Background: The hepatitis C virus (HCV) effectively establishes persistent infection in human livers. The non-structural (NS) 3/4A complex participate in this process by cleavage of IFN-β promoter stimulator-1 (IPS-1; also termed Cardif/MAVS/VISA), which inhibits responses to double stranded (ds) RNA. However, it is not known whether this effect extends beyond innate responses.

Aims: To test if HCV NS3/4A affect innate and adaptive immune responses in vivo.

Methods: NS3 levels were semi-quantified in human liver biopsies, transfected cells, and in transgenic (Tg) mouse livers by western blot. The effect of NS3/4A on dsRNA-mediated signaling and on integrity of IPS-1 was analyzed using in vitro translation, transfected cells and Tg mice. Cytotoxic T cell (CTL)-mediated clearance of transiently Firefly luciferase (FLuc)- and/or NS3/4A-Tg hepatocytes was determined using in vivo imaging and western blot.

Results: NS3-protein levels were at somewhat comparable range (0,1 - 49 µg/g tissue) in infected human livers and Tg mouse livers. Importantly, these levels of NS3/4A reduced murine innate responses to synthetic dsRNA in vivo, supporting that this occurs also in infected humans. The likely explanation for this was the NS3/4A-mediated cleavage of mouse IPS-1, albeit less efficiently than human IPS-1. Despite this were FLuc- and/or NS3/4A-expressing murine hepatocytes effectively eliminated by hepatic CTLs, utilizing the classical molecules for virus-infected cell lysis, including CD8, IFN-, perforin, and FasL.

Conclusions: Although HCV NS3/4A inhibits the innate immunity, this does not prevent CTL-mediated clearance of NS3/4A-expressing hepatocytes in vivo. Thus, other HCV proteins are most likely responsible for interfering with the adaptive immunity.

Background & Aim: Colon epithelial cell (CEC) apoptosis and NFkB activation may compromise barrier function, and we have reported that STAT5b deficient mice exhibit increased susceptibility to colitis. We hypothesized that the growth hormone (GH) target, STAT5b maintains mucosal barrier integrity by promoting CEC survival and inhibiting NFkB activation.

Methods: The GH effect upon mucosal injury due to TNBS administration was determined in STAT5b deficient mice and wild type (WT) controls. The effect of STAT5b deficiency upon CEC survival and NFkB activation was determined and related to differences in intestinal permeability and bacterial translocation. RNA interference (RNAi) was used to knock down STAT5b expression in the T84 CEC line and the effect upon basal and GH dependent regulation of pro-apoptotic and inflammatory pathways induced by TNFalpha was determined.

Results: GH suppression of mucosal inflammation in TNBS colitis was abrogated in STAT5b deficient mice. STAT5b deficiency led to activation of a pro-apoptotic pattern of gene expression in the colon, and increased mucosal permeability. The frequency of apoptotic CEC was increased in STAT5b deficient mice while tight junction protein abundance was reduced. This was associated with up regulation of CEC TLR2 expression and NFkappaB activation. STAT5b knock down in T84 CEC increased TNFalpha dependent NFkappaB and caspase 3 activation. Growth hormone (GH) inhibition of TNFalpha signaling was prevented by STAT5b knock down.

Conclusion: STAT5b maintains colonic barrier integrity by modulating CEC survival and NFkappaB activation. STAT5b activation may therefore represent a novel therapeutic target in Inflammatory Bowel Disease.

Background: Acid in the esophageal lumen is often sensed as heartburn. We hypothesized that luminal CO2, a permeant gas, rather than H+, permeates through the epithelium, and is converted to H+, producing an afferent neural signal by activating chemosensors.

Methods: We superfused the rat lower esophageal mucosa with pH 7.0 buffer, and pH 1.0 or pH 6.4 high CO2 (PCO2 = 260 Torr) solutions with or without the cell-permeant carbonic anhydrase (CA) inhibitor methazolamide (MTZ, 1 mM), the cell-impermeant CA inhibitor benzolamide (BNZ, 0.1 mM), the transient receptor potential vanilloid 1 (TRPV1) antagonist capsazepine (CPZ, 0.5 mM), or the acid-sensing ion channel (ASIC) inhibitor amiloride (0.1 mM). We measured interstitial pH (pHint) with 5',6'-carboxyfluorescein (5 mg/kg iv) loaded into the interstitial space and blood flow with laser-Doppler.

Results: Perfusion of a high CO2 solution induced hyperemia without changing pHint, mimicking the effect of pH 1.0 perfusion. Perfused MTZ, BNZ, CPZ and amiloride all inhibited CO2-induced hyperemia. CA XIV was expressed in the prickle cells with CA XII in the basal cells. TRPV1 was expressed in the stratum granulosum and in the muscularis mucosa, whereas all ASICs were expressed in the prickle cells with ASIC3 additionally in the muscularis mucosa.

Conclusions: The response to CO2 perfusion suggests that CO2 diffuses through the stratum epithelium, interacting with TRPV1 and ASICs in the epithelium or in the submucosa. Inhibition of the hyperemic response to luminal CO2 by CA, TRPV1 and ASIC inhibitors implicates CA and these chemosensors in transduction of the luminal acid signal. Transepithelial CO2 permeation may explain how luminal H+ equivalents can rapidly be transduced into hyperemia, and the sensation of heartburn.

Background & Aims: The effect of adiponectin on colorectal carcinogenesis has been proposed but not fully investigated. We investigated the effect of adiponectin deficiency on the development of colorectal cancer.

Methods: We generated three types of gene-deficient mice; adiponectin-deficient, Adiponectin receptor 1-deficient and Adiponectin receptor 2-deficient, and investigated chemical-induced colon polyp formation and cell proliferation in colon epithelium. Western blot analysis was performed to elucidate the mechanism which affected colorectal carcinogenesis by adiponectin deficiency.

Results: The numbers of colon polyps were significantly increased in adiponectin-deficient mice compared with wild-type mice fed with high-fat diet. However, no difference was observed between wild-type and adiponectin-deficient mice fed with basal diet. A significant increase in cell proliferative activity was also observed in the colonic epithelium of the adiponectin-deficient mice when compared with wild-type mice fed with high-fat diet, however, no difference was observed between wild-type and adiponectin-deficient mice fed with basal diet. Similarly, an increase in epithelial cell proliferation was observed in Adiponectin receptor 1-deficient mice, but not in Adiponectin receptor 2-deficient mice. Western blot analysis revealed activation of mammalian target of rapamycin, p70 S6 kinase, S6 protein and inactivation of AMP-activated protein kinase in the colon epithelium of adiponectin-deficient mice fed with high-fat diet.

Conclusions: Adiponectin suppresses colonic epithelial proliferation via inhibition of mammalian target of rapamycin pathway under the high-fat diet, but not under basal diet. These studies indicate a novel mechanism of suppression of colorectal carcinogenesis induced by western-style high-fat diet.

Objective: Colorectal cancer is the second commonest cause of cancer death in Europe and North America. Alarm features are used to prioritise access to urgent investigation, but there is little information concerning their utility in the diagnosis of colorectal cancer.

Design: Systematic review and meta-analysis of published literature to assess diagnostic accuracy of alarm features in predicting colorectal cancer. Studies were identified by searching MEDLINE, EMBASE, and CINAHL (up to October 2007).

Setting: Primary or secondary care-based studies. Patients: Unselected cohorts of adult patients with lower gastrointestinal symptoms.

Main outcome measures: Accuracy of alarm features or statistical models in predicting presence of colorectal cancer after investigation. Data were pooled to estimate sensitivity, specificity, and positive and negative likelihood ratios. Quality of included studies was assessed according to pre-defined criteria.

Results: Of 11169 studies identified, 205 were retrieved for evaluation. Fifteen studies were eligible for inclusion, evaluating 19443 patients, with a pooled prevalence of colorectal carcinoma of 6% (95% CI 5-8%). Pooled sensitivity of alarm features was poor (5% to 64%) but specificity was greater than 95% for dark red rectal bleeding and abdominal mass, suggesting presence of either rules the diagnosis of colorectal cancer in. Statistical models had a sensitivity of 90%, but poor specificity.

Conclusions: Most alarm features had poor sensitivity and specificity for the diagnosis of colorectal carcinoma, whilst statistical models performed better in terms of sensitivity. Future studies should examine utility of dark red rectal bleeding and abdominal mass, and concentrate on maximising specificity when validating statistical models.

Objective: To evaluate the efficacy and safety of long-term budesonide therapy for maintenance of clinical remission in patients with collagenous colitis.

Design: Randomised, placebo-controlled study with a 24-week, blinded follow-up period without any treatment.

Setting: Three gastroenterology clinics in Denmark.

Patients: Forty-two patients with histologically-confirmed collagenous colitis and diarrhoea (>3 stools/day).

Interventions: Patients in clinical remission after 6 weeks' open-label therapy with oral budesonide (Entocort CIR capsules, 9 mg/day) received 24 weeks' double-blind maintenance therapy with budesonide 6 mg/day or placebo. Thereafter, patients entered the 24-week, blinded follow-up period.

Main outcome measure: Proportion of patients in clinical remission (≤3 stools/day) at the end of maintenance therapy.

Findings: A total of 34 patients in remission at week 6 were randomised to budesonide 6 mg/day (n = 17) or placebo (n = 17). After 24 weeks' maintenance treatment, the proportions of patients in clinical remission were 76.5% (13 of 17) with budesonide and 12% (2 of 17) with placebo (p<0.001). At 48 weeks (the end of the follow-up period, without any treatment) these values were 23.5% (4 of 17) and 12% (2 of 17), respectively (p=0.6). The median times to relapse after stopping active treatment (6+24 weeks in the budesonide group; 6 weeks in the placebo group) were 39 and 38 days, respectively. Long-term treatment with budesonide was well tolerated.

Conclusions: Long-term maintenance therapy with oral budesonide is efficacious and well tolerated for preventing relapse in patients with collagenous colitis. However, the risk of relapse after 24 weeks' maintenance treatment is similar to that observed after 6 weeks' induction therapy.

Background: Needle biopsy of a suspicious liver lesion could guide management in the setting of equivocal imaging and serology, though not recommended generally due to fear of tumour dissemination outside the liver. The incidence of needle track seeding following biopsy of a suspicious liver lesion is however ill defined.

Methods: A systematic review and meta-analysis of observational studies published before March 2007 was performed. Studies that reported on needle tract seeding following biopsy of suspicious liver lesions were identified. Lesions suspected to be hepatocelleular cancer (HCC) were considered. Data on the type of needle biopsy, diagnosis, incidence of needle track seeding duration to seeding, follow up and impact on outcome were tabulated.

Results: Eight studies identified by systematic review on biopsy of HCC were included in a meta-analysis. The pooled estimate of patient with seeding per 100 patients with HCC was 0.027 (95% CI 0.018 to 0.040). There was no difference whether a fixed or random effects model was used. Q was 4.802 with 7 degrees of freedom, p=0.684, thus observed heterogeneity was compatible with variation by chance alone. The pooled estimate of patient with seeding per 100 patients per year was 0.009 (95% CI 0.006 to 0.013), p=0.686.

Conclusions: In this systematic review we have shown that the incidence of needle tract tumour seeding following biopsy of a HCC is 2.7% overall, or 0.9% per year.

The development of lymphoma in chronic inflammatory conditions has been a topic of great interest. Studies in inflammatory bowel disease (IBD) have demonstrated conflicting results and it is often difficult to disassociate disease severity, disease duration and the risk attributable to drug exposure. Recently presented results from the very large French population based CESAME study suggest a doubling of the risk of lymphoma in patients with IBD, with the majority of cases occurring in association with immunosuppressive therapy. Similarly, a meta-analysis of previous cohort studies concluded that the risk of lymphoma is increased four-fold in patients with IBD on thiopurine treatment (azathioprine and 6-mercaptopurine) compared to those not receiving such therapy. Such analyses cannot demonstrate causation, and it is possible that an increased lymphoma risk relates to more active underlying disease rather than thiopurine therapy, an interpretation supported by results from studies in IBD patients unexposed to such treatment.

Background and Aims: Hepcidin is an iron homoeostasis regulator peptide. Loss-of-function mutations cause juvenile hemochromatosis while its overexpression results in anemia. However, the mechanism and function of preprohepcidin conversion to mature hepcidins (25, 22 and 20 amino acids C-terminal peptides) are not well known. After the signal peptide removal, the first proteolytic cleavage occurs within the basic motif RRRRR⁵⁹DT, suggesting the involvement of the proprotein convertases (PCs) family members in this process.

Methods and Results: Using cell transfection experiments, the processing of preprohepcidin in the human hepatocyte line Huh-7 was found to be inhibited by the Furin inhibitors 1-PDX and ppFurin. Site-directed mutagenesis analysis confirmed the RRRRR⁵⁹DT preprohepcidin cleavage site. In parallel, the lack of preprohepcidin processing found in the PCs activity-deficient cell line LoVo was restored by the expression of Furin, PACE4, PC5 or PC7. This finding is consistent with the in vitro digestions of a synthetic peptide mimicking the cleavage site of preprohepcidin. In addition, during mouse embryonic development the major expression of hepcidin found in the liver coincided with that of Furin. While hepcidin induces the degradation of the iron transporter ferroportin, its RRRRR⁵⁹ to ^SSSSS59 mutant is not active.

Conclusions: These results demonstrate the key role of the convertases Furin, PACE4, PC5 and/or PC7 in the generation and secretion of active hepcidin and suggest that the control of hepcidin processing as a potential therapeutic/diagnostic strategy in hepcidin-related disorders such as hemochromatosis, inflammatory diseases, anemia and cancer.

Background: The accumulation of reactive oxygen species and subsequent oxidative DNA damage underlie the development of Barrett's esophagus (BE) and its progression to Barrett's dysplasia (BD) and adenocarcinoma (BAC).

Methods: We systematically analyzed the promoter regions of 23 genes of the Glutathione S-transferase (GST) and Glutathione peroxidase (GPX) families. Quantitative bisulfite pyrosequencing, real-time RT-PCR (qRT-PCR), Western blot, and immunohistochemical (IHC) analysis methods were utilized in this study.

Results: We identified 14 genes that have CpG islands around their transcription start sites; GSTs (M2-M5, A4, P1, Z1, T2, O1-O2) and GPXs (GPX1, GPX3, GPX4, GPX7). Analysis of an initial set of 20 primary samples demonstrated promoter DNA hypermethylation and mRNA down-regulation of GPX3, GPX7, GSTM2, GSTM3, and GSTM5 in more than half of the BACs samples. Further analysis of 159 primary human samples (37 normal, 11 BE, 11 BD, and 100 BACs) indicated frequent hypermethylation (≥10% methylation) of GPX3 (62%), GPX7 (67%), GSTM2 (69.1%), and GSTM3 (15%) in BACs. A significant inverse correlation between DNA methylation and mRNA expression level was shown for GPX3 (P<.0001), GPX7 (P=.002), GSTM2 (P<.0001), and GSTM5 (P=.01). Treatment of esophageal cancer cell lines with 5-Aza-2'-deoxycytidine and Trichostatin-A led to reversal of the methylation pattern and re-expression of these genes at the mRNA and protein levels. The IHC analysis of GPX3, GPX7, and GSTM2 on a tissue microarray that contained 75 BACs with normal squamous esophageal samples demonstrated an absent-to-weak staining in tumors (52% for GPX3, 57% for GPX7, and 45% for GSTM2) and a moderate-to-strong immunostaining in normal samples.

Conclusion: Epigenetic inactivation of members of the glutathione pathway can be an important mechanism in Barrett's tumorigenesis.

Objective: The chemokine CXCL12, together with its specific receptor, CXCR4, have been shown to mediate invasiveness and metastatic behavior in pancreatic cancer cells. The expression of CXC12/CXCR4 has not been previously examined in pancreatic intraepithelial neoplasias (PanIN), the accepted precursor lesions to pancreatic duct cancer.

Design: In this study we sought to characterize the expression of CXCL12 and CXCR4 during the progression of PanIN using both a murine model and human tissues.

Results: These studies reveal that both CXCL12 and CXCR4 are expressed in PanIN and that the frequency increases during PanIN progression (0% CXCR4 expression in normal mouse and human ducts vs. 100% in mouse PanIN 3 and 77% in human PanIN 3). Next we demonstrate a dose-dependent increase in the proliferation of murine PanIN cells when exposed to CXCL12. Finally, we show that expression of CXCR4 in murine PanIN cells is partially dependent on MAPK signaling and that the effect of CXCL12 on PanIN proliferation can be abrogated by a MAPK inhibitor.

Conclusions: Together these results demonstrate that CXCL12/CXCR4 expression begins in the pre-invasive stages of pancreatic neoplasia, and suggest that the presence of an autocrine loop that is at least partially regulated by MAPK signaling. Further studies that define the role of CXCR4 signaling in PanIN progression will determine if CXCR4 could serve as a novel target for chemoprevention and early stage therapy in pancreatic cancer.

Background & Aims: KITENIN was previously reported to promote metastasis in mouse colon tumor models; however, the signaling mechanism of KITENIN at the cellular level was unknown. We investigated the functional role of KITENIN with respect to colorectal cancer (CRC) cell invasion and its expression in CRC tissues.

Methods: The effect of KITENIN on cell motility was analyzed in a migration and invasion assay upon its overexpression and knockdown. Immunoprecipitation was used to elucidate binding partners and immunohistochemistry was used to study expression levels.

Results: KITENIN overexpression enhanced the migration of rat intestinal epithelial cells, whereas a loss of invasiveness was observed in CRC cells after KITENIN-knockdown. Mechanically, KITENIN served as a scaffolding molecule that simultaneously recruited both Dishevelled (Dvl) and PKC_ through the membrane-spanning C-terminal region to form a complex that stimulated ERK/AP-1 via a PKC_ component but also organized the actin filament via a Dvl component. The KITENIN complex controlled the invasiveness of CRC cells etiologically harboring various mutations in APC, beta-catenin, or K-ras, in which AP-1 activation is redundant but the organization of the actin filament is indispensable for cell motility. Clinically, KITENIN expression was significantly higher in colon cancer tissues from advanced stage (III, IV) than that of stage I CRC and also in corresponding metastatic tissues.

Conclusions: The functional KITENIN complex acts as an executor in regard to cell motility and thereby controls CRC cell invasion, which may contribute to promoting metastasis.

Background: A novel Th cell lineage, Th17, that exclusively produces the proinflammatory cytokine interleukin (IL)-17 has been reported to play important roles in various inflammatory diseases. IL-23 is also focused upon for its potential to promote Th17. Here, we investigated the roles of the IL-23/-17 axis in inflammatory bowel diseases such as ulcerative colitis (UC) and Crohn's disease (CD).

Materials and methods: Mucosal samples were obtained from surgically resected specimens (controls: n=12; UC: n=17; CD: n=22). IL-17 production by isolated peripheral blood (PB) and lamina propria (LP) CD4+ cells was examined. Quantitative polymerase chain reaction amplification was performed to determine the mRNA expression levels of IL-17, interferon-gamma (IFN-, IL-23 receptor (IL-23R) and retinoic acid-related orphan receptor-gamma (RORC) in LP CD4+ cells, and IL-12 family members, such as IL-12p40, IL-12p35 and IL-23p19, in whole mucosal specimens. The effects of exogenous IL-23 on IL-17 production by LP CD4+ cells were also examined.

Results: IL-17 production was higher in LP CD4+ cells than in PB. Significant IL-17 mRNA upregulation in LP CD4+ cells was found in UC, while IFN- was increased in CD. IL-23R and RORC were upregulated in LP CD4+ cells isolated from both UC and CD. IL-17 production was significantly increased by IL-23 in LP CD4+ cells from UC but not CD. Upregulated IL-23p19 mRNA expression was correlated with IL-17 in UC and IFN- in CD.

Conclusions: IL-23 may play important roles in controlling the differential Th1/Th17 balance in both UC and CD, although Th17 cells may exist in both diseases.

Background: Chromosomal instability (CIN) is recognized as a hallmark of cancer and is caused by a spindle assembly checkpoint disorder or chromosome mis-segregation during mitosis. Although the recent identification of human shugoshin (hSgo1), an important player in proper chromosome segregation, has suggested involvement of hSgo1 in colorectal tumorigenesis, little is known about how it is involved.

Aims: To obtain information about the status of hSgo1 in human colorectal cancer.

Method/results: Among the 46 colorectal cancer cases, hSgo1 mRNA expression was decreased in the tumor tissue in comparison with the corresponding normal tissue (P=0.032). Human Sgo1 down-regulated tumors (T/N ratio<0.5) had preferential location on the left side large bowel rather than on the right side (P=0.012), and a higher variation of centromere numbers revealed by Fluorescence in situ hybridization (FISH). To assess the effects of hSgo1 down-regulation, we performed hSgo1 knockdown by transfecting the diploid HCT116 cell line with a short hairpin RNA expression vector. Human Sgo1 knockdown cells proliferated slowly because of both G2/M arrest and apoptosis (P<0.001), and marked of CIN in the form of aneuploidy (P<0.001) and micronuclei (P<0.005) were later observed in hSgo1 knockdown cells. Increased centrosome amplification (P<0.05), the presence of binucleated cells, and mitotic catastrophes were also noted in hSgo1 knockdown cells.

Conclusions: These findings suggest that hSgo1 down-regulated colorectal cancers have a clinicopathological character of CIN and hSgo1 down-regulation leads to CIN in colorectal cancer cells.

Background Gastric sensorimotor dysfunction, psychosocial factors and somatization are all implicated in symptom generation in functional dyspepsia (FD). Aim To determine the relative contribution of each of these factors to overall dyspeptic symptom severity and weight loss, in FD.

Methods In 201 consecutive tertiary care FD patients (mean age 40.1±12.6 years), gastric sensorimotor function was studied using barostat (sensitivity, compliance & accommodation). Psychosocial factors (depression and anxiety disorders, positive & negative affect, perceived stress, alexithymia and abuse history), somatization and co-morbid irritable bowel syndrome (IBS) & (chronic) fatigue symptoms were assessed using self-report questionnaires. Variables were correlated with dyspepsia symptom severity (DSS) and weight loss. Hierarchical multiple linear regression was used to identify determinants of DSS and weight loss.

Results Multiple linear regression identified the following determinants of DSS: gastric sensitivity (β=.77,p=0.25), depression (β=.12,p=.06) and somatization (β=.48,p<.0001) (controlling for age & occupation, R²=.29, p<.0001). The effect of depression on DSS is (partially) mediated by somatization. Gastric sensitivity (β=2.87,p=0.08), childhood sexual abuse history (β=9.37,p=0.0006), depression (β=.19,p=.24) and somatization (β=.67,p=.01) are independent determinants of weight loss (controlling for gender & occupation, R²=.42, p<.0001). The effect of depression on weight loss is (fully) mediated by somatization.

Conclusion Symptom severity and weight loss in FD are determined by psychosocial factors (depression, abuse history) and somatization, and only to a lesser extent by gastric sensorimotor function. The importance of psychosocial factors and somatization compared to gastric sensorimotor function is most pronounced in hypersensitive patients.

Background/aims: In Lynch syndrome, the clinical phenotype in MSH6 mutation families differs from that in MLH1 and MSH2 families. Therefore, MSH6 mutation families are less likely to fulfil diagnostic criteria such as the Amsterdam II criteria (AC II) and the revised Bethesda guidelines (rBG), and will be underdiagnosed. The aim of the present study was to evaluate the contribution of MSH6 gene mutations in families that were analysed for Lynch syndrome in a diagnostic setting.

Methods: Families that had molecular analysis for Lynch syndrome were included in this study. Complete molecular screening of the MLH1, MSH2 and MSH6 genes was performed in all families. Microsatellite instability (MSI) and immunohistochemical (IHC) analysis was performed in almost all families. Clinical data were collected from medical records and family pedigrees.

Results: A total of 108 families were included. MSI and IHC analysis was performed in 97 families and in 40 an MSI-high phenotype with absent protein expression was found. Germline mutation analysis detected mutations in 23 families (7 MLH1, 4 MSH2 and 12 MSH6). The majority of MSH6 families were AC II negative, but fulfilled the rBG.

Conclusions: There is a high incidence of MSH6 mutations in families tested for Lynch syndrome in a diagnostic setting. Many of these families remain underdiagnosed using the AC II. The rBG are more useful to select these families for further analysis. However, to optimize the detection of MSH6 families, MSI and IHC analysis should also be performed in families with clustering of late onset endometrial carcinoma.

Objective. Defects in Fas-mediated apoptosis are supposed to contribute to the accumulation of T lymphocytes in the gut of patients with Crohn's disease (CD). This phenomenon has been functionally linked with the elevated expression of Flip, an inhibitor of Fas-mediated apoptosis. In this study, we examined the molecular mechanisms that control Flip in CD.

Design. Paired colonic biopsies of patients with CD, patients with ulcerative colitis (UC), and normal controls were analysed for Flip by real-time PCR and Western blotting. Flip was also evaluated in CD3+ lamina propria lymphocytes (T-LPL) cultured with TPCK (NF-kB inhibitor), AG490 (JAK2/Stat inhibitor), or DMAG (inhibitor of heat shock protein 90). The rate of apoptosis was examined by flow-cytometry.

Results. In CD, up-regulation of Flip occurred at both RNA and protein level. Treatment of CD CD3+ T-LPL with TPCK or AG490 markedly reduced Flip RNA, suggesting a role for NF-kB and Jak/Stat pathways in the transcriptional control of Flip in this condition. Consistently, both TPCK and AG490 sensitized CD T-LPL to FAS-mediated apoptosis. Flip protein in cells from normal gut was rapidly degraded by the proteasome pathway. In contrast, in inflamed gut of both CD and UC patients, there was a reduced degradation of Flip via the ubiquitin-proteasome-dependent pathway, but Flip expression can be decreased by DMAG.

Conclusions. Data demonstrate that Flip is regulated at both transcriptional and post-translational level in CD, and indicate that in the normal but not inflamed gut Flip is degraded via the ubiquitin proteasome-dependent pathway.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) has a high risk of pancreatitis although the underlying mechanisms are unclear. Transient receptor potential vanilloid 1 (TRPV1) is a cation channel expressed on C and A fibers of primary sensory neurons and is activated by low pH. TRPV1 activation causes release of inflammatory mediators that produce edema and neutrophil infiltration. We previously demonstrated that neurogenic factors contribute to the pathogenesis of pancreatitis. Resiniferatoxin (RTX) is a TRPV1 agonist that, in high doses, destroys C and A fibers. When we discovered that the pH of radio-opaque contrast solutions used for ERCP was 6.9, we hypothesized that low pH may contribute to the development of contrast-induced pancreatitis via activation of TRPV1.

Methods: Rats underwent equal pressure pancreatic ductal injection of contrast solutions at varying pH with or without RTX.

Results: Contrast solution (pH 6.9) injected into the pancreatic duct caused a significant increase in pancreatic edema, serum amylase, neutrophil infiltration, and histological damage. Solutions of pH 7.3 injected at equal pressure caused little damage. Pancreatitis severity was significantly increased by injection of solutions at pH 6.0. To determine if the effects of low pH were mediated by TRPV1, RTX was added to the contrast solutions. At pH levels of 6.0 and 6.9, RTX significantly reduced pancreatitis severity.

Conclusions: Low pH contrast solutions contribute to the development of pancreatitis through a TRPV1-dependent mechanism. It is possible that increasing the pH of contrast solution and/or adding an agent that inhibits primary sensory nerve activation may reduce the risk of post-ERCP pancreatitis.

Background: Hepatitis C virus (HCV) infection is associated with decreased health-related quality of life (HRQOL). Although HCV has been suggested to directly impair neuropsychiatric functions, other factors may also play a role.

Patients and methods: In this cross-sectional study, we assessed the impact of various host-, disease- and virus-related factors on HRQOL in a large, unselected population of anti-HCV-positive subjects. All individuals (n=1736) enrolled in the Swiss Hepatitis C Cohort Study (SCCS) were asked to complete the Short Form 36 (SF-36) and the Hospital Anxiety Depression Scale (HADS).

Results: 833 patients (48%) returned the questionnaires. Survey participants had significantly worse scores in both assessment instruments when compared to a general population. By multivariable analysis, reduced HRQOL (mental and physical summary scores of SF-36) was independently associated with income. In addition, a low physical summary score was associated with age and diabetes, whereas a low mental summary score was associated with intravenous drug use (IVDU). HADS anxiety and depression scores were independently associated with income and IVDU. In addition, HADS depression score was associated with diabetes. None of the SF-36 or HADS scores correlated with either the presence or the level of serum HCV RNA. In particular, SF-36 and HADS scores were comparable in 555 HCV RNA-positive and 262 HCV RNA-negative individuals.

Conclusions: Anti-HCV-positive subjects have decreased HRQOL compared to controls. The magnitude of this decrease was clinically important for the SF-36 vitality score. Host and environmental, rather than viral factors, seem to impact on HRQOL level.

The incidence of the inflammatory bowel diseases (IBD) ulcerative colitis (UC) and Crohn's disease (CD) markedly increased in industrialised countries during the past decades. In contrast to these countries where helminthosis are rare, IBD is still uncommon in global areas where most people carry worms. Thus lack of exposure to parasites may critically contribute to the risk of IBD. In a recent article in Gut, Summers et al. demonstrated efficacy of treatment with Trichuris suis in active CD (Gut 2005;54:87-90). Trichuris suis was additionally shown to be effective in UC in a randomized trial carried out by the same group. Both studies did not address mechanisms of action. Here we present a real life scenario, which supports the impact of helminths in the prevention of IBD, and provide a rationale for the mechanisms of action.

Angiogenesis, the growth of new blood vessels, is a critical homeostatic mechanism which regulates vascular populations in response to physiologic requirements and pathophysiologic demand, including chronic inflammation and cancer. The importance of angiogenesis in gastrointestinal chronic inflammation and cancer has been defined, as anti-angiogenic therapy has demonstrated benefit in models of inflammatory bowel disease and colon cancer treatment. Curcumin is a natural product undergoing evaluation for the treatment of chronic inflammation, including inflammatory bowel disease (IBD). The effect of curcumin on human intestinal angiogenesis is not defined. We examined the anti-angiogenic effect of curcumin on in vitro angiogenesis using primary cultures of human intestinal microvascular endothelial cells (HIMEC), stimulated with VEGF. Curcumin inhibited proliferation, cell migration and tube formation in HIMEC induced by VEGF. Activation of HIMEC by VEGF resulted in enhanced expression of COX-2 mRNA, protein and PGE2 production. Pre-treatment of HIMEC with 10 uM curcumin as well as 1 uM NS398, a selective inhibitor of COX-2, resulted in inhibition of COX-2 at the mRNA and protein level and PGE2 production. Similarly COX-2 expression in HIMEC was significantly inhibited by JNK (SP600125) and p38 MAPK (SB203580) inhibitors and was reduced by p44/42 MAPK inhibitor (PD098059). Taken together these data demonstrate an important role for COX-2 in the regulation of angiogenesis in HIMEC via MAPKs. Moreover, curcumin inhibits microvascular endothelial cell angiogenesis through inhibition of COX-2 expression and PGE2 production, suggesting that this natural product possesses anti-angiogenic properties, which warrants further investigation as adjuvant treatment of IBD and cancer.

Objective: No effective drugs have been developed until date to prevent or treat non-alcoholic fatty liver disease (NAFLD), although diet modification and exercise to improve obesity have been attempted. Therefore, development of a novel drug/strategy to treat NAFLD is urgently needed. In the present study, we propose a novel concept for the treatment of NAFLD.

Methods: Fisher 344 male rats were given a choline-deficient, l-amino acid-defined (CDAA) diet or high-fat high-calorie (HF/HC) diet with or without the antiplatelet agents, aspirin, ticlopidine or cilostazol for 16 weeks. Liver steatosis, inflammation and fibrosis and the possible mechanisms involved were investigated.

Results: All the three antiplatelet drugs, namely, aspirin, ticlopidine and cilostazol, significantly attenuated liver steatosis, inflammation and fibrosis in the CDAA diet group. Of the three agents, cilostazol was the most effective, and the drug also suppressed HF/HC diet-induced liver steatosis. Cilostazol appeared to exert its beneficial effect against NAFLD by suppressing MAP kinase activation induced by oxidative stress and platelet-derived growth factor (PDGF) via intercepting signal transduction from Akt to c-Raf.

Conclusion: Antiplatelet agents, especially cilostazol, offer the promise of becoming key agents for the treatment of NAFLD.

Mechanisms of acinar cell death in pancreatitis are poorly understood. Cytochrome c release is a central event in apoptosis in pancreatitis. Here, we assessed the regulation of pancreatic cytochrome c release by Ca2+, mitochondrial membrane potential (m), and reactive oxygen species (ROS), the signals involved in acute pancreatitis. We used both isolated rat pancreatic mitochondria and intact acinar cells hyperstimulated with CCK-8 (in vitro model of acute pancreatitis). Micromolar Ca2+ depolarized isolated pancreatic mitochondria through a mechanism different from the ''classical'' (i.e., liver) permeability transition pore (mPTP). In contrast with liver, Ca2+-induced mPTP opening caused a dramatic decrease in ROS and was not associated with pancreatic mitochondria swelling. Importantly, we found that Ca2+-induced depolarization inhibited cytochrome c release from pancreatic mitochondria, due to blockade of ROS production. As a result, Ca2+ exerted two opposite effects on cytochrome c release: Ca2+ per se stimulated whereas Ca2+-induced depolarization inhibited it. This dual effect caused a non-monotonous dose-dependence of cytochrome c release on Ca2+. In intact acinar cells, cytochrome c release, caspase activation and apoptosis were all stimulated by ROS and Ca2+ and inhibited by depolarization, corroborating the findings on isolated pancreatic mitochondria. These data implicate ROS as a key mediator of CCK-induced apoptotic responses. The results indicate a major role for mitochondria in the effects of Ca2+ and ROS on acinar cell death. They suggest that the extent of apoptosis in pancreatitis is regulated by the interplay between ROS, m and Ca2+. Stabilizing mitochondria against loss of m may represent a strategy to mitigate the severity of pancreatitis.

Background and aim: Chronic idiopathic intestinal pseudo-obstruction (CIIP) is characterized by severe impairment of intestinal propulsive motility that mimics bowel obstruction. JC virus (JCV) is a polyomavirus that can infect brain glial cells causing a fatal disease, but may also be found throughout the normal gastrointestinal tract. We tested the hypothesis that JCV infects the myenteric plexuses of patients with CIIP.

Methods: We studied 10 patients with CIIP and 61 normal specimens (30 ascending colon and 31 ileum) from patients with uncomplicated colon cancer. DNA was extracted from the myenteric plexuses, and JCV T antigen (TAg) DNA and the viral regulatory region were detected by PCR and sequencing. Immunohistochemistry was performed to detect JCV viral protein expression, neuronal and glial markers. Fluorescence in situ hybridization was performed for cellular localization of the JCV infection.

Results: Clinical studies demonstrated neurogenic impairment, and pathological analyses showed neuropathy in each CIIP patient. JCV TAg DNA was found in the myenteric plexuses of 8/10 (80%) of the CIIP and 3/31 (9.7%) of the control patients (P<0.001). All samples were JCV Mad-1 strains. Seven of the 10 CIIP specimens expressed both JCV TAg and the JCV viral protein VP1, while none of the controls expressed either. JCV infection co-localized with GFAP expression, a marker of enteric glial cells.

Conclusion: JCV infection occurs in the myenteric plexuses of patients with CIIP. The JCV localization in enteroglial cells suggests a possible pathological role for this virus in enteric neuropathy.

BACKGROUND: Severe duodeno-gastro-oesophageal reflux (DGOR) is a risk factor for oesophagitis and Barrett's oesophagus. Patients with non-erosive reflux disease (NERD) have a slight increase in DGOR. Patients with GORD, "on" PPI, still have reflux but of weakly acidic pH and persistence of bile. In these two groups of patients, heartburn might be due to increased oesophageal mucosal permeability and dilated intercellular spaces (DIS). We aimed to asses whether experimental short exposure of the oesophageal mucosa to bile acids, in low concentrations, (in acidic, weakly acidic and weakly alkaline conditions) can increase mucosal permeability and provoke DIS.

METHODS: Rabbit oesophageal mucosa was studied in diffusion and Ussing chambers. We assessed the effect of different solutions containing bile acids, applied in the mucosal side, on transepithelial resistance (RT) and permeability to fluorescein. Diameter of intercellular spaces was assessed with transmission electron microscopy.

RESULTS: Incubation of oesophageal mucosa with acidic solutions (pH 2.0) containing a range of bile acids (0.5mM-5mM) markedly decreased RT and increased mucosa permeability. Weakly acidic solutions (pH 5.0), and to some extent neutral solutions (pH 7.4), containing some bile acid also decreased RT and increased permeability though the effects were much less marked and in some combinations no effect was seen. Bile acids exposure provoked DIS in acid and weakly acidic conditions but not in neutral (pH 7.4) solutions.

CONCLUSIONS: Experimental short exposure of the oesophageal mucosa to solutions with bile acids concentration and acidity, similar to that observed in gastric contents of NERD patients or ERD patients "on" PPI, may impair oesophageal mucosal integrity and even induce dilated intercellular spaces. Such situation could, theoretically, underlie the occurrence and/or persistence of symptoms in these patients.

Background and aim: It was demonstrated that polymorphisms within inflammation-related genes are associated with risk of gastric carcinoma (GC) in Helicobacter pylori-infected individuals. Recently, polymorphisms in the gene encoding the interferon gamma receptor 1 (IFNGR1) were found to be associated with increased susceptibility to H. pylori infection. We aimed to determine the association between polymorphisms in the IFNGR1 gene and development of chronic gastritis and GC.

Methods: In a case-control study including 733 controls, 213 individuals with chronic gastritis and 393 GC patients, the IFNGR1 -611*G/*A, -56*C/*T, +1004*A/*C and +1400*T/*C polymorphisms were genotyped. A second independent case-control study including 100 controls and 65 GC patients was used for confirmation of the original results. The effect of the -56*C/*T promoter polymorphism in the level of expression of the IFNGR1 gene was evaluated by an IFNGR1-56*C/*T allele specific luciferase reporter assay.

Results: In individuals with early onset GC (defined as having less than 40 years of age at the time of diagnosis) we found a significant over-representation of the IFNGR1-56*T/*T homozygous genotype with an odds ratio (OR) of 4.1 (95% confidence interval [CI] 1.6-10.6). This result was confirmed in a second independent case-control study. In the luciferase reporter assay we observed a 10-fold increase (P < 0.001) in luciferase expression associated with the IFNGR1-56*T allele.

Conclusions: Our results indicate that the IFNGR1-56C/T polymorphism is a relevant host susceptibility factor for GC development. Our data also indicate that this genetic polymorphism is functionally relevant and may be related with early development of GC.

Background: Autoimmune pancreatitis (AIP) is a peculiar type of chronic pancreatitis that responds dramatically to steroid therapy. To date, there are no worldwide consensus criteria for AIP. Different criteria with institutional preference (HISORt, revised Kim, and the revised Japanese criteria) are being used to diagnose AIP, and there is a controversy on the inclusion of steroid responsiveness in the diagnostic criteria. In contrast to the HISORt and revised Kim criteria, the revised Japanese criteria do not include steroid responsiveness as a diagnostic component.

Aims: This study was performed to evaluate whether "a two-week steroid trial and subsequent assessment of its response" is a useful diagnostic tool for the differentiation of AIP from pancreatic cancer. We also wanted to discover the surgical and clinical outcome for a patient who followed our treatment algorithm based on the steroid responsiveness.

Design: Prospective study.

Patients and methods: From January 2004 to June 2007, in the setting of clinically suspected AIP, twenty-two consecutive patients with atypical imaging for AIP while not meeting the classic imaging criteria for pancreatic cancer were challenged to undergo two weeks of steroid therapy (0.5mg/kg of oral prednisolone per day). After the two-week steroid trial, steroid responsiveness was assessed based on a marked improvement of the main pancreatic ductal narrowing and a reduction of the pancreatic mass. The steroid trial was continued in the case of positive steroid responsiveness, whereas surgical exploration was conducted in the case of negative steroid responsiveness. Final diagnosis was made by surgical exploration or long-term clinical and radiologic follow-up.

Results: All patients (n=15) who responded to steroids were diagnosed as having AIP, whereas all patients (n=7) who did not show a response to steroids were confirmed as having pancreatic cancer. Complete resection was possible in all (6/6; 100%), except one individual who refused surgery.

Conclusion: In the clinical setting of suspected AIP with the continued need of differentiation from pancreatic cancer due to atypical imaging for AIP, "a two-week steroid trial and subsequent assessment of its response" may be helpful in confirming the diagnosis of AIP without negative consequences for resectable pancreatic cancer. However, a steroid trial should be performed carefully by only specialist in pancreatology.

Objective: Ursodeoxycholic acid (UDCA) exerts anticholestatic effects in part by PKC-dependent mechanisms. Its taurine conjugate, TUDCA, is a cPKC agonist. We tested whether PKA might contribute to the anticholestatic action of TUDCA via cooperative cPKC-/PKA-dependent mechanisms in taurolithocholic acid (TLCA)-induced cholestasis.

Methods: In perfused rat liver, bile flow was determined gravimetrically, organic anion secretion spectrophotometrically, LDH release enzymatically, CREB phosphorylation by immunoblotting, cAMP by immunoassay. PKC/PKA inhibitors were tested radiochemically. In vitro phosphorylation of the conjugate export pump, Mrp2/Abcc2, was studied in rat hepatocytes and human Hep-G2 hepatoma cells.

Results: In livers treated with TLCA(10µmol/l)+TUDCA(25µmol/l), combined inhibition of cPKC by the cPKC-selective inhibitor Gö6976 (100nmol/l) or the nonselective PKC inhibitor staurosporine (10nmol/l) and of PKA by H89 (100nmol/l) reduced bile flow by 36% (p<0.05) and 48% (p<0.01), and secretion of the Mrp2/Abcc2 substrate, 2,4-dinitrophenyl-S-glutathione, by 31% (p<0.05) and 41% (p<0.01), respectively; bile flow was unaffected in control livers or livers treated with TUDCA only or TLCA+taurocholic acid. Inhibition of cPKC or PKA alone did not affect the anticholestatic action of TUDCA. Hepatic cAMP levels and CREB phosphorylation as readout of PKA activity were unaffected by bile acids tested suggesting a permissive effect of PKA for the anticholestatic action of TUDCA. Rat and human hepatocellular Mrp2 were phosphorylated by phorbolester pretreatment and recombinant cPKC, nPKC, and PKA, respectively, in a staurosporine-sensitive way.

Conclusion: UDCA conjugates exert their anticholestatic action in bile acid-induced cholestasis in part via cooperative posttranslational cPKC-/PKA-dependent mechanisms. Hepatocellular Mrp2 may be one target of bile acid-induced kinase activation.

Budd-Chiari syndrome (BCS) · Many patients with BCS harbour several prothrombotic disorders. · Liver disease blurs the diagnostic features of most prothrombotic disorders. · Myeloproliferative disease account for 50% of BCS patients. Their recognition largely relies on the assessment of V617F JAK2 mutation in peripheral blood. · Treatment for BCS consists of the successive implementation of anticoagulation, percutaneous angioplasty, transjugular intrahepatic shunt and last, liver transplantation. · Using this progressive treatment strategy, overall 5-year survival rates approaching 90% are currently achieved. Veno-occlusive disease/Sinusoidal obstruction syndrome (VOD/SOS) · VOD/SOS is produced by a toxic injury to sinusoidal endothelial cells. · Many chemotherapeutic agents can induce VOD/SOS. · Knowledge in the metabolic determinants of drug toxicity to sinusoidal endothelium has deepened. The translation of new knowledge into prevention and treatment of VOD/SOS still need clinical studies. · Reduced intensity myeloablative regimens have proved efficient in reducing the incidence of VOD/SOS.

Background & aims: Helicobacter pullorum is an entero-hepatic Helicobacter species of avian origin detected in patients with acute diarrhoea and inflammatory bowel disease. Our aim was to determine whether H. pullorum exerts a direct effect on human intestinal epithelial cells in vitro and to characterise the bacterial mechanisms and the signalling pathways involved.

Material and methods: The proinflammatory properties of H. pullorum from human and avian origins were measured on human gastric (AGS) and intestinal (CaCo-2 and HT-29) epithelial cell lines after co-culture with different H. pullorum strains, and the extent of nuclear factor kappa B (NF-B) involvement was determined.

Results: All of the H. pullorum strains tested stimulated interleukin-8 (IL-8) secretion by the three cell lines. Similar results were obtained with heat-killed H. pullorum. Incubation of cells with filtered-H. pullorum culture supernatants did not stimulate IL-8 secretion. The same observation was made when bacterial adherence was inhibited by Transwell inserts. H. pullorum induced NF-B activation and rapid nuclear translocation as demonstrated by immunofluorescent staining and cellular fractionation. NF-B involvement was confirmed by using SN50 specific inhibitor and siRNA which abolished H. pullorum-induced IL-8 production.

Conclusions: H. pullorum strains stimulate IL-8 secretion by human gastric and intestinal epithelial cell lines. This effect requires bacterial adherence and probably lipopolysaccharides and is mediated by NF-B signalling. The present study strengthens the argument that H. pullorum is a potent human pathogen and highlights its putative role in acute and chronic digestive diseases such as inflammatory bowel disease.

Background: Obesity is a risk factor for acute pancreatitis (AP), but the molecular mechanism remains unclear. Adiponectin, an adipose tissue-derived secretory factor, has anti-inflammatory properties in addition to various biological functions, and its plasma concentrations are reduced in obese subjects. However, the role of adiponectin in AP has not been investigated.

Aim: To determine the effects of adiponectin on AP.

Methods: We investigated the effects of adiponectin on experimental AP by using adiponectin-knockout (APN-KO) mice and adenovirus-mediated adiponectin overexpression. AP was induced by 10 hourly intraperitoneal injections of low-dose caerulein (10 µg/kg) after 2-week feeding of normal chow or high-fat diet (HFD) in wild-type (WT) and APN-KO mice. We evaluated the severity of AP biochemically and morphologically.

Results: Low-dose caerulein treatment did not induce pancreatic damage, in both WT and APN-KO mice under normal chow feeding. APN-KO mice, but not WT mice, fed HFD then treated with caerulein developed pancreatic damage and inflammation, accompanied by increased macrophage/neutrophil infiltration and upregulation of pro-inflammatory mediators such as tumor necrosis factor- in the pancreas. Adenovirus-mediated overexpression of adiponectin attenuated the severity of HFD/caerulein-induced AP in APN-KO mice.

Conclusions: Adiponectin plays a protective role in caerulein-induced AP in HFD-fed mice.

Background and aims: C-reactive protein (CRP) levels are often used in following up patients with inflammatory bowel disease (IBD). The aims of this study were to establish the relationship of CRP levels to disease extent in patients with ulcerative colitis (UC) and to phenotype in patients with Crohn’s disease (CD), and to investigate the predictive value of CRP levels for disease outcome.

Methods: CRP was measured at diagnosis and after one and five years in patients diagnosed with IBD in south-eastern Norway. After five years, 454 UC and 200 CD patients were alive and provided sufficient data for analysis.

Results: CD patients had a stronger CRP response than UC patients. In UC patients, CRP levels at diagnosis increased with increasing extent of disease. No differences in CRP levels at diagnosis were found between subgroups of CD patients as defined according to the Vienna classification. In UC patients with extensive colitis, CRP levels above 23 mg/L at diagnosis predicted increased risk of surgery (OR 4.8 95 % CI 1.5 - 15.1 p = 0.02) and CRP levels in UC patients above 10 mg/L after one year predicted increased risk of surgery during the subsequent four years (OR 3.0 95 % CI 1.1 - 7.8, p = 0.02). A significant association between CRP levels at diagnosis and risk of surgery was found in CD patients with terminal ileitis (L1), and the risk increased when CRP levels were above 53 mg/L in this subgroup (OR 6.0 95 % CI 1.1 - 31.9, p = 0.03).

Conclusions: CRP levels at diagnosis were related to the extent of disease in UC patients. Phenotype had no influence on CRP levels in CD patients. CRP is a predictor of surgery in subgroups of UC and CD patients.

One of the most important symptoms in chronic pancreatitis (CP) is constant or recurrent abdominal pain that is present in 80-90 % of patients during the course of the disease 1. Pancreatic pain presents characteristically with severe dull epigastric pain, often radiating directly to the back. The pain is often recurrent, intense, and long-lasting and may be associated with malnutrition, narcotic addiction, and major socio-economical problems. Pain mechanisms are incompletely understood and probably multifactorial. In some cases the reason for the pain is obvious, such as extrapancreatic (e.g., peptic ulcer or bile duct and duodenal stenosis due to extensive pancreatic fibrosis and inflammation) or intrapancreatic (e.g., pseudocysts) complications. However, in most patients the source of the pain remains unknown. In these cases the following pathophysiological mechanisms have been suggested: 1) Increased intrapancreatic pressure either within the pancreatic duct or in the parenchyma causing tissue ischaemia; 2) Inflammation in the pancreas; and 3) alterations in pancreatic nerves, including an increase in nerve fibre diameter and evidence for neurogenic inflammation 2-4. Genetic factors probably also play a role in an individual�s pain experience 4. Because the pain mechanisms are poorly understood, treatment is often empirical and insufficient.

In October 2007 the BBC performed a survey of British Society of Gastroenterology members in which they asked a number of questions about the changing patterns of alcohol related disease they were seeing in the UK. Of the 115 responses, only 9 had seen no change in alcohol-related liver disease over the last 10 years; 92% reported a rise, usually large. Recurrent themes were the increase in women presenting with alcoholic liver disease and the younger age of presentation. Nearly three quarters of responders had seen patients of 25 or under with alcoholic hepatitis or cirrhosis, and nearly a quarter had patients in their late teens. These depressing findings are in line with the report by the chief medical officer in 2001: 'In the last 30 years of the 20th Century deaths from liver cirrhosis steadily increased, in people aged 35 to 44 years the death rate went up 8-fold in men and almost 7-fold in women, in 25-34 year-olds a 4-fold increase was seen over the 30 year period'. The UK situation is in stark contrast to the decrease in liver mortality in Mediterranean countries over the same period of time (figure 1).

Objective: To determine the variation in the rates of use of abdominoperineal excision (APE) by cancer network, hospital trust and surgeon across England between 1998 and 2004 and determine if any variation could be explained by differences in patient characteristics such as stage of disease, age, gender or socioeconomic deprivation

Design: Retrospective study of a population-based dataset comprised of cancer registry and hospital episode statistics data.

Setting: All NHS providers of rectal cancer surgery within England

Patients: All 31,223 patients diagnosed with rectal cancer and receiving a major abdominal procedure within the NHS in England between 1998 and 2005

Main Outcome Measure: Rates and odds of use of APE were determined in relation to patient casemix and each patient's managing surgeon, trust and cancer network.

Results: The rate of use of APE decreased from 30.5% in 1998 to 23.0% in 2004. Males, the economically deprived and those managed by surgeons operating on fewer than 7 rectal cancer cases per year were all significantly more likely to receive an APE. There were also significant variations in the odds of receiving an APE over time and between individual surgeons and hospital trusts independently of patient casemix.

Conclusions: Over the study period the use of APE decreased but statistically significant variation was observed in its application independently of casemix. Reducing this variation will remove inequalities, reduce colostomy rates, and improve outcomes in rectal cancer. Rates of APE use could be a national performance measure.

Objective: The aim of this study was to investigate differential intestinal gene expression in patients with ulcerative colitis (UC) and controls.

Design: Genome wide expression study (41058 expression sequence tags, 215 biopsies).

Setting: Western General Hospital, Edinburgh, UK, Genentech Inc, San Francisco, USA. Patients: 67 UC and 31 control subjects- 23 normal and 8 inflamed non-inflammatory bowel disease patients.

Interventions: Paired endoscopic biopsies were taken from 5 specific anatomical locations for RNA extraction and histology. The Agilent microarray platform was used and confirmation of results was undertaken by real time PCR and immunohistochemistry.

Results: In healthy control biopsies, cluster analysis showed differences in gene expression between the right and left colon. (2=25.1, p<0.0001). Developmental genes HOXA13, (p=2.3x10-16), HOXB13 (p <1x10-45), GLI1 (p=4.0x10-24), and GLI3 (p=2.1x10-28) primarily drove this separation. When all UC biopsies and control biopsies were compared, 143 sequences had a fold change of >1.5 in the UC biopsies (0.01>p>10-45) and 54 sequences had a fold change of <-1.5 (0.01>p>10-20). Differentially upregulated genes in UC included SAA1 (p<10-45) the alpha defensins, DEFA5&6 (p=0.00003 and p=6.95x10-7 respectively), MMP3 (p=5.6x10-10) and MMP7 (p=2.3x10-7). Increased DEFA5&6 expression was further characterized to Paneth cell metaplasia by immunohistochemistry and in-situ hybridization. Sub-analysis of the IBD2 & IBD5 loci, and the ABC transporter genes revealed a number of differentially regulated genes in the UC biopsies.

Conclusions: Key findings are the expression gradient in the healthy adult colon and the involvement of novel gene families, as well as established candidate genes in the pathogenesis of UC.

Background: Germline mutations in DNA mismatch repair (MMR) genes cause Lynch syndrome colon and extra-colonic cancers. Less understood is the risk of colon cancer associated with common polymorphisms in MMR genes and the potential interacting role of lifestyle factors known to damage DNA.

Methods: We examined whether MLH1 (-93G>A and Ile219Val) and MSH6 (Gly39Glu) polymorphisms were associated with risk of colon cancer in data from 1,609 colon cancer cases and 1,972 controls. Genotype data were further stratified by microsatellite instability status, smoking, alcohol, Western-diet, alcohol, and obesity, to investigate potential heterogeneity.

Results: The MSH6 39Glu allele was associated with increased risk of colon cancer among men (Gly/Glu or Glu/Glu vs Gly/Gly odds ratio (OR): 1.27; 95% confidence interval (CI): 1.04-1.54). Neither MLH1 polymorphism was associated with colon cancer risk overall. When stratified by microsatellite stability status, however, the MLH1 -93 A allele was associated with a more than doubling in MSI-positive colon cancer risk (AA vs GG OR: 2.47; 95%CI: 1.48-4.11); no associations were observed between the MMR polymorphisms examined and MSI-negative colon cancer. Statistically significant interactions were observed between: MLH1 -93 G>A and smoking (MSI-negative colon cancer only, p-value interaction: 0.005); and MLH1 Ile219Val and Western-diet (p-value interaction: 0.03).

Conclusions: The MSH6 Gly39Glu and MLH1 -93G>A polymorphisms were associated with risk of overall colon and MSI-positive colon cancers, respectively. Risk for colon cancer, stratified by MMR genotype, was further modified by smoking and Western-diet.

Objective Colonoscopy, the gold standard colorectal cancer (CRC) screening test, has known diagnostic limitations. Advances in endoscope technology have focused to improve mucosal visualization. In addition to increased angle of view and resolution features, recent colonoscopes have non-white light optics, such as Narrow Band Imaging (NBI), to enhance image contrast. We aimed to study the neoplasia diagnostic characteristics of NBI, by comparing the neoplasm miss rate when the colonoscopy was performed under NBI versus white light (WL).

Design Randomized controlled trial.

Setting US Veterans hospital.

Patients Elective colonoscopy adults.

Intervention We randomly assigned patients to undergo a colonoscopic examination using NBI or WL. All patients underwent a second examination using WL, as the reference standard.

Main outcome measures The primary end point was the difference in the neoplasm miss rate, and secondary outcome was the neoplasm detection rate.

Results In 276 tandem colonoscopy patients, there was no significant difference of miss or detection rates between NBI or WL colonoscopy techniques. Of the 135 patients in the NBI group, 17 patients (12.6%; 95%CI:7.5-19.4%) had a missed neoplasm, as compared with 17 of the 141 patients (12.1%; 95%CI:7.2-18.6%) in the WL group, with a miss rate risk difference of 0.5% (95%CI: -7.2 - 8.3). 130 patients (47%) had at least 1 neoplasm. Missed lesions with NBI showed similar characteristics to those missed with WL. All missed neoplasms were tubular adenomas, the majority (78%) was ≤5 mm and none were larger than 1 cm (one sided 95%CI: up to 1%). Nonpolypoid lesions represented 35% (13/37) of missed neoplasms.

Interpretation NBI did not improve the colorectal neoplasm miss rate compared to WL - the miss rate for advanced adenomas was less than 1% and for all adenomas was 12%. The neoplasm detection rates were similarly high using NBI or WL -almost a half of the study patients had at least one adenoma. ClinicalTrials.gov Identifier: NCT00628147.

Background: Identification of patients at risk for mortality early in the course of acute pancreatitis (AP) is an important step to improving outcome.

Methods: Using Classification and Regression Tree (CART) analysis, we developed a clinical scoring system for prediction of in-hospital mortality in AP. We derived the scoring system on data collected from 17,992 cases of AP from 212 hospitals in 2000-2001. We validated the new scoring system on data collected from 18,256 AP cases from 177 hospitals in 2004-2005. Accuracy of the scoring system for prediction of mortality was measured by the area-under the receiver-operating curve (AUC). We further validated the performance of the new scoring system by comparing its predictive accuracy to APACHE II.

Results: CART analysis identified five variables for prediction of in-hospital mortality. One point is assigned for the presence of each of the following during the first 24 hours: BUN>25 mg/dL, Impaired mental status, SIRS, age>60 years or the presence of a Pleural effusion (BISAP). Mortality ranged from >20% in the highest risk group to <1% in the lowest risk group. In the validation cohort, the BISAP AUC was 0.82 [95% CI 0.79, 0.84] vs. APACHE II AUC of 0.83 [95% CI 0.80, 0.85].

Conclusions: We have derived and validated a new mortality-based prognostic scoring system for use in acute pancreatitis. The BISAP is a simple and accurate method for the early identification of patients at increased risk for in-hospital mortality.

A subset of functional dyspepsia (FD) patients report meal-related symptoms, possibly representing a pathophysiologically homogeneous subgroup. Our aim was to establish the time-course of symptoms in relation to meal ingestion, and to assess the relationship between self-reported meal-related symptoms and pathophysiological mechanisms in FD. Methods: 218 FD patients (149 women, mean age 39±1) filled out a symptom questionnaire, including meal-induced aggravation. All patients underwent a gastric emptying breath test with severity (0-4) scoring of 6 symptoms (pain, fullness, bloating, nausea, burning and belching) at each sampling (15 min interval for 4 hrs). In 129 patients, gastric sensitivity and accommodation were assessed by barostat. Results: The intensity of each FD symptom was significantly increased 15 minutes after the meal, compared to the pre-meal score, and remained elevated until the end of the measurement period (all p<0.05). Time course of individual symptoms varied, with early peaks for fullness and bloating, intermediate peaks for nausea and belching, and late peaks for pain and burning. Meal-induced aggravation was reported by 79% of patients, and in these patients postprandial fullness, which peaked early, was the most intense symptom. In patients without self-reported meal-induced aggravation, epigastric pain, which had a delayed peak, was the most intense symptom and they had a lower prevalence of gastric hypersensitivity (27.5 vs. 7.7%). Conclusion: Meal ingestion aggravates FD symptoms in the vast majority of patients, with symptom-specific time courses. Postprandial fullness is the most severe symptom in patients reporting meal aggravation, while it is pain in those not reporting meal-related symptoms.

Background and aims: Pancreatic cancer is among the most dismal of human malignancies. Current therapeutic strategies are virtually ineffective in controlling advanced, metastatic disease. Recent evidence suggests that the Hedgehog signaling pathway is aberrantly reactivated in the majority of pancreatic cancers, and that Hedgehog blockade has the potential to prevent disease progression and metastatic spread.

Methods: Here we show that the Hedgehog pathway is activated in the Pdx1-Cre; LsL-KrasG12D; Ink4a/Arflox/lox transgenic mouse model of pancreatic cancer. The effect of Hedgehog pathway inhibition on survival was determined by continuous application of the small molecule smoothened antagonist cyclopamine. Microarray analysis was performed on non-malignant human pancreatic ductal cells overexpressing Gli1 in order to screen for downstream Hedgehog target genes likely involved in pancreatic cancer progression.

Results: Hedgehog inhibition with cyclopamine significantly prolonged median survival in the used transgenic mouse model (67 vs. 61 days; p=0.026). In vitro data indicated that Hedgehog-activation might at least in part be ascribed to oncogenic Kras signaling. Microarray analysis identified 26 potential Hedgehog target genes that had previously been found to be overexpressed in pancreatic cancer. Five of them, BIRC3, COL11A1, NNMT, PLAU and TGM2 had been described as upregulated in more than one global gene expression analysis before.

Conclusion: This study provides another line of evidence, that Hedgehog signaling is a valid target for the development of novel therapeutics for pancreatic cancer that might be worth soon to be evaluated in a clinical setting.

Background: MUTYH associated polyposis (MAP) is a recessive trait characterised by multiple colorectal adenomas and a high risk of colorectal cancer. MUTYH functions in the DNA base excision repair pathway and has a key role in the repair of oxidative DNA damage.

Objectives: To assess the contribution of inherited variants in genes involved in base excision repair and oxidative DNA damage including MUTYH, OGG1, NEIL1, NEIL2, NEIL3, NUDT1 and NTH1 to the multiple colorectal adenoma phenotype.

Methods: Inherited variants of MUTYH, OGG1, NEIL1, NEIL2, NEIL3, NUDT1 and NTH1 were sought in 167 unrelated patients with multiple colorectal adenomas whose family histories were consistent with recessive inheritance. We also characterised these variants in ~ 300 population controls.

Results: Thirty three patients (20%) and no controls were MUTYH homozygotes or compound heterozygotes (i.e. carried two mutations) and therefore had MAP. Eight different pathogenic MUTYH mutations were identified of which 4 were novel. MAP cases had significantly more adenomas than non-MAP cases (P=0.0009; Exact test for trends in proportions) and presented earlier (P=0.013; ANOVA). Twenty four protein altering variants were identified upon screening of OGG1, NEIL1, NEIL2, NEIL3, NUDT1 and NTH1. However, all combinations of two (or more) variants that were identified at an individual locus in patients were also seen in controls and no variants were significantly over (or under-) represented in cases.

Conclusion: Multiple rare alleles of MUTYH are associated with autosomal recessive MUTYH Associated Polyposis (MAP) whilst OGG1, NEIL1, NEIL2, NEIL3, NUDT1 and NTH1 do not contribute significantly to autosomal recessive polyposis.

A lasting lesson for gastroenterologists was the failure of traditional epidemiologic approaches to raise the possibility of a transmissible agent as a cause of peptic ulcer disease. Another lesson was that the solution to some human disorders can never be found by reliance on research focused exclusively on the human host, without due reference to the interface with the microbial environment. In the case of inflammatory bowel diseases (IBD), excessive reliance on conventional risk factor epidemiology without adequate rapprochement with concepts of disease mechanisms is likely to provide more controversy, conflict and confusion than consensus. However, the changing epidemiology of IBD associated with societal transition from developing to developed status is of such consistency that it represents a model, and may facilitate reconciling disparate lifestyle and environmental factors with causal mechanisms.

Background/Aims: IL-26, a novel IL-10 like cytokine without murine homologue, is expressed in Th1 and Th17 cells. Currently, its function in human disease is completely unknown. The aim of this study was to analyse its role in intestinal inflammation.

Methods: Expression studies were performed by RT-PCR, quantitative PCR, Western Blot and immunohistochemistry. Signal transduction was analysed by Western blot experiments and ELISA. Cell proliferation was measured by MTS assay. IL-26 serum levels were determined by an immunoluminometric assay (ILMA).

Results: All examined intestinal epithelial cell (IEC) lines express both IL-26 receptor subunits IL-20R1 and IL-10R2. IL-26 activates ERK-1/2 and SAPK/JNK MAP kinases, Akt, and STAT1/3. IL-26 stimulation increases the mRNA expression of proinflammatory cytokines but decreases cell proliferation. In inflamed colonic lesions of patients with Crohn's disease, we found an elevated IL-26 mRNA expression that correlated highly with the IL-8 and IL-22 expression. Immunohistochemical analysis demonstrated IL-26 protein expression in colonic T cells including RORgammat expressing Th17 cells with an increased number of colonic IL-26 expressing cells in active Crohn's disease.

Conclusion: Intestinal cells express the functional IL-26 receptor complex. IL-26 modulates IEC proliferation and proinflammatory gene expression and its expression is up-regulated in active Crohn's disease indicating a role for this cytokine system in the innate host cell response during intestinal inflammation. For the first time, we demonstrate IL-26 expression in colonic RORgammat expressing Th17 cells in situ supporting a role for this cell type in the pathogenesis of Crohn's disease.

Objective: Unsafe therapeutic injections and transfusions are held responsible for many cases of Hepatitis C virus (HCV) transmission in developing countries, but cannot account for a substantial proportion of present infections. The aim of the present work was to investigate familial clustering of HCV infection in a population living in a highly endemic area.

Design, setting and participants: A large seroepidemiological survey was conducted on 3994 subjects (age range 2-88 years) from 475 familial clusters in an Egyptian rural area. Epidemiological methods appropriate for the analysis of correlated data were used to estimate risk factors and familial dependences for HCV infection. A phylogenetic analysis was conducted to investigate HCV strain similarities within and among families.

Main outcome measures: HCV familial correlations adjusted for known risk factors, similarities between viral strains.

Results: Overall HCV seroprevalence was 12.3%, increasing with age. After adjustment for relevant risk factors, highly significant intrafamilial resemblances in HCV seroprevalence were obtained between father-offspring (odds ratio =3.4[95%CI 1.8-6.2]), mother-offspring (3.8[2.5-5.8]), and sib-sib (9.3[4.9-17.6]), while a weaker dependence between spouses (2.2[1.3-3.7]) was observed. Phylogenetic analysis showed greater HCV strain similarity between family members than between unrelated subjects indicating that correlations can be explained in part by familial sources of virus transmission. In addition, refined dissection of correlations between first-degree relatives supported the role of host genes predisposing to HCV infection.

Conclusions: Current HCV infection in endemic countries has a strong familial component explained, at least partly, by specific modes of intrafamilial viral transmission and by genetic predisposition to infection.

Background: Synchronous occurrence of intraductal papillary mucinous neoplasm (IPMN) and ductal carcinoma of the pancreas has been reported. Branch duct IPMNs with lower likelihood of malignancy are not submitted to resection but are followed up, so ductal carcinoma may develop during the follow-up. We investigated the development of ductal carcinoma of the pancreas during follow-up of branch duct IPMNs.

Patients and Methods: Sixty patients of branch duct IPMN that had intraductal tumor of less than 10mm on imaging examinations and negative result for malignancy in cytologic examination of pancreatic juice were investigated. They were followed up mainly by ultrasonography (US), and additionally by endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), or endoscopic retrograde cholangiopancreatography (ERCP) with cytologic examination of pancreatic juice for an average period of 87 months.

Results: Ductal carcinoma of the pancreas distinct from IPMN developed in 5 of 60 (8%) branch duct IPMNs during follow-up. 5-year rate of development of ductal carcinoma was 6.9% (95%CI 0.4-13.4%), incidence of ductal carcinoma was 1.1% (95%CI 0.1-2.2%) per year, and standardized incidence ratio of development of ductal carcinoma was 26 (95%CI 3-48). Patients over 70 years old developed ductal carcinoma significantly more frequently than those under 69. Four of 5 ductal carcinomas identified during follow-up were resectable. Cancer developed in IPMN in 2 of 60 (3%) branch duct IPMNs during follow-up.

Conclusions: During follow-up of branch duct IPMNs ductal carcinoma of the pancreas not infrequently developed apart from IPMN. In the follow-up of IPMN, special attention should be paid to the development of ductal carcinoma of the pancreas.

Background: With the introduction of laparoscopic anti-reflux surgery (LARS) for GORD along with the increasing efficacy of modern medical therapy, a direct comparison is warranted. We report the 3-year interim results of a randomised study comparing both efficacy and safety of LARS and esomeprazole (ESO).

Methods: LOTUS is an open, parallel-group multicentre, randomised, and controlled trial conducted in dedicated centres in eleven European countries. LARS was completed according to a standardised protocol, comprising a total fundoplication and a crural repair. Medical treatment comprised ESO 20 mg od, which could be increased stepwise to 40 mg od and then 20 mg bid in case of incomplete GORD control. The primary outcome variable was time to treatment failure (Kaplan-Meier analysis). Treatment failure was defined on the basis of symptomatic relapse requiring treatment beyond that stated in the protocol.

Results: 554 patients were randomised of whom 288 were allocated to LARS and 266 to ESO. The two study arms were well matched. The proportions of patients who remained in remission after 3 years were similar for the two therapies: 90% of surgical patients compared with 93% medically treated for the ITT population, p=0.25 (90% vs 95% PP). No major unexpected post-operative complications were experienced and ESO was well tolerated. However, post-fundoplication complaints remain a problem after LARS.

Conclusions Over the first 3 years of this long-term study, both laparoscopic total fundoplication and continuous esomeprazole treatment were similarly effective and well-tolerated therapeutic strategies for providing effective control of GORD.