Monoethylglycinexylidide formation kinetics: a novel approach to assessment of liver function

A novel quantitative liver function test is described which is based on monoethylglycinexylidide (MEGX) formation after lidocaine bolus injection. Following the administration of small single doses of lidocaine hydrochloride (1 mg/kg), monoethylglycinexylidide serum concentration-time curves were determined by a novel highly sensitive fluorescence polarisation immunoassay (FPIA) in healthy volunteers, liver donors and patients with liver cirrhosis. The FPIA allowed rapid and reliable monoethylglycinexylidide determinations in serum and urine (between-days coefficient of variation: less than 10.3%, recovery: 80-113%). Monoethylglycinexylidide concentrations measured by FPIA in 32 serum samples from patients correlated well those determined by HPLC. The monoethylglycinexylidide concentration in serum determined 15 min after a lidocaine bolus injection proved to be a highly sensitive and specific indicator of hepatic dysfunction. Average monoethylglycinexylidide concentrations in serum obtained 15 min after lidocaine injection were substantially lower in patients with liver cirrhosis than in healthy volunteers. The average monoethylglycinexylidide concentrations in serum were also substantially lower in liver donors with ballooning or fatty changes of hepatocytes than in donors without relevant alterations of liver histology. By means of monoethylglycinexylidide formation in the liver donors, primary function of the transplanted liver was correctly predicted in 32/37 cases and initial non-function in 4/6 cases.

[Cryptogenic multifocal stenosing enteritis]

The case of a patient suffering from multifocal idiopathic stenosing enteritis is described. The clinical picture is characterized by a recurrent ileus-symptomatology, which is conditioned by multiple strictures of the small bowel with a considerable dilatation of the inserted small bowel segments, by a differently marked malabsorption syndrome and by an intermittent clinical course. Aspects of the differential diagnosis are discussed, especially in relation to the non-granulomatous ulcerative jejuno-ileitis.

Enzyme release

Enzyme release was studied in various tissues in intact animals or by means of tissue slices, organ perfusion or isolated and cultured cells. The factors that determine the extent and the time course of the leakage were studied extensively with several liver enzymes. It was found that the molecular properties of the enzymes, their topology within the organ, their intracellular localisation, their inducibility on the one hand, the nutritional and energetic state of the organ, and the respective protein turnover on the other, and finally, the type of the organ lesion all contribute to the different release patterns, which are known from experimental studies, and which are utilized for the diagnosis of diseases. While these preconditions of enzyme release are fairly well understood, the nature of the membrane alterations and the mechanism of detachment and transport of the enzyme proteins are less clear. Different models have been proposed, which may not exclude each other. Alterations of the cytoskeleton and the lipid composition of the plasma membranes are closely linked to ion imbalance, which is, in turn, dependent on the energy state of the individual cellular compartments.

Primary malignant melanoma of the esophagus

We report the case of a 74-year-old woman who was admitted to hospital with progressive dysphagia. Further examinations revealed a tumor in the esophagus in which the macroscopic aspect and the histological work-up showed a primary malignant melanoma. The histogenesis of primary malignant melanoma in the esophagus is discussed, and a short review of the literature presented.

CO2 laser management of laryngeal stenosis

The introduction of the carbon dioxide laser as an endoscopic surgical instrument has stimulated interest in its application for removal of stenotic lesions of the larynx. Clinical reports have indicated mixed results in the efficacy of this treatment modality. Nineteen large dogs received acute subglottic injuries from a high-speed electric drill and electrocautery. All animals developed obstructing lesions from 7 to 21 days after injury. With at least weekly removal of granulation tissue and dilations, all animals developed mature subglottic and/or posterior commissure scars. Two animals required tracheostomy. The 15 animals in the experimental group underwent 16 laser procedures. Three animals had vaporization of one third of the scar, three of one half of the scar, and three had total circumferential vaporization. Five animals underwent microtrapdoor flap procedures. Of these, four had a single flap and one had three separate flaps created. In the remaining animal in the experimental group a glottic web developed, which was totally ablated. In one animal treated with a microtrapdoor flap procedure a posterior sinus tract also developed and was treated with laser ablation. The animals undergoing segmental resection of scar demonstrated no improvement in airway size. Those undergoing total resection experienced a worsening of the condition. Those undergoing microtrapdoor flap repair demonstrated moderate improvement in airway size. It can be concluded that large areas of scar removal in the larynx by the CO2 laser will result in prompt recurrence and possible worsening of the scar and smaller submucosal resection of the scar, with preservation of mucosa by the microtrapdoor flap technique, may be helpful in improving the airway.

Endotoxaemia in active Crohn's disease. Treatment with whole gut irrigation and 5-aminosalicylic acid

Endotoxins in plasma were monitored during treatment in 18 patients hospitalised for acute exacerbation of Crohn's disease: systemic endotoxaemia was found on admission in all but one. The patients were randomly divided into two groups: one receiving treatment with total parenteral nutrition and steroids. To decrease the absorbable endotoxin pool, the other group was additionally treated with whole gut irrigation and 5-aminosalicylic acid was added to the lavage fluid. In most of these patients endotoxaemia cleared after intestinal lavage and they needed shorter hospitalisation. Earlier improvement was also indicated by a faster decrease of the Crohn's disease activity index and vanHees index. In the group receiving conservative treatment alone, endotoxaemia was controlled within three weeks. We conclude that endotoxaemia occurs in most patients suffering from active Crohn's disease. Control of endotoxaemia after intestinal lavage suggests that systemic endotoxaemia is caused by absorption of endotoxins from the gut. Earlier improvement after whole gut irrigation indicates its beneficial effect in active Crohn's disease.

[Gabexate mesilate in the treatment of acute pancreatitis. Results of a Hannover multicenter double-blind study with 50 patients]

We investigated the effect of a new synthetic protease- and phospholipase A2-inhibitor gabexate mesilate (FOY) in a multicenter (6 hospitals in Hannover and vicinity) double-blind study on the clinical course of acute pancreatitis. 50 patients were randomized into two subgroups. One group was treated with 3 X 300 mgs of gabexate mesilate per day for 9 days as a continuous intravenous infusion, the control group received placebo. There was no difference in these two groups regarding age and sex, but there was a discrepancy concerning the severity (stage I-IV) of the acute pancreatitis at the onset of treatment. More of the patients in the gabexate mesilate-group had severe disease on admission to hospital. Of the 7 patients (14%) who died, 5 were in the gabexate mesilate-group whereas only 2 were in the placebo group. This difference in the mortality rate is not significant. There was, however, a significant difference at the 5% level between the verum-group and the control group concerning the decline in alpha-amylase activity in serum and the number of complications. The difference was greatest in alcohol induced acute pancreatitis. A non-parametric test showed a significant reduction in hospitalisation time in the gabexate mesilate-group. Due to the small number of patients and the inhomogeneous clinical course of the acute pancreatitis a definite conclusion concerning the effect of gabexate mesilate on the clinical course of acute pancreatitis is not possible. Further studies with a much greater number of patients and more homogeneous groups with respect to the severity of the acute pancreatitis at the onset of the therapy with gabexate mesilate or placebo are necessary.

Organic Carbon-14 in the Amazon River System

Coarse and fine suspended particulate organic materials and dissolved humic and fulvic acids transported by the Amazon River all contain bomb-produced carbon-14, indicating relatively rapid turnover of the parent carbon pools. However, the carbon-14 contents of these coexisting carbon forms are measurably different and may reflect varying degrees of retention by soils in the drainage basin.

Developments in liver transplantation

Liver transplantation has gained increasing interest. While liver grafting for tumor is successful over prolonged periods only in its early course, liver grafting for end-stage cirrhosis may lead to a long survival. Liver grafting in children is the most successful indication; in adults the results depend largely on timing and indication. Actual developments are mainly seen in the following points: a. Improvement in immunosuppression by use of Cyclosporin A. The resorption and metabolism of the drug, in relation to liver function, have to be carefully observed. b. The tendency to perform liver grafting electively instead of in emergency. c. Improvement in operative management, particularly the use of veno-venous bypass. d. The best possible anaesthesiological and intensive care management for the patients. It can be expected, that these developments will enable continuous improvement of results, particularly in an elective situation. One hundred and forty liver grafts have been done in our institution and the results are discussed herein. Progress in liver transplantation is marked by steadily growing numbers of liver grafts performed, and of centers performing grafts, as well as by improved success rates and the recommendation of the U.S. National Institutes of Health, based on discussions at a liver transplantation consent meeting, held in June 1983. This interest is also reflected in discussions among the medical and non-medical community. The first section of this paper will deal with the present state and results of liver grafting particularly, at our own institution and some actual developments in this field will be discussed.

Gabexate mesilate and camostate: new inhibitors of phospholipase A2 and their influence on the alpha-amylase activity in serum of patients with acute pancreatitis

The new synthetic polyvalent protease inhibitors gabexate mesilate (ethyl-p[6-guanidinohexanoyloxy]-benzoate methansulfonate) and camostate (N,N-dimethylcarbamoylmethyl-4-[4-guanidinobenzoyloxy]-phenylacetate methansulfonate) were tested for possible inhibition of phospholipase A2 activity. In a pilot study, we treated 17 patients suffering from acute pancreatitis with continuous intravenous administration of gabexate mesilate, 450 mg/d. The results were compared with a placebo group (same standard therapy) of 21 patients suffering from acute pancreatitis. In vitro experiments showed that, at concentrations between 10(-4) and 5 X 10(-4) mol/L (depending on the enzyme assay employed) for gabexate mesilate and between 10(-3) and 5 X 10(-4) mol/L for camostate, a 50% reduction in phospholipase A2 activity was effected. Comparing the two groups of acute pancreatitis patients after 6 days of treatment with gabexate mesilate, we observed a statistically significantly lower alpha-amylase activity in the serum of treated patients compared with the placebo group.

[Hereditary chronic calcifying pancreatitis]

Four family members covering three generations presented with chronic calcifying pancreatitis. A tumor at the pancreas head was detected intraoperatively in a fifth elderly member of the family. Two of the four cases of chronic pancreatitis were diagnosed in childhood and one in adolescence. The fourth patient had typical symptoms during adolescence but the disease was not recognized at that time. Hereditary chronic pancreatitis has an autosomal-dominant inheritance with incomplete penetrance. The pathogenesis is not known. The course of the disease differed between the family members. Duodenal stenosis with gastrointestinal bleeding was observed, but also a more mild development with recurrent pain and long complaint-free intervals. The occurrence of complications and pain appears to decrease with increasing age. The extent of calcification, widening of the duct, exocrine and endocrine pancreatic insufficiency varies. The question of conservative or operative therapy depends on the course of the disease. A Whipple operation was vitally necessary in one child at the age of six. A pancreo-jejunostomy had to be introduced in a further member of the family at the age of 20 years due to an occlusion of the duct. Two patients receive only conservative treatment.

[Chronic pancreatitis: sensitivity, specificity and predictive value of the pancreolauryl test]

Assessment of the clinical value of the pancreolauryl test (PLT) in the literature range from "useless" to a specifity of 95% and a sensitivity of 98%. In this work, our own data are presented in relation to various reference methods. The results are derived from the largest collective investigated to data, comprising 40 controls and 391 patients (108 with chronic pancreatitis and 283 with other gastrointestinal disorders). The specifity of the the PLT varies between 81% and 95% according to the "quality" of the control collective. The PLT is particularly frequently pathological in patients with diseases in the region of the gallbladder/bile duct and the gastrointestinal tract. The sensitivity of the PLT for chronic pancreatitis varies between 68% and 100%, depending on 9 different reference methods employed. Based on the prevalence of chronic pancreatitis with exocrine insufficiency in various patient collectives, the predictive value of the PLT for the presence of this disorder can be calculated using our data.

HBV-vaccination in recipients of kidney allografts

Recipients of renal transplants were vaccinated with 20 ng hepatitis B surface antigen aluminium-adsorbed vaccine in order to gauge their resistance to hepatitis B infection, to which these patients are at high risk. The patients were given three 40 micrograms doses of the vaccine over a period of six months and their antibody titres were measured. Only 9% of patients developed antibodies to hepatitis B and it was established that if possible all patients should receive at least one injection of hepatitis B vaccine prior to surgery.

[Diagnostic and prognostic significance of massively increased serum glutamate dehydrogenase activity]

In a retrospective analysis of case reports of 115 patients with glutamate-dehydrogenase (GLDH) activity in serum of more than 100 U/l in 1979-1981, the most common causes of this increase were: acute right heart failure (28 patients), protracted septic-toxic circulatory failure (20), obstructive jaundice (18) and severe respiratory insufficiency (16), i. e. diseases causing perfusion or excretion disorders in the liver. The ratio of GLDH activity to transaminase activity provided a reliable separation of acute viral hepatitis, but not of different forms of perfusion disorders. The correlation between GLDH activity and death rate, especially in acute right-heart failure, is of prognostic value.

[HBs-antigen-positive chronic aggressive hepatitis]

In the treatment of HBs-Ag positive, chronic aggressive hepatitis three therapeutic methods can principally be applied: immunosuppression, immunostimulation and an attempt at medicamentous inhibition of the virus propagation. According to the present view, the immunosuppressive treatment with glucocorticoids and azathioprine is very risky in the antigen positive form and doubtful as far as the application is concerned; it simply suppresses the defensive reaction of the organism, thus encouraging the virus replication. In individual cases remissions could be achieved by immuno-stimulation with BCG vaccine or cell wall preparations of the Propionibacterium granulosum, or by an abrupt discontinuation of an immunosuppression. Neither has the virostatic treatment with vidarabin and its monophosphatester , which was introduced in the last few years, brought any new breakthroughs. Under treatment it is mostly possible to block the virus propagation, however, after discontinuation relapses are usually the rule and lasting therapeutic successes the exception to the rule.

Whole-gut irrigation as antiendotoxinaemic therapy in inflammatory bowel disease

Marked endotoxaemia was found in 12 patients suffering from severe relapse of chronic inflammatory bowel disease. These patients did not respond satisfactorily to conservative treatment. Whole gut irrigation was employed to reduce drastically the absorbable endotoxin pool in the gut. Following the lavage the condition of all the patients thus treated improved. Plasma endotoxins dropped rapidly, serum iron increased, and in 7 febrile patients body temperature normalized. The results obtained suggest a beneficial use of whole gut irrigation as a therapeutic means in endotoxaemia associated with inflammatory bowel disease.