Effects of peppermint oil and caraway oil on gastroduodenal motility

The effect of enteric-coated (Enteroplant) and non-enteric-coated preparations containing a peppermint-caraway oil combination with 90 mg peppermint oil and 50 mg caraway oil was studied on gastroduodenal motility with stationary manometry in six healthy volunteers. The results showed that: (1) both enteric-coated and non-enteric-coated preparations have effects on the migrating motor complex (MMC); (2) mainly a decrease in the number of contractions and contraction amplitudes is seen during the various phases of the MMC; (3) non-enteric-coated preparations have their effects mainly during the first MMC after administration; (4) enteric-coated preparations have their effects temporally delayed during the second MMC after administration. In conclusion, enteric-coated and non-enteric-coated peppermint-caraway oil combinations are safe preparations, acting locally to cause smooth muscle relaxation.

Orthograde whole gut irrigation with mannite versus paromomycine + lactulose as prophylaxis of hepatic encephalopathy in patients with cirrhosis and upper gastrointestinal bleeding: results of a controlled randomized trial

BACKGROUND/AIMS

In patients with liver cirrhosis and upper gastrointestinal bleeding development of hepatic encephalopathy is a major problem. The aim of the present study was to evaluate the efficacy of the mannite lavage in a controlled randomized trial with respect to the Child-Pugh classification.

METHODOLOGY

After initial gastroscopy (+/- sclerotherapy) 39 patients with cirrhosis (18 F, 21 M; age: 57.5 +/- 11.9 yr; Child A: 6, Child B: 16, Child C: 17) and upper gastrointestinal-bleeding were classified according to the Child-Pugh-criteria (A,B,C) and randomized in 2 groups (A,B) for each Child-Pugh level. Patients in group A (n = 18) were initially treated with 2000 mL mannite solution (10%) during the first 2 hours using a naso-gastric tube. Treatment was continued using 2000 mL mannite solution (10%) per day until no rectal blood could be observed. Patients in group B (n = 21) were treated with paromomycine ter in die (1 g tid) and lactulose (10 mL tid). There were no statistical differences between both groups concerning age, sex, Child-Pugh-scores, severity or source of bleeding, initial hemoglobin-levels, number of given blood-transfusions or number of patients with sclerotherapy.

RESULTS

Patients in group A were treated with a total of 3325 +/- 1897 mL mannite solution. The application was well tolerated. In addition, kinetics of serum creatinine, potassium and sodium levels did not show any significant changes. No significant differences between both groups could be shown with respect to clinical criteria of encephalopathy according to O'Grady and the length of intensive care unit treatment. Moreover, kinetic of ammonia-levels showed a pronounced decrease (P = 0.05) on day 2 versus day 1 in group A (110.0 +/- 24.2 vs. 156.4 +/- 98 mg/dL) as compared to group B (210.0 +/- 52.7 vs. 162.0 +/- 45 mg/dL). In group A, 6 patients (33.3%) died during the study as compared to 3 patients (14.3%) in group B (P > 0.05). The lethality rate was strongly associated with the larger proportion of Child-C-patients in group A.

CONCLUSIONS

The data indicate that whole gut irrigation with mannite is equally efficacious as compared to standard treatment for prophylaxis of hepatic encephalopathy after upper gastrointestinal bleeding in liver cirrhosis. In contrast to previously published controlled studies, no impact of the lavage on the mortality rate or duration of intensive care unit treatment could be shown. With respect to the lower costs for the mannite solution as compared to paromomycine and lactulose (ROTE LISTE, Germany), the mannite lavage should be recommended for the prophylaxis of hepatic encephalopathy after upper gastrointestinal bleeding in patients with liver cirrhosis.

Effects of peppermint oil and caraway oil on gastroduodenal motility

The effect of enteric-coated (Enteroplant) and non-enteric-coated preparations containing a peppermint-caraway oil combination with 90 mg peppermint oil and 50 mg caraway oil was studied on gastroduodenal motility with stationary manometry in six healthy volunteers. The results showed that: (1) both enteric-coated and non-enteric-coated preparations have effects on the migrating motor complex (MMC); (2) mainly a decrease in the number of contractions and contraction amplitudes is seen during the various phases of the MMC; (3) non-enteric-coated preparations have their effects mainly during the first MMC after administration; (4) enteric-coated preparations have their effects temporally delayed during the second MMC after administration. In conclusion, enteric-coated and non-enteric-coated peppermint-caraway oil combinations are safe preparations, acting locally to cause smooth muscle relaxation.

Polymyositis of the skeletal muscles as an extraintestinal complication in quiescent ulcerative colitis

Myositis of the skeletal muscle is a rare complication of inflammatory bowel disease. We report about a 33-year-old woman with quiescent ulcerative colitis known since 1995. She had suffered from recurring fever and pain in the thighs for about 4 weeks. Electromyography of quadriceps and deltoid muscles revealed myopathic changes. Diagnosis of polymyositis was confirmed by magnetic resonance imaging indicating edematous changes in the distal extremity muscles. The symptoms rapidly responded to high doses of steroids. Review of the literature indicates only a few cases describing an association of ulcerative colitis and myositis, most of them during acute exacerbations of the disease. In contrast, the present patient was in remission. Diagnosis of myositis should be considered in inflammatory bowel disease patients complaining of myalgia or muscular weakness. Magnetic resonance imaging may show specific features and can be used in addition to laboratory investigations and muscle biopsy for diagnosis of polymyositis.

Oral mesalazine for the treatment of Crohn's disease: clinical efficacy with respect to pharmacokinetic properties

The release of 5-ASA from various preparations depends on the presence of bacterial azoreductases (sulphasalazine, olsalazine, balsalazide) or the pharmacokinetic properties of the mesalazine-containing pharmaceutical preparations. The differences of the 5-ASA release from the various preparations account for the different anatomic sites of actions. In this regard, a close relationship between the regional intraluminal concentrations of 5-ASA and the clinical response can be assumed. The aim of the present paper is to survey clinical trials in Crohn's disease with special respect to the pharmacokinetic properties of the used mesalazine containing preparations. There are clear differences between the different coated 5-ASA formulas in respect to 5-ASA release and in respect to their pharmacokinetic properties leading to a different therapeutic efficacy in Crohn's disease. The detailed analysis indicates that higher doses of 5-ASA (> 3 g/d) are required for the acute phase treatment. 4.5 g Eudragit-L-coated 5-ASA tablets are almost equally as potent as glucocorticosteroids for the treatment of active Crohn's disease. Clinical efficacy has been demonstrated for Eudragit-L-coated tablets even at a low dose of 1-1.5 g 5-ASA/day in the maintenance treatment of remission of Crohn's disease. This has also been shown for Eudragit-S-coated tablets at a dose of 2.4 g 5-ASA/day, while even 3 g 5-ASA of an Eudragit-L/S formula as well as the ethylcellulose-coated formulas up to 4 g 5-ASA/day were ineffective, except for a high risk group. On the basis of the published trials, there is clear evidence that post-operative prophylaxis with 5-ASA requires daily doses higher than 1.5 g. Ethylcellulose-coated 5-ASA has only been effective in Crohn's disease limited to the small bowel and should not be given to patients with ileo-colonic or colonic disease. Moreover, Eudragit-L-coated 5-ASA preparations have shown to be effective in both ileal and colonic disease concerning their clinical efficacy in post-operative prophylaxis. In contrast, endoscopic efficacy has been demonstrated for ethylcellulose as well as Eudragit-S-coated formulas. Treatment of Crohn's disease with orally administered 5-ASA can generally be regarded as an effective and well-tolerated therapy. However, the distinct therapeutic goal (acute phase treatment, maintenance therapy or post-operative prophylaxis), the involved areas of the gut and the specific release of the drug administered have to be considered.

Effects of ginger on gastroduodenal motility

The effect of a ginger rhizome extract (2 x 100 mg) was studied on fasting and postprandial gastroduodenal motility with stationary manometry in 12 healthy volunteers. The results showed that: the interdigestive antral motility was significantly increased by ginger during phase III of the migrating motor complex; the volunteers also had a significantly increased motor response to a test meal in the corpus; a trend to an increased motor response during ginger treatment was seen in all other regions of interest. Oral ginger improves gastroduodenal motility in the fasting state and after a standard test meal.

Budesonide for the treatment of collagenous colitis: first results of a pilot trial

OBJECTIVE

Collagenous colitis is a chronic watery diarrhea disorder characterized by a subepithelial collagen layer and a lymphoplasmacytic infiltration within the lamina propria. However, no standard treatment has been introduced by controlled clinical trials. Aim of the present pilot trial was to investigate the clinical effects of orally administered budesonide (3 mg t.i.d.) in 7 patients with collagenous colitis. In addition, the histomorphological changes after budesonide treatment were described in a group of 3 patients.

METHODS

The study was performed as an open label pilot trial. Study end point was the clinical remission of collagenous colitis defined by stool frequency and stool consistency.

RESULTS

The results indicate a rapid and sustained clinical response in all patients. Stool frequency significantly decreased (p < 0.001) from 10.43 +/- 5.56 per day (4-20 per day) to 3.3 +/- 1.2 (1-5 per day) after 10 days and to 1.86 +/- 0.69 per day (1-3 per day) after 10 wk. Moreover stool consistency changed from watery (6 patients) or soft (1 patient) to soft (1 patient) or solid (6 patients). Clinical improvement was achieved within the first 10 days in all patients and maintained after dose reduction. In 3 patients no diarrhea recurred within 7, 12, or 15 months after treatment with budesonide was terminated. In these patients control biopsies were taken and showed a marked regression of both characteristics, the collagen band and the lymphoplasmacytic infiltration.

CONCLUSIONS

With respect to the preliminary data from this pilot trial, budesonide with its high topical and low systemic effects seems to be of therapeutic clinical benefit in collagenous colitis. A therapeutic effect could be demonstrated for both therapeutic goals, the clinical response and morphological changes. Further studies on the effects of budesonide on mucosal collagen metabolism and long-term follow-up are warranted.

Vascular endothelial growth factor (VEGF) in Crohn's disease: increased production by peripheral blood mononuclear cells and decreased VEGF165 labeling of peripheral CD14+ monocytes

Recently, increased serum levels of vascular endothelial growth factor (VEGF) have been shown in patients with inflammatory bowel disease. The origins of the circulating VEGF are still not described. Monocytes play an important role in the inflammatory process. VEGF binding to monocytes mediates monocyte recruitment and activation. The present study investigates the VEGF production of peripheral blood mononuclear cells and the ability of peripheral monocytes to bind VEGF165 in patients with Crohn's disease. Nineteen patients with Crohn's disease and 10 healthy volunteers were studied. VEGF165 labeling of CD14+ monocytes was measured using two-color flow cytometry. Density of VEGF labeling was expressed as the mean fluorescence intensity (MFI). Furthermore, VEGF levels were determined in culture supernatants of unstimulated peripheral blood mononuclear cells. VEGF in culture supernatants was measured using a solid-phase enzyme-linked immunosorbent assay. There was a significantly decreased VEGF165 labeling of monocytes of patients with active Crohn's disease (MFI: 369.9+/-121.6, N = 7, P < 0.002) compared to patients with inactive disease (MFI: 457.7+/-74.5, N = 6) and healthy controls (MFI: 542.9+/-96.2, N = 10). Unstimulated peripheral blood mononuclear cells of patients with active Crohn's disease produced significantly higher amounts of VEGF (1142.6+/-483.9 pg/ml, N = 12, P < 0.001) compared with peripheral blood mononuclear cells of healthy volunteers (113.4+/-101.8 pg/ml, N = 10). VEGF production by peripheral blood mononuclear cells of patients with active disease was significantly increased compared to patients with quiescent disease (261.6+/-254.8 pg/ml, N = 7, P < 0.001). In conclusion, our data describe peripheral blood mononuclear cells as one of the origins of the elevated VEGF serum levels in patients with active Crohn's disease. Furthermore, a decrease in VEGF165 binding sites on peripheral monocytes of patients with active Crohn's disease has been shown. The study underlines the important role of VEGF in Crohn's disease.

[Effect of stomach motility on measuring stomach permeability with saccharose in vivo]

Determination of the urinary excretion of sucrose after an oral dose has been used as a noninvasive test to measure gastric permeability in several clinical studies. Regarding different contact times of sucrose solution within the gastric mucosa, the present study investigates a possible influence of the gastric emptying rate on the sucrose permeability test. Urinary sucrose excretion and the gastric emptying rate of liquids using 13C-acetate breath test were determined in twelve healthy volunteers. Furthermore, in seven volunteers gastric emptying was accelerated by intravenous erythromycin and prolongated by oral anticholinergic propantheline in nine healthy controls. Breath samples were measured using infrared spectroscopy. The half-emptying time and Lag-phase were correlated with the urinary sucrose excretion. Erythromycin caused a significant (p = 0.02) reduction of the half-emptying time (median 35.0 min) compared with untreated controls (median 59.9 min), whereas propantheline significantly increased the half-emptying time (median 69.4 min, p = 0.01). After pharmacological increase of the half-emptying time the urinary sucrose excretion only slightly differs from the sucrose excretion of controls (median [range] 0.057 [0.034-0.106]% versus 0.031 [0.017-0.162]%), but there was an increase of urinary sucrose excretion in probands following reduction of the half-emptying time with erythromycin (0.077 [0.023-0.221]%. The present study shows that gastric motility has a possible influence on the sucrose permeability test. The sucrose permeability has to be interpreted critically concerning its clinical use especially in patients with altered gastric motility.

Increased production of vascular endothelial growth factor by intestinal mucosa of patients with inflammatory bowel disease

BACKGROUND/AIMS

Vascular endothelial growth factor (VEGF) is a heparin-binding glycoprotein with potent angiogenic, mitogenic and vascular permeability-enhancing activities specific for endothelial cells. Recent studies have shown significantly increased VEGF serum levels in patients with active Crohn's disease and ulcerative colitis. The origin of the circulating VEGF is not yet completely described. The present investigation examines the VEGF production of colonic mucosa in consideration of mucosal disease activity in patients with inflammatory bowel disease.

METHODOLOGY

Fifteen patients with inflammatory bowel disease were studied, 9 patients with Crohn's disease and 6 patients with ulcerative colitis. Biopsies were taken from endoscopically inflamed and non-inflamed colonic mucosa. Therefore, an analysis of the spontaneous VEGF production of cultured biopsies without stimulus and of the histological grade of inflammation scored on a scale of 0-3 (normal mucosa--severe chronic colitis) were performed. Eight patients with irritable bowel syndrome served as controls. VEGF levels in the supernatant of cultured mucosal biopsies were measured using an enzyme linked immunosorbent assay.

RESULTS

VEGF production is expressed as pg/mg wet weight of the biopsies. Inflamed mucosa of patients with active ulcerative colitis (16.27 +/- 10.39, p = 0.003, n = 6) and active Crohn's disease (9.88 +/- 5.98, p < 0.012, n = 9) showed a significantly higher spontaneous production of VEGF by colonic mucosa than normal mucosa of controls (3.16 +/- 1.63, n = 8). In addition, there was an increased unstimulated VEGF production by cultured inflamed mucosa of patients with Crohn's disease compared with non-inflamed mucosa (3.88 +/- 3.66, p < 0.015, n = 9). In both Crohn's disease and ulcerative colitis, there was no significant difference between VEGF production by non-inflamed mucosa and normal mucosa of controls.

CONCLUSIONS

The present study identifies the intestinal mucosa as one of the origins of the elevated VEGF serum levels in patients with active inflammatory bowel disease and verifies the findings of recent studies about the importance of VEGF in Crohn's disease and ulcerative colitis.

Increased production of vascular endothelial growth factor by peripheral blood mononuclear cells in patients with inflammatory bowel disease

BACKGROUND

Vascular endothelial growth factor (VEGF) is a potent angiogenic, vascular permeability-enhancing cytokine with overexpression in various pathological disorders, including tumour growth, chronic inflammation and tissue repair. Recent studies have shown significantly increased serum levels of VEGF in patients with inflammatory bowel disease. The origin of the circulating VEGF is still unknown. The present investigation examines the VEGF production by peripheral blood mononuclear cells (PBMCs) in patients with inflammatory bowel disease.

METHODS

VEGF levels were measured in culture supernatants of unstimulated PBMCs of 27 patients with inflammatory bowel disease and 10 healthy volunteers using a solid phase ELISA. In addition, VEGF serum levels were determined.

RESULTS

PBMCs of both active Crohn's disease patients (1142.6+/-483.9 pg/ml, P < 0.001, n = 12) and active ulcerative colitis patients (748.0+/-637.6 pg/ml, P = 0.006, n = 4) produced significantly higher amounts of VEGF compared with PBMCs of healthy volunteers (113.4+/-101.8 pg/ml, n = 10). In addition, there was a significantly increased VEGF production by PBMCs of patients with active disease compared with PBMCs of patients with quiescent Crohn's disease (261.6+/-254.8 pg/ml, P < 0.001, n = 7) and inactive ulcerative colitis (147.7+/-100.3 pg/ml, P = 0.02, n = 4). There was no significant difference in VEGF release between patients with inactive inflammatory bowel disease and healthy controls.

CONCLUSIONS

Significantly increased VEGF production by PBMCs was found in patients with active Crohn's disease and active ulcerative colitis. The study helps to clarify one of the origins of the significantly enhanced VEGF serum levels in patients with active inflammatory bowel disease observed in recent studies.

Anorectal functions in patients with spinal cord injury

We wished to establish anorectal functions in patients with spinal cord lesions, related to the level of lesion and its completeness. We also wished to determine the value of neurophysiological tests for completeness of transsections in comparison with manometry and visceral sensory testing. In 32 patients (31.5 +/- 14.1 years, 25 males) with spinal trauma, completeness of transsection was assessed clinically. In 16 of these patients (30 +/- 15.6 years, nine males), a neurological work-up included recording of somatosensory evoked potentials (SEP) and motor evoked potentials (MEP) from the pudendal nerve within the first week after trauma. Also, anal sphincter EMG and pudendal nerve terminal motor latency (PNTML) were assessed. All patients also underwent conventional anorectal manometry and visceral sensory testing. Of all 32 patients, 15 were judged as 'complete' based on their clinical signs. Of those 16 tested neurologically, seven were labelled 'complete' since no MEP or SEP were detectable; one had pudendal SEP and MEP present, while SEP were present but delayed (47.0 +/- 8.8 msec) in the remaining patients. In four of these patients, also MEP were recorded (27.9 +/- 5.2 msec) and normal. PNTML was present in 12/16 patients independent of the completeness of lesion, and was rated normal in nine and delayed in three patients. EMG was normal in five, and pathological in 11 cases. In 5/15 cases of those judged as 'complete' (in 3/7 evaluated neurologically), visceral sensory testing revealed a minimal threshold for rectal perception of distension of 44 mL (range: 10-130), which sometimes was also perceived as urge to defecate. In a further case, manometry showed major voluntary action of the anal sphincter. These patients had lesions at all levels of the spinal column, ranging from cervical (C4,C6,C7) via thoratical (2 x T7,T8,T12) to lumbar segments. Anorectal function testing, and specifically visceral sensory testing may be superior to neurological assessment of 'completeness' of spinal cord lesions. It may be that visceral afferent pathways others than spinothalamic tract are involved in rectal perception that are less accessible to conventional neurophysiological diagnostic work-up.

[Jaundice and progressive liver failure: delayed diagnosis of autoimmune hepatitis due to abrupt termination of steroid therapy?]

A 27-year-old woman was successfully treated with a highly dosed steroid therapy over several months during summer 1994 in the event of urticaria. In October 1994, when the patient was complaint free, therapy was abruptly terminated. In November 1994 jaundice, nausea and loss of appetite occurred. Biochemical results showed markedly elevated serum transaminases, negative hepatitis serology, normal immunoglobulins and inconspicious autoantibodies. Histology showed a florid hepatitis. In January 1995 the patient was hospitalized again in very low general and nutritional condition with a marked jaundice, high serum transaminases, insufficient liver synthesis function, established ANA(+), ASMA(+2) and normal immunoglobulins. This time histology painted out an active hepatitis going into liver cirrhosis. Evaluation in view of liver transplantation was carried out in this case of liver failure. At that time, tests showed a distinct gamma globulin fraction increase although the antibody pattern had remainded identical. An immunosuppressive therapy with azathioprine and steroids was decided upon under suspicion of an autoimmune hepatitis leading to a prompt positive response and therefore confirmation of the diagnosis. Complete biochemical remission was attained in April 1995 and a complete histological remission in March 1998.

[Acid esophago-pharyngeal reflux as etiology of hoarseness]

BACKGROUND

Gastroesophageal reflux has been implicated in otolaryngologic problems, particularly chronic hoarseness that cannot be attributed to other causes.

PATIENTS AND METHODS

To study this relationship between gastroesophageal reflux and chronic hoarseness we used 24-h dual-site ambulatory pH-recordings in 68 patients with chronic hoarseness and laryngeal lesions suggestive of acid irritation.

RESULTS

Thirty-eight patients (56%) had evidence of at least one esophago-pharyngeal reflux episode. The mean number of esophago-pharyngeal episodes was 6.7 +/- 12 within 24 hours (range: 1-34 episodes). The mean duration of these episodes was 201 +/- 28 seconds (range: 6 seconds-19.6 minutes). Most patients with esophago-pharyngeal reflux had no evidence of pathologic gastroesophageal reflux. Only 28.9% of the patients with esophago-pharyngeal reflux episodes also had pathologic gastroesophageal phageal reflux, whereas 23.3% of the patients without esophago-pharyngeal reflux had no gastroesophageal reflux disease. The esophago-pharyngeal reflux occurred mainly in the upright position.

CONCLUSIONS

Occult esophago-pharyngeal reflux, predominantly in the upright position, appears to be common and severe in patients with chronic hoarseness. Gastroesophageal reflux may be an important factor in the pathogenesis of chronic hoarseness. The causative mechanisms are not clear.

Increased serum levels of vascular endothelial growth factor in patients with inflammatory bowel disease

BACKGROUND

Vascular endothelial growth factor (VEGF) is a potent angiogenic, vascular permeability-enhancing, and calcium-dependent enzyme-modulating cytokine with overexpression in various pathologic disorders, including granulomatous inflammation, tissue repair, delayed hypersensitivity reactions, rheumatoid arthritis, and tissue ischemia. The present study investigates the role of VEGF in chronic inflammatory bowel disease.

METHODS

Thirty-one patients with Crohn's disease, 15 patients with ulcerative colitis, and 9 healthy volunteers were studied. VEGF serum levels were measured with a solid-phase enzyme-linked immunosorbent assay.

RESULTS

Significantly increased VEGF serum levels were observed in both active Crohn's disease and active ulcerative colitis when compared with healthy controls. Patients with active Crohn's disease and active ulcerative colitis showed significantly higher VEGF serum levels than patients with quiescent disease. No difference was observed between inactive disease and healthy controls. In addition, strongly increased VEGF serum levels were found in patients with Crohn's disease with fistulas in the absence of clinical, endoscopic, histologic, and laboratory findings of disease activity.

CONCLUSIONS

Significantly increased VEGF serum levels were observed in patients with active Crohn's disease and ulcerative colitis, which suggests that VEGF has an important role in chronic inflammatory bowel disease. Its possible association with fistulas has yet to be determined.

[Optimizing antrum planimetry for ultrasound determination of gastric emptying using emptying function reference lines]

Previous studies have shown high inter- and intraindividual variation coefficients (Vkinter; Vkintra) of the gastric emptying time t(end) determined by sonographical antrum planimetry.

PURPOSE

Are there new parameters reflecting the functional process of gastric emptying?

METHOD

Gastric emptying of 300 ml water was studied in 20 healthy volunteers by sonographical antrum planimetry. 10 volunteers were examined a second time on another day.

RESULTS

High variation coefficients Vkinter (42%) and Vkintra (31%) could be demonstrated. Moreover, a correlation of r = +0.922 between tend and the maximal percentual increase of the antral area was evident. This relation is introduced as the functional-emptying-line (FEL).

CONCLUSION

Using the functional aspects of FEL, gastric emptying can be studied sonographically under functional aspects.

[Perforation of the esophagus after esophageal manometry]

HISTORY AND FINDINGS

A 75-year-old man was admitted for oesophageal manometry because of dysphagia for the past 2 years and retrosternal burning sensation unrelated to exercise. His general condition was appropriate for his age.

INVESTIGATIONS

An oesophagogram showed corkscrew-like deformation of a diffuse oesophageal spasm. The first, but incomplete, manometry recorded clearly propulsive contractions with markedly raised and prolonged pressure, as in "nutcracker oesophagus". The lower oesophageal sphincter could not be demonstrated initially. Subsequent pH measurements provided no evidence for increased gastrooesophageal reflux.

TREATMENT AND FURTHER COURSE

After the first manometry conservative treatment was initiated with molsidomine, nifedipine and nitrospray sublingual, but the dysphagia was not significantly improved. A second manometry was performed before a planned surgical exploration. Placing of the catheter was again difficult and mild resistance experienced. Endoscopy revealed only minimal, presumably superficial, mucosal lesions. 2 days later bilateral pleural effusions together with mediastinitis occurred. Conservative treatment was continued until finally a distal oesophageal perforation was demonstrated. At surgery the perforation was seen and a oesophagectomy with gastric pull-through and intrathoracic anastomosis performed. However, the patient died of septic multi-organ failure.

CONCLUSIONS

Oesophageal manometry is a safe but invasive method with few complications for measuring oesophageal motility. Although this has not previously been reported, oesophageal perforation with mediastinitis may end fatally, if the particular circumstances are unfavourable. In addition to special anatomical features, type and state of the manometric catheter may present a risk factor.

Efficacy of a fixed peppermint oil/caraway oil combination in non-ulcer dyspepsia

The efficacy and safety of the standardized herbal combination preparation of Enteroplant, consisting of peppermint oil (90 mg) and caraway (50 mg) in an enteric coated capsule, have been studied in a double-blind, placebo-controlled multicentre trial in patients with non-ulcer dyspepsia. A total of 45 patients were included in the trial after thorough physical and gastro-enterological examination. The primary outcome variables were the change in the intensity of pain and the global clinical impression (Clinical Global Impression [CGI], Item 2), which were evaluated for 39 patients (test preparation: 19, placebo: 20). After four weeks of treatment both target parameters were significantly improved for the group of patients treated with the peppermint oil/caraway oil combination compared to the placebo group (p = 0.015 and 0.008, respectively). Before the start of treatment all patients in the test preparation group reported moderate to severe pain, while by the end of the study 63.2% of these patients were free of pain. The pain symptoms had improved in a total of 89.5% of the patients in the active treatment group. After 4 weeks the Clinical Global Impressions were improved for 94.5% of the patients treated with the peppermint oil/caraway oil combination. The trial medication was also superior to placebo with respect to pain frequency, medical prognosis, the severity of the disorder and the efficacy index (CGI, Items 1 and 3), which were adopted as secondary end-points for evaluation of efficacy. There were similarly favourable findings for the herbal combination, compared with placebo, with respect to the reduction of other gastrointestinal symptoms. The combination preparation was found to be excellently tolerated. There was a total of 7 adverse events (test preparation: 4, placebo: 3), with a causal association with the treatment being ascribed in one case for the test preparation group and one case for the placebo group.

[Pharmacologic and clinical differentiation of prokinetic drugs]

In the treatment of gastrointestinal motility disorders 3 prokinetic agents are principally available. They are differentiated from their pharmacological mode of action, their clinical efficacy and tolerability. Metroclopramide is an antidopaminergic benzamide with mainly antiemetic effects and minor prokinetic efficacy in the GI-Tract. Domperidon is a pure dopaminantagonist. It accelerates gastric emptying but has less effect on bowel motility. Cisapride stimulates indirect the secretion of acetylcholine and acts via 5 HT-receptors selective at the plexus myentericus. These pharmacological differences have clinical relevance: metoclopramide and domperidon could not consistently prove efficacy in functional dyspepsia and GORD. In addition the data in other indications are rare. Only cisapride has shown significant responder rates in controlled studies in the treatment of gastrointestinal motility disorders particularly in long term treatment. As concerns tolerability cisapride presents a progress by its selective mode of action in contrast to the agents crossing the blood-brain-barrier.

[Neuropsychiatric symptoms in vitamin B12 deficiency and microcarcinoidosis. The complications of chronic atrophic gastritis]

HISTORY AND FINDINGS

A 69-year-old woman reported marked restriction of voluntary movements of the hands in the preceding 6 months. She had also experienced loss of motivation, memory and concentration. Her skin was pale yellow, and scratches on her skin indicated marked pruritus.

INVESTIGATIONS

Neurological examination revealed decreased vibratory sense in both legs. Haemoglobin concentration was 8.3 g/dl, mean corpuscular volume 114 fl, vitamin B12 level < 100 ng/l, folic acid level normal. Antibody titre against parietal cells was increased, vitamin B12 resorption diminished. Gastroscopy revealed small raised lesions, made up of hyperplastic cells which stained with chromogranin, indicating a diagnosis of microcarcinoid of the gastric mucosa.

TREATMENT AND COURSE

On administration of cobalamine (1,000 micrograms i.m. daily for 2 weeks, twice weekly for 6 weeks, then once per week for the last 7 months) the blood picture returned to normal, but the microcarcinoids, the psychological symptoms and the apraxia of the hands were unchanged.

Enhanced superoxide anion release of normal neutrophil granulocytes primed with sera of patients with inactive inflammatory bowel disease

During active inflammatory bowel disease (IBD) the respiratory burst of neutrophil granulocytes has been shown to be impaired using isolated circulating neutrophil granulocytes of patients with active disease. Using normal neutrophil granulocytes of healthy volunteers the present study examines the potential priming effect of sera of patients with active and quiescent IBD. The superoxide anion (O2-)-release of normal neutrophil granulocytes in response to N-formyl-methionyl-leucyl-phenylalanine (FMLP) has been investigated after incubation with sera of patients with active and inactive Crohn's disease and ulcerative colitis. O2(-)-release was measured using the superoxide dismutase inhibitable reduction of ferricytochrome c. The O2(-)-release of normal neutrophil granulocytes primed with sera of patients with inactive Crohn's disease (607.1 +/- 218.2 nmol/60 min, n = 10, p = 0.001) or cultured with sera of patients with quiescent ulcerative colitis (497.4 +/- 94.9 nmol/60 min, n = 3, p = 0.005) was significantly enhanced when compared with sera of normal controls (319.8 +/- 86.5 nmol/60 min, n = 10). There was no significant difference between priming with sera of patients with quiescent or active Crohn's disease (481.0 +/- 113.0 nmol/60 min, n = 5). Normal neutrophil granulocytes primed with sera of patients with active ulcerative colitis produce significantly larger amounts of O2- (809.5 +/- 256.9 nmol/60 min, n = 4, p = 0.001) when compared with sera of normal controls. The study shows that sera of patients with quiescent IBD as well as sera of patients with active disease have the potential to prime normal neutrophil granulocytes for an enhanced O2(-)-release in response to FMLP.(ABSTRACT TRUNCATED AT 250 WORDS)

Muscarinic receptors in gastric mucosa are increased in peptic ulcer disease

Muscarinic receptors stimulate the secretion of acid pepsinogen and mucous in gastric mucosa. Whether muscarinic receptors are involved in the pathogenesis of benign gastric disease is unknown. Receptor changes in these conditions were therefore sought. An autoradiographic technique was developed to determine quantitatively muscarinic receptors in microtome sections of biopsy specimens obtained during gastroscopy. Muscarinic receptor density was mean (SEM) 18.4 (1.2) fmol/mg protein in the corpus and 8.9 (0.7) fmol/mg protein in the antrum (n = 53). Neither chronic nor active gastritis was associated with receptor changes in the antrum but chronic gastritis was associated with a receptor loss in the corpus. Patients with acute or recent duodenal or antral ulcers (n = 23) had significantly higher levels of muscarinic receptors in the corpus than controls (n = 25) (22.2 (1.5) v 16.9 (1.7) fmol/mg protein respectively (p < 0.025). These results suggest that muscarinic M3 receptor is overexpressed in duodenal ulcer disease and may play a part in its pathogenesis.

[Rheumatoid disorders in Crohn disease and ulcerative colitis. Dominance of non-inflammatory factors]

82 consecutive outpatients with Crohn's disease (n = 52) and ulcerative colitis (n = 30) were examined ambulatory. Rheumatic complaints, objective results and diagnosis were correlated to the activity of the underlying illness and the extent of the bowel affected. 61% of the examined patients complaint about rheumatic pains. In two thirds this could be attributed to noninflammatory causes (30% insertion tendinitis. 16% degenerative arthritis, 16% wrong carriage), which appeared to be independent of the activity and severity of the underlying disease. One fourth of the rheumatic complaints was caused by inflammation (21% arthritis, 5% sacroileitis). In these cases a dependency on the disease activity and the extent of the colon involvement could be found. No cause was found for 12% of the rheumatic complaints. In patients with ulcerative colitis suffering from arthritis a significant increase of disease activity (Rachmilewitz index) could be shown as compared to ulcerative colitis patients without arthritis (p < 0.02). For patients with Crohn's disease no significant correlation between arthritis and disease activity could be established. In these cases the occurrence of arthritis was associated with the colon involvement (Chi2 = 8.48). The data indicate the high frequency of rheumatic complaints in inflammatory bowel diseases due to noninflammatory causes.

Neurotoxicity, haemostatic disturbances and haemolytic anaemia after a bite by a Tunisian saw-scaled or carpet viper (Echis 'pyramidum'-complex): failure of antivenom treatment

A young man in Germany was bitten by a large captive saw-scaled viper (Echis 'pyramidum'-complex) of Tunisian origin. During the first few hours after the bite he developed evidence of disseminated intravascular coagulation and fibrinolysis, and bled spontaneously. Despite being given a total of 310 ml of three different Echis-specific antivenoms (together with large amounts of fresh frozen plasma and concentrated clotting factors), venom antigenaemia (measured by enzyme immunoassay) and coagulopathy persisted for more than 10 days, and he developed a haemolytic anaemia and mild renal dysfunction. Transient bilateral ptosis was attributed to envenoming. The venom of the snake responsible for the bite was immunologically distinct from that of Nigerian E. ocellatus and was clearly not neutralised by the three monospecific antivenoms which had been administered. This case is another illustration of the geographical variation in snake venoms and the need for pooling venoms from snakes from different parts of the geographical range in the preparation of antivenoms. Envenoming by North African Echis species may not be reversible by available antivenoms.

[Osteopenia in chronic inflammatory bowel diseases. Results of a cross-sectional study using quantitative computerized tomography]

53 unselected patients with Crohn's disease (CD) (35 female, 18 men; mean age: 32.3 +/- 12.5 y.; mean duration of CD: 78.6 +/- 65.7 months) and 23 patients with ulcerative colitis (UC) (8 female, 15 men; mean age: 43.7 +/- 17.9 y.; mean duration of UC: 100.7 +/- 86.0 months) were examined by quantitative computertomography (lumbar spine 1-3). Incipient (manifest) osteopenia (OP) was defined as a reduced axial bone mineral density from -1 standard deviations (SD) to -2 (SD) (< -2SD) as compared to a control Group. Reduced bone mineral density was found in 30.2% (16/53) of patients with CD and 9% (2/23) with UC (p < 0.05). In particular 12/53 pts. (22.6%) with CD and 1/23 pts. (4.35%) with UC showed incipient OP, whereas 4/53 pts. (7.5%) with CD and 1/23 pts. (4.35%) with UC showed manifest OP. With respect to the location of CD the mean relative bone density (SD) was found to be significantly lower in patients with ileal involvement of CD (-0.88 +/- 0.8 SD; n = 39) as compared to patients with colonic involvement (-0.09 +/- 0.86 SD; n = 14) and UC (-0.09 +/- 0.55 SD; n = 23) (p < 0.05). No significant correlation to the duration of the disease was found. Previous therapy with steroids led to lower mineral bone density as compared to untreated patients. As a trend duration of steroid treatment and bone density were shown to be correlated inversely.(ABSTRACT TRUNCATED AT 250 WORDS)

[Manometric studies of the esophagus in healthy subjects of different age groups]

Oesophageal manometry was performed under standardized conditions in 100 healthy persons of different ages (54 males, 46 females; mean age 43.1 [18-84] years). They were grouped by age in decades (< or = 29 years: n = 23; 30-39 years: n = 18; 40-49 years: n = 19; 50-59 years; n = 20; and > or = 60 years: n = 20). The mean resting pressures at the lower oesophageal sphincter ranged among the different age groups from 18-22 mm Hg (total group 19 +/- 7 mm Hg), the mean contraction force at the distal tubular oesophagus ranged from 77-100 mm Hg (84 +/- 35 mm Hg), in the proximal tubular oesophagus from 53-58 mm Hg (56 +/- 22 mm Hg), and the resting pressures at the upper oesophageal sphincter from 34-45 mm Hg (37 +/- 17 mm Hg). There was no statistically significant difference between the various age groups for any of the motility parameters. It is concluded that age does not influence the findings in comparative studies of healthy persons and patients of differing ages.

[Acute effect of metoclopramide on esophagus motility in diabetes mellitus]

The acute effect of metoclopramide on oesophageal motility was investigated prospectively in 33 consecutive patients (20 men and 13 women; mean age 60.5 +/- 12.6 years) with type I (n = 8) or type II (n = 25) diabetes. 15 patients had a peripheral sensory-motor polyneuropathy only and three just an autonomic cardial neuropathy. Both lesions were present in ten, none in five. No patient had oesophago-gastroduodenal lesions. Sphincter pressure, relaxation time, contraction amplitude and propulsion velocity of bolus-induced oesophageal peristalsis were measured manometrically after intravenous administration of 10 mg metoclopramide. Resting pressure in the lower oesophageal sphincter rose significantly by 26.7%, contraction amplitude in the tubular portion of the oesophagus by more than 30%, and propulsion velocity by more than 20% (P for each < 0.05). At the same time the amount of segmental and aperistaltic oesophageal contractions regressed significantly. The effect of metoclopramide was demonstrated regardless of the type of diabetes, duration of diabetes and any manifestation of autonomic cardial or peripheral sensory-motor neuropathy.

A tobacco gene family for flower cell wall proteins with a proline-rich domain and a cysteine-rich domain

Flowering is known to be associated with the induction of many cell wall proteins. We report here five members of a tobacco gene family (CELP, Cys-rich extensin-like protein) whose mRNAs are found predominantly in flowers and encode extensin-like Pro-rich proteins. CELP mRNAs accumulate most abundantly in vascular and epidermal tissues of floral organs. In the pistil, CELP mRNAs also accumulate in a thin layer of cells between the transmitting tissue and the cortex of the style and in a surface layer of cells of the placenta in the ovary. This unique accumulation pattern of CELP mRNAs in the pistil suggests a possible role in pollination and fertilization processes. CELP genes encode a class of plant extracellular matrix proteins that have several distinct structural features: a Pro-rich extensin-like domain with Xaa-Pro3-7 motifs and Xaa-Pro doublets, a Cys-rich region, and a highly charged C terminus. The extensin-like domains in these proteins differ significantly in their length and these differences appear to be results of both long and short deletions within the coding regions of their genes. Furthermore, the number of charged amino acid residues in the C-terminal region varies among the CELPs. These structural differences may contribute to functional versatility in the CELPs. On the other hand, the Cys-rich domain is highly conserved among CELPs and the positions of the Cys residues are conserved, suggesting that this region may have a common functional role. The presence of a Pro-rich domain and a Cys-rich domain in these CELPs is reminiscent of a class of hydroxyproline-rich glycoproteins, solanaceous lectins, that are believed to be important in cell-cell recognition. The structure of these CELPs indicates that they may be multifunctional and that their genes may have arisen from recombinational events.

[The long-term effect of molsidomine on frequency of hemorrhage, portal and cardiac hemodynamics in patients with liver cirrhosis--a pilot study]

The aim of the study was to examine the effects of maintenance molsidomine therapy on portal and cardiac haemodynamics in patients with confirmed alcoholic or nonalcoholic liver cirrhosis and portal hypertension. Molsidomine is a selective reducer of preload without development of tolerance. 16 patients with portally decompensated cirrhosis of the liver following an initial or recurrent episode of bleeding form oesophageal/fundal varices were on long-term treatment (4-24 months) with 2 or 3 x 8 mg molsidomine/day (Corvaton retard). They were followed up after 3-6 months. 6 of the 16 had been treated previously with propranolol for haemorrhage prophylaxis over 11 +/- 15 months. In a total of 70 treatment months with propranolol, 10 recurrent bleeds had occurred. During 166 treatment months with propranolol, 10 recurrent bleeds had occurrences of bleeding. This long-term treatment showed reductions in hepatic venous pressure gradient of 24.8% (n = 8) (p < 0.05), variceal pressure of 28.7% (n = 7) (p < 0.05) and size of varices of 17% (n = 8). This occurred without any clinically relevant impairment of systemic cardiovascular regulation. Therefore long-term therapy with molsidomine may be suitable for prophylaxis of haemorrhage of oesophageal varices.

Transfected cGMP-dependent protein kinase suppresses calcium transients by inhibition of inositol 1,4,5-trisphosphate production

cGMP is a key regulatory molecule in visual transduction, integration of neuronal response to excitatory neurotransmitters, relaxation of smooth muscle, intestinal secretion of water and salt, and reabsorption of sodium and water in the distal tubules of the nephron. Some of these cellular functions are associated with the activation of cGMP kinase and a decrease in cytosolic calcium levels ([Ca2+]i). The mechanism by which cGMP kinase lowers [Ca2+]i is controversial. We have used CHO cells stably transfected with cGMP kinase to test several of the proposed [Ca2+]i-lowering mechanisms. Thrombin induces a calcium transient in wild-type and cGMP kinase-expressing CHO cells by releasing calcium from intracellular stores. Preincubation of wild-type cells with 8-bromo-cGMP had no effect on the calcium transient, whereas 8-bromo-cGMP prevented the thrombin-stimulated calcium transient in cGMP kinase-expressing CHO cells. In both cell types 8-bromo-cGMP had no effect on [Ca2+]i transients induced by replacing extracellular sodium by tetramethylammonium, ruling out an effect of cGMP kinase on Ca(2+)-ATPases. However, cGMP kinase activation effectively suppressed thrombin-induced stimulation of inositol 1,4,5-trisphosphate production. These results show that cGMP kinase lowers [Ca2+]i by interfering with the inositol 1,4,5-trisphosphate synthesis.

[The anterior sonographic-guided celiac plexus blockade. Review and personal observations]

The coeliac plexus block is an approved method for the relief of upper abdominal pain due to cancer of the upper intra-abdominal viscera or to chronic pancreatitis. While there are many reports concerning the posterior approach to the coeliac plexus block, little attention has been given the anterior approach. There are two ways of implementing the anterior approach to the coeliac plexus: CT-guided and the ultrasound guided approach. METHODS. The ultrasonic-guided anterior approach to the coeliac plexus block is used with the patient in the supine position. The aorta and discharge of the truncus coeliacus or the a. lienalis respectively, are ultrasonographically presented at two levels. After setting local cutaneous and subcutaneous anaesthesia, a 15-cm-long 25 G-needle is introduced into the epigastrium. The point of the needle is--ultrasonographically guided--inserted into the pre-aortic area near the discharge of the truncus coeliacus. The position of the needle point is ultrasonographically controlled on two levels. For the enforcement of a diagnostic coeliac plexus block after careful aspiration on two levels, 10 ml of bupivacaine 0.5% is injected. The spread of the solution is evaluated by ultrasound. If the needle position is correct; a few minutes later the patient has a feeling of warmth in the upper abdominal region. For the enforcement of a neurolytic coeliac plexus block 10 ml ethanol 96% and 10 ml prilocaine 1% can be administered. The two solutions are applied as small volumes in permanent succession. Thus the burning pain, which is often observed after the injection of alcohol, is avoided. RESULTS. In the literature there are only a few reports, about the results and side-effects after use of the anterior approach in the coeliac plexus block. The results of these investigations and our own show total pain relief or at least good pain reduction by at best 85%. The reduction in pain achieved continues in as many as 60% of the treated patients. There is the possibility to stop or at least reduce the analgesic premedication. These results are comparable with those after using the posterior approach to the coeliac plexus block. When carrying out the anterior approach in the coeliac plexus block, most of the patients showed increased intestinal motility. Therefore, about 60% of all patients had transitory diarrhoea. In 12-25% of the patients orthostatic hypotension was observed. This side-effect is avoided by an appropriate infusion before enforcement of the block. In a frequency of 4-100% the occurrence of burning pain was reported during injection of the alcohol. No serious side-effects were observed. CONCLUSIONS. The results concerning total pain relief or at least pain reduction are comparable to the posterior approach for the block. Nevertheless, there are some advantages to the ultrasound-guided anterior approach. There is less risk using this technique. No methodological complications have been observed so far. There is no risk of neurological complications such as paraplegia. Because the patients remain in the supine position, the anterior approach to the coeliac plexus block is suitable for terminally ill patients, who are not able to tolerate the prone position and need careful supervision and good ventilation. Also, no contrast medium is necessary. Only a small volume of local anaesthetics or alcohol is required. We prefer the anterior approach of the coeliac plexus block as a fast, safe and cost-effective method, which should receive increasing attention during the next few years.

[Toxic alcohol-induced, acute intrahepatic cholestasis with reversible increase of the CA 19-9 tumor marker in chronic alcoholic hepatitis]

The case report on an acute intrahepatic cholestasis caused by alcoholic intoxication in a 52-year-old medical laboratory assistant is given. In addition to extreme pathologic cholestasis parameters the increase of the tumor marker CA 19-9 was remarkable. By means of laparoscopy and histology, chronic fatty liver hepatitis due to alcoholic intoxication was found. The tumor marker CA 19-9 returned to normal following abstinence from alcohol parallel to the deline of the cholestasis parameters, which means the diagnostic importance of tumor markers in diseases with intrahepatic cholestasis is to be seen in relative terms.

[Cholestasis in imipenem/cilastatin treatment]

The case report on a 22-year-old female patient shows how the treatment with Imipenan/Cilastatin resulted in a severe intrahepatic cholestasis. The serum-bilirubin rapidly decreased after discontinuation of the antibiotic. The laboratory findings were no longer conspicuous four weeks after discharge from hospital.

[Crigler-Najjar syndrome type II in a 17-year-old girl]

The Crigler-Najjar-Syndrome type II is characterised by the decreased activity of the bilirubin-UDP-glucuronyltransferase. This fact leads to an increase of the indirect bilirubin to 6-10 mg/dl. The mode of hereditary transmission is autosomal dominant with variable penetrance. The age of manifestation varies from the first year to the second decade of life. The Crigler-Najjar-Syndrome type II of a 17-year-old girl is reported. The diagnosis was made on the basis of the pattern of laboratory parameters in combination with an uneventful morphology of the liver. Under treatment with Chlofibrat the decrease of the serum total bilirubin from 10.4 mg/dl to 2 mg/dl was achieved.

Characterization of cDNAs for stylar transmitting tissue-specific proline-rich proteins in tobacco

The pistil of flowers is a specialized organ which contains the female gametophytes and provides the structures necessary for pollination and fertilization. Pollen deposited on the stigmatic surface of a compatible plant germinates a pollen tube which penetrates the stigmatic papillae and grows intercellularly through the style towards the ovules in the ovary. Pollen tube growth is largely restricted to the transmitting tissue in the style. Therefore the stylar transmitting tissue is extremely important for the migration of the pollen cell towards the ovary. We have isolated two related cDNAs, transmitting tissue-specific (TTS)-1 and TTS-2, derived from two proline-rich protein (PRP)-encoding mRNAs that accumulate specifically in the transmitting tissue of tobacco. The deduced PRP sequences share similarities with proline-rich cell wall glycoproteins found in a variety of plants. TTS-1 and TTS-2 mRNAs are induced in very young floral buds, accumulate most abundantly during the later stages of flower development when style elongation is the most rapid, and remain at relatively high levels at anthesis. These mRNAs become undetectable in maturing green fruits. In situ hybridization shows that TTS-1 and TTS-2 mRNA accumulation is restricted to the transmitting tissue of the style. The possible roles that these transmitting tissue-specific PRPs may play in maintaining the structural integrity of the style or in the function of this organ is discussed.