Unusual Bochdalek hernia in puerperium

The authors present an unusual case of a true left-sided posterolateral (Bochdalek) hernia containing stomach, transverse colon and spleen within a hernial sac in a 25-year-old female patient. They presume this voluminous herniation took place due to a rupture of congenitally preformed hernial ostium on account of increased intraabdominal pressure during repeated pregnancy. They describe an effective surgical transabdominal laparoscopic treatment.

[Drug therapy of portal hypertension]

The author presents a list of preparations used to influence portal hypertension resulting from cirrhosis of the liver, in particular in treatment or prevention of haemorrhage from oesophageal varices or gastropathy. The author describes the mechanism of action of drugs administered in acute haemorrhage (vasopressin, terlipressin, somatostatin, octreotide)) and preparations used in primary or secondary prevention of this haemorrhage (beta-blockers, nitrates, newly tested preparations or combinations). In the conclusion are recommendations for practical procedures according to principles of evidence-based medicine.

[Bacterial infections in patients with acute hemorrhage due to portal hypertension--personal experience]

Acute haemorrhage from the upper gastrointestinal tract is a frequent and serious complication which affects 20-60% patients with cirrhosis of the liver and portal hypertension. It is assumed that bacterial infections can be the direct cause of haemorrhage but accurate data on the influence of infection on the development and course of haemorrhage are lacking. Acute haemorrhage as a result of portal hypertension has a very high mortality, 30-50%, and an early relapse of haemorrhage occurs in as many as 40% of these patients. Most recent meta-analyses indicate that bacterial infection is an independent prognostic factor in failure of haemostasis and has a significant impact on the mortality of these patients. The authors examined for the presence of bacterial infection (blood, urine, throat, ascites) 25 patients with cirrhosis of the liver and acute haemorrhage as a result of portal hypertension and compared the results with a group of 25 patients with cirrhosis of the liver and portal hypertension without acute haemorrhage. According to the results in patients with acute haemorrhage due to portal hypertension there is a significantly higher incidence of bacterial infections than in patients with cirrhosis of the liver and portal hypertension without acute haemorrhage. The results confirm the necessity to administer antibiotic prophylaxis to cirrhotic patients with varicose bleeding, not only to patients with symptoms and evidence of infection but also in their absence. Antibiotic prophylaxis extends the survival period of these patients.

[Influence of bacterial infection on the development and course of acute haemorrhage from oesophageal varices]

Acute haemorrhage from the upper portion of the gastrointestinal tract is a frequent complication which develops in ca 35-66 % of patients with cirrhosis of the liver and portal hypertension. It is assumed that one of the trigger mechanisms of varicose haemorrhage can be bacterial infection. However accurate data on the influence of infection on the development and course of haemorrhage are still lacking. The mortality of patients bleeding from oesophageal varices is very high (30-70%). Usually the cause of death is not haemorrhagic shock but haemorrhage-induced changes which lead to hepatic failure. It is assumed that in this very process an important part is played by bacterial infection with subsequent release of endotoxins. Most recent metaanalyses indicate that bacterial infection is an independent prognostic factor as regards failure to arrest haemorrhage and influences in a significant way the mortality of these patients. Antibiotic treatment of patients with varicose haemorrhage increases the survival period of these patients. Therefore to cirrhotic patients with varicose haemorrhage antibiotics should be administered prophylactically, i.e. not only to patients with evidence of infection but also those without these symptoms. The authors consider as the optimal antibiotic treatment administration of quinolones orally or by the i.v. route, possibly cephalosporins which seem to be equally effective as quinolones.

Double-blind randomized, comparative multicenter study of the effect of terlipressin in the treatment of acute esophageal variceal and/or hypertensive gastropathy bleeding

BACKGROUND/AIMS

1) To compare the effect of 2-day application of 0.2 mg terlipressin i.v. every 4 hours (group I) with that of 5-day application of 1 mg i.v. every 4 hours (group II) in the treatment of bleeding esophageal varices and portal gastropathy. 2) To assess the incidence of adverse events.

METHODOLOGY

Eighty-six patients with liver cirrhosis (54 men and 32 women, average age 51 years) were randomized over a period of 2 years into 2 groups. Acute bleeding was diagnosed endoscopically within 24 hours of its onset. The two groups fully comparable; treatment failure rated according to "Baveno II".

RESULTS

Success rate in group I was 78% at day 2 and 75% at day 5; in group II 89% and 79%, respectively (no statistical significance). Rebleeding had occurred by day 5 in 15% in group I, and in 16.3% in group II. Transfusion needs by day 2 were significantly lower in group II (2.4 units compare to 3.4 units in I). The 30-day mortality was 17.1% in group I and 20% in group II. No statistical difference between I and II in the occurrence of adverse events.

CONCLUSIONS

At a dosage of 1 mg i.v. every 4 hours, the success rate at day 2 was as much as 90% while blood consumption was significantly lower compared with the lower dosage. Rebleeding during first 48 hours occurred almost exclusively at lower dosage. There was no increase in the rate of adverse events relative to the higher dosage.

[Rifaximin in the treatment of hepatic encephalopathy]

Hepatic encephalopathy is a frequent and serious complication of liver cirrhosis. Usually it is treated by non-absorbable disaccharides or antibiotics and its treatment is often difficult and associated with undesirable effects. The objective of our investigation was to evaluate the safety and effectiveness of a new antibiotic used in this indication--rifaximine. With rifaximine, 400 mg three times per day, a total of 25 patients were treated for a 10-day period. Significant improvement of the manifestations of encephalopathy occurred (evaluated by the grade of encephalopathy, test of combining numerals, the degree of flapping tremor and the arterial ammonia level). None of the patients developed undesirable effects. Rifaximine seems an effective, safe drug for hepatic encephalopathy.

[Spontaneous bacterial peritonitis in the Czech Republic]

The objective of the study was to assess the prevalence and more detailed data pertaining to the incidence of spontaneous bacterial peritonitis (SBP) in the Czech Republic. The authors examined 99 patients with cirrhosis of the liver and ascites. SBP was diagnosed in a high percentage--35 patients, i.e. 35.4%. It was found more frequently in patients with an alcoholic etiology of cirrhosis who had a history of subfebrile and febrile temperatures and increasing trend of ascites. For the diagnosis the increase of leucocytes in serum and C reactive protein levels may prove useful. Lower values of total protein and albumin in ascites predispose to the development of this infection. Reduction of the number of thrombocytes in the group of patients with SBP indicates the influence of portal hypertension in the etiology of this disease.

[Chronic pancreatitis in endoscopic ultrasonography--analysis of newly diagnosed cases during a 28-month period]

Endoscopic ultrasonography (EUS) is an imaging method visualising the entire pancreas by use of high-frequency ultrasound probes introduced into the close proximity of the pancreas. During the 38-month period, our clinic has examined 148 patients with the diagnostic conclusion of chronic pancreatitis. This diagnosis was newly assessed in 72 of them. Approximately one third of cases with chronic pancreatitis were in their early stages. Despite this fact, in 22% of them, the first manifestation of chronic pancreatitis was represented by biliary duct stenosis while in 15% of cases the stenosis was not caused by the presence of any focal process, but by diffuse inflammatory changes. This proportion is unusually high in comparison with literature data. (Tab. 5, Ref. 22.)

Cytotoxicity of natural compounds in hepatocyte cell culture models. The case of quaternary benzo[c]phenanthridine alkaloids

The quaternary benzo[c]phenanthridine alkaloids (QBA) produce a plethora of species- and tissue-specific effects but the molecular basis of their biological activities remain mysterious. The objective of the present study was to investigate the cytotoxicity of QBA alkaloids, sanguinarine (SA), chelerythrine (CHE), fagaronine (FA), and the extract from Macleaya cordata in primary cultures of human and porcine hepatocytes. The cellular damage was assessed by the MTT assay, lactate dehydrogenase (LDH) leakage and the determination of intracellular glutathione (GSH) levels. The results are summarised as follows: (i) The alkaloids tested in doses 0.1 and 10 microM did not display statistically significant cytotoxicity for 0-3 h incubation; (ii) SA and CHE showed the dose- and time-dependent toxicity within the range 25-100 microM whereas FA was not toxic; (iii) the LDH leakage into the medium was higher for SA than for CHE, thus revealing a potent potential of SA to disturb cell-membrane integrity; (iv) after 3 h incubation with 100 microM SA/CHE, mitochondrial dehydrogenase activity (MTT assay) and the cellular GSH levels decreased to residual values of about 40% suggesting that mitochondria are unlikely to be a primary target for SA/CHE in the cell; (v) no differences were found in the response to QBA application in human vs porcine hepatocyte.

[Transplantation of hepatocytes--present status and future perspectives]

Transplantation of hepatocytes as an alternative to the transplantation of the liver has been investigated since the 70s of the 20th century. Work on animal models confirmed that transplanted hepatocytes can survive, reproduce and compensate for missing liver functions, Recent clinical studies indicate that hepatocyte transplantation can also play its part in the treatment of acute liver failure, some inborn metabolic deficiencies and liver cirrhosis. In the acute liver failure, metabolic support by means of hepatocytes can help to overcome the period up to transplantation or regeneration of the liver. In the case of loss of a major fraction of the liver cells, transplanted hepatocytes may colonize the liver. the isolation of hepatocytes and procedure of transplantation proper are under control and the work focusing on the improvement of cell preservation is under way. Hepatocyte gene manipulation proves to be promising. The shortage of donors and the necessity of long-term immunosuppression represent the greatest problem. The article analyzes the basic principles of hepatocyte transplantation, the contemporary state of clinical application and further perspectives of research.

[Protective effect of essential phospholipids on liver injury due to total parenteral nutrition]

OBJECTIVE

It is known that total parenteral nutrition (TPN) causes liver damage by various mechanisms and leads to an increase of transaminases and obstructional enzymes. From this aspect TPN can be considered an external factor which causes liver damage. In our investigation we wanted to find out whether parenteral administration of essential phospholipids (EPL) can have a protective effect on this damage.

PATIENTS AND METHODS

Our investigation comprised 20 patients where TPN was indicated, usually on account of severe acute exacerbation of a non-specific inflammation of the gut. The patients were divided into two groups. Ten patients were treated by intravenous administration of essential phospholipids (Essentiale, Aventis), 50 mg every 6 hours for a period of two weeks. The control group comprised ten patients without hepatoprotection. The bilirubin, ALT, AST, GMT, ALP values were assessed before the initiation of the study, on the seventh and fourteenth day. The results were statistically processed by the paired and non-paired t-test.

RESULTS

The baseline results of the mentioned tests did not differ significantly between groups. Bilirubin and AST did not change significantly during the investigation. In the control group we found, as compared with baseline values, a significantly increase of ALT on the seventh and fourteenth day, a significantly increase of GMT on the seventh and fourteenth day and a slight non-significant rise of ALP on the fourteenth day. In the ELP treated group, as compared with baseline values, a significant rise of ALT occurred on the fourteenth day. We did not observe a significant rise of GMT and ALP. Between the ELP treated and control group a significant increase of GMT and ALP occurred in the control group, the other values did not differ between groups.

CONCLUSION

Parenteral EPL administration can have a favourable effect on liver damage caused by TPN, associated with cholestasis and biliary sludge. This conclusion can be hypothetically explained by improved bile fluidity and protection of the bile pole of the hepatocyte by essential phospholipids. Therefore their administration during TPN can be recommended.

Incidence of chronic pancreatitis in the Czech Republic

There have been only a few studies dealing with the incidence of chronic pancreatitis published. Over the last 80 years, original studies describing the incidence of chronic pancreatitis were undertaken, including studies in Scandinavia, Switzerland, Hungary and Poland. Incidence varied geographically, from 1.6 new cases per year among 100,000 inhabitants in Switzerland to 23 new cases among 100,000 inhabitants in Finland. The aetiology of 70% of all cases was alcoholic pancreatitis. The incidence of chronic pancreatitis in the Czech Republic is 7.9 per 100,000 inhabitants per year, similar to that of Denmark and Germany, but higher than that of Poland or Switzerland. In our study, the main aetiological factor was alcohol (65.4% of all cases, with consumption of alcohol of > 75.0 g/day).

[Acute hemorrhage of the upper digestive tract--personal experience]

The authors submit a retrospective investigation of 50 patients hospitalized at the intensive care unit of the Medical gastroenterological department, Faculty Hospital Brno treated in 1999 with the diagnosis of acute haemorrhage into the upper digestive tract. In the investigated group the most frequent cause of haemorrhage was portal hypertension (21 patients, 32.8%) and a peptic gastroduodenal lesion (15 patients, 23.4%). During the investigation period 12 patients died (18.8%), 6 developed haemorrhage as a complication of a serious condition (decompensated cirrhosis of the liver). In haemorrhage from oesophageal and gastric varicosities pharmacotherapy is equally important as endoscopic intervention.

[Uncommon case of a giant diaphragmatic hernia in a pregnant patient]

The authors submit an uncommon case of a true leftsided posterolateral (Bochdalek) hernia with the stomach, transverse colon and spleen in the hernial sac in a 25-year-old patient. They assume that the large hernation developed as a result of rupture of an already congenitally preformed hernial opening as a result of intraabdominally increased pressure during repeated pregnancies. The authors describe effective surgical solution of the case by laparoscopy from a transabdominal approach.

[Acute pancreatitis as the road to diagnosis of primary hyperparathyroidism]

The authors present the case of a 78-year-old female patient who was admitted on account of acute pancreatitis complicated by acute myocardial infarction. The authors detected in the patient a serum repeatedly high calcium levels and high levels of intact parathormone. Scintigraphic examination revealed marked foci in the middle of the neck at the level of the inferior pole of the thyroid gland. These examinations confirmed the diagnosis of primary hyperparathyroidism. In view of the patient a serious condition, conservative treatment of hypercalcaemia and acute pancreatitis and myocardial infarction was started. The patient was released into domiciliary care after 40 days in hospital in a state of cardiopulmonary compensation, with cystic transformation of the pancreas and without signs of acute pancreatitis.

[Helicobacter pylori negative gastroduodenal lesions in subjects treated with NSAID]

The authors examined retrospectively the frequency of NSAID use by patients with gastroduodenal ulcer without HP. The objective was to evaluate whether the use of NSAID is the predominating factor in the development of ulceration in subjects with HP negative ulceration. The group comprised 525 patients with confirmed presence of H, incl. 52 who used NSAID. From the results ensues that the incidence of ulcerous lesions with HP negativity and NSAID medication is significantly higher than in subjects who use NSAID and suffer from a confirmed HP infection.

Overgrowth of a costochondral graft in temporomandibular joint reconstructive surgery: an uncommon complication

A 16-year-old girl had a history of unilateral ankylosis of the temporomandibular joint, which was reconstructed with an autogenous costochondral graft. About 2.5 years after surgery, the patient presented with overgrowth of the costochondral graft, resulting in deviation of the jaw toward the unaffected side.

[The bioartificial liver--an alternative in the treatment of acute liver failure]

One of the therapeutic approaches in acute liver failure is the use of an artificial system replacing hepatic function--bioartificial liver. Its application is the most perspective in fulminant liver failure during preparation for transplantation of the liver (so-called bridge to transplantation) or in case of a non-functioning hepatic graft, and to reduce the mortality and morbidity of patients with acute liver failure where transplantation is not indicated or where a suitable graft was not found. The authors discuss briefly the construction of these systems, analyze different indications of treatment and its results, obscure questions and perspectives of further development.

[Principles of conservative treatment in chronic pancreatitis]

The authors summarize the principles of conservative treatment of chronic pancreatitis with special attention to treatment of exocrine pancreatic insufficiency and pancreatic pain. They emphasize the principles of the rational administration of drugs with pancreatin, the position of analgesics, and other possible procedures, if medicamentous treatment fails. An outline of dietetic treatment is also given.

[An attack of malignant hyperthermia caused by a combination of the effects of succinylcholine, increased physical exertion and alcohol abuse]

The authors submit the case-history of a 29-year-old man, followed up on account of liver steatosis with a toxic-nutritional etiology who developed, after previous increased physical exertion and alcohol abuse, fever associated with major muscular weakness. Gradually he developed an amental delirious state which was evaluated as suspect delirium tremens. Fever of 40-41 degrees C continued, the patient developed muscular rigidity, tremor and hypotension. After intubation during which succinylcholine was administered, the patient's condition deteriorated further with a rise of temperature and muscular rigidity. The patient developed acute renal failure with anuria and the necessity of repeated haemodialyses and severe acidosis of the mixed type on account of which he was intubated and switched to artificial ventilation. According to the case-history clinical and laboratory picture of the disease (extremely high creatine kinase activity, hyperkalaemia, acidosis, hepatorenal failure) malignant hyperthermia was suspected. After a single intravenous injection of sodium dantrolene, 2.5 mg/kg, the temperature dropped and within 24 hours the patient was afebrile. Gradually the acidosis improved, the blood pressure became stabilized and artificial ventilation was no longer used. The patient was discharged after 34 days in hospital in a state of cardiopulmonary compensation with mild polyuria but without signs of retention of nitrogenous substances with sideropenic anaemia and marginal creatine kinase and lactate dehydrogenase values. Within one month after discharge the laboratory values reached normal levels and only slight muscular weakness and greater fatiguability persisted.

[Drug therapy of esophageal varices hemorrhage in portal hypertension]

The author discusses the etiopathogenesis of portal hypertension and possibilities how to influence it during treatment of acute haemorrhage from varicosities and how to implement primary and secondary prevention. In treatment of acute haemorrhage the author recommends terlipresin, 1 mg every 4 hours. In primary and in particular in secondary prevention he emphasizes the necessity of early administration of beta-blockers.

Sturge Weber syndrome with intraoral manifestations. A case report

A 15 Year old female patient with Sturge Weber Syndrome is presented. This neurocutaneous syndrome consists of angiomatosis of the skin and mucosa as well as the leptomeninges. This case report describes the classic presentation of the syndrome, emphasizing the oral manifestations. The radiographic and CT scan show the typical "tram line" intracranial calcifications. This case report presents a typical case of Sturge Weber Syndrome. It gives the radiological and CT scan findings and the important role played by them in the diagnosis of this syndrome. Emphasis is given to the differentiation of diphenylhydantoin induced gingival hyperplasia from the angiomatous enlargement of the gingiva before any treatment is planned.

[Effect of octreotide on the clinical course of acute pancreatitis and levels of free oxygen radicals and antioxidants]

Twenty-one patients with a medium severe form of acute pancreatitis were divided into two groups. Eleven were treated with octreotide, 200 micrograms s.c. every 8 hours, combined with standard conservative treatment, 10 patients had the same treatment but without octreotide. In the octreotide-treated group the level of free oxygen radicals and important antioxidants--vitamins A, E and C--was assessed. In the octreotide-treated group the authors found after five days normal levels of originally elevated free oxygen radicals and a significant increase of the vitamin C level. As compared with the control group, in the octreotide group the period of hospitalization was significantly shorter (9.8 +/- 3.2 vs. 13.7 +/- 4.7). The number of complications was not affected.

A rare foreign body impaction: a case report

A case of unusual foreign body impaction of 6 years' duration is reported. The foreign body was retained in the right infraorbital region, extending to the ethmoid sinus. The importance of careful history taking and clinical examination and the problems encountered in evaluation of relatively radiolucent foreign bodies with magnetic resonance imaging are discussed.

Oral myiasis. A case report

Myiasis is a disease commonly seen in animals, especially sheep and cattle. The condition is rare in man. A patient with a neglected fractured mandible with superimposed myiasis is reported.