The pathogenesis of the hepatic encephalopathy (HE) in spite of substantial progresses in this field still rests unclear. Actually four main hypotheses of the pathogenesis are discussed: the ammonia-hypothesis, the synergism-hypothesis, the hypothesis of the false neurotransmitters and that one of the changes of the normal neurotransmitters and their receptors. A connecting function seems to come up to ammonia. --Reduction of oral protein intake, selection of certain proteins, oral administration of nonabsorbable antibiotics and enemas should be used in order to prevent the intestinal absorption of toxic metabolic products. The parenteral nutrition has the therapy of HE substantially improved. Primarily, the patients receive special amino acid mixtures with a high content of branched chain amino acids and a low content of aromatic acids. The exchange of carbohydrate to some extent through fat improves the parenteral nutrition regime for these patients. The different liver support systems have failed to improve the prognosis of fulminant hepatic failure.
Benign tumors of the gallbladder are rare. Under them often is found the adenomyoma. About 13 of such cases is reported. They are not true neoplasias and will be called as tumorlike lesions. Clinical and aetiological problems are discussed.
Antithrombin III/AT III/, plasminogen (Plg) and proactivator of plasminogen [PPlg] activity were studied in 663 patients with various liver diseases and 547 healthy subjects. Parallel analysis of AT III, Plg and PPlg gives a very valuable prognostic information concerning the forthcoming evolution of viral hepatitis [v.h] and acute liver failure. The prognosis of v.h. in the cases with normal Plg activity is independent from the AT III activity in 98% of the cases it is associated with clinical improvement. The combination with low Plg and elevated AT III activity suggested clinical improvement in 65-90% of the patients. Most critical is the combination between low Plg and low AT III activity. This combination suggests clinical aggravation and danger of hepatic coma. The existence of 4 patterns of AT III activity is shown: elevated, normal in physiological condition, normal in pathological condition and decreased activity.
Until recently, vasomotor effects of gastrointestinal polypeptide hormones have been observed primarily in animal experimentation. 33 volunteers were observed to survey the influence of secretin (1 CU/bw./h) and pentagastrin (0.75 micrograms/bw/h) on peripheral blood gas concentrations and on the acid/base balance. Compared to a control group, secretin caused a significant increase in pO2 and in O2 saturation (p less than 0.05). In contrast to secretin, pentagastrin caused a significant decrease in the pO2 as well as in the O2 saturation (p less than 0.05) pCO2, pH and HCO3 were not significantly affected by either secretin or pentagastrin. These results can be interpreted as possible direct vasodilatative/constrictive as well as local metabolic effects of secretin and pentagastrin.
The elimination of caffeine from the plasma and the excretion of the major metabolites of metamizol (AnalginR) in the urine was studied in 25 women on long-term oral steroid contraceptives. Both tests allowed to draw conclusions about metabolic liver function. A steroid-induced delay of the elimination of caffeine in clinically healthy women with/without serologic elevation of aminotransferase activities was demonstrated. --We regard this as the consequence of an inhibition of the cytochrome P-450-dependent poly-functional oxidases of the P-450MC type, which was produced by oral contraceptives. The differences in the elimination of metamizol were not significant.
110 patients with benign gastric ulcer and concomitant joint diseases (rheumatoid arthritis, osteoarthrosis) were treated in a comparative short-term clinical trial to assess the relative efficacy of calcitonin (daily 100 MRC of salmon calcitonin intramuscularly), cimetidine (daily 1000 mg orally) and colloidal bismuth subcitrate (De-Nol-four times a day in doses of 5 ml diluted with 15 ml of water). Groups of patients were comparable according to age, sex, duration of ulcer disease, smoking habits, gastric acid secretion and mean ulcer size. The ulcer healing was controlled endoscopically after 2 and 4 weeks of the treatment. There was no significant difference in the ulcer healing rate between three groups neither after 2 weeks (calcitonin-36.7% of healed ulcers, cimetidine-37.5% and De-Nol-35.0% nor after 4 weeks respectively (76.7%, 72.5% and 77.5%). In the calcitonin group a gradual joint pain relief was observed in 84% of patients who complained arthralgia. The moderate side effects (headache, nausea, flush) were observed only in the patients treated with calcitonin (8 subjects). We suggest that calcitonin may be considered as a valid anti-ulcer drug in the peptic ulcer patients with concomitant rheumatological diseases especially with osteoporosis.
We observed 87 patients with duodenal ulcer disease about one year. 46 patients (first group) after proximal gastric vagotomy were observed. A second group (41 patients) were treated with antacids only. We compared our patients for their complaints, consumption of antacids, relapse rate and clinical, social and genetic aspects. The clearly better results of the surgically treated patients allow the conclusion for a better quality of life in patients after proximal gastric vagotomy.
Case report about a carcinoma of the appendix, recognized by obduction of an 58-years old man. Discussion of rarity, difficult clinical diagnostic, histological classification, metastasis and problems of differential diagnosis and therapy.
Two cases are described, which revealed the picture of a dihydralazine-induced chronic aggressive hepatitis bioptically. One case was laparotomized under the clinical diagnosis of obstruction jaundice, the other exhibited no symptoms and was detected by elevated transaminases only. The time of exposure was 2-3 years. After withdrawal of dihydralazine the patients recovered within 2-3 months. Elevated transaminases (more than 1 mumol) should given occasion for withdrawing the drug or for performing of liver biopsy. In a total of 6,581 liver biopsies within five years an acute dihydralazine-hepatitis was seen more frequent than a chronic one (ratio 77:2).
The iron content of liver and gastric mucosa was quantitatively examined by means of atomic absorption spectrometry in 36 patients with iron overload (22 with idiopathic haemochromatosis, 14 with therapy-resistant anaemia) and in 17 subjects without anomaly of iron metabolism. Diagnostically evaluable iron deposits in gastric mucosa were only found in severe iron overload. In this case it was correlated with the hepatic iron content, and was indicative of iron-related disturbances also in other organs. The quantitative iron determination represents a diagnostic enlargement. It is indicated, if simple noninvasive methods are failing, and it should never be omitted in suspected iron overload, whenever other reasons as well are demanding gastroscopy.
Our investigations in 134 patients showed corresponding to literature porphyria cutanea tarda (PCT) diagnosed by biochemical methods not to be a paraneoplastic dermatosis (but one possible exception acquainted). Relations between PCT and extrahepatic non-porphyrin producing tumours are improbable. Nevertheless but extremely seldom an irregular urinary porphyrin excretion associated with cutaneous changes of hepatic porphyria should lead to the presumption of a porphyrin producing hepatoma. PCT lasting for decades apparently presents a higher frequency of hepatocellular carcinoma in patients suffering from liver cirrhosis than in cirrhotics without PCT. It is supposed that this possible progredience of liver disease in PCT into hepatocellular carcinoma may be prevented by chloroquine phosphate therapy.
In 731 hyperplasiogenic polyps which have been removed by endoscopical polypectomy there were 9 polyps with an early cancer and 8 polyps with severe dysplasias (borderline lesions) as well as 1 polyp, in which an advanced carcinoma has been developed. This is the outstanding greatest number of hyperplasiogenic polyps with a malignant transformation. In addition in 9 patients with hyperplasiogenic polyps carcinomas could be discovered, i.e. a rate for malignant developments of 3.7%. It seems that stomachs with multiple polyps are endangered in particular. The recurrence rate of follow-up examinations covering a period of up to 8 years was 36.1%.
In a prospective study 187 patients with diffuse fatty infiltration of the liver, estimated by ultrasound tomography, were investigated. In any case the history as well as the results of clinical investigation and the lab findings were known to the observer. Liver blind punctions were performed after a short time, on an average of 11 days. In 91.4% the sonographic diagnosis "fatty infiltration of the liver" could be confirmed by histological findings, while in the other cases the diagnosis was incorrect or incomplete respectively. Following sonographic criterions any results were graduated into three groups and compared with the percentage of fat infiltrated liver cells found by histological investigation. There was a high accuracy in patient with fatty liver: 90.9% could be established by ultrasound tomography. Only in those cases, in which the sonographic diagnosis "fatty infiltration" is not confirmed by case history, clinical and lab findings, the liver biopsy is to be performed.
Specificity and sensitivity of ALTAB test have been estimated in 40 healthy children and 13 cystic fibrosis patients. The test has been carried out in the modification as 2-hour-serum PABA-test. The found specificity was 90%, the sensitivity 100% respectively. Therefore this test is suitable for evaluation of exocrine pancreas function.
We examined 21 patients with duodenal ulcer confirmed by endoscopy for disturbances of esophageal function, using manometric techniques and long-term pH measurement. Pathological manometric findings, largely of a mild degree, were obtained in 48 per cent of the patients examined, and a pathological gastro-esophageal reflux was found in 81 per cent, with only 33 per cent suffering from reflux esophagitis as confirmed by endoscopy and/or histological examination. Although duodenal ulcer and disturbed esophageal function often appear simultaneously, a causal connection seems unlikely. Alcohol and nicotine stimulate reflux, with the degree of severity depending on the amount.
An examination of esophageal function using manometric techniques and long-term pH measurement was carried out on 14 patients suffering from cirrhosis of the liver who had esophageal varices. The resting pressure in the lower esophageal sphincter was found to be slightly reduced in 50 per cent of those examined, while 100 per cent showed a slightly reduced contraction amplitude in the distal tubular esophagus which became progressively lower in the distal direction, and a pathological gastro-esophageal reflux was observed in 57 per cent. We were able to carry out a control examination on 10 of these patients after sclerosing procedure. Sclerotherapy was found to have lowered resting pressures in the lower esophageal sphincter in 80 per cent of those patients, while all of them showed a grossly impaired tubular peristalsis in the form of simultaneous, mostly repetitive contractions with a considerably lowered contraction amplitude, however it had no negative influence on gastro-esophageal reflux patterns.
The tolerability of the compound AWD 26-06 (which is to classify as a M1-antagonist in consequence of the pharmacological investigations) was investigated in 11 healthy male persons with increasing dosage from 5 to 150 mg. Dryness of the mouth and scratch in the throat were observed by a dosage of 50 mg onwards, a diminuation of the flow of saliva and the accommodation were observed by a dosage of 100 and 150 mg, respectively. The frequency of the heart, but not the blood pressure, is increased by 150 mg of AWD 26-06. The influence on the secretion of the gastric juice was investigated in normal conditions and after stimulation by Pentagastrin with a dosage of AWD 26-06 of 25 mg in comparison with a placebo on 7 healthy male persons. The volume of gastric juice was diminished by 35% in all fractions, but the secretion of HCl, measured as basal acid output and peak acid output, was diminished in 5 of the 7 persons by 20%. A further investigation in order to check the therapeutic effect in patients with ulcus ventriculi and ulcus duodeni, respectively, is necessary and useful.
The increased oxalic acid absorption is a well documented finding in gastroenterological diseases. The malabsorption of bile acids and fat is important in the pathogenesis of the hyperoxaluria. The enteric absorption of 14C-labelled oxalic acid was measured in 49 patients with different diseases. The dihydroxy-trihydroxy-ratio of bile acids is significantly decreased in patients with hyperoxaluria over 20% of the ingested dosage. We didn't find any correlation between the excretion of oxalic acid and the intraduodenal pancreatic lipase activity.
The domain of cryosurgery in proctology is in the field of inoperable anal and rectal carcinoma therapy with the aim of improving living quality. By intravital microscopy the role of microcirculation as the causative factor for counterheating could be proved. There by the cryodestruction is restricted. By temperature measurements we know that the limit for absolute tissue destruction is given at 3-8 mm tissue depth. A new device for cryosurgical treatment of inoperable anal and rectal carcinoma was developed (2nd generation of the device) and introduced into praxis. A total of 247 cases were our own patients at the average age of 75 years and a lethality of 0.25%. Generally, an improvement of living quality was achieved by the cryotherapy in those patients with stenosing colorectal carcinoma. 50% of all patients lived longer than 2 years. In 242 patients of the total of 247 cryosurgically treated patients the establishing of an anus praeter could be spared.
Biopsies taken from various regions of the duodenal mucosa were investigated with a quantitative histological method with a view to frequency, quantity, and localisation of the duodenitis in clinically proven chronic pancreatitis. The histologic classification of duodenitis was made according to Whitehead et al. Out of 46 patients suffering from a chronic pancreatitis, 19 had a duodenitis grade 1 in the pars superior and pars descendens. A more frequent occurrence of duodenitis with concomitant chronic gastritis or a pathologic condition of the bile duct or a chronic alcohol abuse could not be proved statistically.
