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PubMed1993

Tissue distribution of autoantigen specific for primary sclerosing cholangitis.

AIM: To investigate the tissue distribution of the autoantigen specific for primary sclerosing cholangitis. METHODS: A range of normal frozen tissues including nervous system, muscle, uterus, ovary, prostate, pancreas, thyroid, salivary gland, adrenal gland, colon, gall bladder, stomach, jejunum, aorta, skin, kidney, liver, spleen and thymus was sectioned, fixed with acetone, and air-dried. Normal bone marrow and HL60, K562, and U937 cells were cytocentrifuged on to slides, air-dried, and alcohol fixed. Four sera from primary sclerosing cholangitis with high titre antibody (> 1/100) were used to screen the tissues using either two-step or APAAP immunohistochemistry. Normal sera were used as controls. RESULTS: Positive signal was detected in neutrophils in spleen with three out of four primary sclerosing cholangitis sera while one out of four primary sclerosing cholangitis sera stained spindle cells in the liver. All four sera stained mature neutrophils of the normal bone marrow. Some bone marrow neutrophil precursors (metamyelocytes and myelocytes) were also positive. All other tissues, including HL60, K562, and U937 cells, were negative. Normal sera were negative on all tissues. CONCLUSION: Antigen specific for primary sclerosing cholangitis seems to be unique to neutrophil polymorphs and is present only after myeloblast differentiation of the myeloid cell line. The antigen may be within the secondary granule of the neutrophil polymorph.

Adult↗
PubMed1999

End-stage primary sclerosing cholangitis: CT findings of hepatic morphology in 36 patients.

PURPOSE: To determine if there is a significant difference in the hepatic morphology depicted on computed tomographic (CT) scans in patients with end-stage cirrhosis caused by primary sclerosing cholangitis versus that in patients with end-stage cirrhosis caused by other factors. MATERIALS AND METHODS: The frequency of five morphologic findings of the liver parenchyma and two intrahepatic biliary findings identified on CT scans in 36 patients with end-stage cirrhosis caused by primary sclerosing cholangitis were compared with the frequency of the same findings in 472 patients with end-stage cirrhosis caused by other factors. The morphologic findings were lobulation of the liver contour, atrophy of the lateral or posterior hepatic segments, hypertrophy of the caudate lobe, and pseudotumor of the caudate lobe. Lobulation, atrophy, and hypertrophy were subclassified as mild-moderate or severe. The biliary findings were ductal dilatation and calculi. RESULTS: Each of the 11 findings occurred more frequently (P < .05) in patients with primary sclerosing cholangitis than in the other 472 patients. Six findings occurred more frequently (P < .05) in patients with primary sclerosing cholangitis than in patients with cirrhosis caused by any other single agent. CONCLUSION: There is a significant difference in the hepatic morphology observed in patients with primary sclerosing cholangitis-induced end-stage cirrhosis versus that in patients with end-stage cirrhosis of other causes.

Adolescent↗
PubMed1999

Primary sclerosing cholangitis: MR imaging findings with pathologic correlation.

OBJECTIVE: The purpose of this study was to evaluate MR imaging findings of primary sclerosing cholangitis, to compare them with histopathologic findings, and to determine if these findings help differentiate primary sclerosing cholangitis from other disorders that result in end-stage liver disease. MATERIALS AND METHODS: MR imaging was performed in 40 patients (27 men, 13 women; age range, 13-72 years; mean, 47 years) with primary sclerosing cholangitis over a 9-year period. In 16 patients who underwent orthotopic hepatic transplantation and in seven patients who underwent needle biopsy, correlation was made between MR imaging and pathologic findings. RESULTS: Focal signal changes in the liver parenchyma were seen on T2-weighted images as peripheral wedge-shaped zones of increased signal intensity in 29 patients (72%), as a reticular pattern in 15 patients (38%), and as periportal edema in 16 patients (40%). Lobar atrophy involved the right lobe in three patients (8%) and the left lobe in 11 patients (28%); hypertrophy of the caudate lobe was seen in nine patients (23%). Features of portal hypertension were seen in 14 patients (35%). Histologic assessment showed zones of segmental atrophy and scarring on the periphery of the liver. CONCLUSION: Peripheral wedge-shaped areas of high T2 signal intensity and dilatation of bile ducts are characteristic MR features of primary sclerosing cholangitis. Pathologic correlation suggests that these features may be related to underlying perfusion changes and bile duct inflammation in patients with primary sclerosing cholangitis.

Adolescent↗
PubMed1980

Sclerosing cholangitis in ulcerative colitis.

In a 5-year period 48 (14%) of 336 patients with ulcerative colitis were found to have hepatobiliary disease. The bile ducts were examined in 35 of these patients, and optimal visualization of both intra- and extra-hepatic bile ducts was obtained in 26. Duct changes compatible with sclerosing cholangitis were found in 14 patients. This finding of sclerosing cholangitis in 4% of all patients admitted with ulcerative colitis by far exceeds previous estimations on the incidence of sclerosing cholangitis in ulcerative colitis. The entire colon was usually affected, and the symptoms of the bowel disease were most often mild or moderate. The age at the onset of the colitis was usually below 20 years in patients with combined ulcerative colitis and hepatobiliary disease. In most patients the hepatobiliary disease gave no symptoms. Biochemical data and the histological findings in the liver biopsies did not distinguish between patients with hepatobiliary disease with and without sclerosing cholangitis. Our follow-up study has so far shown that most patients with sclerosing cholangitis remain asymptomatic for a considerable period of time.

Adolescent↗
PubMed2000

Linkage of persistent cholangitis after bilioenterostomy with biliary carcinogenesis in hamsters.

Biliary carcinoma occurring after bilioenterostomy has been reported as a late complication of this surgical procedure. The present study was designed to determine if bilioenterostomy promotes biliary carcinogenesis, and also to clarify the relationship between biliary inflammation and biliary carcinogenesis in hamsters. Syrian hamsters underwent a simple laparotomy (SL), choledochoduodenostomy (CD) or choledochojejunostomy (CJ). All hamsters received subcutaneous injections of the chemical carcinogen, N-nitrosobis (2-oxopropyl) amine (BOP), and were sacrificed 20 weeks after surgery. Neoplastic lesions in the biliary tree were histologically examined, and the presence and degree of cholangitis was also evaluated with special reference to biliary carcinogenesis. The incidence of bile duct carcinoma was not significantly different among the three groups. Numerous bile duct carcinomas, however, were recognized in the bilioenterostomized animals, especially in the CJ group. Moreover, significant correlations between biliary carcinogenesis and the presence of cholangitis were noted in both the CD and CJ groups, but not in the SL control group. Severe cholangitis was evident in the CJ group, and the number of biliary carcinomas was well correlated with the degree of cholangitis. In conclusion, the risk of carcinoma in the biliary tract may increase when persistent cholangitis is present after biliary reconstruction.

Animals↗
PubMedDate not supplied

Endoscopic therapy in primary sclerosing cholangitis: outcome of treatment and risk of cancer.

BACKGROUND/AIMS: Primary sclerosing cholangitis is a cholestatic liver disease characterized by multifocal strictures in the intra- and extrahepatic biliary tree. Dominant strictures may arise in the extrahepatic bile ducts, and in these circumstances, endoscopic therapy has been introduced to relieve cholestasis and perhaps also delay the development of liver cirrhosis. The experience of endoscopic treatment at this point in time is limited and the long-term benefit is not clear. Neoplastic transformation in primary sclerosing cholangitis is unpredictable, which is illustrated in the present study along with an evaluation of the efficacy of endoscopic treatment. METHODOLOGY: Endoscopic retrograde cholangiopancreatography was performed in 25 patients with primary sclerosing cholangitis. In 15 there were dominant strictures in the hilum of the liver and/or the distal bile duct and these patients were treated by dilation and/or endoprostheses. Four patients in the treatment group had just cholestatic biochemical test results and 11 were symptomatic. RESULTS: Endoscopic therapy was technically successful in all 15 patients. In 43 sessions, 5 patients were treated by dilation, 2 with endoprostheses, and 8 by both methods. Improvement was achieved radiologically in 12 patients, clinically in 8, and according to liver function tests in 7. Therapy was complicated by cholangitis in 5 patients. Complications were mild and there was no mortality related to the procedure. However, 6 patients in the treatment group died, 5 of cholangiocarcinoma and 1 of colon cancer. CONCLUSIONS: Endoscopic therapy in primary sclerosing cholangitis is indicated in selected patients. The cancer incidence is high, not least in patients with deteriorating disease. It is important to find techniques for identifying patients at risk in order to perform liver transplantation before malignant transformation.

Adult↗
PubMedDate not supplied

Atypical primary sclerosing cholangitis cases associated with unusual pancreatitis.

BACKGROUND/AIMS: We encountered one group of primary sclerosing cholangitis cases which met classic criteria, but demonstrated better clinical courses. METHODOLOGY: We evaluated the clinical characteristics of several cases of primary sclerosing cholangitis, especially those associated with chronic pancreatitis. RESULTS: Of a total of 25 cases, eight had a background of pancreatitis with unusual irregularly segmental or diffuse narrowing features on pancreatography. Abdominal ultrasonography and computed tomography also revealed segmental or diffuse enlargement of the pancreas. Pathological findings of surgical specimens in two cases pointed to lymphoplasmacytic sclerosing pancreatitis. The walls of the lower biliary ducts were also thickened with a similar appearance to the pancreatic ducts. In seven cases, cholangiography displayed stenosis of the lower part of the common bile duct and in one case, only the hepatic hilar region was affected. In this case both biliary and pancreatic lesions responded to steroid therapy simultaneously. One case developed hepatic hilar stenosis four months after a lesion in the lower part of the common bile duct had disappeared. The cases of primary sclerosing cholangitis with pancreatitis demonstrated better clinical courses than did typical cases of primary sclerosing cholangitis. Six cases were characterized by autoimmunological abnormalities. CONCLUSIONS: We concluded that similar etiological agents might impact on both the pancreas and biliary tract, either simultaneously or in sequence. We propose new criteria for these atypical primary sclerosing cholangitis cases.

Aged↗
PubMedDate not supplied

Primary sclerosing cholangitis associated with autoimmune pancreatitis.

We present 2 cases of primary sclerosing cholangitis complicated with autoimmune pancreatitis with narrowing of the pancreatic duct. In both cases, endoscopic retrograde cholangiography showed the characteristic findings of primary sclerosing cholangitis. In addition, positivity for autoantibody, hypergamma-globulinemia and narrowing of the pancreatic duct shown on endoscopic retrograde pancreatography were noticed in both. They were thu diagnosed as autoimmune pancreatitis. Whereas it is well known that primary sclerosing cholangitis is often complicated with chronic pancreatitis, it has rarely been studied whether the chronic pancreatitis is autoimmune pancreatitis or not. In English literature, possibly 7 equivalent cases have been reported so far. In those cases, the onset was in the post-prime of life, and the disease was frequently accompanied with Sjögren's syndrome, but not with ulcerative colitis; frankly the nature of the disease was slightly different from what has traditionally been thought as a typical primary sclerosing cholangitis. In primary sclerosing cholangitis complicated with autoimmune pancreatitis, the autoimmune mechanism seems to be much involved, and thus steroid therapy might be effective as in Case 2 in our series.

Adenocarcinoma↗
PubMed2002

Jaundice clearance and cholangitis in the first year following portoenterostomy for biliary atresia.

Sixty-one patients with biliary atresia, who underwent portoenterostomy (PE) between 1992 to 1998 in the Institute of Pediatrics, Kuala Lumpur and were followed for a period of one year, were studied to analyze the factors associated with jaundice clearance and cholangitis following PE. Sex distribution was equal. Majority of patients were Malays. Mean age in days at admission to the surgical ward was 66.90 +/- 23.36 and mean age at PE was 75.85 +/- 24.05. At the end of one-year follow-up, six patients (10%) had died, 35 (57%) developed one or more attacks of cholangitis, 35 (57%) had portal hypertension, eight (13%) liver failure and six patients had esophageal variceal bleeding. Thirty-three patients (54%) had jaundice clearance with a mean clearance time of 85 days after PE. The study shows that when the ductules in the porta hepatis were < 150 mu in size, persistence of jaundice after PE and the incidence of cholangitis in the first post-operative year were higher; patients with cholangitis in the first year had lower rate of jaundice clearance. Jaundice clearance was achieved in more patients when their postnatal age at the time of PE was lower but the relationship was not linear. Age at PE also did not have a linear temporal relationship to the incidence of cholangitis and the size of portal ductules. Prospective, multi-center based local studies on a bigger patient population are needed to identify other indicators of successful outcome following PE. This would help to define the indications for primary liver transplantation in the local population.

Biliary Atresia↗
PubMedDate not supplied

Does colitis associated with primary sclerosing cholangitis represent an actual subset of ulcerative colitis?

BACKGROUND/AIMS: The clinical course and endoscopic features of colitis associated with primary sclerosing cholangitis have not been well documented. METHODOLOGY: Since 1980, a total of 485 patients with ulcerative colitis have been seen in our departments. During this period, we experienced 6 patients with primary sclerosing cholangitis, 4 of whom had ulcerative colitis concomitantly. RESULTS: Colitis preceded primary sclerosing cholangitis in 3 of the 4 patients. There were 2 males and 2 females. One patient had left-sided colitis while 3 had total colitis, 1 with a first attack and 3 with relapsing-remitting type. Two of the 4 patients had colonoscopically dominant inflammation in the proximal colon with continuous histological inflammation from the rectum to the proximal colon. Three colitic patients have been well controlled with oral sulfasalzine or mesalazine administration. Only 1 female patient had been hospitalized twice for moderately severe attacks of ulcerative colitis that required systemic prednisolone administration, however, this patient quickly responded to this treatment for each admission. CONCLUSIONS: Colitis associated with primary sclerosing cholangitis exhibited atypical colonoscopic findings and exhibited milder disease activity than ulcerative colitis without primary sclerosing cholangitis.

Adult↗
PubMed2003

Prostaglandin E receptors in bile ducts of hepatolithiasis patients and the pathobiological significance for cholangitis.

BACKGROUND & AIMS: In hepatolithiasis, chronic proliferative cholangitis may influence the progression of the disease. Prostaglandin (PG) E(2) experimentally causes morphologic changes to intrahepatic bile ducts, analogous to the changes found in cholangitis. This study was designed to gain an understanding of the involvement of PGE(2) and PGE receptor (EP) subtypes in the development of cholangitis. METHODS: The expression levels of secretory-type group IIA phospholipase A(2) (sPLA(2)-IIA) and cyclooxygenase (COX)-2 as well as EP subtypes were determined in the bile ducts with change of cholangitis. In in vitro experiments, growth promotion and mucin secretagogue properties of biliary epithelial cells in response to EP-selective agonists or antagonists were studied. RESULTS: The messenger RNA (mRNA) level of sPLA(2)-IIA and the protein and mRNA levels of COX-2 were significantly increased in the bile ducts of patients with hepatolithiasis compared with the levels of the bile ducts of control subjects. These changes were associated with a concomitant increase in PGE(2) and total mucin concentrations in the bile. The mRNAs of EP subtypes EP(2), EP(3), and EP(4) but not EP(1) were amplified in the bile ducts. Treatment with an EP(4)-selective agonist (ONO-AE1-329) caused a dose-dependent increase in DNA synthesis, colony number, and mucin secretion in the cells. Conversely, treatment with an EP(4)-selective antagonist (ONO-AE3-208) abolished the biological effects of PGE(2) on the cells. CONCLUSIONS: In hepatolithiasis, an enhanced synthesis of sPLA(2)-/COX-2-derived PGE(2) and its actions mediated via the EP(4) receptor in the bile ducts may be of pathobiological significance for chronic proliferative cholangitis.

Aged↗
PubMed2004

Endoscopic treatment of primary sclerosing cholangitis.

BACKGROUND/AIMS: Dominant stricture of an extrahepatic bile duct is responsible for symptoms and an exacerbation of cholestasis in 15-20% of patients with primary sclerosing cholangitis. The aim of this study was to evaluate the efficacy and safety of endoscopic treatment in this selected patient group. METHODS: Retrospectively, we evaluated 16 patients who were treated endoscopically due to elevation of serum biochemical liver tests and symptoms which were attributable to dominant bile duct strictures during the period 1990 to 2003. Symptoms and biochemical liver tests were compared before and after treatment. RESULTS: Sixteen patients underwent a total of 58 therapeutic endoscopic retrograde cholangiopancreatographies (ERCP). Sixteen endoscopic sphincterotomies, 15 balloon dilatations, 6 bougie dilatations, 3 stone/sludge extractions and 8 stentings were performed. Endoscopic therapy was technically successful in all patients (100%). Biochemical liver tests were significantly improved when compared with pretreatment values (p<0.001). Patients have been followed-up without stents except for the patients who had cholangiocarcinoma and cirrhosis at the beginning. Procedure-related early complications occurred in 8.6% of therapeutic endoscopic biliary procedures. There was no mortality due to endoscopic treatment. Two patients whose stents were changed every two to three months had cholangitis due to stenting during 13 stent periods. Four patients whose stents were changed in seven to 10 days developed suppurative cholangitis (total 6 stent periods). CONCLUSIONS: Endoscopic therapy of symptomatic dominant strictures in primary sclerosing cholangitis is safe and effective. The cholangitis seen in long-term stenting seems to be solved by short-term stenting.

Adult↗
PubMed1991

The role of endoscopic papillotomy in ascending cholangitis.

The role of endoscopic papillotomy in calculous cholangitis is unclear. A retrospective review of 41 patients admitted to hospital with calculous cholangitis was carried out. There were 30 women and 11 men and their ages ranged between 49 and 98 years (mean age 77). All patients presented with abdominal pain, tenderness, chills, and fever. Clinical jaundice was present in 95 per cent of the patients. Initial endoscopic papillotomy was successful in 17 of the 41 patients. In 24 patients cholangitis persisted or recurred and further therapy was carried out. Surgery was successful in controlling sepsis in ten of the 24 patients. Repeat endoscopic papillotomy was successful in four of 13 patients. Surgery was successful in one of nine patients who had failed repeat endoscopic papillotomy. Nasobiliary drainage and percutaneous transhepatic drainage of the common bile duct after failed repeat endoscopic papillotomy was successful in only two of nine patients. Six patients died after failed repeat endoscopic papillotomy. We conclude that initial endoscopic papillotomy should be attempted in patients with calculous cholangitis. Surgical exploration of the common bile duct should then be carried out if initial endoscopic papillotomy fails to control cholangitis.

Aged↗
PubMedDate not supplied

The relationship between a subcutaneously placed afferent jejunal loop in a hepaticojejunostomy and postoperative cholangitis.

A subcutaneously placed afferent jejunl loop pexis, which is often performed during a hepaticojejunostomy, opens a route to the biliary tract, through which appropriate instruments can be passed should postoperative complications arise, requiring a choledochoscopy, the removal of calculi, and for the dilatation of the anastomotic site. From our clinical experience with such a pexis, however, postoperative cholangitis showing a transient fever with abdominal pain and liver dysfunction frequently develops. Further, in cases in which a subsequent dissection of this jejunal pexis was performed, there was a reduction in the incidence of cholangitis, which suggests a possible correlationship between such a pexis and cholangitis. In this investigation, bile stasis in jejunal loop has been studied, using hepatobiliary scintiscanning in examining 31 patients given a hepaticojejunostomy. Fourteen of these patients were also given a jejunal loop pexis, and 17 patients were without such a pexis. Bile stasis was found to be more frequent in the group given a jejunal loop pexis (p less than 0.001). Further, bile stasis was found in 90% of patients showing postoperative cholangitis whereas postoperative cholangitis was observed in 60% of patients with bile stasis (p less than 0.01). Thus, based on the data obtained, as well as our clinical experience, it would seem that a subcutaneously placed jejunal loop pexis should be avoided while performing a hepaticojejunostomy, unless the possibility of anastomotic stenosis and/or the retention of stones are strongly expected.

Anastomosis, Roux-en-Y↗
PubMed1988

The occurrence of cholangitis after percutaneous biliary drainage: evaluation of some risk factors.

Sepsis of the biliary tract is often reported after percutaneous transhepatic biliary drainage (PTBD) and is considered a life-threatening condition. The authors studied 39 patients with biliary stenosis (35 with neoplastic stricture and four with benign disease) with the purpose of identifying some factors possibly associated with a higher risk of cholangitis. None of the patients complained of biliary sepsis at the first clinical examination. Several factors were taken into account and were statistically tested according to Miettinen rate ratios to differentiate patients in whom cholangitis would consequently develop: nature, site and extent of basic disease, type and functioning of PTBD, skin contamination at puncture site of PTBD, and bile contamination at PTBD and at follow-up. The presence of bacteria in the first bile (31.5%) was not related to a higher risk. All subjects showed bile contamination after PTBD, but cholangitis developed in only 15 patients, and it was always supported by enteric microorganisms. When we compared patients with cholangitis and subjects without infection, it was possible to demonstrate a statistically significant association of cholangitis and the following: nature of the stricture, presence of multiple intrahepatic biliary obstruction, neoplastic invasion or compression on the duodenum, and presence of Staphylococcus aureus on the skin at puncture site at drainage.

Adult↗
PubMed1994

Endoscopic nasobiliary drainage in acute suppurative cholangitis.

BACKGROUND: Acute suppurative cholangitis is associated with significant mortality. It is best managed by drainage of the biliary tree, endoscopic, percutaneous or surgical. AIMS: To study the effect of emergency endoscopic nasobiliary drainage (ENBD) in acute suppurative calculous cholangitis. METHODS: In 37 patients with calculous cholangitis, an endoscopic nasobiliary drain (7 F) was placed in the biliary tree above the site of obstruction to ensure continuous biliary drainage. RESULTS: Success rate was 100% and there was no mortality. ENBD was performed in 4 very sick patients without the aid of fluoroscopy. Cholangitis improved in 36 of 37 patients within 12-24 hours. When the clinical condition improved, all the 36 patients were taken up for elective biliary surgery or endoscopic sphincterotomy and stone extraction. CONCLUSIONS: Emergency endoscopic nasobiliary drainage is an effective method in managing patients with acute suppurative calculous cholangitis.

Acute Disease↗
PubMed1996

[The choice of the operation and management in cholangitis].

Irrespective of the high rate of bacterial flora (intestinal, respectively) penetration into the biliary apparatus, clinically manifested cholangitis cases are relatively seldom met with. The predisposing factors involved are: penetration of virulent flora (anaerobic inclusive) into the bile ducts, presence of conditions promoting delay or discontinuation of the bile passage (biliary hypertension), and longstanding of the disease. Cholangitis associated with cholangiohepatitis development is one of the severest conditions of cholelithiasis (ChL), being observed as an independent nosological entity also. Over the period 1974 through 1993, in the clinic of abdominal surgery a total of 144 patients presenting cholangitis undergo treatment, of which in 74 (8.7 per cent) it is associated with ChL, in 58 it is discovered during reoperation on the biliary apparatus, and in twelve it is diagnosed as an independent disease, unrelated to calculosis. Acute cholangitis runs a foudroyant course with a poor prognosis, whereas the chronic form is characterized by larvate (masked) development with exacerbation periods. The clinical picture is dominated by Charcot's triad. The disease runs a rather severe course in the contingent liable to reoperation. As a rule, it occurs as the result of stricture of the bile ducts or obliteration of bilidigestive anastomosis. 58 per cent of the patients are older than 50 years. Operative intervention in acute cholangitis should be done on an emergency basis. External drainage insertion is a palliative measure, practicable in heavily damaged patients. The operation in acute and chronic cases is aimed at maximum possible healing of the biliary tract and elimination of the underlying causes of obstructed passage. Lethality is higher than the medium rate, and the prognosis remains serious.

Acute Disease↗
PubMed2001

Sclerosing cholangitis.

Primary sclerosing cholangitis is a chronic cholestatic disease that may have an autoimmune basis. Most patients have a circulating antineutrophil cytoplasmic antibody that appears to be targeted against a 50-kD nuclear envelope protein. The clinical applications of this antibody have not yet been defined. Other autoantibodies directed against antigens, such as cathepsin G, elastase, and anticardiolipin, may also be detected in some patients. It is suggested that primary sclerosing cholangitis may have a bacterial cause. Helicobacter gene sequences have been detected in liver tissues in primary sclerosing cholangitis. The role of Helicobacter spp and other bacteria in the etiopathogenesis of primary sclerosing cholangitis remains to be determined. Primary sclerosing cholangitis may overlap with autoimmune hepatitis in some cases, although the real prevalence of this association remains to be determined. Many prognostic models have been created, but they lack cross-validation, and their clinical usefulness remains limited. Endoscopic retrograde cholangiography remains the gold standard for diagnosis, but magnetic resonance imaging may be a viable alternative in many cases. Clinical trials with cladibrine, pentoxifylline, and budesonide have failed to demonstrate benefits. Orthotopic liver transplantation remains the only effective treatment.

Journal Article↗