Faculty Bibliography

An elevated bilirubin level can be classified as hyperbilirubinemia only if results of all other liver function tests are normal. In contrast, cholestatic syndromes are characterized by elevations in various measurements of liver function, particularly alkaline phosphatase, bile acid, gammaglutamyl transferase, and 5'-nucleotidase

Although the morphologist continues to describe cholestasis on the basis of precipitated bile seen on light microscopic sections of the liver or dilated canaliculi with loss of microvilli seen by electron microscopy, the physiologist can distinguish clearly between hyperbilirubinemia and cholestasis. Both bilirubin and bile acids are specifically removed from sinusoidal plasma by the normal hepatocyte and appear in bile in high concentration. Bilirubin conjugation and excretion appear to be governed by hepatocellular mechanisms that are, for the most part, separate from the conjugation and excretion of bile acids. Disturbances in bilirubin transport are recognized by hyperbilirubinemia which represents a number of clinical syndromes that can be classified by the nature of the block in the transport system. Serum bile acids appear to remain normal in hyperbilirubinemic syndromes. By contrast, cholestatic syndromes are characterized by marked bile acidemia with normal to slightly elevated bilirubin levels. Severe cholestasis, because of the marked reduction in bile flow, can however, engender jaundice. Further exploration of these excretory pathways will provide interesting new insights on the numerous cholestatic and hyperbilirubinemic syndromes that occur in nature

The quantitative significance of renal excretion of bile acid ester sulfates as an alternate excretory pathway was evaluated in hamsters. After bile duct ligation, total serum bile acid fell from a mean level of 454 microgram/ml at 24 h to 64 microgram/ml by 96 h. During this period the bulk of the bile acid pool could be accounted for as esterified bile acids in urine. Renal pedicle ligation of animals with bile duct obstruction led to retention of the bile acid ester sulfates in serum. Thioacetamide hepatotoxicity diminished ester sulfation of bile acids causing diminished renal secretion with relatively greater retention of nonesterified bile acids in serum. We conclude that secretion of esterified bile acids by the kidney is an efficient alternate pathway for maintaining bile acid excretion in obstructive biliary tract disease. Coexistent hepatocellular disease diminishes ester sulfation and the effectiveness of the alternate pathway in maintaining bile acid excretion

The direct quantitative measurement of total bile acids in serum has been achieved using an enzymatic fluorescent method with a dual-beam spectrophotofluorimeter. By use of a 3alpha-hydroxysteroid dehydrogenase, oxidation of bile acids with NAD is completed in 200 seconds with the observed NADH fluorescence being proportional to the concentration of serum bile acids. This method is rapid (8 minutes per individual sample), has an intrinsic sensitivity of +/- micronM of total bile acids, requires no sample preparation and less than 0.8 ml of serum. Paired data analysis using enzymatic fluorescence and gas-liquid chromatographic methods gives a correlation coefficient (r) of 0.99 for 34 samples ranging from 2 to 530 micronM