Increased Intestinal Permeability Cholestatic Jaundice

Increased Intestinal Permeability and Altered Mucosal Immunity in Cholestatic Jaundice

Fenella K. S. Welsh, F.R.C.S,* Carol W. Ramsden, F.I.M.B.L.S.,* Kenneth MacLennan, F.R.C.Path.,* Maria B. Sheridan, F.R.C.R.,* G. Robin Barclay, Ph.D.,t Pierre J. Guillou, F.R.C.S.,* and John V. Reynolds, F.R.C.S.I. *

From the Professorial Surgical Unit, Department of Pathology, and Department of Radiology, St. James's University Hospital, Leeds, England,* and the Regional Blood Donor Center, t Edinburgh, Scotland

Objective To examine the effects of cholestatic jaundice on gut barrier function. Summary Background Data Gut barrier failure occurs in animal models of jaundice. In humans, the presence of endotoxemia indirectly implicates failure of this host defense, but this has not previously been investigated in jaundiced patients. Methods Twenty-seven patients with extrahepatic obstructive jaundice and 27 nonicteric subjects were studied. Intestinal permeability was measured using the lactulose-mannitol test. Small intestinal morphology and the presence of mucosal immunologic activation were examined in endoscopic biopsies of the second part of the duodenum. Systemic antiendotoxin core IgG antibodies and serum interleukin-6 and C-reactive protein were also quantified. Intestinal permeability was remeasured in 9 patients 5 weeks after internal biliary drainage. Results The median lactulose-mannitol ratio was significantly increased in the jaundiced patients. This was accompanied by upregulation of HLA-DR expression on enterocytes and gut- associated lymphoid tissue, suggesting immune activation. A significant increase in the acute phase response and circulating antiendotoxin core antibodies was also observed in the jaundiced patients. After internal biliary drainage, intestinal permeability returned toward normal levels. Conclusions A reversible impairment in gut barrier function occurs in patients with cholestatic jaundice. Increased intestinal permeability is associated with local immune cell and enterocyte activation. In view of the role of gut defenses in the modern paradigm of sepsis, these data may directly identify an important underlying mechanism contributing to the high risk of sepsis in jaundiced patients.

205 206 Welsh and Others Ann. Surg. * February 1998 Sepsis and its sequelae are the leading cause of morbid- Twenty-seven patients with extrahepatic obstructive jaun- ity and mortality in jaundiced patients,' and this risk cor- dice and 27 nonicteric controls were investigated. The relates with the severity of the jaundice. A potential rela- groups were matched for age, sex, and the presence of tion with gut barrier function was suggested more than neoplastic disease. Postoperative patients, patients with 30 years ago, when Fine et al.2 postulated that the intestine evidence of infection or sepsis, and patients taking ste- was a source of systemic endotoxemia. Many subsequent roids or nonsteroidal anti-inflammatory drugs were ex- investigators have reported a high incidence of portal and cluded from the study. Each patient was defined as being systemic endotoxemia in jaundice, and endotoxin has well-nourished or mildly or moderately malnourished, us- been incriminated in the pathophysiology of postoperative ing the method of subjective global assessment, as pre- complications in such patients.3 Bile salts and lactulose viously described.12 Severely malnourished patients were may neutralize gut endotoxin and alter enteric microflora, excluded from the study because of the impact nutritional and their administration has been reported to result in depletion may have on mucosal permeability. clinical benefit in jaundiced patients.45 Although a number of related abnormalities result from jaundice, including impaired endotoxin clearance by Kupffer's cells6 and Intestinal Permeability altered systemic immunity,7 these observations indirectly Intestinal permeability was quantified using the lactu- suggest that impairment of gut barrier function may be lose-mannitol test.'3 The principle of this test is that relevant in jaundiced patients. lactulose and mannitol are absorbed from the intestine by There is an emerging consensus that a failure of the different pathways. Mannitol, the smaller molecule, is gut barrier to exclude endogenous bacteria and toxins absorbed via the transcellular route, lactulose by the para- from the portal and systemic circulation contributes to the cellular route. Both probes are rapidly excreted in the pathophysiology of the systemic inflammatory response urine. In conditions associated with increased permeabil- syndrome, sepsis, and multiple organ failure.89 In hu- ity, the lactulose-mannitol excretion ratio is increased mans, this hypothesis is supported by the frequent absence through relatively greater absorbence of lactulose com- of an identifiable focus'0 in septic patients with microbio- pared to mannitol. After a 6-hour fast, a pretest urine logic evidence of infection and by unexplained sepsis and specimen was collected from each patient, who then drank multiple organ failure in patients with no microbiologic the test solution containing 5 g lactulose, 2 g mannitol, evidence of infection." This theory of gut-origin sepsis and 22.4 g glucose in 100 mL of water. Urine was then is supported by data from animal models.9 Although the collected for the following 5 hours into 0.2 g chlorhexi- integrity of intestinal defenses and barrier function is cen- dine. Urinary mannitol was measured by spectrophotome- tral to the thesis, there have been few studies of gut barrier try, using a color change reaction with potassium perio- function in relevant clinical situations in humans. date; urinary lactulose was measured by paper chromatog- The aims of this study were to determine whether gut raphy.'4 The results are expressed as a ratio of the barrier function was impaired in jaundiced patients and recovery of the two molecules. The normal range for the to investigate the effects of any altered barrier function urinary lactulose-mannitol ratio is 0 to 0.07. on intestinal morphology or gastrointestinal immune function. In addition, we attempted to determine whether increased intestinal permeability was associated with an Intestinal Morphology and altered cytokine profile and acute phase response, or with Immunohistochemistry evidence of endotoxin exposure. Intestinal permeability All patients underwent endoscopy, at which time biop- was also examined before and after internal biliary drain- sies were taken from the second part of the duodenum, age. distal to the ampulla of Vater. One biopsy was fixed in 10% buffered formalin and embedded in paraffin, and 5- /,m sections were cut and stained with hematoxylin and METHODS eosin. Intestinal villus height and crypt depth were mea- Patients sured using a microscope eyepiece graticule. At least 10 Ethical approval was obtained from the Ethics Commit- villi or crypts were measured for each section, and the tee of St. James's University Hospital, according to the mean value was determined. A second biopsy was snap- Helsinki agreement. Informed consent was mandatory. frozen in liquid nitrogen; 5-,um sections were cut in a cryostat and the sections were stained using a standard three-stage immunoperoxidase reaction as follows. After Address reprint requests to John V. Reynolds, Academic Surgical Unit, blocking nonspecific binding sites with 5% serum in phos- St. James's University Hospital, Leeds LS9 7TF, United Kingdom. phate buffered saline (PBS) and avidin and biotin Accepted for publication January 1997. blocking solutions (Vector AB Blocking kit; Vector, UK), Vol. 227 * No. 2 Jaundice Impairs Gut Barrier Function 207

Table 1. PRIMARY ANTIBODIES USED Antibody Cellular Distribution Source Description Dilution

CD3 T cells DAKO* Rabbit polyclonal 1:100 CD4 Helper T cells PGt Mouse monoclonal CD8 Cytotoxic T cells PG Mouse monoclonal CD30 Late activated T cells DAKO Mouse monoclonal IgGl 1:40 CD68 Macrophages DAKO Mouse monoclonal IgGl 1:50 HLA-DR (MHC class 11) B cells, activated T cells, DAKO Mouse monoclonal IgGl 1:100 macrophages IgA Secretory IgA DAKO Rabbit polyclonal 1:500

* DAKO, High Wycombe, Buckinghamshire, United Kingdom. t PG = personal gift, Dr. Ros Banks, Institute of Cancer Studies, University of Leeds, United Kingdom.

tissue sections were incubated at room temperature for signed ranks test. Analysis of categorical variables was 30 minutes with a primary antibody (Table 1) or serum performed using the chi square test with Yates' correc- (negative control). After washing in PBS, sections were tion. incubated with a biotinylated second-layer antibody for 30 minutes at room temperature (swine antirabbit RESULTS [DAKO, High Wycombe, Buckinghamshire, UK]; polyclonal primary antibodies) or rabbit antimouse (DAKO; Patient Demographics monoclonal primary antibodies). After a further washing The characteristics of the control subjects and jaun- step, samples were incubated with StreptABComplex/ diced patients are shown in Table 2. The groups were HRP (DAKO) and visualized with a diaminobenzidine matched for age, sex, and the presence of neoplastic dis- chromogen (Sigma, Poole, Dorset, UK). Sections were ease. Twenty of the 27 jaundiced patients had pancreatic counterstained with hematoxylin. The numbers of positive cancer. By subjective global assessment, 5 subjects (19%) cells and the intensity of staining within cells were scored from the control group and 12 patients (37%) from the from + 1 to +4. Mucosal morphology and immunohisto- jaundiced group had evidence of malnutrition (chi square chemistry were scored by a consultant pathologist who = 3.1, p = 0.08, Yates' correction). was unaware of the source of the tissue. Intestinal Permeability Serum Assays Lactulose-mannitol ratios from control and jaundiced Evidence of chronic exposure to endotoxin was sought persons are shown in Figure 1. The median lactulose- by measuring the IgG antibody response to endotoxin.'5 Serum concentrations of antiendotoxin core antibody (En- doCAb) of the IgG class were quantified using an enzyme- Table 2. PATIENT DEMOGRAPHICS* linked immunosorbent assay (ELISA), as previously described."6 Serum interleukin-6 (IL-6) was measured using Controls Jaundiced a commercially available ELISA (R&D Systems, Abin- gdon, Oxfordshire, UK) and serum C-reactive protein Number of patients 27 27 Age (yr) 69 (62-78) 69 (60-81) (CRP) was determined by routine autoanalysis (Beckman Male:female 19:8 12:15 autoanalyzer, Beckman, Brear, CA). Neoplastic disease (n) 23 24 Gastroesophageal carcinoma 16 1 Pancreatic carcinoma 1 20 Statistical Analysis Cholangiocarcinoma 0 2 Colorectal carcinoma 6 0 Statistical analysis was performed using Statview soft- Lymphoma 0 1 ware (Apple Computers Inc., Abacus Concepts Inc., Gall stones (n) 0 3 Berkeley, CA). Data were expressed either as individual Plasma bilirubin (rmolL-1) 9 (7-11) 356 (261-386)t data points or as median (with interquartile range in pa- * with in renthesis). Nonparametric analysis was performed using Values are medians, interquartile range parentheses. t p < 0.01, Mann-Whitney U test. the Mann-Whitney U test or the Wilcoxon matched pairs 208 Welsh and Others Ann. Surg. * February 1998

_._ '1.08 266 Table 3. IMMUNOHISTOCHEMISTRY el.77 RESULTS*

0.6 Controls Jaundiced Lactulose- Mannitol Secretory IgA 2 2 Ratio CD3, CD4, CD8 2 2 0.4 CD68 2 4t CD30 1 3t 0:0. HLA-DR (lamina propria mononuclear cells) 1 3t 0.2 00 HLA-DR (epithelial cells) 1 3t

* Median scores. u *- *sx t p < 0.05, Mann-Whitney U test. Control Jaundiced Figure 1. Intestinal permeability in control and jaundiced patients. Individual data points are shown. Median values are represented by In jaundiced patients, there was also a significant increase lines. p < 0.001. horizontal in activated T cells (CD30+ cells) and expression of the activation marker HLA-DR on the lamina propria mono- cells and with mannitol ratio of 0.16 (0.03-0.5) in the jaundiced group nuclear cells (T macrophages) compared An added feature was the markedly was significantly greater than that in the controls (0.02 controls. significant of HLA-DR expression on intestinal epithe- [0.01-0.05], p < 0.001). The control values were not upregulation significantly different from nonpatient population controls lial cells from jaundiced patients (Fig. 2). (0-0.07).13 Sixteen of the 27 (59%) jaundiced patients Antiendotoxin Antibody Levels and the had an increased lactulose-mannitol ratio versus only 4 Acute Phase Response of the 27 (26%) controls (chi square = 9.8, p < 0.01, Yates' correction). Serum IgG EndoCAb was significantly elevated in the jaundiced patients (205 [114-290]) versus controls (102 [66-182]; p < 0.05). The level of endotoxin exposure in Intestinal Morphology the controls was comparable to a population of 604 nor- There was a significant reduction in villus height in the mal healthy blood donors (100 [79-128], p not significant jaundiced patients (335 am [317-360]) versus 396 pm versus controls) (R. Barclay, personal communication). (368-410) in the controls (p < 0.02). However, there There was also evidence of an activated acute phase re- was no difference in crypt depth between the groups (64 sponse in the jaundiced group. These patients had signifi- Mm [60-83] in jaundiced patients vs. 75 ILm [60-90] in cantly elevated levels of circulating IL-6 (17 pg/mL [7- the controls, p not significant). There was also a signifi- 60]) versus controls (3 ng/mL [<3-8]; p < 0.001). There cant increase in the numbers of lamina propria mononu- was also a significant increase in serum levels of CRP in clear cells in the jaundiced patients, with a median score the jaundiced group (30 mg/L [10-93]) versus controls of 3 (2-4) versus 2 (2-2) in the controls (p < 0.05). (7 mg/L [5-20]; p < 0.05). Moreover, the median plasma albumin was 29 g/L (27-35) in the jaundiced patients, significantly lower that of controls (35 g/L [32-41], p < Intestinal Immunohistochemistry 0.01). The intensity of antibody staining of gut-associated lymphoid tissue and enterocytes is shown in Table 3. Correlation of Permeability With There was no difference in total mucosal T-cell numbers Bilirubin, Endotoxin Exposure, IL-6, and between groups. However, there was a significant increase CRP in mucosal macrophages (CD68+ cells) infiltrating the The lactulose-mannitol ratios showed significant cor- lamina propria in the sections from the jaundiced patients. relation with serum bilirubin (Fig. 3; r = 0.4, p = 0.004,

Figure 2. Immunoperoxidase staining for HLA-DR. Magnification x330. Control mucosa (A) shows scat- tered HLA-DR positive lymphocytes in the lamina propria, with no staining of crypt epithelial cells. In contrast, HLA-DR staining is increased on the lamina propria lymphocytes in the jaundiced mucosa and the crypt epithelial cells are positive (B). Vol. 227 - No. 2 Jaundice Impairs Gut Barrier Function 209 210 Welsh and Others Ann. Surg. * February 1998 activation of components of the gut-associated lymphoid tissue and enterocytes, and a heightened acute phase re- 0 0 0 sponse with evidence of exposure to endotoxin. This 1.0 0 ..0 study thus corroborates the experimental evidence of Lactulose- 0* Mannitol O0 compromised gut barrier function in cholestatic jaundice, Ratio o.1 0 *a. although the significance of our findings with respect to * :0* bacterial translocation is unclear. Moreover, the data identify potential underlying mechanisms and indicate that * * 0 0.01 * Mie 0 00 this deficit may be reversible. Intestinal permeability was markedly increased compared 0 with controls. Increased permeability is observed in a variety of conditions, such as bums, inflammatory bowel disease, 1 10 100 1000 and after trauma.20'2 It may also occur in severely malnour- Serum Bilirubin/ FmolL-1 ished patients, albeit to a lesser degree than in jaundice Figure 3. Scattergram to show the relationship between lactulose- (unpublished observations). For this reason, severely mal- mannitol ratio and serum bilirubin in control and jaundiced patients. nourished patients were excluded from this study and pa- Individual data points are shown. The upper limit of the normal range tients with mild to moderate malnutrition were included in is indicated by the horizontal dotted line. r = 0.04, p = 0.004, Spear- the control group, with no significant difference between man rank correlation coefficient. groups. An increase in the lactulose-mannitol ratio is a reflection of increased lactulose absorption through the para- cellular pathway, representing absorption through the tight Spearman rank correlation coefficient). There was no sig- junctions or cell extrusion zones and areas of damaged mu- nificant correlation with serum IL-6 (p = 0.14), CRP (p cosa. These findings are unlikely to relate to altered metabo- = 0.4), IgG EndoCAb (p = 0.24), or serum albumin (p lism and excretion of lactulose or mannitol in jaundice, as = 0.20). The level of IgG EndoCAb significantly corre- this is not influenced in liver failure or renal failure.22 More- lated with serum IL-6 (p = 0.009) and CRP (p = 0.009). over, Budillon et al.,23 using a similar dual-sugar test, has demonstrated normal intestinal permeability in patients with Effect of Internal Biliary Drainage on hepatic cirrhosis. Intestinal Permeability The mechanism underlying the increased permeability may relate to altered intestinal morphology and local im- Nine patients underwent successful internal biliary munologic activation. The reduction in villus height and drainage via an endoscopic prosthesis. Lactulose-manni- the increased mononuclear cell infiltration in the lamina tol ratios were measured before stenting and at 5 weeks propria are consistent with morphologic changes in ani- after stenting. The median bilirubin level was 317 (278- 392) ,mol/L before stenting and 23 (11-36) HimolfL after stenting (p < 0.01, Wilcoxon). The effect of internal drainage on intestinal permeability is shown in Figure 4. 1. There was a significant (p = 0.008, Wilcoxon) reduction in the lactulose-mannitol ratios, from 0.22 (0.12-0.93) Lactulose- before stenting to 0.02 (0.02-0.04) after stenting. Serum Mannitol levels of EndoCAb, IL-6, CRP, and albumin all returned Ratio toward normal levels, but these were not significantly 0.1 different from prestent values. DISCUSSION 0.01X Bacterial translocation is a marker of gut barrier failure in experimental animals and has been described by several investigators after bile duct ligation.'7'18 In humans, bacte- 0.001 rial translocation can be detected only in patients undergo- Pre-stent Post-stent ing laparotomy, and its clinical significance is controver- Figure 4. The effect of internal biliary sial.'9 In this study, several components gut drainage on intestinal permeabil- of barrier ity in nine jaundiced patients. Individual data points are shown. The function were measured, revealing an increase in gut per- upper limit of the normal mage is indicated by the horizontal dotted meability in association with altered villus morphology, line. Vol. 227 * No. 2 Jaundice Impairs Gut Barrier Function 211 mal models.24 More intriguing as a possible etiologic fac- function in trauma patients in the absence of a direct correla- tor was the finding of heightened immunologic activity tion with gut barrier function. and activation within the intramucosal lymphoid tissue The clinical significance ofcompromised gut barrier func- and enterocytes. The mucosal immune system under nor- tion is unclear. In small series of patients with burns and mal conditions is in a state of controlled immunosuppres- after trauma, increased permeability has correlated with an sion to a constant oral antigenic load. This tolerance repre- increased risk of sepsis and the systemic inflammatory re- sents a state of nonreactivity that protects the host from sponse syndrome.'920 We do not know how this relates to intestinal damage by inappropriate immune activity, bacterial translocation, and there is as yet no clinical evi- which is characterized by local generation of harmless dence that bacterial translocation occurs in jaundiced pa- specific secretory IgA and an absent hypersensitivity re- tients. What is clear, however, is the difference between the sponse to the same antigen in the systemic circulation. jaundiced patients and control subjects, and our efforts will Tolerance is an active process, with either anergy of anti- be to define the impact ofthis difference on clinical outcome, gen-specific T cells or selective expansion of T-helper- particularly in the postoperative period. Clinical evidence of 2 cells, which elaborate immunosuppressive cytokines, neutrophil priming in jaundiced patients,30 in conjunction including interleukin-4, transforming growth factor-beta, with evidence from this study of heightened gut immune and interleukin-1O. The enhanced expression of the major activity and an exaggerated acute phase response, suggests histocompatibility complex (MHC) class II antigen HLA- that the immune system is primed in the jaundiced patient DR on mucosal immune cells and enterocytes in jaun- and thus more readily activated in response to further stim- diced patients suggests activation of these cells. What uli, such as surgical trauma or an infective challenge. initiates the cellular activation in cholestatic jaundice is The significance of the finding ofrestored barrier function unclear, but it may be the result of direct local exposure after internal biliary drainage supports the clinical therapeu- of immune cells and enterocytes to antigens, including tic value of this procedure. Whether external drainage bacteria and toxins, although systemic factors cannot be achieves the same effect is unknown, but in experimental excluded. Whatever the activating stimulus, the T-helper- models internal biliary drainage is superior to external drain- 1 proinflammatory cytokine gamma-interferon (IFN-y) age with respect to reducing bacterial translocation,31 lim- is a possible candidate mediator. IFN-y increases tight iting endotoxemia,32 restoring Kupffer's cell responses,33 junction permeability25 and reduces the integrity of intes- and augmenting the host's capacity to withstand a septic tinal epithelial monolayers in vitro. IFN-y also induces challenge.34 In addition, Wells et al.35 reported that bile in MHC class II antigen expression on intestinal epithelial the intestinal lumen decreased bacterial translocation by de- cell lines26 and jejunal biopsies.27 The functional rele- creasing epithelial internalization of enteric bacteria. In three vance of the upregulation of MHC class II on enterocytes randomized clinical trials,36-38 preoperative external biliary is unclear, but these cells may behave as antigen-present- drainage failed to reduce septic morbidity compared with ing cells for lamina propria lymphocytes28 and may there- no drainage at all. Conversely, two prospective studies3940 fore play an active role in initiating or perpetuating a reported decreased septic complications in jaundiced pa- local immunoinflammatory response, leading to tissue tients who were stented before pancreatic or hepatobiliary damage and a breakdown in intestinal barrier function. resections. In a retrospective analysis, Trede4' reported that Further studies of T-helper-l- and T-helper-2-derived preoperative stenting decreased infective complications in cytokines within the mucosal immune system and entero- both moderately and severely jaundiced patients. Thus, the cytes may shed light on the precise mechanism. observation that gut barrier function may be restored after Increased gut permeability directly correlated with the internal biliary drainage is consistent with these observations severity ofjaundice, but there was no significant correlation and provides a scientific basis for this treatment, particularly with the observed increase in CRP levels, IL-6 levels, and in severely jaundiced patients, because the magnitude of endotoxin antibodies, or the decrease in serum albumin. The impaired barrier function directly correlates with the plasma lack of direct correlation between permeability data and bilirubin level. these parameters may not be surprising in view of the com- plexity of the gut barrier. In addition to its role in limiting CONCLUSION bacterial and endotoxin translocation, the gut barrier also prevents the uptake of undegraded antigens and mediates Intestinal permeability is increased in patients with tolerance. The intestine is the largest immune organ in the cholestatic jaundice. This change is accompanied by evi- body, and the gut-associated lymphoid tissue contains ap- dence of activation of the mucosal immune system and proximately 40% of the total immune effector cells. It is suggests the hypothesis that certain cytokines may be possible that the heightened immunologic activity within the responsible for the increased permeability. Finally, the gut correlates best with systemic events. In this respect, increased intestinal permeability is restored toward nor- Fanciose et al.29 have identified heightened regional immune mal by internal biliary drainage. 212 Welsh and Others Ann. Surg. * February 1998 Acknowledgments 22. Cobden I, Hamilton I, Rothwell J, Axon ATR. Cellobiose/mannitol test: physiological properties of probe molecules and influence of The authors thank Jill Rothwell, Gastroenterology Unit, Leeds Gen- extraneous factors. Clin Chim Acta 1985; 148:53-62. eral Infirmary, and Jane Ramsdale, Chief MLSO, Department of Pathol- 23. Budillon G, Parrili G, Pacella M, et al. Investigation of intestine ogy, St. James's University Hospital, for their excellent technical help. and liver function in cirrhosis using combined sugar oral loads. J Hepatology 1985; 1:513-524. 24. Saitoh N, Hiraoka T, Uchino R, Miyauchi Y. Endotoxaemia and References intestinal mucosal dysfunction after the relief of obstructive jaundice by internal and external drainage in rats. Eur Surg Res 1. Holman JM, Rikkers LM, Moody FG. Sepsis in the management 1995;27: 11-18. of complicated biliary disorders. Am J Surg 1979; 138:809-813. 25. Madara JL, Stafford J. Interferon-gamma directly affects barrier 2. Fine J, Frank ED, Ravin HA, et al. The bacterial factor in traumatic function of cultured intestinal epithelial monolayers. J Clin Invest shock. N Engl J Med 1959;260:214-220. 1989; 83:724-727. 3. Wardle EN, Wright NA. Endotoxin and acute renal failure associ- 26. Brandtzaeg P, Halstensen TS, Huitfeldt HS, et al. Epithelial expres- ated with obstructive jaundice. Br J Med 1970;4:472-474. sion of HLA, secretory component (poly-Ig receptor) and adhesion 4. Cahill CJ. Prevention of postoperative renal failure in patients with molecules in the human alimentary tract. New York Acad Sci obstructive jaundice-the role of bile salts. Br J Surg 1983;70:590- 1992;64:157- 179. 595. 27. Sturgess RP, Hooper LB, Spencer J, et al. Effects of interferon- 5. Pain JA, Bailey ME. Experimental and clinical study of lactulose gamma and tumour necrosis factor-alpha on epithelial HLA Class in obstructive jaundice. Br J Surg 1986;73:775-779. II expression on jejunal mucosal biopsy specimens cultured in vitro. 6. Clements WDB, Halliday MI, McCaigue M, et al. Effects of extra- J Scand Gastr 1992;907-911. hepatic obstructive jaundice on Kupffer cell clearance capacity. 28. Bland PW, Warren LG. Antigen presentation by epithelial cells of Arch Surg 1993; 128:200-205. the rat small intestine. 1. Kinetics, antigen specificity and blocking 7. Vane DW, Redlich P, Weber T, et al. Impaired immune function by Ia antisera. Immunology 1986;58:1-7. in obstructive jaundice. J Surg Res 1988;45:287-293. 29. Franciose RJ, Moore EE, Moore FA, et al. Post-ischaemic gut is 8. Bone RC. The pathogenesis of sepsis [review]. Ann Intern Med the priming bed for PMNs. Surgical Forum 1993;44:142-144. 1991; 115:457-469 30. Jiang WG, Puntis MCA, Hallett MB. Neutrophil priming by cyto- 9. Deitch EA. Multiple organ failure. Pathophysiology and potential kines in patients with obstructive jaundice. HPB Surgery future therapy. Ann Surg 1992;216:117-134. 1994;7:281 -289. 10. Carrico CJ, Meakins JL, Marshall JC, et al. Multiple organ failure 31. Slocum MM, Sittig KM, Specian RD, Deitch EA. Absence of intes- syndrome: the gastrointestinal tract: the motor of MOF? Arch Surg tinal bile promotes bacterial translocation. Am Surg 1992;58:305- 1986; 121:197-201. 310. 11. Goris RJ, Beokhorst PA, Nutynick KS. Multiple organ failure: gen- 32. Gouma DJ, Coelho JCU, Fischer JD, et al. Endotoxaemia after eralised autodestructive inflammation. Arch Surg 1985; 120:1109- relief of biliary obstruction by internal and external drainage in rats. 1118. Am J Surg 1986; 151:476-479. 12. Baker JP, Detsky AS, Weeson DE, et al. Nutritional assessment. A 33. Clements WDB, McCaigue M, Erwin P, et al. Biliary decompres- comparison of clinical judgment and objective measurements. N sion promotes Kupffer cell recovery in obstructive jaundice. Gut Engl J Med 1982;306:969-972. 1996; 38:925-931. 13. Juby LD, Rothwell J, Axon ATR. Lactulose/mannitol test: an ideal 34. Gouma DJ, Coelho JCU, Schlegel JF, et al. The effect of preopera- screen for celiac disease. Gastroenterology 1989;96:79-85. tive external and internal biliary drainage on mortality of jaundiced 14. Menzies IS. Quantitative estimation of sugars in blood and urine by rats. Arch Surg 1987; 122:731. paper chromatography using direct densitometry. J Chromatography 35. Wells CL, Jechorek RP, Erlandsen SL. Inhibitory effect of bile on 1973;81:109-127. bacterial invasion of enterocytes: possible mechanism for increased 15. Barclay GR. Endogenous endotoxin-core antibody (EndoCAb) as translocation in associated with obstructive jaundice. Crit Care Med a marker ofendotoxin exposure and a prognostic indicator: a review. 1995;23:301 -307. Progress in Clinical and Biological Research (Bacterial Endotoxins: 36. McPherson GAD, Benjamin IS, Hodgson HJF, et al. Pre-operative Lipopolysaccharides From Genes to Therapy) 1995;392:263-272. percutaneous transhepatic biliary drainage: the results of a con- 16. Scott BB, Barclay GR. Endotoxin-polymyxin complexes in an im- trolled trial. Br J Surg 1984;71:371-375. proved enzyme-linked immunosorbent assay for IgG antibodies in 37. Pitt HA, Gomes AS, Lois JF, et al. Does preoperative percutaneous blood donor sera to Gram-negative endotoxin core glycolipid. Vox drainage reduce operative risk or increase hospital cost? Ann Surg Sang 1987;52:272-280. 1985;201:545-553. 17. Reynolds JV, Murchan P, Redmond HP, et al. Failure of macro- 38. Hatfield ARW, Terblanche J, Fataar S, et al. Preoperative external phage activation in experimental obstructive jaundice: association biliary drainage in obstructive jaundice: a prospective controlled with bacterial translocation. Br J Surg 1995;82:534-538. trial. Lancet 1992;ii:896-899. 18. Deitch EA, Berg R, Specian R. Endotoxin promotes the transloca- 39. Smith RC, Pooley M, George CRP, Faithful GR. Preoperative per- tion of bacteria from the gut. Arch Surg 1985; 122:185-195. cutaneous transhepatic internal drainage in obstructive jaundice: 19. Reynolds JV. Gut barrier function in the surgical patient. Br J Surg a randomised controlled trial examining renal function. Surgery 1996; 83:1668-1669. 1985; 86:641-647. 20. Ziegler TR, Smith RJ, O'Dwyer ST, et al. Increased intestinal per- 40. Lygidakis NJ, Van der Heyde MN, Lubbers MJ. Evaluation of meability associated with infection in burn patients. Arch Surg preoperative biliary drainage in the surgical management of pancre- 1988; 123:1313-1319. atic head carcinoma. Acta Chir Scand 1987; 153:665-668. 21. Pape HC, Dwenger A, Regel G, et al. Increased gut permeability 41. Trede M. The complications of pancreatectomy. Ann Surg after multiple trauma. Br J Surg 1994;81:850-852. 1988; 207:39-47.