Endogenous ethanol production and hepatic disease following jejunoileal bypass for morbid obesity”2 Esteban Kenneth
Mezev,3 M.D., AnthontL. Imbembo,4 C. Rent6, Robert Lombardo,7 M.D.
ABSTRACT were
contribute samples obese
patients
2 dogs
of
the
to surgery,
ml with ml
and
in of
in the
dogs.
resulted
correlation obtained,
between the presence postoperativeh. Since
in onls
one-third
Nutr.
28:
1277
in
the
pathogenesis
1283,
1.59
production
American
Journal
of Clinical
Nutrition
mg/I00
of of
the
bypass
that
of
disease
liver
elevated
after
of
ethanol
might
b pass. bypass
from
and
ranged
bypassed
intestine
ethanol.
0.15
to
from
0.20
there
by bacteria
in
hpass.
7
4.12 to
ith
sas
when liver biopsy small concentrations
jejunoileal
and
in only
of a dog
However,
histolog. in only
production
following
jejunoileal
ranged
ml in the 7 patients of the
of ethanol which
obesit. Venous serum in 8 normal subjects. 9
afterjejunoileal
concentrations
amounts
levels
production.
for morbid were obtained
of ethanol in the serum and liver ethanol was detected in the serum it is unlikel
not
to 40 months
contents
significant
B.S.,
ethanol
was detected
ethanol
(SD)
no sas and
the intestine Am.
is
J. C/in.
1975.
The development of hepatic disease as a serious complication in the treatment of morbid obesity by jejunoileal bypass operations has caused concern for the safety of patients undergoing such operations. The histologic findings usually consist of fatty infiltration of parenchymal cells (I, 2) but sometimes demonstrate a lesion resembling alcoholic hepatitis (3) or even progressive cirrhosis (4). Protein malnutrition (5) and the bacterial production of a hepatotoxic substance (I) in the bypassed loop have been proposed as causes of the hepatic abnormalities. The striking similarity of the hepatic lesions with the spectrum of liver disease found in chronic alcoholism lead us to suggest as a hypothesis that excessive ethanol production by intestinal bacteria might cause or contribute to the hepatic disease complicating jejunoileal bypass. The colonization of bypassed intestinal segments by bacteria (6, 7) and the ability of such organisms to produce ethanol and higher alcohols from carbohydrate has been demonstrated (8). Significant ethanol concentrations have been found also in the gastrointestinal tract and portal vein of
The
2 weeks
Ethanol
Serum
or
endogenous
jejunoileal chromatography
Incubation
of the patients. in the
±
whether
from
patients
2 dogs.
1.18
dextrose
of significance
to determine
bypass.
the
a mean
M.D.. James J. Potter,5 Peter R. Holt,8 M.D.
resulting
20 obese
and aftenjejunoileal
20 patients mg/lOO
we sought
circulation,
hepatic damage following of ethanol by gas liquid
prior
before
mg/l00
study.
in the systemic
to the for assay
in
2.23
In this
present
and
28:
NOVEMBER
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/11/1277/4732872 by guest on 15 March 2018
fed rats (9) and in the jejunal contents of patients with tropical sprue (10). Incubation of the coliform organisms isolated from the jejunal contents of such sprue patients in a culture medium containing dextrose revealed that ethanol was the principal fermentation product (10). Epidemiological and experimental studies (I 1 13) suggest that alcoholic liver disease I
From
the
Baltimore City versitv School
Departments
of
Medicine
Hospitals and The Johns of Medicine, Baltimore,
the Department of Medicine, and The College of Physicians University. New York City. 2 Supported by Public
St.
and Hopkins Maryland,
Sungers. Uniand
Luke’s Hospital Center and Surgeons, Columbia
Health
Service
Grants
AA00626. AM13436 and AM05499. 3 Associate Professor of Medicine, The Johns Hopkins University School of Medicine. Assistant Professon of Surgery. The Johns Hopkins University School of Medicine. ‘Research Associate, Baltimore Cit Hospitals. 6 Surgical Research Technician, Baltimore Cit Hospitals. 7NIH Trainee in Gastroentenologv. St. Luke’s Hospital Center. ‘Chief of The Division of Gastroenterology. Medical Service at St. Luke’s Hospital Center. and Associate Professor of Medicine at The College of Physicians and Surgeons. Columbia University.
1975,
pp.
277
1283,
Printed
in U.S.A.
277
1278
MEZEY
develops only when the amounts of alcohol ingested exceed the capacity of the liver to metabolize alcohol so that ethanol is present in body fluids for prolonged periods of time. The purpose of the present study was to determine whether or not jejunoileal bypass was associated with sufficient intestinal endogenous ethanol production to exceed the hepatic ethanol metabolizing capacity as evidenced by the appearance of ethanol in the systemic circulation. In addition, we sought to identify other volatile compounds that might result from bacterial fermentation of unabsorbed substrate and which might be detected in the systemic circulation.
Patients
and experimental
methods
proximally. At the time ofsurgeny samples of the jejunal and ileal contents were taken for bacterial culture and a liven biopsy was performed. Postoperatively, the dogs were fed a commercial dog food preparation (ALPO Manufacturing). Fasting and postprandial serum samples were taken before and at about weekly intervals after surgery. An open liver biopsy was performed in one dog 56 days after surgery. Ninety and 65 days after surgery in the first and second dog, respectively. laparatomy for culture of the bypassed intestinal segment and a liven biopsy were done. The intestinal contents were collected under anaerobic conditions and diluted serially in phosphate buffer pH 7.4. Aliquots were incubated in Mac agar
(Difco)
and
in
blood
agar
AL.
anaerobic) culture media and counted. Blood for the determination was collected in 10-mI tubes
the colonies of ethanol containing
identified
and
concentration 10 mg sodium
fluoride, centrifuged at 2,000 g for 10 mm and the separated serum was frozen. Serum ethanol concentration was determined by gas-liquid chromatography (14), using a Packard gas-liquid chromotograph equipped with a hydrogen flame detector. The serum was diluted 10 times with distilled water and lOsl of this sample were injected into a Poropak Q (Waters Associates, Framingham, Mass.) chromatographic column maintained at 185 C. Ethanol standards were injected before and after the injection of each sample. This method detects ethanol concentrations greater than 0. I mg per 100 ml. In addition, the method permitted the detection of acetone, propanol, butanol, acetaldehyde, acetic, propionic, butynic, isobutynic and valenic acids in amounts greaten than 0.1 mg per 100 ml.
Results
One or more blood samples were obtained from 8 normal subjects, 9 obese patients prior to surgery, and 20 obese patients 2 weeks to 40 months after jejunoileal bypass. The skin was cleansed with an isopropanol soaked gauze and allowed to dry before blood was drawn. The operation consisted, in 19 patients. of end-to-end anastomosis of 30 35 cm of proximal jejunum to 10-22 cm of terminal ileum, and in one patient (LG) of anastomosis of 30 cm of proximal jejunum to 30 cm to terminal ileum. The bypassed intestine was closed proximally and the distal end anastomosed to the side of the transverse or sigmoid colon. Liven biopsy was performed at the time of the surgery in 16 of the 20 patients and subsequently in 9 patients. Fourteen patients were female and six male, and their ages ranged from 20 to 60 years. Their mean body weight prior to surgery was 199.4 ± 55.4 (SD) kg and the mean percent weight loss up to the time of the present study was 24.2 ± 14.8. Serum samples were obtained after an overnight fast in all patients. Thirteen of the patients were hospitalized at the time the blood samples were taken, while seven were seen as outpatients. Also, in order to provide increased substrate for possible bacterial action in the intestine, serum samples were obtained in some of the patients 2 hours after the supervised intake of a standard breakfast and lunch. Two healthy well-fed dogs underwent end-to-side jejunoileal bypass of 30 cm of proximal jejunum to I 2 cm of terminal ileum. The bypassed segment was closed
Conkey
ET
(aerobic
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/11/1277/4732872 by guest on 15 March 2018
and
Patient
studies
No ethanol was detected in the serum of the 8 normal subjects and 9 obese patients prior tojejunoileal bypass. On the other hand, ethanol was detected in the fasting serum of 7 of the 20 patients after jejunotleal bypass (Table I). The ethanol concentrations ranged between 0.15 and 4.12 with a mean of 1.18 ± 1.59 (SD) mg/lOO ml in the 7 patients. Five of these patients were hospitalized at the time of the determination, while two were outpatients (RT and PD). In 12 patients serum samples were also obtained postprandially, and in 3 of these ethanol was detected. There was no correlation between the presence ofethanol in the serum and hepatic histology when liver biopsy was obtained postoperatively. Of 2 patients who had developed increasing hepatic fibrosis (KS and DS), only one (DS) showed detectable levels of ethanol in the serum. In the other patient (KS) who in addition had evidence of focal parenchymal cell necrosis and alcoholic hyaline, no ethanol was detected. Neither was ethanol detected in the serum of the one patient who developed cirrhosis following surgery (SB). Furthermore, repeated determinations in 2 patients who had detectable ethanol levels on initial sampling (EH and VW), 1.25 and 6 months postoperatively, failed to reveal persistence of ethanol in their serum. A peak of volatile material with a longer retention time than ethanol was detected during gas-liquid chromatography of the
ENDOGENOUS
ETHANOL
PRODUCTION
AND
HEPATIC
1279
DISEASE
TABLE 1 Weight loss, serum ethanol and acetone concentrations and liver morphology in 20 obese patients following jejunoileal bypass
CL
after surgery, months
Weight loss. %
fasting
PC
Serum
Atone
fasting
PC
mg/ 100 ml
Mezev,3 M.D., AnthontL. Imbembo,4 C. Rent6, Robert Lombardo,7 M.D.
ABSTRACT were
contribute samples obese
patients
2 dogs
of
the
to surgery,
ml with ml
and
in of
in the
dogs.
resulted
correlation obtained,
between the presence postoperativeh. Since
in onls
one-third
Nutr.
28:
1277
in
the
pathogenesis
1283,
1.59
production
American
Journal
of Clinical
Nutrition
mg/I00
of of
the
bypass
that
of
disease
liver
elevated
after
of
ethanol
might
b pass. bypass
from
and
ranged
bypassed
intestine
ethanol.
0.15
to
from
0.20
there
by bacteria
in
hpass.
7
4.12 to
ith
sas
when liver biopsy small concentrations
jejunoileal
and
in only
of a dog
However,
histolog. in only
production
following
jejunoileal
ranged
ml in the 7 patients of the
of ethanol which
obesit. Venous serum in 8 normal subjects. 9
afterjejunoileal
concentrations
amounts
levels
production.
for morbid were obtained
of ethanol in the serum and liver ethanol was detected in the serum it is unlikel
not
to 40 months
contents
significant
B.S.,
ethanol
was detected
ethanol
(SD)
no sas and
the intestine Am.
is
J. C/in.
1975.
The development of hepatic disease as a serious complication in the treatment of morbid obesity by jejunoileal bypass operations has caused concern for the safety of patients undergoing such operations. The histologic findings usually consist of fatty infiltration of parenchymal cells (I, 2) but sometimes demonstrate a lesion resembling alcoholic hepatitis (3) or even progressive cirrhosis (4). Protein malnutrition (5) and the bacterial production of a hepatotoxic substance (I) in the bypassed loop have been proposed as causes of the hepatic abnormalities. The striking similarity of the hepatic lesions with the spectrum of liver disease found in chronic alcoholism lead us to suggest as a hypothesis that excessive ethanol production by intestinal bacteria might cause or contribute to the hepatic disease complicating jejunoileal bypass. The colonization of bypassed intestinal segments by bacteria (6, 7) and the ability of such organisms to produce ethanol and higher alcohols from carbohydrate has been demonstrated (8). Significant ethanol concentrations have been found also in the gastrointestinal tract and portal vein of
The
2 weeks
Ethanol
Serum
or
endogenous
jejunoileal chromatography
Incubation
of the patients. in the
±
whether
from
patients
2 dogs.
1.18
dextrose
of significance
to determine
bypass.
the
a mean
M.D.. James J. Potter,5 Peter R. Holt,8 M.D.
resulting
20 obese
and aftenjejunoileal
20 patients mg/lOO
we sought
circulation,
hepatic damage following of ethanol by gas liquid
prior
before
mg/l00
study.
in the systemic
to the for assay
in
2.23
In this
present
and
28:
NOVEMBER
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/11/1277/4732872 by guest on 15 March 2018
fed rats (9) and in the jejunal contents of patients with tropical sprue (10). Incubation of the coliform organisms isolated from the jejunal contents of such sprue patients in a culture medium containing dextrose revealed that ethanol was the principal fermentation product (10). Epidemiological and experimental studies (I 1 13) suggest that alcoholic liver disease I
From
the
Baltimore City versitv School
Departments
of
Medicine
Hospitals and The Johns of Medicine, Baltimore,
the Department of Medicine, and The College of Physicians University. New York City. 2 Supported by Public
St.
and Hopkins Maryland,
Sungers. Uniand
Luke’s Hospital Center and Surgeons, Columbia
Health
Service
Grants
AA00626. AM13436 and AM05499. 3 Associate Professor of Medicine, The Johns Hopkins University School of Medicine. Assistant Professon of Surgery. The Johns Hopkins University School of Medicine. ‘Research Associate, Baltimore Cit Hospitals. 6 Surgical Research Technician, Baltimore Cit Hospitals. 7NIH Trainee in Gastroentenologv. St. Luke’s Hospital Center. ‘Chief of The Division of Gastroenterology. Medical Service at St. Luke’s Hospital Center. and Associate Professor of Medicine at The College of Physicians and Surgeons. Columbia University.
1975,
pp.
277
1283,
Printed
in U.S.A.
277
1278
MEZEY
develops only when the amounts of alcohol ingested exceed the capacity of the liver to metabolize alcohol so that ethanol is present in body fluids for prolonged periods of time. The purpose of the present study was to determine whether or not jejunoileal bypass was associated with sufficient intestinal endogenous ethanol production to exceed the hepatic ethanol metabolizing capacity as evidenced by the appearance of ethanol in the systemic circulation. In addition, we sought to identify other volatile compounds that might result from bacterial fermentation of unabsorbed substrate and which might be detected in the systemic circulation.
Patients
and experimental
methods
proximally. At the time ofsurgeny samples of the jejunal and ileal contents were taken for bacterial culture and a liven biopsy was performed. Postoperatively, the dogs were fed a commercial dog food preparation (ALPO Manufacturing). Fasting and postprandial serum samples were taken before and at about weekly intervals after surgery. An open liver biopsy was performed in one dog 56 days after surgery. Ninety and 65 days after surgery in the first and second dog, respectively. laparatomy for culture of the bypassed intestinal segment and a liven biopsy were done. The intestinal contents were collected under anaerobic conditions and diluted serially in phosphate buffer pH 7.4. Aliquots were incubated in Mac agar
(Difco)
and
in
blood
agar
AL.
anaerobic) culture media and counted. Blood for the determination was collected in 10-mI tubes
the colonies of ethanol containing
identified
and
concentration 10 mg sodium
fluoride, centrifuged at 2,000 g for 10 mm and the separated serum was frozen. Serum ethanol concentration was determined by gas-liquid chromatography (14), using a Packard gas-liquid chromotograph equipped with a hydrogen flame detector. The serum was diluted 10 times with distilled water and lOsl of this sample were injected into a Poropak Q (Waters Associates, Framingham, Mass.) chromatographic column maintained at 185 C. Ethanol standards were injected before and after the injection of each sample. This method detects ethanol concentrations greater than 0. I mg per 100 ml. In addition, the method permitted the detection of acetone, propanol, butanol, acetaldehyde, acetic, propionic, butynic, isobutynic and valenic acids in amounts greaten than 0.1 mg per 100 ml.
Results
One or more blood samples were obtained from 8 normal subjects, 9 obese patients prior to surgery, and 20 obese patients 2 weeks to 40 months after jejunoileal bypass. The skin was cleansed with an isopropanol soaked gauze and allowed to dry before blood was drawn. The operation consisted, in 19 patients. of end-to-end anastomosis of 30 35 cm of proximal jejunum to 10-22 cm of terminal ileum, and in one patient (LG) of anastomosis of 30 cm of proximal jejunum to 30 cm to terminal ileum. The bypassed intestine was closed proximally and the distal end anastomosed to the side of the transverse or sigmoid colon. Liven biopsy was performed at the time of the surgery in 16 of the 20 patients and subsequently in 9 patients. Fourteen patients were female and six male, and their ages ranged from 20 to 60 years. Their mean body weight prior to surgery was 199.4 ± 55.4 (SD) kg and the mean percent weight loss up to the time of the present study was 24.2 ± 14.8. Serum samples were obtained after an overnight fast in all patients. Thirteen of the patients were hospitalized at the time the blood samples were taken, while seven were seen as outpatients. Also, in order to provide increased substrate for possible bacterial action in the intestine, serum samples were obtained in some of the patients 2 hours after the supervised intake of a standard breakfast and lunch. Two healthy well-fed dogs underwent end-to-side jejunoileal bypass of 30 cm of proximal jejunum to I 2 cm of terminal ileum. The bypassed segment was closed
Conkey
ET
(aerobic
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/11/1277/4732872 by guest on 15 March 2018
and
Patient
studies
No ethanol was detected in the serum of the 8 normal subjects and 9 obese patients prior tojejunoileal bypass. On the other hand, ethanol was detected in the fasting serum of 7 of the 20 patients after jejunotleal bypass (Table I). The ethanol concentrations ranged between 0.15 and 4.12 with a mean of 1.18 ± 1.59 (SD) mg/lOO ml in the 7 patients. Five of these patients were hospitalized at the time of the determination, while two were outpatients (RT and PD). In 12 patients serum samples were also obtained postprandially, and in 3 of these ethanol was detected. There was no correlation between the presence ofethanol in the serum and hepatic histology when liver biopsy was obtained postoperatively. Of 2 patients who had developed increasing hepatic fibrosis (KS and DS), only one (DS) showed detectable levels of ethanol in the serum. In the other patient (KS) who in addition had evidence of focal parenchymal cell necrosis and alcoholic hyaline, no ethanol was detected. Neither was ethanol detected in the serum of the one patient who developed cirrhosis following surgery (SB). Furthermore, repeated determinations in 2 patients who had detectable ethanol levels on initial sampling (EH and VW), 1.25 and 6 months postoperatively, failed to reveal persistence of ethanol in their serum. A peak of volatile material with a longer retention time than ethanol was detected during gas-liquid chromatography of the
ENDOGENOUS
ETHANOL
PRODUCTION
AND
HEPATIC
1279
DISEASE
TABLE 1 Weight loss, serum ethanol and acetone concentrations and liver morphology in 20 obese patients following jejunoileal bypass
CL
after surgery, months
Weight loss. %
fasting
PC
Serum
Atone
fasting
PC
mg/ 100 ml
