[Possibilities of drug therapy of acute hemorrhage of the upper digestive system]

Early detection of bleeding site by immediate endoscopy is the key of effective treatment in massive upper gastrointestinal (GI) bleeding. Upper GI endoscopy gives useful information about the risk, re-bleeding and mortality. Algorithm of treatment is also based on findings upon early endoscopy. Meta-analysis of prospective, randomized, multicenter clinical trials assessing H2-receptor antagonists and proton pump-inhibitors in the treatment of peptic ulcers suggest that these drugs cannot be justified for stopping bleeding or prevent re-bleeding. Other drugs, such as somatostatin, might be effective, but further studies are needed to prove their effectiveness. Both vasopressin and somatostatin are also successfully employed the treatment of bleeding related to portal hypertension, and a recent meta-analysis found significant benefit for beta-blockade in the prevention of recurrent bleeding. Although beta-blocker therapy does not improve survival, it reduces re-bleeding rate, therefore, it can be used as prophylactic therapy for esophageal varices. As for the treatment of erosions, none of the drugs currently employed are effective in reducing or preventing clinically significant bleeding.

[Octreotide in the prevention of hyperamylasemia following ERCP (a controlled multicenter study)]

The aim of the multicentric trial was to study the effect of octreotide (Sandostatin) on the rise of pancreatic amylase in the serum after ERCP based on a large number of patients. The study was carried out in a prospective random manner in 2102 patients in 11 endoscopic centers. Patients in the treated group received 0.1 mg octreotide acetate, and those of the nontreated (control) group received isotonic sodium-chloride subcutaneously before the ERCP and 45 minutes after. Serum amylase and blood sugar were checked before the endoscopic procedure, 6 and 24 hours later. Out of the total number of patients involved, data of 1199 patients (599 in the treated group, and 600 in the control group) were evaluated. Octreotide diminished the percentual increase of serum amylase levels following ERCP. However, the frequency of hyperamylasaemia was decreased only after in patients with chronic obstructive pancreatitis or in such patients after endoscopic sphincterotomy. The peak serum level of blood sugar was higher in the treated group compared to the controls. There was no difference in the clinical symptoms following ERCP between the two groups.

CONCLUSION

the prophylactic use of long-acting somatostatin may diminish the frequency of hyperamylasemia after ERCP in patients with chronic obstructive pancreatitis or in those patients who subsequently underwent EST.

[Small intestinal leiomyoma causing gastrointestinal hemorrhage]

Leiomyomas are uncommon benign tumors of smooth muscle which may occur wherever smooth muscle is present. The small bowel is the most frequent site. Bleeding is the most common presenting symptom. Other symptoms, nausea, vomiting, abdominal pain are rare. In this article a 44 year-old male, presented, who was admitted with intermittent gastrointestinal bleeding in requence of jejunal leiomyoma with exulceration.

[Prognostic role of cisteine and serin proteases in gastriC cancer]

Cysteine proteases (cathepsin B and L), the serine protease urokinase-type plasminogen activator and its inhibitor type-1 play an important part in cancer invasion and metastasis. The authors determined the protease concentrations in gastric cancer tissues, using the ELISA method, in patients with gastric cancer. They evaluated the prognostic role of proteases and the relationship that these proteases may have with other histomorphological prognostic parameters such as tumor staging, grading, histotype, Borrmann classification. The Cox survival analysis showed that cathepsin B (p = 0.002), urokinase-type plasminogen activator (p = 0.0001) and the inhibitor type-1 (p = 0.0004) significantly correlated with poor prognosis. The tumor staging, grading, Borrmann classification correlated also significantly with survival time. Urokinase-type plasminogen activator was selected as the single independent variable in the Cox model (p = 0.0001).

Efficacy of nizatidine, clarithromycin and bismuth subcitrate therapy for Helicobacter pylori eradication in duodenal ulcer patients--a preliminary report

The triple combination of nizatidine, clarithromycin, and bismuth subcitrate resulted in an ulcer healing rate of 98% and an H. pylori eradication rate of 90%. Corresponding 'intention-to-treat' figures were 92% and 84%, respectively. These results suggest that further studies, shorter in duration, using lower dosages, and possibly testing other combinations with a double-blind methodology, are required.

[Effect of interferon-alpha2b therapy in chronic hepatitis C]

In chronic hepatitis C the interferon treatment given three times a week in a dosage of 3 million units (MU) normalizes the values of alanin-amino-transferase in a part of cases (25-40%), and produces bettering in the subjective complains of patients. In the short term therapy (3-6 months) the activity of ALT increases again after leaving the therapy, and the disease becomes active. The aim of this multicenter study in Hungary was to give newer data in the case of longterm efficacy with alpha-interferon. Ninety-one patients with chronic hepatitis C were selected into the open prospective clinical study in university and hospital departments. Treatment protocol was the following: Patients with chronic hepatitis C diagnosed by clinical and histological methods were treated with interferon-alpha 2B given 3 times a week in a dosage of 3 MU. Treatment period had lasted for one year and afterwards the patient had been on control for an other half a year. In non responder cases after 3 month treatment with interferon the dose of therapy was increased for 3 x 5 MU. In 37 cases (40.6%) out of 91 patients the authors found longterm sustained remission and in other 22 cases (24.2%) they observed a partial remission (among them 5 cases with late relapse). The rate of longterm sustained remission under 40 years was higher, than above 40. Higher rate was found when the treatment was started with a shorter chronicity of the disease. On te basis of the results the authors conclude: Interferon-alpha 2B is a good therapeutic modality for the treatment of patients with chronic hepatitis C. Efficacy of therapy is higher in younger patients and also in earlier application.

Age-dependent influence of octreotide on stimulated pancreatic growth in the postnatal period of rats

OBJECTIVE

To investigate the effect of long-acting octreotide (SMS 201-995) on the plasma growth hormone level in preweaning rats and to study the growth and composition of the exocrine pancreas in these rats after stimulation by caerulein- and camostate-induced endogenous cholecystokinin (CCK).

METHODS

Wistar rats of both sexes were treated as littermate pairs in two periods of postnatal age, from days 1 to 11 and from days 11 to 21. To stimulate pancreatic growth, caerulein (3 micrograms/kg subcutaneously three times daily) was given from days 1 to 11, and oral camostate (200 mg/kg given once daily) or CCK-8 (10 micrograms/kg subcutaneously three times daily) was administered from days 11 to 21. Octreotide (6 or 15 micrograms/kg subcutaneously twice daily) was administered alone or in combination with caerulein or camostate. The rats were exsanguinated on days 11 or 21, and each pancreas was removed, weighed and analysed.

RESULTS

Caerulein stimulated pancreatic growth and raised the trypsin concentration; camostate induced pancreatic hypertrophy and hyperplasia. By day 11, octreotide had decreased the plasma growth hormone level and the basal pancreatic trypsin concentration and content. Given in combination with caerulein, octreotide reduced the growth hormone level and the stimulated trypsin and DNA contents. By day 21, rats treated with octreotide in the camostate group showed a reduced basal pancreatic trypsin concentration and a decreased basal trypsin content (although the changes were not significant). Plasma growth hormone levels were not significantly reduced.

CONCLUSION

The antitrophic pancreatic action of octreotide and its plasma growth hormone-lowering effect were shown in rats during the first 10 days after birth. These effects were less notable from days 11 to 21, a period when CCK receptors increase in number and components of the stimulus-secretion mechanism are mature.

[Crohn disease: diagnosis by graded compression ultrasound]

Fifty-four patients with suspected Crohn's disease of the small bowel underwent ultrasound examination with graded compression. The pathologic sonographic findings were compared with the clinical, endoscopic and in 32 cases with the parallel performed CT and selective enterographic examinations. Of the 29 proven cases of Crohn's disease 26 (89.7%) had bowel wall thickening detectable with US. The change in the bowel wall structure correlated to the stage of the disease. The luminal narrowing, the mesenteric involvement, the enlargement of the mesenteric lymph nodes, the abscesses and fistulas were judged easily, but the length and the location of the bowel segment were estimated only approximately. The characteristic but nonspecific signs observed by ultrasound were found to be a useful adjunct to the endoscopic and roentgen examinations. The ultrasound with graded compression in our view is a well usable alternative method for both diagnosis and follow-up, informing about the transmural spread of the pathology.

[Somatostatin plasma level in patients with liver cirrhosis]

The significance of changes in plasma somatostatin level at patients with vascularly decompensated liver cirrhosis was investigated. The plasma level of somatostatin, glucagon, gastrin and blood glucose concentration were determined under basal condition and after testmeal in patients with vasculary decompensated cirrhosis, in cirrhotic-patients without ascites formation and in control subjects. The basaline levels and the postprandial increases of plasma somatostatin concentrations were significantly lower in cirrhotic patients with ascites, compared to the other two groups. The glucagon concentrations--both the basaline and the postprandial--were significantly higher in the cirrhotic patients-groups, compared to the controls. The gastrin and blood glucose levels were not different in the three groups. The decrease in plasma somatostatin concentration present in cirrhosis associated with ascites represents a secondary phenomena, and suggest that endogen somatostatin plays a role in maintaining body fluid homeostasis.

The effect of the long-acting somatostatin analogue octreotide on caerulein-induced pancreatic injuries in rats

The efficacy of long acting somatostatin analogue, octreotide acetate (SMS 201-995) on the caerulein-induced acute pancreatitis and on the regeneration of the gland was examined. The effect of the drug on the acute injury was examined at 6 and 24 hours following the intervention, while the regeneration was examined on Day 3 and Day 5 in all cases by determination of plasma amylase levels and by analysis of the pancreatic tissue. The use of octreotide could not counteract the occurrence of acute pancreatitis, however, it has some benefit as seen by it's ability to moderate the increases of serum amylase levels. During the examination of pancreatic regeneration it was found that the weight of the pancrease decreased and this was not affected by octreotide. As a matter of fact, the octreotide coadministered with caerulein counteracted the caerulein-induced increase of pancreatic DNA content and therefore acted against the reactive pancreatic hyperplasia. Thus long term administration of octreotide in acute pancreatic injury may not be rational.

Short report: octreotide in the treatment of external pancreatic fistulas

The efficacy of the long-lasting somatostatin analogue, octreotide, in the treatment of high-output pancreatic fistulas was investigated in this prospective, open study. Sixteen patients with post-operative pancreatic fistulas were treated with subcutaneous injections of octreotide 0.1 mg b.d. The output of the fistulas before the somatostatin therapy ranged between 190 and 570 ml/day. The therapy was begun on average 17 days following the appearance of the fistula (range 4 to 35 days). The decrease in volume one day after initiation of therapy ranged from 26% to 69%. By the third day of treatment the fistula volume decreased to 0-45% of the initial output. The treatment resulted in the closure of 14 of the 16 fistulas; the time to closure ranging from 3 to 15 days. The results suggest that octreotide is a useful adjuvant agent in the treatment of an external pancreatic fistula.

The effect of somatostatin in dumping syndrome after gastric surgery

The effect of somatostatin on early and late dumping syndrome was studied in 12 patients with gastric resection. Each patient underwent two glucose challenges with 75 gram of glucose administered orally. In the control study isotonic sodium chloride was given, while in the other study cyclic somatostatin in a dose of 80 ng/kg/min was given for a period of 270 minutes. In the control study all patients showed subjective symptoms of the early dumping syndrome with significant (p < 0.001) increases in pulse rate, hematocrit, and vasoactive intestinal polypeptide. Ten patients showed asymptomatic hypoglycemia, as a sign of the late dumping syndrome associated with a significant (p < 0.001) increase of insulin, gastric inhibitory peptide and glucagon levels. During the administration of somatostatin these changes failed to develop. The difference between the results of the two challenges are significant. These results indicate that somatostatin alleviates the symptoms both of early and late dumping syndrome partly by inhibiting the vasoactive intestinal polypeptide, gastric inhibitory peptide and insulin release, which are increased in dumping syndrome and may, therefore, be implicated as to have an etiological role.

Atrial natriuretic peptide in dumping syndrome

The significance of atrial natriuretic peptide (ANP) was investigated in the maintenance of the fluid volume in hypovolemia associated with dumping syndrome following gastric resection. The study was performed on 10 patients who had undergone a Billroth II procedure. Ten age- and sex-matched patients without previous gastric surgery served as control. Each patient underwent an oral glucose challenge. The patients with gastric resection underwent another glucose challenge with intravenous infusion to maintain the fluid volume. All patients with gastric resection showed subjective symptoms of the early dumping syndrome with significant (p < 0.001) increases (initial and maximum rates; mean +/- SD) in heart rate (from 70 +/- 3 to 122 +/- 4 beats/min) and in hematocrit (from 0.40 +/- 0.005 to 0.45 +/- 0.003). The plasma ANP level decreased significantly from 27.24 +/- 5.01 to 15.94 +/- 3.61 fmol/ml (p < 0.01). A significant negative correlation was found between the changes in hematocrit and the changes in plasma ANP level (r = 0.68; p < 0.001). Neither the subjective symptoms characteristic of the early dumping syndrome nor changes in laboratory parameters were noted in the patients during the challenge with infusion. The results show that the hypovolemia in dumping syndrome is associated with a significant decrease in ANP activity. The regulation of ANP release is also affected: apart from the well-known stimulating effect of hypervolemia, there exists an inhibition of secretion in volume-depleted states.

[Somatostatin in the prevention of postoperative increase of pancreatic enzyme after pancreatic surgery]

The prophylactic effect of perioperative use of somatostatin on postoperative increase of pancreatic digestive enzymes was investigated in this double blind, randomized study. Thirty three patients undergoing pancreatic surgery because of chronic pancreatitis were divided randomly into two groups. Fifteen patients received somatostatin- (dose 125 micrograms/hour), 18 placebo-infusion, pre- and postoperatively for a total time of 48 hours. The level of serum amylase, lipase, gammaGT, calcium, creatinine and blood glucose was determined every 12 hours. In the placebo group the serum lipase and amylase increased significantly (p less than 0.001), while the calcium decreased. In the somatostatin treated patients only the lipase level increased significantly (p less than 0.01), while the amylase and calcium showed no significant changes compared to their initial values. The postoperative increase in serum enzyme levels is interpreted as being an indicator of pancreatic injury. These results suggest that the perioperative use of somatostatin has beneficial effect for the prevention of pancreatic enzymes increases, associated with pancreatic surgery or its complications in patients with chronic pancreatitis.

Somatostatin versus secretin in the treatment of actively bleeding gastric erosions

In a double-blind, prospective, randomized trial, 63 patients with actively bleeding gastric erosions were treated with somatostatin (31 patients) or secretin (32 patients). Both drugs were administered by intravenous infusions for 48 or 72 h. The active bleeding and the effect of the therapy was endoscopically established. Somatostatin had a significantly (p < 0.05) better effect on the control of bleeding (29 vs. 23 patients), transfusion requirements (5.8 vs. 7.4 units, p < 0.01) and on the need of surgery (1 vs. 6 patients, p < 0.01). The mortality and the rebleeding rate did not differ between the two groups. The results show that somatostatin is more effective than secretin in the control of active bleeding form gastric erosions.

[Effect of somatostatin on kidney function]

The renal effect of cyclic somatostatin was studied on healthy subjects. The somatostatin was used at therapeutical dose in intravenous infusion. Somatostatin decreases the renal plasma flow, glomerular filtration rate, osmotic and free water clearances, sodium and potassium excretion and the tubular reabsorption of phosphorus while urinary osmolality increases. Under somatostatin infusion the urinary excretion of catecholamines, PGE2, PGF2 alfa and the plasma renin activity and the plasma concentration of glucagon and growth hormone decrease. The antidiuretic activity of somatostatin is due to a) a direct haemodinamic effect, b) an influence on the renal tubular transport as well and also c) because of change the water handling in the collecting ducts.

Effect of somatostatin on kidney function and vasoactive hormone systems in health subjects

The acute effects of i.v. somatostatin (250 mcg bolus followed by 250 mcg/h continuous infusion for two hours) on renal hemodynamics, renal electrolyte and water handling, and urinary excretion of catecholamines and prostaglandins, as well as on plasma concentrations of arginine vasopressin, atrial natriuretic factor, norepinephrine, epinephrine, dopamine, glucagon, and plasma renin activity were studied in seven normal subjects. Somatostatin decreased effective renal plasma flow and glomerular filtration rate, osmotic and free water clearances, urine volume, and sodium and potassium excretion, while urinary osmolality, fractional excretion of sodium, and phosphate excretion increased significantly. Plasma concentrations of arginine vasopressin, atrial natriuretic factor, norepinephrine, epinephrine, and dopamine remained unchanged, while plasma renin activity (3.0 +/- 0.25 vs 2.4 +/- 0.2 ng AngI/ml/h; p less than 0.01) and glucagon levels (40 +/- 11 vs 20 +/- 16 pg/ml; p less than 0.01) decreased. Urinary excretion of norepinephrine, epinephrine, dopamine, PGE2, and PGF2 alpha was suppressed under somatostatin. A significant positive correlation was found between urinary dopamine and sodium excretion (r = 0.7; p less than 0.001) and urinary prostaglandin E2 and glomerular filtration (r = 0.52; p less than 0.01). Without accompanying changes in plasma osmolality and vasopressin concentration significant antidiuresis occurred, suggesting a direct tubular effect of somatostatin. However, the hormone-induced changes are due mainly to the decrease in renal plasma flow. The results demonstrate that somatostatin at supraphysiological doses exerts significant effects on the kidney.

[Effect of somatostatin analogue on experimental pancreatic lesions and their sequelae]

The authors examined the effect of long acting somatostatin analogue (Sandostatin, Sandoz) on acute experimental pancreatitis and on the subsequent regeneration. Acute injury to the pancreas was produced by an intraductal intervention (ligature of the bile duct and intraductal injection of taurocholic acid) and by a metabolic route (supramaximal dose of caerulein by repeated subcutaneous injections). The effect of the drug on the acute injury was examined at 6 and 24 hours following the intervention and the effect on regeneration was examined on day 3 and 5 in all cases by determination of plasma enzyme levels and examination of the pancreatic tissue. Long acting somatostatin analogue did not prove to be effective in the serious acute pancreatitis produced by the intraductal intervention. However, in the acute phase of the caerulein induced pancreatitis, it had a beneficial effect as seen by it's ability to moderate the serum enzyme levels. During the examination of pancreatic regeneration was found that in caerulein induced pancreatitis the weight of the pancreas decreases due to atrophy and that this was not affected by long acting somatostatin analogue. As a matter of fact, the somatostatin counteracted the caerulein induced DNA increase, and therefore acted against the reactive hyperplasia. Therefore, the favorable effect of long acting somatostatin analogue is witnessed only in the caerulein induced acute injury but it does not accelerate the rate of pancreatic regeneration following injury. Due to this fact, protracted administration of this agent can not be rationalized.