Epidemiology and treatment of gastric Campylobacter pylori infection: more questions than answers

Two-hundred and ten consecutive patients undergoing routine gastroscopy were additionally investigated for evidence of Campylobacter pylori (C.p.). 106 patients were positive in one or more tests: 99.1% using a rapid urease detecting test (CLO-test), 80.2% histology, 78.3% cytology and 60% culture. We found no difference between the CLO-test results from biopsies taken from different parts of the stomach in individual patients. C.p. was found in 100% of patients with significant chronic antral gastritis, 67.7% with gastric ulcers, 65% with duodenal ulcers and in 12.1% of normal individuals. The C.p. infection was apparently eliminated in 50% of cases treated with bismuth subsalicylate (BSS) for four weeks. The combination of BSS with amoxicillin, tinidazole or an H2-receptor antagonist offered no advantage over BSS alone. Treatment with BSS led to improvement in symptoms and histological findings including healing of ulcers in patients with or without persistent C.p. infection. The recurrence of C.p. infection after apparently successful treatment was, however, 75% in 4 weeks. In conclusion, C.p. infection correlates strongly with the presence of chronic gastritis, and significantly with gastric and duodenal ulceration. The best diagnostic approach is the combination of a rapid urease detecting test and histology. C.p. infection is of long duration and difficult to eliminate. The most effective treatment for C.p. infection remains BSS as single agent.

Advances in the enzyme diagnosis of pancreatic diseases

This paper reviews recent developments of analytical methods for the determination of alpha-amylase, of its isoenzymes, and of lipase. The evaluation of severity and etiology of acute pancreatitis by enzyme assays, e.g., pancreatic elastase 1, phospholipase A2, and routine enzymes are discussed. The limited significance of enzyme determinations as compared to imaging and endoscopic procedures for the diagnosis of chronic pancreatitis is demonstrated. Indirect "tubeless" tests for the evaluation of pancreatic exocrine insufficiency with respect to the secretion of chymotrypsin (chymotrypsin in stool and NBT-PABA test) and cholesterol esterase (pancreolauryl test) are reviewed. Finally, the superiority of morphologic investigations over biochemical tests for the timely detection of pancreatic carcinoma is shown.

Progress in the enzyme diagnosis of liver disease: reality or illusion?

This paper discusses the progress of enzyme diagnosis by different examples. These include: the requirement for improved enzymological screening, despite the introduction of a test for hepatitis C; the imbalance between the popularity of "unexplained chronic aminotransferase elevations" and efforts to solve the inherent problems; the inadequate attempts to use the metabolic changes in the hepatocytes to improve diagnosis, prognosis, and pathophysiological understanding of viral liver diseases; the remarkable investigations into the 2'-5'-oligoadenylate synthetase for better control of interferon therapy in chronic viral hepatitis; the use of enzymes as markers of etiology, particularly for the detection of alcohol induced liver diseases; the continuing preference for the aminotransferases in this scenario although the ratios of aspartate aminotransferase over alanine aminotransferase, or of mitochondrial aspartate aminotransferase over total aspartate aminotransferase activity, largely depend on the severity and intralobular localization of damage and the stage of the liver disease.

[The Alagille syndrome in an adult]

Severe bleeding from gastric varices occurred in an 18-year-old male known, since he was three years old, to have liver cirrhosis with beginning protal hypertension. The cause of the portal hypertension was chronic cholestasis due to hypoplasia of the interlobular bile ducts. There was also peripheral pulmonary stenosis with pulmonary hypertension (106 mmHg systolic), and a posterior embryotoxon (arcus juvenilis). Skeletal anomalies, particularly of the vertebrae, and a striking facial dysmorphism provided the features of arteriohepatic dysplasia, Alagille's syndrome, an autosomal dominant disease generally becoming manifest during childhood. As the patient's liver functions were only slightly abnormal, liver transplantation was not indicated and a shunt operation performed. A septicaemia developed on the third postoperative day after an at first complication free course, and he died from right-heart failure.

Lidocaine metabolite formation as a measure of liver function in patients with cirrhosis

A method for rapid assessment of hepatic function in cirrhotics based on the formation of the lidocaine metabolite, monoethylglycinexylidide (MEGX), was evaluated. The formation kinetics and urinary excretion patterns of MEGX clearly distinguished cirrhotics (n = 12) from healthy volunteers (n = 16). In a prospective study, we compared the prognostic value of the MEGX test with that of traditional parameters in transplant candidates. Patients who underwent transplantation during follow-up were excluded. The study included 58 adult patients with biopsy-proven posthepatitic or biliary cirrhosis. During the follow-up period of 120 days, 10 of 58 patients died of their liver disease. At the time of inclusion, we recorded MEGX formation, indocyanine green (ICG) half-life, caffeine clearance, and the Child-Pugh score. These variables were subjected as covariates to a survival analysis (Cox proportional hazards regression model). The results of the MEGX and the ICG test were significantly related to the 120-day survival. In the stepwise analysis, none of the parameters evaluated contributed to a further significant improvement of our predictive ability when added to the values of ICG (improvement: p less than 0.0005) and MEGX (improvement: p less than 0.0005). These findings suggest that the ICG and MEGX tests were the best short-term prognostic indicators. The easy handling favors the MEGX test over the ICG test as a tool for assessment of hepatic function and short-term prognosis in transplant candidates with cirrhosis.

[Review article: colostral leukocytes and their significance for the immune system of newborns]

The colostrum contains a comparably high concentration of leukocytes as the peripheral blood. The majority of them are vital leukocytes, namely neutrophils, macrophages and lymphocytes. There is some evidence in mouse and man that lymphocytes from the gut-associated lymphoid tissue home selectively to the peripartal mammary gland. The phagocytic cells may be involved in the transportation of certain immunoglobulins into the neonate. In vitro colostral leukocytes exhibit a variety of immunological activities such as blastogenesis after mitogenic and antigenic stimulation, cytotoxicity and phagocytosis, but the medium milk confines these activities in comparison with those of blood leukocytes. Intact colostral leukocytes reach the gut of the gut of the newborn and may even cross the intestinal wall, gaining access to the neonates system and influencing its immunologic reactions, e.g. hypersensitivity and antibody-formation. The knowledge on the significance of colostral leukocytes for the protection against infection of the neonate is still limited.

Neurophysiological assessment of early hepatic encephalopathy

The spontaneous EEG, pattern reversal VEPs, and the P300 wave were studied in patients with liver cirrhosis and early stages of hepatic encephalopathy (HE). The sensitivities of the different neurophysiological methods in the early stages of hepatic encephalopathy were compared with each other and with several neuropsychological tests. P300 latency was shown to be the most appropriate neurophysiological method for detection of early HE. The diagnostic sensitivity of the P300 latency resembled that of the number connection test (NCT). These results are discussed with regard to methodological considerations and the clinical use of both methods.

Diagnostic application of mitochondrial enzymes and isoenzymes

Evolutionary, topological and metabolic aspects of mitochondrial enzymes and isoenzymes are reviewed, and the structural and functional heterogeneity of mitochondria is demonstrated. Primary deficiencies of mitochondrial enzymes are described and the need for their proper recognition is illustrated. Species differences of secondary dysfunction of mitochondrial enzymes are shown. The release of mitochondrial enzymes is compared to that of cytosolic enzymes from liver and heart muscle cells and the diagnostic significance of assays of mitochondrial enzymes in serum is evidenced. Possible mechanisms of mitochondrial enzyme release from cells and unresolved questions pertaining to this process are discussed in light of potential diagnostic utility of mitochondrial enzymes in serum.

[Erythrohepatic protoporphyria with rapidly progressing liver cirrhosis]

A 49-year-old man, known to have had an increased light sensitivity since childhood, was admitted to hospital because of jaundice. Biochemical and morphological examination revealed cirrhosis of the liver with cholestasis. There was a 70-fold increase of protoporphyrin content in the erythrocytes, increased fecal protoporphyrin excretion as well as secondary coproporphyrinuria. Despite symptomatic treatment with ursodeoxycholic acid and cholestyramine hepatic failure ensued for which orthotopic liver transplantation was performed five months after the diagnosis had been made. The patient died two months later of treatment-resistant septicaemia and multiorgan failure. This case demonstrates the need for annual monitoring of liver functions and porphyrin parameters to ensure earliest possible diagnosis of hepatic involvement in erythrohepatic protoporphyria.

Unusually rapid development of a HBsAG-positive liver cirrhosis after liver transplantation

We report the case of a 44-year-old man who was transplanted in 1986 for hepatocellular carcinoma in a HBsAG-positive liver cirrhosis. The patient had no severe complications postoperatively. He received passive immunization for the prevention of hepatitis B reinfection during the first 6 months after liver grafting. Twelve months after the transplantation the new liver was reinfected with hepatitis B virus. Without any clinical or laboratory signs of severe hepatitis, the patient developed a histologically proven complete liver cirrhosis within 8 months after reinfection of the graft. The reasons for this might have been, first, a deleterious course of the infection under immunosuppressive therapy, and, second, the additional influence of a postoperatively acquired CMV infection or the combined toxic influence of cyclosporin A and its metabolites on the acute inflammation in the liver.

Energy expenditure in children with type I diabetes: evidence for increased thermogenesis

The aim of the study was to assess whether increased energy expenditure causes the negative energy balance (tissue catabolism) commonly seen in children with insulin dependent (type I) diabetes. Resting metabolic rate and thermogenesis induced by adrenaline were measured in five healthy children and 14 children with type I diabetes who were all free of clinical signs of late complications of diabetes mellitus but differed in their degree of glycaemic control (in eight glycated haemoglobin concentration was less than 10% and in the six others greater than or equal to 10%). When compared with the control subjects children with type I diabetes had normal resting metabolic rates but their urinary nitrogen excretion was significantly raised (11.5 (SD 5.4) mg/min in those with glycated haemoglobin concentration less than 10%, 11.6 (5.2) mg/min in those with concentration greater than or equal to 10% v 5.4 (3.0) mg/min in control subjects). During the infusion of adrenaline the diabetic children showed a threefold and sustained increase in thermogenesis and disproportionate increases in the work done by the heart, in lipid oxidation rate, and in plasma concentrations of glucose, free fatty acids, and ketone bodies. The increased thermogenic effect of adrenaline did not correlate with the degree of glycaemic control. Increased thermogenesis may explain the tissue wasting commonly seen in children with type I diabetes during intercurrent stress.

[Effect of captopril therapy on sodium and water excretion in patients with liver cirrhosis and ascites]

Ascites in patients with cirrhosis of the liver frequently is refractory to diuretic treatment. It was postulated that vasoconstriction of the renal cortex, mediated by activation of the renin-angiotensin-aldosterone-system (RAAS), may be one course of the disturbed sodium- and water-excretion in these patients. We therefore investigated in 14 cirrhotic patients with ascites under constant diuretic treatment the effects of low-dose captopril therapy on urinary sodium- and potassium-excretion, body weight, abdominal girth, serum-sodium, -potassium, creatinine-clearance, plasma-renin-activity (PRA), plasma-aldosterone (PA) and mean arterial pressure (MAP). After a control period of 4 days the patients received 2 x 6.25 mg/d captopril for 5 days and 4 x 6.25 mg/d for further 5 days. Treatment was followed by a second control period without captopril. PRA increased significantly after 2 days of captopril treatment. 2 x 6.25 mg/d captopril induced a significant increase in sodium excretion and a significant decrease of body weight. MAP decreased slightly but significantly without clinical signs of hypotension. 4 x 6.25 mg/d captopril resulted in a further reduction of body weight and a further enhancement of sodium excretion. Three days after withdrawal of captopril sodium output was significantly reduced again.

CONCLUSION

In cirrhotic patients low-dose captopril seems to be efficient in the treatment of ascites resistant to diuretics without causing major side effects.

The role of glucocorticoids in the regulation of thyrotropin

The potentially inhibitory action of endogenous or exogenous synthetic glucocorticoids on TSH secretion was investigated. Pulsatile and circadian TSH and cortisol rhythms were measured in healthy subjects (12 rhythms), but no correlation between the hormones could be detected. Acute stimulation of endogenous cortisol secretion by CRH tests (1 microgram/kg of ovine CRH) at 20.00 h in 9 healthy volunteers did not significantly alter the nightly increase in TSH. Chronic elevation of endogenous cortisol serum levels in patients with Cushing's disease revealed a heterogeneous pattern. In 2 patients serum TSH and thyroid hormone levels showed a normal 24-h rhythm, whereas the other 2 patients had low TSH serum levels. Acute treatment of 9 healthy volunteers with 0.5, 1 or 2 mg dexamethasone po at 23.00 h resulted in a significant dose-dependent suppression of mean basal TSH levels 9h later. Treatment with 30 mg of prednisone for 1 week in 7 patients with Crohn's disease did not influence basal TSH. The TSH response to TRH was only temporarily suppressed on day 3, but not on day 7 of treatment. The results suggest than under physiological conditions glucocorticoids have no regulatory influence on pulsatile and circadian TSH secretion.

[Epidemiology and therapy of Campylobacter pylori infection]

The prevalence of Campylobacter pylori in gastric mucosa was investigated prospectively (by histology, cytology, bacterial culture and urease rapid-test) in 302 patients of a routine gastroenterological endoscopy programme. According to the histopathological findings the following prevalence of C. pylori was established: 3 of 35 normals (9%); 116 of 167 with antral gastritis (69%), 28 of 40 with gastric ulcers (70%); 26 of 33 with duodenal ulcers (79%); 5 of 27 with other conditions (19%). The activity degree of the gastritis correlated closely with the presence of C. pylori. In a prospective open trial 110 patients with antral gastritis or gastroduodenal ulcer were treated according to the following schedule: (a) bismuth subsalicylate, 1800 mg/d for four weeks (35 patients); (b) amoxycillin 2250 mg/d for two weeks (6); (c) ranitidine 300 mg/d for four weeks (26); (d) bismuth plus amoxycillin (20); (e) bismuth plus ranitidine (23). Immediately after the end of treatment and four weeks later the elimination rates were: (a) bismuth 51% (18) and 23% (8), respectively; (b) amoxycillin 50% (3) and 17% (1); (c) ranitidine 0% (0); (d) bismuth plus amoxycillin 60% (12) and 25% (5); (e) bismuth plus ranitidine 43% (10) and 17% (4). These data indicate that treatment with bismuth plus amoxycillin will achieve a negative bacterial result in about half the patients. But frequently as early as four weeks later C. pylori can again be demonstrated, so that the long-term elimination rate is only 15-30%.

[Chemoembolization of hepatocellular carcinoma with lipiodol, epirubicin and cisplatin]

The therapeutic effect of combined chemoembolization with lipiodol, epirubicin and cisplatin in 22 patients with nonresectable tumours, predominantly in livers with cirrhotic transformation, was analysed. Lipiodol was demonstrated in tumour tissue on average three months, maximally six months, after injection. Repeat embolization was done, if possible, after storage had subsided. There were only minor side effects. Quality of life suffered only from the, though delayed, continuing cancer growth. Survival rate was 73% after six months, 54% after one year.

Glutamate dehydrogenase: biochemical and clinical aspects of an interesting enzyme

The molecular properties and possible metabolic functions of glutamate dehydrogenase (GLDH-EC 1.4.1.3) are described. The distribution of this enzyme in the body and particularly in the liver are outlined. The significance of these properties for GLDH release into the extracellular space, for the distribution and elimination of the enzyme and, foremost, for the assay of GLDH as a diagnostic indicator of hepatic and biliary disease are shown. Analytical methods are reviewed.

Standardization by reference methods: a German viewpoint

The problems of applying optimized as well as standardized methods to the determination of enzyme activities in modern clinical laboratories are described. The failure of the so-called 'New Concept of Reference Method Values' in the quality assessment of enzyme assays is evidenced, and the advantages of standardized methods rather than only standard materials is demonstrated. Finally, the great similarities among European national recommended methods for enzyme assay is emphasized by a comparison of results obtained in estimating 5 enzymes.