BILIARY TRACT ANOMALIES—The Utilization of Modern Techniques in Differential Diagnosis

The diagnostic aids used in dealing with biliary disease in adults were applied to the study in infants of the principal congenital anomalies of the biliary tract such as choledochal cyst, biliary atresia and biliary stenosis.Choledochal cysts were distinguished from other upper abdominal masses occurring in childhood by the use of intravenous cholecystography.Since the clinical manifestations in infants with biliary atresia or stenosis are almost identical to those associated with the obstructive phase of neonatal hepatitis, the problem of differentiation is difficult. The serial total serum bilirubin curve, a careful analysis of the pigment content of feces and urine and duodenal intubation for bilirubin determinations were found to be useful in making the distinction. Operative cholangiograms were helpful in some cases. Frozen section examinations of liver tissue during operation were of little value except to demonstrate certain unusual cases of intrahepatic biliary atresia. Routine liver function studies, including serum transaminase determination in a limited number of cases, did not help in differentiation.     

Biliary tract anomalies: the utilization of modern techniques in differential diagnosis

The diagnostic aids used in dealing with biliary disease in adults were applied to the study in infants of the principal congenital anomalies of the biliary tract such as choledochal cyst, biliary atresia and biliary stenosis. Choledochal cysts were distinguished from other upper abdominal masses occurring in childhood by the use of intravenous cholecystography. Since the clinical manifestations in infants with biliary atresia or stenosis are almost identical to those associated with the obstructive phase of neonatal hepatitis, the problem of differentiation is difficult. The serial total serum bilirubin curve, a careful analysis of the pigment content of feces and urine and duodenal intubation for bilirubin determinations were found to be useful in making the distinction. Operative cholangiograms were helpful in some cases. Frozen section examinations of liver tissue during operation were of little value except to demonstrate certain unusual cases of intrahepatic biliary atresia. Routine liver function studies, including serum transaminase determination in a limited number of cases, did not help in differentiation.     

Effect of rotavirus strain on the murine model of biliary atresia

Biliary atresia is a devastating disorder of the newborn in which afflicted infants develop inflammation and fibrosis of the extrahepatic biliary tract, resulting in cirrhosis and end-stage liver disease. Infection with a virus is thought to be a contributing factor in the etiology of biliary atresia. In the murine model of biliary atresia, perinatal exposure to rhesus rotavirus (RRV) results in biliary epithelial cell infection causing bile duct obstruction. The purpose of this study was to determine if tropism for the biliary epithelial cell was unique to RRV. Newborn mice underwent intraperitoneal injection with five strains of rotavirus: RRV (simian), SA11-FM (simian/bovine), SA11-SM (simian), EDIM (murine), and Wa (human). RRV and SA11-FM caused clinical manifestations of bile duct obstruction and high mortality. SA11-SM caused clinical signs of hepatobiliary injury but the mortality was markedly reduced. EDIM and Wa caused no sign of hepatobiliary disease. The systemic and temporal distribution of viral protein and live virus varied according to the injected strain. Immunohistochemistry revealed that RRV and SA11-FM targeted the biliary epithelial cells. In contrast, SA11-SM was found in the liver but in not in the biliary epithelium. These results indicate that strain-specific characteristics dictate tropism for cells of hepatobiliary origin which in turn impact the ability to induce the murine model of biliary atresia.     

A New Clarification Method to Visualize Biliary Degeneration During Liver Metamorphosis in Sea Lamprey (Petromyzon marinus)

Biliary atresia is a rare disease of infancy, with an estimated 1 in 15,000 frequency in the southeast United States, but more common in East Asian countries, with a reported frequency of 1 in 5,000 in Taiwan. Although much is known about the management of biliary atresia, its pathogenesis is still elusive. The sea lamprey (Petromyzon marinus) provides a unique opportunity to examine the mechanism and progression of biliary degeneration. Sea lamprey develop through three distinct life stages: larval, parasitic, and adult. During the transition from larvae to parasitic juvenile, sea lamprey undergo metamorphosis with dramatic reorganization and remodeling in external morphology and internal organs. In the liver, the entire biliary system is lost, including the gall bladder and the biliary tree. A newly-developed method called “CLARITY” was modified to clarify the entire liver and the junction with the intestine in metamorphic sea lamprey. The process of biliary degeneration was visualized and discerned during sea lamprey metamorphosis by using laser scanning confocal microscopy. This method provides a powerful tool to study biliary atresia in a unique animal model.     

Alagille Syndrome Mimicking Biliary Atresia in Early Infancy

Alagille syndrome may mimic biliary atresia in early infancy. Since mutations in JAG1 typical for Alagille syndrome type 1 have also been found in biliary atresia, we aimed to identify JAG1 mutations in newborns with proven biliary atresia (n = 72). Five biliary atresia patients with cholestasis, one additional characteristic feature of Alagille syndrome and ambiguous liver histology were single heterozygotes for nonsense or frameshift mutations in JAG1. No mutations were found in the remaining 67 patients. All “biliary atresia” carriers of JAG1 null mutations developed typical Alagille syndrome at the age of three years. Our data do not support association of biliary atresia with JAG1 mutations, at least in Czech patients. Rapid testing for JAG1 mutations could prevent misdiagnosis of Alagille syndrome in early infancy and improve their outcome.     

胆总管内注射无水乙醇致胆道闭锁动物模型的建立

目的应用胆总管内注射无水乙醇建立SD大鼠胆道闭锁模型。方法将SD雄性大鼠随机分为实验组和对照组,在实验组中经静脉留置针插入胆总管注入无水乙醇,对照组注入生理盐水。观察SD大鼠的生化及病理结果。结果在实验组中SD大鼠根据病理及生化检测分为肝功能持续恶化组和肝功能修复组,肝功能持续恶化组在8周以后生化明显高于对照组及肝功能修复组。常规HE染色及SMA、Masson染色也出现明显变化。结论胆总管无水乙醇注射诱导胆道闭锁模型是一种可靠的动物模型,此动物模型会帮助人们进一步研究胆道闭锁提供更多的研究手段。     

Gap junctions and zonulae occludentes of hepatocytes during biliary atresia in the lamprey

Gap junctions and zonulae occludentes of hepatocytes were examined in thin sections and freeze-fracture replicas from livers of larval and juvenile adult lampreys and during the phase of metamorphosis when bile ducts and bile canaliculi disappear (biliary atresia). Larvae possess zonulae occludentes at the canaliculi which are composed of one to five (mean = 2.81) junctional strands that provide a bile-blood barrier. Morphometry demonstrates that during biliary atresia the decreases in number of junctional strands and apico-basal depth of the zonulae occludentes are accompanied by an increase in the frequency of gaps or interruptions in the strands and in a breakdown of the bile-blood barrier. The zonulae occludentes completely disappear during metamorphosis and are not found in the adult liver. Gap junctions of the larval liver occupy 1% of the surface of the plasma membrane and have a mean area of 0.167 micron 2 but, following an initial decline in these parameters during early biliary atresia, they rise sharply in later stages of metamorphosis and in adults are 3.2% and 0.502 micron 2, respectively. The events of alteration in junctional morphology during lamprey biliary atresia is in many ways comparable to the changes in gap junctions and zonulae occludentes during experimental and pathological intra- and extrahepatic cholestasis in mammals.     

Morphological changes in the liver of the sea lamprey, Petromyzon marinus L., during metamorphosis: I. Atresia of the bile ducts

The bile ducts in the liver of larval sea lamprey, Petromyzon marinus, undergo programmed degeneration during metamorphosis. The degenerative process is most dramatic in the middle metamorphic stages (3-5), and is asynchronous, occurring more rapidly in small peripheral biliary components than in larger, medial ducts. All classes of bile ducts within the biliary tree exhibit similar histological changes during regression. The initial evidence of degeneration in the epithelium is a folding of the basal lamina, and this is accompanied by cell shrinkage and disruption of cell order. "Shedding" of microvilli and cytoplasmic constituents then takes place at the apical surface resulting in the accumulation of periodic acid-Schiff positive membranous debris in the Lumen. The appearance of "hyalin bodies" in the lumen coincides with the depletion of intermediate-sized filaments from the cytoplasmic matrix. Numerous, large dense bodies, myelin figures, and autophagic vacuoles are consistently observed in necrotic cells. Following cytolysis, bile duct remnants become ensheathed within regions of fibrosis. Ultimately, these fibrous regions are replaced with cords of hepatocytes. By stage 7, all bile ducts have disappeared. The events of biliary atresia in lampreys are comparable to tissue regression which is associated with normal development and pathological conditions in other vertebrates but are particularly reminiscent of those in human biliary atresia. The unique ability of the adult lamprey to service without bile ducts enhances the value of this organism as an experimental model for studying human biliary atresia.     

Association of the reovirus S1 gene with serotype 3-induced biliary atresia in mice.

A panel of serotype 3 (T3) reovirus strains was screened to determine their relative capacities to cause lethal infection and hepatobiliary disease following peroral inoculation in newborn mice. A wide range of 50% lethal doses (LD50s) was apparent after peroral inoculation of the different virus strains. Two of the strains, T3 Abney and T3 clone 31, caused mice to develop the oily fur syndrome associated with biliary atresia. The capacity to cause biliary atresia was not related to the capacity to cause lethal infection, however, because the LD50s of T3 Abney and T3 clone 31 were grossly disparate. Examination of liver and bile duct tissues revealed histopathologic evidence of biliary atresia and hepatic necrosis in T3 Abney-infected mice but not in mice inoculated with a T3 strain of similar virulence or with the hepatotropic T1 Lang strain. The consistency with which T3 Abney-infected mice developed biliary atresia-associated oily fur syndrome permitted us to determine the viral genetic basis of reovirus-induced biliary atresia. Analysis of reassortant viruses isolated from an in vitro coinfection with T3 Abney and T1 Lang indicated a strong association of the hepatobiliary disease-producing phenotype with the T3 Abney S1 gene, which encodes the viral cell attachment protein, sigma 1. Amino acid residues within the sigma 1 protein that were unique to disease-producing T3 strains were identified by comparative sequence analysis. Specific changes exist within two regions of the protein, one of which is thought to be involved in binding to host cell receptors. We hypothesize that changes within this region of the protein are important in determining the tropism of this virus for bile-ductular epithelium.     

Preventive effect of malotilate on carbon tetrachloride-induced liver damage and collagen accumulation in the rat.

Malotilate is a new drug suggested for use in chronic liver diseases. It is shown here to prevent liver damage caused by CCl4. The concomitant administration of malotilate with CCl4 significantly decreased hydroxyproline accumulation in the liver, liver prolyl 4-hydroxylase and liver and serum galactosylhydroxylysyl glucosyltransferase activities. However, it had no effect on the daily urinary hydroxyproline excretion or the hydroxyproline content of the skin, liver or lungs in normal young growing rats. It also had no specific inhibitory effect on hydroxyproline synthesis or secretion in fibroblast cultures, and did not affect the amount of procollagen-alpha 1(I)-specific mRNAs in these cultures. Thus it seems to have no direct inhibitory effect on collagen metabolism. In addition to inhibition of liver collagen accumulation, malotilate was also able to prevent the development of morphological changes in the liver such as focal necrosis, fatty infiltration and inflammatory changes. It also normalized almost completely the standard liver-function tests. It is possible that malotilate may prevent excessive collagen deposition by inhibiting the inflammation caused by CCl4-induced liver damage.     

Identification of HSP90 as Potential Biomarker of Biliary Atresia Using Two-Dimensional Electrophoresis and Mass Spectrometry

Biliary atresia (BA) is a devastating cholestatic liver disease targeting infants. Current diagnosis depends on surgical exploration of the biliary tree. The aim of the present study was to identify potential biomarkers for the diagnosis of biliary atresia (BA). Two-dimensional electrophoresis was utilized for the identification of proteins that were differentially expressed in liver biopsies of 20 BA patients and 12 infants with non-BA neonatal cholestasis (NC) as controls. Using mass spectrometry, we identified 15 proteins with expressions significantly altered. Out of the 15 proteins identified, heat shock protein (HSP) 90 was the most significantly altered and was down-regulated in BA samples compared to NC samples using immunoblotting analysis. Our findings suggest that HSP90 might be a potential biomarker for the diagnosis of BA and may be used for monitoring further development and therapy for BA. This study demonstrated that a comprehensive strategy of proteomic identification combined with further validation should be adopted in biomarker discovery.     

Natural Killer Cells Promote Long-Term Hepatobiliary Inflammation in a Low-Dose Rotavirus Model of Experimental Biliary Atresia

ConclusionsLower inoculation of RRV-induced progressive liver injury and fibrosis via NK cells. These findings point to the potential use of NK cell-depleting strategies to block progression of liver disease in biliary atresia.     

Nonparenchymal liver cells and granulomas during lamprey biliary atresia

Transmission (thin sections and freeze-fracture replicas) and scanning electron microscopy were used to describe the nonparenchymal liver cells during the seven (1-7) stages of metamorphosis in the sea lamprey, Petromyzon marinus L., when bile ducts and canaliculi degenerate. The biliary atresia is accompanied by an increased diameter of fenestrae in the endothelium, an active phagocytosis by Kupffer cells in the sinusoids, and large lipid inclusions in perisinusoidal lipocytes (fat-storing or Ito cells). Plasma-like cells and foci of nonparenchymal cells (granulomas) are present in the liver interstitium during at least four stages of metamorphosis. The fenestrae in the sinusoidal wall are wider (up to 2.8-micron diameter) than normally reported for vertebrate livers but are likely a reflection of the morphogenetic and physiological events and consequences of the biliary atresia. Kupffer cells are involved in an extensive erythrophagocytosis, the storage of iron, and perhaps the incorporation of cellular components from hepatocytes. Lipocytes are the vitamin A-storing cells of the transforming liver and may be responsible for some perisinusoidal fibrosis. Granulomas are present during stages 3-6 and are focal areas where mononuclear leukocytes (lymphocytes and plasmalike cells), macrophages, and neutrophils have infiltrated the hepatic parenchyma. The function of the granulomas is not known; but their presence may be related to the porous nature of the sinusoidal wall, the tissue degeneration, and/or the physiological change (e.g., bile stasis) during biliary atresia.     

Local but not systemic administration of mesenchymal stromal cells ameliorates fibrogenesis in regenerating livers

Chronic liver injury leads to the accumulation of myofibroblasts resulting in increased collagen deposition and hepatic fibrogenesis. Treatments specifically targeting fibrogenesis are not yet available. Mesenchymal stromal cells (MSCs) are fibroblast‐like stromal (stem) cells, which stimulate tissue regeneration and modulate immune responses. In the present study we assessed whether liver fibrosis and cirrhosis can be reversed by treatment with MSCs or fibroblasts concomitant to partial hepatectomy (pHx)‐induced liver regeneration. After carbon tetrachloride‐induced fibrosis and cirrhosis, mice underwent a pHx and received either systemically or locally MSCs in one of the two remaining fibrotic/cirrhotic liver lobes. Eight days after treatment, liver fibrogenesis was evaluated by Sirius‐red staining for collagen deposition. A significant reduction of collagen content in the locally treated lobes of the regenerated fibrotic and cirrhotic livers was observed in mice that received high dose MSCs. In the non‐MSC‐treated counterpart liver lobes no changes in collagen deposition were observed. Local fibroblast administration or intravenous administration of MSCs did not ameliorate fibrosis. To conclude, local administration of MSCs after pHx, in contrast to fibroblasts, results in a dose‐dependent on‐site reduction of collagen deposition in mouse models for liver fibrosis and cirrhosis.     

Advances in the generation of bioengineered bile ducts

The generation of bioengineered biliary tissue could contribute to the management of some of the most impactful cholangiopathies associated with liver transplantation, such as biliary atresia or ischemic cholangiopathy. Recent advances in tissue engineering and in vitro cholangiocyte culture have made the achievement of this goal possible. Here we provide an overview of these developments and review the progress towards the generation and transplantation of bioengineered bile ducts. This article is part of a Special Issue entitled: Cholangiocytes in Health and Diseaseedited by Jesus Banales, Marco Marzioni and Peter Jansen.     

microRNA-222 modulates liver fibrosis in a murine model of biliary atresia

microRNA-222 (miR-222) has been shown to initiate the activation of hepatic stellate cells, which plays an important role in the pathogenesis of liver fibrosis. The aim of our study was to evaluate the role of miR-22 in a mouse model of biliary atresia (BA) induced by Rhesus Rotavirus (RRV) infection. New-born Balb/c mice were randomized into control and RRV infected groups. The extrahepatic bile ducts were evaluated. The experimental group was divided into BA group and negative group based on histology. The expression of miR-222, protein phosphatase 2 regulatory subunit B alpha (PPP2R2A), proliferating cell nuclear antigen (PCNA) and phospho-Akt were detected. We found that the experimental group showed signs of cholestasis, retardation and extrahepatic biliary atresia. No abnormalities were found in the control group. In the BA group, miR-222, PCNA and Akt were highly expressed, and PPP2R2A expression was significantly inhibited. Our findings suggest that miR-222 profoundly modulated the process of fibrosis in the murine BA model, which might represent a potential target for improving BA prognosis.     

The Pathology of Liver Cirrhosis in Patients with Cystic Fibrosis of the Pancreas

The peculiarities of the type of liver cirrhosis that occurs in patients with cystic fibrosis of the pancreas depend on a number of factors. Two such factors, which have received little attention in the past, became apparent during a study of the livers of patients dying of this disease at the Henry Ford Hospital, Detroit. Firstly, the onset of the disease in fetal life may disturb the development of the bile duct system whose normal development is essential for normal structural relationships to be maintained in the liver. Focal lesions of intrahepatic biliary atresia will then complicate the histologic picture of “multi-lobular biliary cirrhosis”. Secondly, scars formed in an infantile liver will considerably distort the subsequent growth of the liver, resulting in bizarre nodularity. Despite massive deformation large portions of the liver will still be composed of primary parenchyma that will enable normal liver functions as revealed by laboratory tests.     

Ultrastructural features of degeneration of the gallbladder during lamprey biliary atresia

Thin sections and freeze-fracture replicas were used to examine the fine structural features of degeneration of the gallbladder during lamprey biliary atresia. The cells of the epithelium undergo a progressive accumulation of dense bodies and vacuoles, loss of glycogen, condensation of the filamentous ectoplasm, fragmentation of microvilli, and dilation of cisternae of rough endoplasmic reticulum but eventually disappear by stage 4 of metamorphosis. Zonulae occludentes in the epithelium show a progressive increase in apical-basal depth as the junctional strands fragment. The possibility of an influence of transformed, subepithelial cells on degeneration of epithelial cells is suggested by close contact of the former with the thickened, highly pleated, epithelial basal lamina. The smooth muscle cells of the larval gallbladder are believed to transform during lamprey metamorphosis into these subepithelial cells which shed their external lamina, become intimately associated with collagen and other microfibrils, and which may be capable of phagocytosis. The events of gallbladder degeneration during lamprey metamorphosis show features of apoptosis.     

Phospholipase D1 decreases type I collagen levels in hepatic stellate cells via induction of autophagy

Hepatic stellate cells (HSCs) are major players in liver fibrogenesis. Accumulating evidence shows that suppression of autophagy plays an important role in the development and progression of liver disease. Phospholipase D1 (PLD1), which catalyzes the hydrolysis of phosphatidylcholine to yield phosphatidic acid (PA) and choline, was recently shown to modulate autophagy. However, little is known about the effects of PLD1 on the production of type I collagen that characterizes liver fibrosis. Here, we examined whether PLD1 regulates type I collagen levels in HSCs through induction of autophagy. Adenovirus-mediated overexpression of PLD-1 (Ad-PLD1) reduced type I collagen levels in the activated human HSC lines, hTERT and LX2. Overexpression of PLD1 in HSCs led to induction of autophagy as demonstrated by increased LC3-II conversion and formation of LC3 puncta, and decreased p62 abundance. Moreover, inhibiting the induction of autophagy by treating cells with bafilomycin or a small interfering (si)RNA for ATG7 rescued Ad-PLD1-induced suppression of type I collagen accumulation in HSCs. The effects of PLD on type I collagen levels were not related to TGF-β/Smad signaling. Furthermore, treatment of cells with PA induced autophagy and inhibited type I collagen accumulation. The present study indicates that PLD1 plays a role in regulating type I collagen accumulation through induction of autophagy.     

Immunohistochemical detection of polyductin and co-localization with liver progenitor cell markers during normal and abnormal development of the intrahepatic biliary system and in adult hepatobiliary carcinomas

The longest open reading frame of PKHD1 (polycystic kidney and hepatic disease 1), the autosomal recessive polycystic kidney disease (ARPKD) gene, encodes a single-pass, integral membrane protein named polyductin or fibrocystin. A fusion protein comprising its intracellular C-terminus, FP2, was previously used to raise a polyclonal antiserum shown to detect polyductin in several human tissues, including liver. In the current study, we aimed to investigate by immunohistochemistry the detailed polyductin localization pattern in normal (ductal plate [DP], remodelling ductal plate [RDP], remodelled bile ducts) and abnormal development of the primitive intrahepatic biliary system, known as ductal plate malformation (DPM). This work also included the characterization of polyductin expression profile in various histological forms of neonatal and infantile cholestasis, and in cholangiocellular carcinoma (CCC) and hepatocellular carcinoma (HCC). We detected polyductin expression in the intrahepatic biliary system during the DP and the RDP stages as well as in DPM. No specific staining was found at the stage of remodelled bile ducts. Polyductin was also detected in liver biopsies with neonatal cholestasis, including mainly biliary atresia and neonatal hepatitis with ductular reaction as well as congenital hepatic fibrosis. In addition, polyductin was present in CCC, whereas it was absent in HCC. Polyductin was also co-localized in some DP cells together with oval stem cell markers. These results represent the first systematic study of polyductin expression in human pathologies associated with abnormal development of intrahepatic biliary tree, and support the following conclusions: (i) polyductin expression mirrors developmental properties of the primitive intrahepatic biliary system; (ii) polyductin is re-expressed in pathological conditions associated with DPM and (iii) polyductin might be a potential marker to distinguish CCC from HCC.