAILURE IN HUMAN ACUTE PANCREATITIS IS ASSOCIATED WITH INCREASED LOCAL AND SYSTEMIC INFLAMMATORY MEDIATORS. Jens M. Mayer, Bettina Rau, Frank Gansauge, Hans G. Beger, Univ of Ulm, Ulm, Germany. Multi- organ complication is the major cause of death in acute pancreatitis. Cytokine- mediated lymphocyte activation has been suggested to trigger the systemic response in this primarily local inflammatory disease. Systemic levels of the proinflammatory mediators sPLAz-II, IL-If3, IL-6, IL-8, the antiinflammatory mediators IL-IRA and IL-lO, the soluble IL-2 receptor sIL-2R and the pancreatic zymogen sPLAz-I were measured by ELISA. Serum samples were obtained on admission and for 7 consecutive days, ascites and lesser sac aspirates were obtained by fine- needle aspiration . Peak values were correlated with the presence of I, 2 or 3 organ failures according to the accepted definitions. 51 patients with acute pancreatitis (16 mild, 35 severe)admitted within 48h after onset of symptoms were included. 13 developed 3 or more organ complications, 12 two and 10 single organ failure. 24 ascites and 9 lesser sac samples from 20 patients were obtained, all patients suffered from multiple organ failure. IL-8 was not significantly increased in the presence of multiple organ complications compared to uncomplicated pancreatitis. Peaking within 48h after onset of symptoms, sPLA2-II distinguished patients developing 3 organ complications from those without any or only I organ complication. Compared to uncomplicated pancreatitis, IL-I RA distinguished patients with 3 organ complications (peak at 72h), IL-If3 and IL-6 (peaks on day 4). Peaking on day 7, sIL-2R was significantly lower in uncomplicated pancreatitis than in three or two organ complications. Local concentrations of IL-I (3 and IL-IO were significantly higher than in serum and highest values were found in lesser sac aspirate. IL-6 was lower in serum than in lesser sac or ascites. No significant difference between values in the local and the systemic compartment could be found for IL-IRA and srr..-2R Early peaks of inflammatory mediators like sPLA2-II,ILlf3 and IL-6 followed by the lymphocyte activation marker sIL-2R are associated with multiple organ complications in acute pancreatitis. This is associated with increased levels of proinflammatory cytokines and lymphocyte activation markers in peripancreatic fluid collections. Cytokine- mediated systemic lymphocyte activation associated with excessively high local cytokine synthesis is involved in the pathogenesis of acute pancreatitis complicated by multiple organ failure.
transgenic mice in which this biosynthetic capacity was blocked because of ectopic expression of arginase I in the enterocytes. In two independent lines, arginine levels were reduced down to 20 % of normal, but levels of other amino acids were not affected. Transgenics suffered from a pronounced retardation of fur- and body-growth, but showed normal enzymatic maturation. Arginine deficiency led to an impaired development of the GALT, as in the transgenics Peyers patches did not develop until adulthood. Row cytometry of intra-epithelial and lamina propria lymphocytes revealed a severe reduction of the B-cell population in the arginine depleted mice, though the T-cell populations were normal, Production of IFN y, IL-4 and IL-6 by in vitro stimulated T-cells, isolated from transgenics was strongly decreased, compared to wild-type. In addition to the immune effects, adult transgenic mice showed behavioural and memory defects. Most phenotypic abnormalities could be reversed by neonatal injection of arginine, but not creatine. Analyses of NOS-deficient mice and mice with severe ornithine transcarbamoylase deficiency indicated that lack of NO synthesis or a state of general malnourishment are not responsible for the observed phenotypes. The results show that intestinal arginine synthesis during the suckling period is important for the normal development of the intestinal immune system and brain function. Our arginine deficient transgenic mice are a promising model to unravel the mechanism of arginine s immunonutrient function.
3684 ALTERATION IN INTESTINAL EPITHELIAL CELL EXPRESSION OF TOLL-LIKE RECEPTORS IN INFLAMMATORY BOWEL DISEASE. Elke Cario, Daniel K. Podolsky, MA Gen Hosp , Gastrointestinal Unit, CSIBD, Boston, MA. Background: Initiation and perpetuation of the inflammatory intestinal responses in inflammatory bowel disease (IBD) may result from an exaggerated host defense reaction of the intestinal epithelium to endogenous lumenal bacterial flora. We have recently shown that intestinal epithelial cell lines constitutively express Toll-like Receptors (TLR2 and 4) (J. Immunol. in press) which appear to be key receptors involved in recognizing various types of lipopolysaccharide and subsequently iniating intracellular signalling. The aim of this study was to characterize the protein expression of TLR2 and TLR4 in primary intestinal epithelial cells from patients with IBD. Material and Methods: Small intestinal and colonic biopsy specimens were collected from patients with IBD (Crohn's Disease (CD); Ulcerative Colitis (UC» and from controls (non-IBD). Diagnosis was confirmed by endoscopy and histology. Specimens were embedded in paraffin and assessed by immunofluorescence histochemistry using antibodies specific for TLR2 and TLR4. Results: TLR4 protein expression was absent or minimally detectable in intestinal epithelial cells of normal, non-diseased mucosa. However, TLR4 was strongly upregulated in acute inflammation of IBD. In active CD, TLR4 was mostly expressed on the apical cytoplasmic side of the intestinal epithelium. In contrast, TLR4 was detected on both the apical and basolateral surfaces of intact intestinal epithelial cells in inflamed Uc. TLR2 was not significantly present in intestinal epithelial cells of patients with either active UC or CD. TLR4 expression was also significantly increased in lamina propria cells from active CD and UC, but was absent in non-inflamed tissue of normal mucosa. Conclusions: These data suggest that immune imbalance in IBD could result from hyperresponsiveness to lumenal bacteria due to an increase in expression of TLR4. This study has been supported by grants from the NIH (DK4I557,DK43351) and from the Deutsche Forschungsgemeinschaft (Ca 22612-1).
3685 CURRENT MANAGEMENT STRATEGIES FOR THE TREAT· MENT OF POST·INFLAMMATORY PANCREATIC PSEUDO· CYSTS. Garth C. Beattie, Alexander Baker, Rowan W. Parks, Ajith K. Siriwardena, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom. Introduction: Internal drainage of post-inflammatory pancreatic pseudocysts at open operation has been replaced by a combination of radiologic and endoscopic techniques. Many of these methods are advocated by enthusiasts in the absence of a strong evidence base. Aims: To examine the multi-modality treatment of pancreatic pseudocysts. Methods: The study
AGAA673
population consists of 21 consecutive pancreatic pseudocysts treated over a 4 year period. There were II males, median age 50(IQR 45-62). Etiologic agents of the index attack of pancreatitis were alcohol in 10 (48%), gallstones in 7, post-ERCP in 2 and idiopathic in a further 2. Median delay to presentation (defined as time from first recalled or recorded symptoms to confirmation of pseudocyst) was 5 months (2-12). Three patients presented with a pseudocyst arising on a background of previously investigated minimal-change chronic pancreatitis (etiology alcohol in all 3). The diagnosis of post-inftammatory pseudocyst ws confirmed by computed tomography in all patients and 15 underwent ERCP in an effort to demonstrate ductal leak. Results: endoscopic trans-gastric drainage was successful in 10 (48%) patients, with II initial (technical) failures. Examining the treatment failures revealed that bleeding occurred as an immediate complication in 3(14%) cases with one patient requiring urgent laparotomy for control of hemorrhage. A further patient developed peritonitis and required laparotomy for perforation. Of the failed procedures 5 went on to have surgical drainage, I died, and 5 were managed conservatively. Of the initially successfully treated patients, 5 required no further intervention. A further 5 developed a recurrent pseudocyst (2 of these resolved with further endoscopic manipulation). Thus endoscopic drainage achieved definitive control of pseudocysts in 7 (33%). During the same 4-year period 17 patients underwent open treatment (8 having failed endoscopic treatment). These were treated either by cyst-gastrostomy [8] or (for pseudocysts with infracolic extension) by roux-en-y pseudocystjejunostomy [9]. There was no significant morbidity associated with surgical drainage and no deaths. No pseudocysts recurred after surgical drainage. CONCLUSIONS: Endoscopic treatment is a reasonable first step but has an appreciable morbidity and treatment failure rate. Surgical treatment will salvage endoscopic failures but appears to be a valid option in its own right. Our evidence justifies a formal prospective comparative trial.
3686 MULTIPLE ORGAN FAILURE IN HUMAN ACUTE PANCREATITIS IS ASSOCIATED WITH INCREASED LOCAL AND SYSTEMIC INFLAMMATORY MEDIATORS. Jens M. Mayer, Bettina Rau, Frank Gansauge, Hans G. Beger, Univ of Ulm, Ulm, Germany. Multi- organ complication is the major cause of death in acute pancreatitis. Cytokine- mediated lymphocyte activation has been suggested to trigger the systemic response in this primarily local inflammatory disease. Systemic levels of the proinflammatory mediators sPLAz-II, IL-If3, IL-6, IL-8, the antiinflammatory mediators IL-IRA and IL-lO, the soluble IL-2 receptor sIL-2R and the pancreatic zymogen sPLAz-I were measured by ELISA. Serum samples were obtained on admission and for 7 consecutive days, ascites and lesser sac aspirates were obtained by fine- needle aspiration . Peak values were correlated with the presence of I, 2 or 3 organ failures according to the accepted definitions. 51 patients with acute pancreatitis (16 mild, 35 severe)admitted within 48h after onset of symptoms were included. 13 developed 3 or more organ complications, 12 two and 10 single organ failure. 24 ascites and 9 lesser sac samples from 20 patients were obtained, all patients suffered from multiple organ failure. IL-8 was not significantly increased in the presence of multiple organ complications compared to uncomplicated pancreatitis. Peaking within 48h after onset of symptoms, sPLA2-II distinguished patients developing 3 organ complications from those without any or only I organ complication. Compared to uncomplicated pancreatitis, IL-I RA distinguished patients with 3 organ complications (peak at 72h), IL-If3 and IL-6 (peaks on day 4). Peaking on day 7, sIL-2R was significantly lower in uncomplicated pancreatitis than in three or two organ complications. Local concentrations of IL-I (3 and IL-IO were significantly higher than in serum and highest values were found in lesser sac aspirate. IL-6 was lower in serum than in lesser sac or ascites. No significant difference between values in the local and the systemic compartment could be found for IL-IRA and srr..-2R Early peaks of inflammatory mediators like sPLA2-II,ILlf3 and IL-6 followed by the lymphocyte activation marker sIL-2R are associated with multiple organ complications in acute pancreatitis. This is associated with increased levels of proinflammatory cytokines and lymphocyte activation markers in peripancreatic fluid collections. Cytokine- mediated systemic lymphocyte activation associated with excessively high local cytokine synthesis is involved in the pathogenesis of acute pancreatitis complicated by multiple organ failure.