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Biomedical subjects

E H Livingston

Publications and source records attributed to E H Livingston.

At least 19 recordsLinked to original sources

Bicarbonate diffusion through mucus.

The mucus layer overlying duodenal epithelium maintains a pH gradient against high luminal acid concentrations. Despite these adverse conditions, epithelial surface pH remains close to neutrality. The exact nature of the gradient-forming barrier remains unknown. The barrier consists of mucus into which HCO3- is secreted. Quantification of the ability of HCO3- to establish and maintain the gradient depends on accurate measurement of this ion's diffusion coefficient through mucus. We describe new experimental and mathematical methods for diffusion measurement and report diffusion coefficients for HCO3- diffusion through saline, 5% mucin solutions, and rat duodenal mucus. The diffusion coefficients were 20.2 +/- 0.10, 3.02 +/- 0.31, and 1.81 +/- 0.12 x 10(-6) cm2/s, respectively. Modeling of the mucobicarbonate layer with this latter value suggests that for conditions of high luminal acid strength the neutralization of acid by HCO3- occurs just above the epithelial surface. Under these conditions the model predicts that fluid convection toward the lumen could be important in maintaining the pH gradient. In support of this hypothesis we were able to demonstrate a net luminal fluid flux of 5 microliters.min-1.cm-2 after perfusion of 0.15 N HCl in the rat duodenum.

Animals

Modeling of the gastric gel mucus layer: application to the measured pH gradient.

The gastric gel mucus layer plays an important role in the defense against acid-induced injury. Previous investigations have modeled the interaction between the mucus, bicarbonate, acid moving towards the epithelial surface, and water carrying ions away from the epithelium. We measured the diffusion coefficient of protons through gastric mucus and applied this parameter to the model. Using the measured diffusion coefficient, we applied the model to previously published gastric mucus gel pH gradients to assess the relative contribution of bicarbonate or water fluxes in maintaining the gradient in the face of luminal acid. Mucus was harvested from the stomachs of anesthetized rats, mixed with bromphenol blue, and placed in capillary tubes. The tubes were submerged in 0.15 N HCl at 37 degrees C. The color change from blue to yellow was measured with time as the HCl migrated through the tube. From the distance and time data, the diffusion coefficient could be calculated. Controls of bromphenol blue in water were studied. The diffusion coefficient for water was 30.2 +/- 0.8 x 10(-6) cm2 s-1, almost identical to the standard value reported in the literature. The HCl diffusion coefficient through saline was 67.8 +/- 0.7 x 10(-6) cm2 s-1. For gastric mucus it was 5.4 +/- 1.3 x 10(-6) cm2 s-1. Application of this diffusion coefficient to the model and subsequently to observed pH gradients suggested that the most potent defense mechanism against concentrations of luminal acid is the bulk movement of water away from the epithelial surface through the mucus gel layer.

Animals

Central vagal activation by TRH induces gastric hyperemia: role of CGRP in capsaicin-sensitive afferents in rats.

The role of calcitonin gene-related peptide (CGRP) in the vagal cholinergic-mediated increase in gastric mucosal blood flow (GMBF) induced by the stable thyrotropin-releasing hormone (TRH) analogue RX-77368 injected intracisternally (ic, 30 ng) was investigated in urethan-anesthetized rats using the hydrogen gas clearance technique. alpha-CGRP (14 micrograms.kg-1.h-1) or bethanechol (150 micrograms.kg-1.h-1) infused close intra-arterially to the stomach or RX-77368 injected intracisternally increased GMBF by 76, 102, and 131%, respectively, 30 min after administration. The CGRP antagonist, human CGRP-(8-37) [hCGRP-(8-37)], injected intravenously (15 micrograms/kg bolus and 3 micrograms.kg-1.h-1) inhibited by 100, 97, and 73% the gastric hyperemic response to alpha-CGRP, TRH analogue, and bethanechol, respectively, whereas the substance P antagonist CP-96,345 (3 mg/kg iv) had no effect. In capsaicin-pretreated rats, hCGRP-(8-37) no longer blocked the increase in GMBF induced by intracisternal RX-77368. These results suggest that the gastric hyperemic response to central vagal activation induced by intracisternal TRH analogue at 30 ng is mediated by local effector function of capsaicin-sensitive afferent fibers releasing CGRP.

Animals

Gastric hyperemia accompanying acid secretion is not mediated by sensory nerves.

It is not known how the signal to increase gastric mucosal blood flow is passed from the gastric parietal cell layer to the resistance vessels in the submucosa. We tested the hypothesis that mucosal hyperemia accompanying stimulated gastric acid secretion is mediated by capsaicin-sensitive sensory nerves. Rats were denervated by systemic capsaicin treatment (125 mg/kg, subcutaneously, 10-14 days prior to experimentation). Acid secretion was stimulated by intravenous pentagastrin (4, 12, and 36 micrograms/kg/hr) and was measured by a continuous perfusion method. Mucosal blood flow was measured by the hydrogen gas clearance method. Sensory denervation did not affect basal blood pressure, gastric acid secretion, or mucosal blood flow. In control rats, increases in gastric mucosal blood flow and acid secretion were dose-related. With denervation, not only was there no inhibition of the blood flow response to acid secretion, but the dose-dependent rise in acid secretion was accompanied by increased mucosal blood flow that was out of proportion to the acid secretory response. The capsaicin-sensitive afferent fibers do not transmit the signal to increase gastric mucosal blood flow in response to stimulated acid secretion. It appears that sensory nerves modulate but do not mediate the mucosal hyperemic response to acid secretion.

Analysis of Variance

Heterogeneous distribution of gastric mucosal blood flow with restraint stress in the rat.

Cold water immersion restraint (CWIR) is associated with gastric hypercontractility and gastric corpus erosions in the rat. Because the gastric blood flow response to CWIR has not been well defined, we performed the following study. Rats were implanted with force transducers, subjected to CWIR for 2 hr, and then blood flow was determined by the iodo[14C]antipyrine autoradiographic (IAP) technique. When compared to control animals, the CWIR-treated animals displayed foci of gastric corpus hyperemia with a marked and significant increase in blood flow in all layers of the gastric corpus. There was approximately a 100% increase in the mucosa and a 50% increase in the muscularis externa. The hyperemia was not uniform, but rather alternated every 2.1 +/- 0.2 mm with regions of low blood flow. Blood flow in the antrum and duodenum was unaffected by CWIR. We conclude that CWIR is associated with alternating regions of high and low blood flow only in the gastric corpus. Reduction of corpus mucosal blood flow might be due to the powerful gastric contractions associated with CWIR.

Animals

Antisecretory and cytoprotective doses of enprostil do not alter gastric mucosal blood flow.

Prostaglandins of the E series are antisecretory and cytoprotective. Cytoprotection occurs in the deep but not superficial gastric mucosa. It has been hypothesized that the mechanism of cytoprotection involves increased gastric mucosal blood flow (GMBF). However, basal and stimulated gastric mucosal blood flow is greater in the deep than superficial corpus mucosa. The purpose of this study was to investigate the effect of a prostaglandin E2 analog, enprostil, on GMBF in the deep mucosa, where cytoprotection is observed, in both antisecretory and cytoprotective doses. Gastric mucosal blood flow in the deep half of the mucosa was measured by the hydrogen gas clearance method before, during and after intragastric perfusion of enprostil, 0.1-100 micrograms/kg, in urethane anesthetized rats. Enprostil did not alter GMBF in any of the doses tested. Therefore, the cytoprotective action of enprostil is mediated by factors other than a primary increase in GMBF.

Analysis of Variance

The stomach as a system and the pathogenesis of experimental ulcer.

The stomach is prone to ulceration because of the hostile environment that exists within its lumen. The most important etiologic factor remains a topic of debate. We have considered the stomach as a system to lend insight into which pathophysiologic mechanisms might be most important. Systems are described by their content, hierarchy, entropy and interactions. The states of health, disease and death (i.e. ulceration) are represented by progressively increasing levels of entropy. It is argued that many of the purported causes of ulcer disease, such as acid back-diffusion or alcohol related necrosis, represent alterations in the system that affect small groups of cells that are low in the hierarchy and cause the tissue to enter the diseased state. We hypothesize that because blood flow is high within the hierarchy it represents the major homeostatic mechanism. If blood flow responds appropriately the system may return to the healthy state. If it does not the death of the system results in ulceration. Experimental evidence to support these contentions is presented.

Animals

Cost-benefit analysis of the work-up for pancreatic cancer.

We reviewed the records of 126 patients with pancreatic cancer to assess the value of diagnostic tests. The most commonly performed studies were computed tomography (CT) (97% of patients), endoscopic retrograde cholangiopancreatography (ERCP) (44%), and fine-needle aspiration (FNA) (41%). Of 34 patients who were found to have a mass in the body or tail of the pancreas on CT, 13 underwent ERCP; the results found by ERCP did not affect the management of the patients, whereas the results of FNA in 12 patients eliminated the need for operation. Of 14 patients with suspected metastases as evidenced by CT, the results of 3 ERCPs had no impact, whereas 5 of 7 patients who had FNAs avoided operation. Of five patients with normal results on CT, three had an ERCP that identified tumor. Of 26 patients with atypical CTs, the results of 12 of 16 ERCPs and 3 of 5 FNAs confirmed cancer. In contrast, in 48 patients with a mass in the head of the pancreas and biliary dilatation, ERCP did not alter the patients' management; only 3 of 14 patients who had FNAs avoided operation. Thus, the results of ERCP rarely altered the management of the patient when the CT showed a mass but was useful when the scan was normal or atypical. FNA was helpful in patients with cancer in the body or tail of the pancreas or with suspected metastases and in confirming the diagnosis when the CT was inconclusive.

Adenocarcinoma

Dynamic in vivo observation of rat islet microcirculation.

In vivo fluorescent microscopy with direct observation of flow through the islet was used to investigate the islet microcirculation. In urethane-anesthetized rats (n = 18), the pancreas was exposed and an islet was identified under direct microscopy. The vertical illuminator for fluorescent microscopy was turned on and fluorescein-albumin conjugate or fluorescent microspheres were injected intravenously or intraarterially. Each study was videotaped; on slow motion playback, the flow of the conjugate or microspheres was followed through the islet, the islet capillaries, and then to venules exiting the islet. One islet in the head of the pancreas in 12 rats was studied. The arterioles first reached the surrounding mantle of the islet where they divided into capillaries that carried conjugate or microspheres to other portions of the mantle or the core of the islet. Flow of conjugate traversed the core and returned to different portions of the mantle. The fluorescent microsphere study permitted a more detailed study of the pathways followed, the individual microspheres being seen to travel through numerous tortuous pathways through the islet. The flow of microspheres was nonhomogeneous in that individual microspheres in one portion of the islet would stop, then move on, while other microspheres flowed freely. The capillaries joined two to six venules that carried the conjugate or microspheres out of the islet. One or two of the exiting microvessels entered the adjacent acinar microcirculation; the others entered larger collecting venules. In six tail islets studied, the microcirculation was similar to that of the islets in the head of the pancreas.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals

Treatment of pancreatic carcinoma.

Pancreatic carcinoma remains a significant cause of cancer death worldwide. In spite of more effective diagnostic techniques, most patients still have advanced and incurable disease when the diagnosis is made. Treatments differ depending on the extent of the disease at presentation, but accurate staging preoperatively is difficult. The Whipple procedure is now done with an operative mortality of 5% or less. More effective means of nonoperative palliation are being developed. Adjuvant therapy is still largely ineffective.

Cause of Death

Spectrum of injury produced in the duodenum by perfusion with luminal acid in the rat.

The dose and time dependence of duodenal mucosal injury by luminal acid perfusion was studied. Saline, 0.01, 0.05, 0.15, and 0.3N HCl, were perfused through the proximal duodena of rats for 5, 15, or 30 minutes and then harvested for histological examination. In a second set of studies, after a 30-minute perfusion, duodena were harvested either immediately or 2, 4, 8, or 24 hours after the perfusion to study the recovery from injury. Acid disappearance (acid delivered minus acid recovered) was measured in all groups. Duodena were examined grossly, then fixed, stained, and scored histologically. Whereas no gross mucosal injury was noted, there was graded histological injury proportional to acid concentration. Injury occurred early in the perfusion and changed little with increased perfusion durations. The initial injury lead to an acid disappearance rate that was proportional to acid concentration and, therefore, the degree of injury. After the initial injury occurred, the rate of acid neutralization was unchanged by increased duration of acid perfusion. This acid neutralization protected against further injury despite the continued presence of acid. Recovery from injury was complete with physiological (0.01 and 0.05N HCl) but not pharmacological (0.15 and 0.3N HCl) concentrations of acid. It is concluded that acid-induced duodenal injury occurs within 5 minutes of exposure, is proportional to the acid concentration, and results in acid neutralization that protects against extension of the injury with continued acid exposure.

Animals

Effect of elevated intracranial pressure on gastric acid secretion, mucosal blood flow and mucosal injury.

Head injury is frequently accompanied by an increase in intracranial pressure and gastric lesion formation. We used a model of controlled intracranial pressure to investigate the effect of elevated intracranial pressure on gastric acid secretion and mucosal blood flow and on the susceptibility of the gastric mucosa to lesion formation. With increasing intracranial pressure, there was a corresponding increase in gastric acid output but no significant change in gastric mucosal blood flow. This imbalance between acid secretion and blood flow could be a factor in the pathogenesis of the gastric lesions seen with head injury. Susceptibility to gastric mucosal injury then was studied in a model that is independent of the acid secretory state--exogenous intragastric HCl plus ethanol. Elevated intracranial pressure did render the gastric mucosa more susceptible to injury in this model, but there was no impairment of the increased gastric mucosal blood flow response to the increased acid back-diffusion. In this situation, factors other than altered overall blood flow appear to be responsible for the increased lesion formation.

Animals

Surgical treatment of pancreatic cancer. The United States experience.

About 28,000 new cases of pancreatic cancer are diagnosed yearly in the United States. The diagnosis is now made up to two months more quickly than just a few years ago, but this has had no impact on survival. In most institutions, 20-25% of patients have resectable lesions. The standard operation is still the Whipple pancreaticoduodenectomy, but many surgeons now use the pylorus preserving modification of that procedure. The operative mortality rate has fallen to less than 5%. The five-year survival rate after a resection for attempted cure is about 9%. Palliation requires cholecysto(docho)jejunostomy and gastrojejunostomy, which is often done prophylactically. The operative mortality rate in patients undergoing palliation is less than 10% (recent UCLA experience), and the average survival is seven months.

Adenocarcinoma

Sensory neurons signal for an increase in rat gastric mucosal blood flow in the face of pending acid injury.

Disruption of the gastric mucosal barrier is quickly followed by an increase in gastric mucosal blood flow, which is thought to be a defensive reaction to prevent further injury. This study examined how this increase in blood flow is brought about. When the stomach of urethane-anesthetized rats was perfused with 0.15N HCl, disruption of the gastric mucosal barrier with 15% ethanol increased the disappearance of acid from the gastric lumen and enhanced gastric mucosal blood flow. This increase in blood flow was blocked by local arterial infusion of tetrodotoxin (60 ng/min) to the stomach and by chemical ablation of capsaicin-sensitive sensory neurons. Inhibition of the blood flow increase was associated with exaggeration of gross and histological injury to the mucosa. IV injection of atropine (0.2 mg/kg) or pyrilamine (2 mg/kg) did not affect blood flow increase in response to barrier disruption, whereas morphine injection (2 mg/kg) inhibited it. The current findings show that the increase in gastric mucosal blood flow that follows disruption of the gastric mucosal barrier in the presence of acid is mediated by sensory neurons that seem to monitor acid back-diffusion and in turn signal for a protective increase in blood flow.

Animals

Elevated intracranial pressure stimulates gastric contractility in the rat.

The gastric contractile response to elevated intracranial pressure (ICP) was studied in conscious rats. Elevation of intracranial pressure to 20 mm Hg was associated with a marked increase in the amplitude of gastric contractions (70-90% over baseline) without any change in contractile frequency (5.2 +/- .5 contractions per min). The increase in contractility continued for 45 min following release of the pressure. Vagotomy completely blocked the increase in gastric contractility seen with elevation in ICP. We conclude that acute elevation of intracranial pressure in rats results in increased force of gastric contractions. The forceful contractions persist despite release of the pressure and the increased contractile force is vagally mediated.

Animals

Resuscitation. Revival should be the first priority.

During resuscitation, it is important to distinguish between those maneuvers directed at patient revival and those directed at examination and measurement. Revival should always be the top priority. The steps for revival are easily remembered as ABCDEF: Airway, Breathing, Circulation, Decompression, Elimination, and Fluids. Once these steps have been completed, vital functions can be assessed and measurements to aid in diagnosis can be taken.

Blood Circulation

Role of peptidergic sensory neurons in gastric mucosal blood flow and protection.

The present findings have revealed a new aspect of how mechanisms of gastric mucosal resistance to injury are called into effect and are coordinated by the nervous system. Capsaicin-sensitive sensory neurons in the stomach play a physiological role in monitoring acid influx into the superficial mucosa. Once activated, they strengthen gastric mucosal defense against deep injury, with a key process in this respect being an increase in blood flow through the gastric mucosa. This concept opens up completely new perspectives in the physiology and pathophysiology of the gastric mucosa if we consider that the long-term integrity of the gastric mucosa may be under the subtle control of acid-sensitive sensory neurons and that, vice versa, improper functioning of these neutral control mechanisms may predispose to gastric ulcer disease. The present observations also indicate that some of the peptides contained in gastric sensory nerve endings might fulfill a transmitter or mediator role in controlling gastric mucosal blood flow and integrity. Whereas substance P and neurokinin A are unlikely to play a role in the regulation of gastric mucosal blood flow, there is severalfold evidence that CGRP is very important in this respect. This peptide, which in the rat gastric mucosa originates exclusively from spinal sensory neurons, is released upon stimulation of sensory nerve endings and is extremely potent in facilitating gastric mucosal blood flow and in protecting the mucosa from injurious factors. Selective ablation of spinal sensory neurons containing CGRP weakens the resistance of the gastric mucosa against acid injury, which is most likely due to inhibition of protective vasodilator reflexes. We now aim at providing direct pharmacological evidence that antagonism of endogenously released CGRP results in similar pathophysiological consequences as ablation of capsaicin-sensitive sensory neurons.

Animals