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The availability of the gamma-labelled bile acid 75SeHCAT, that allows a non-invasive assessment of the enterohepatic circulation of bile acids, has prompted in the last 10 years the implementation of several studies involving wide series of normal subjects and patients with various organic and functional bowel disorders. The clinical indications for performing a SeHCAT test have been clearly defined: the test can identify with high accuracy, in the setting of the irritable bowel syndrome, the patients with bile acid malabsorption that can be confidently and successfully treated with cholestyramine; it can also assess whether, and to what extent, the diarrhoea presenting in patients with intestinal organic disorders is due to bile acid malabsorption, permitting an optimal therapeutic strategy to be designed. The parameters of the hepatic handling of SeHCAT after bolus intravenous administration have been characterized in normals, and studies on various chronic hepatic disorders are now in progress. Interesting results are emerging from studies performed in patients with chronic non-obstructive cholestatic disease, where a specific defect in the excretion rate of SeHCAT is present: these studies may cast more light on the abnormalities of bile secretion and on the mechanism of action of drugs used to treat this condition, forming the rationale for the use of intravenous SeHCAT for hepatobiliary dynamic scintigraphy as a sophisticated liver function test. In conclusion, the SeHCAT test has become an important diagnostic tool for the gastroenterologist studying the diarrhoea, and awaits more studies to be used also by the hepatologist. The relatively long physical half-life of 75Se (180 days), preventing a wider use of the test, could theoretically be overcome by the synthesis of a similar gamma-labelled bile acid with a shorter half-life.

The enterohepatic circulation of bile acids in man is reviewed. The chemistry of biliary bile acids is summarized and related to the formation of primary bile acids in the liver and secondary bile acids in the intestinal lumen. New findings showing that lithocholic acid is absorbed in man are presented, and the recent experiments showing that lithocholic acid is extensively sulfated are reviewed. The consistent hepatotoxicity of chenodeoxycholic acid in the rhesus monkey, which contrasts with its non-toxicity in man, is explained by the inability of the rhesus monkey to sulfate abosrbed lithocholic acid; this accumulates in the enterohepatic circulation of the monkey causing liver damage. In man, absorbed lithocholic acid is rapidly sulfated, and the sulfated conjugates are excreted fecally without enterohepatic cycling. The physical chemistry of bile is highlighted, and it is shown that the saturation of bile with cholesterol depends on the amount of bile acids passing through the liver: at low bile acid flow rates, such as occurs during overnight fasting, bile is supersaturated in both gallstone and healthy persons. Chenodeoxycholic acid decreases cholesterol secretion into bile, renders bile unsaturated during most of the day and night, and thus induces gallstone dissolution.

The authors have reviewed their cases of neonatal obstructive malformations of the intestinal tract and analyzed the incidence of association with indirect hyperbilirubinemia. 39 patients in four years are considered. In 23 of them there is a bilirubin level greater than 5 mg/100 ml. A great number of high bilirubin levels (greater than 15 mg/100 ml) is associated with volvulus, malrotations and intestinal atresias. Bilirubin levels between 11 and 15 mg/100 ml are often connected with meconium ileus while ano-rectal atresias have a low bilirubin level (less than 5 mg/100 ml). The reported data allow to conclude that the jaundice is an early, but unfortunately, not specific symptom of congenital intestinal obstruction. The entero-hepatic circulation seems to be an important cause of the neonatal hyperbilirubinemia.