Efficacy of Retreatment After Failed Direct-acting Antiviral Therapy in Patients With HCV Genotype 1-3 Infections

Hepatitis C virus infection is causing chronic liver disease, cirrhosis, and hepatocellular carcinoma. By combining direct-acting antivirals (DAAs), high sustained virologic response rates (SVRs) can be achieved. Resistance-associated substitutions (RASs) are commonly observed after DAA failure, and especially nonstructural protein 5A (NS5A) RASs may impact retreatment options.^1-3 Data on retreatment of DAA failure patients using first-generation DAAs are limited.^4-7 Recently, a second-generation protease- and NS5A-inhibitor plus sofosbuvir (voxilaprevir/velpatasvir/sofosbuvir [VOX/VEL/SOF]) was approved for retreatment after DAA failure.⁸ However, this and other second-generation regimens are not available in many resource-limited countries or are not reimbursed by regular insurance, and recommendations regarding the selection of retreatment regimens using first-generation DAAs are very important. This study aimed to analyze patients who were re-treated with first-generation DAAs after failure of a DAA combination therapy.

G-POEM in patients with gastroparesis - gambling for healing or bigger armamentarium ? A case series and review of the literature

Approximately 30% of all affected patients suffering from gastroparesis do not respond to any available treatment modality. Gastric peroral endoscopic myotomiy (G-POEM, antropyloromyotomy) represents a new principle of therapy. In this single center study, G-POEM showed a high technical success rate with a very low procedural complication rate. However, the clinical response beyond a short-term post-interventional improvement did not succeed in a single patient. The heterogeneity of the clinical picture, which represents a spectrum of different pathophysiological, etiological and clinical characteristics, still requires a therapy tailored to the individual patient. G-POEM should be considered especially in patients with pylorus-dominant gastroparesis.

Calprotectin as Diagnostic Marker for Hepatic Encephalopathy and Spontaneous Bacterial Peritonitis in Cirrhosis

BACKGROUND

Calprotectin is a well-established marker for intestinal inflammation, mainly in inflammatory bowel disease, and represents one of the most studied biomarkers in stool samples.

METHODS

Apart from its important diagnostic role in inflammatory bowel disease, there are few studies showing that calprotectin can also be used as a diagnostic tool in patients suffering from hepatic encephalopathy (HE) and spontaneous bacterial peritonitis (SBP) in cirrhosis.

RESULTS

Since calprotectin concentration in the human stool or in ascites is elevated at an early stage of inflammation, it might serve as an early screening tool for patients suffering from cirrhosis who are at risk to develop these conditions. As detection and monitoring of HE and SBP may be unclear and resource-intensive, identification of valid new markers of disease activity is necessary. In this review, we summarize the current knowledge of calprotectin as a diagnostic biomarker in cirrhosis, indicating that it is a highly promising diagnostic surrogate marker to screen for the presence of HE and SBP.

CONCLUSIONS

To screen cirrhotic patients for SBP, calprotectin should be assessed in ascitic fluid while it should be measured in feces when screening for HE. However, the value of calprotectin in managing individual patients must be considered in the specific clinical context.

Patient perception and approval of faecal microbiota transplantation (FMT) as an alternative treatment option for obesity

INTRODUCTION

Fecal microbiota transplantation (FMT) represents a treatment option for some diseases, e.g. recurring Clostridium difficile-associated colitis. However, there is also evidence that FMT can be effective in treating obesity. This pilot study established the approval and willingness of obese patients to undergo FMT.

METHODS

We conducted a survey of adults with obesity using a questionnaire containing 21 both multiple choice and open questions was dispatched to a cohort of 101 persons with obesity. It included questions aiming at the process of FMT itself, donors as well as possible concerns. Additionally aspects of social background and disease activity were dealt with.

RESULTS

The response rate amounted to 30.1% (n = 31). In our population, mean BMI was 40.5 kg/m2 while the vast majority already tried out treatment modalities to lose weight before. 25.8% of persons with obesity were aware of FMT. 62.1% were willing to undergo FMT if the donor was healthy and anonymous while only 6.9% clearly refused this option. Sixty preferred an anonymous donor or a person proposed by their doctor while colonoscopy was the preferred application by 76.7%. The absence of risks of the procedure (47.8%) formed the principal motivation while reduction of medication was considered as least important reason (in 26.1). Insufficient testing of the faeces concerning infections raised the most concerns (in 61.6%).

CONCLUSION

For the majority of the persons with obesity surveyed FMT represents a treatment option. Approximately two thirds of the questionees would consider FMT as an alternative treatment option, even in spite of a satisfactory disease response to current standard therapies. Unsurprisingly there are concerns in regard to the transmission of possible infectious agents as well as to the hygieneic implementation of FMT itself.

Clinical manifestations and treatment options in patients with cirrhosis and diabetes mellitus

BACKGROUND

Diabetes is frequently diagnosed in patients with cirrhosis and represents an important risk factor for morbidity and mortality. Pharmacological therapy is limited due to hepatotoxicity and the risk of hypoglycemia. Investigations on medical practice in this patient population, frequency of diabetes-associated complications and the impact of quality of metabolic control are rare.

AIMS AND METHODS

A retrospective analysis was performed to compare the effects of hypoglycemic treatment, the achieved glycemic control under therapy, the prevalence of typical cirrhosis-related or microangiopathic complications, and cardiovascular comorbidities between a group of diabetic patients with cirrhosis (n = 87) and a nondiabetic cirrhotic population (n = 198).

RESULTS

The prevalence of diabetes in our cohort was 30.5%. Of all diabetic patients, 39.1% received therapy which might potentially result in serious side effects in patients with end-stage liver disease. The rate of ongoing alcohol abuse (28.7%) and noncompliance under medication (41.4%) was high. Only 28.7% of all diabetic subjects showed satisfactory (as defined by HbA1c ≤ 6.5%) glycemic control under therapy. Patients achieving satisfactory control experienced a lower rate of certain cirrhosis-related complications such as hepatic encephalopathy (HE) and hepatocellular carcinoma (HCC), arterial hypertension, and hypercholesterolemia. HE was significantly more frequent in diabetic than nondiabetic cirrhotic patients.

Accuracy of anorectal manometry in patients with fecal incontinence

BACKGROUND/AIM

Patients with fecal incontinence (FI) have lower anal resting (MRP) and squeeze (MSP) pressure and an impaired sensitivity compared to healthy people. However, whether anorectal manometry (ARM) can separate precisely between health and disease is discussed controversially. The aim was to evaluate the accuracy of ARM in a huge cohort of patients and controls.

METHODS

ARM was obtained in 144 controls and in 559 FI patients. MRP, MSP, and balloon volume at first perception (BVP) and urge sensation (BVU) were determined. Receiver operating curve analysis was used to determine optimal cut-offs and sensitivity, specificity and accuracy calculated.

RESULTS

FI patients showed lower MRP, MSP, BVU (p < 0.001) and a higher BVP (p = 0.007). Deterioration of the ARM parameter increased with FI severity. ARM demonstrated an excellent sensitivity (91.4%) and accuracy (85.8%), but only a moderate specificity (62.5%). The sensitivity of ARM rose with FI severity. The pressure data showed higher sensitivity and accuracy than the sensory data despite comparable specificity.

CONCLUSIONS

Sensitivity and accuracy of single ARM parameters is only moderate for the pressure data and poor for the sensory data. In contrast, ARM demonstrated an excellent sensitivity, a moderate specificity, and a convincing accuracy justifying its use in clinical routine.

The effect of osmolarity and caloric load on small bowel motility

BACKGROUND

Although there is profound knowledge about cyclic fasting motility, the postprandial intestinal motor response is not well investigated. It is intriguing to speculate that nutrient composition alters small bowel motility significantly and, in a clinical setting, may account for adverse gastrointestinal symptoms in enteral nutrition (EN). We aimed to assess the impact of different caloric loads and osmolarities of EN on human jejunal motility.

METHODS

Sixteen healthy subjects underwent a series of duodenal infusions of EN solutions, either with iso-osmolar solution with different caloric loads (1.32, 2.64, or 3.96 kcal min(-1)), or with solutions of different osmolarities with constant caloric loads (300, 600, or 1200 mosmol). Jejunal solid-state manometry was analyzed over 90 min both visually and using dedicated computer software.

KEY RESULTS

All tested nutrient solutions were able to trigger conversion to a postprandial jejunal motility pattern after a mean lag phase of 9.4 + 2.3 min (P = NS between different nutrient solutions). Different caloric loads did not result in significant differences in small bowel motility. However, increasing osmolarities caused a significant inhibition of contractile and propagative activity.

CONCLUSIONS & INFERENCES

Small bowel motility under duodenal infusion of nutrient solutions is not influenced by caloric load in a physiological range, whereas high osmolarities inhibit small bowel motility.

[Management of impacted foreign bodies in the upper gastrointestinal tract in adult patients - results of a retrospective case series]

INTRODUCTION

Impaction of foreign bodies in the upper gastrointestinal tract represents a rare endoscopic emergency regarding the danger of organic lesions. Therefore, the therapeutic strategy, rational postinterventional monitoring and potential consequences for the course in the future are often not clear.

METHODS

Out of all oesophagogastroduodenoscopies performed between 2008 and 2010 (n = 10,830), the endoscopies due to bolus impaction were analysed retrospectively concerning endoscopic findings, course of intervention and causative predisposing factors using descriptive statistics.

RESULTS

In the study period, endoscopy was performed in 45 different patients 49 times when foreign body impaction was suspected. In 38 cases (77.6%) a foreign body could be detected by endoscopy, most frequently a meat bolus (65.8%), followed by dental prostheses and tablets. Endoscopic removal could be successfully performed in 97.4%. An operation was necessary in only one patient. A macroscopically unremarkable upper gastrointestinal tract without any predisposing conditions for foreign body impaction could be detected in 33.3%. In one case eosinophilic oesophagitis could be diagnosed histologically. The foreign body was pushed into the stomach by the "push technique" in 54.1%. The foreign body removal was performed as an ambulant intervention in 63.2%.

DISCUSSION

In the majority of cases, impacted foreign bodies of the upper gastrointestinal tract could be removed safely by endoscopy, e.g., using the "push technique". However, the therapeutic strategy should be individually adjusted based on the consistancy of the foreign body. If no predisposing conditions can be found, histological diagnosis should be performed to detect potential eosinophilic oesophagitis early enough.

[Frequency of cardiac arrhythmia in patients with liver cirrhoses and evaluation of associated factors]

INTRODUCTION

Studies analysing the frequency of rhythm disorders in patients with cirrhosis are rare. Nevertheless, factors triggering rhythm disorders occur frequently in cirrhosis. Therefore, a retrospective case control study was performed investigating the frequency of cardiac arrhythmia in a population of patients with cirrhosis while evaluating several associated factors.

METHODS

The files of patients with cirrhosis (n  =  293) in the period 2004 - 2008 were analysed retrospectively regarding cardiac arrhythmia. The frequency of cardiac arrhythmia in the presence of relevant risk factors was analysed using χ ²tests and logistic regression models.

RESULTS

61.1  % of all patients were male (mean age 61.7 years) and 38.9  % female (mean age 62.8 years). The severity of cirrhosis according to the Child-Pugh score (CP) was as follows: CP A 43.3  %, CP B 32.8  % and CP C 23.9  %. Altogether, rhythm disorders were diagnosed in 16.4  % (48/293) of the study population, most frequently atrial fibrillation (68.8  %) and atrial flutter (6.7  %). An advanced age and comorbidities such as arteriosclerotic diseases, hypercholesterinemia (p  <  0.001, each) and diabetes mellitus (p  =  0.013) correlated significantly with the frequency of rhythm disorders which occurred more often in males than in females (p  = 0.066). Ongoing alcohol abuse, the severity of cirrhosis and arterial hypertension were not associated significantly with the onset of rhythm disorders. 84.4  % of all patients with cardiac arrhythmia were treated by diuretics. Decreased (<  3.5 mmol/L) and elevated (>  5 mmol/L) potassium values were observed in 60.6  % of the study collective. Rhythm disorders were more often observed in patients with hyperkalemia (especially atrioventricular block, p  < 0.01).

CONCLUSION

Compared to the average population, the prevalence of atrial fibrillation was increased in our cirrhotic cohort. The occurrence of rhythm disorders was significantly associated with arteriosclerotic diseases, hypercholesterinaemia and diabetes mellitus. Additionally, cardiac arrhythmia must be considered under diuretic therapy and in the presence of electrolyte disturbances.

Comparison of small-bowel motility of the human jejunum and ileum

BACKGROUND

Knowledge about human cyclic fasting motility (MMC) and the postprandial response is mostly based on manometric findings in the upper small intestine. Hardly any data exist on human ileal motility, as the acquisition of data has been limited by methodological concerns. The aim was to study human jejunal and ileal motility in an optimized manometric setting.

METHODS

Solid-state 24-h-manometry was performed in the jejunum and ileum of healthy individuals, applying a strict protocol for fasting, resting, and the consumption of a standardized meal. Both visual qualitative and validated computerized quantitative contraction and propagation analysis were performed.

KEY RESULTS

MMC occurs in similar frequency in the jejunum and ileum, but it was significantly shorter in the jejunum at night. By many characteristics, ileal motility was less intense and propagative than jejunal: less migrating clustered contractions, and slower propagation velocity and shorter distance in phases II and III, and postprandially - possibly slowing and enhancing nutrient absorption. Prolonged propagated contractions in some individuals were identified as a unique ileal propulsive pattern. Postprandially, an abrupt conversion to a digestive motility pattern occurs simultaneously independent of the region.

CONCLUSIONS & INFERENCES

  We found similar basic phenomena of fasting and postprandial motility in the jejunum and ileum of healthy humans. However, different calibration of propagative and contractile activity and special motor events in the ileum may account for a different physiological role in digestion. Future studies of small-bowel motility in healthy and diseased subjects focusing on segmental differences of proximal and distal intestine may be rewarded.

Effect of low-proof alcoholic beverages on duodenogastro-esophageal reflux in health and GERD

BACKGROUND

Alcoholic beverages are known to increase acidic gastro-esophageal reflux (GER) and the risk of esophagitis. Moreover, duodenogastro-esophageal reflux (DGER), containing bile acids, was shown to harmfully alter the esophageal mucosa, alone and synergistically with HCl and pepsin. However, studies directly addressing potential effects of different low proof alcoholic beverages on DGER in health and disease are missing.

METHODS

Bilitec readings for beer and white, rose, and red wine were obtained in vitro from pure and from mixtures with bile. One-hour DGER monitoring and pH-metry were performed in 12 healthy subjects and nine reflux patients with DGER after ingestion of a standardized liquid meal together with 300 mL of water, white wine, and in the volunteers, beer and rose wine.

KEY RESULTS

Bilitec measurement was found to be feasible in the presence of beer, white wine, and using a threshold of 0.25, rose wine. However, the presence of red wine resulted in extinction values above this threshold. The consumption of all investigated alcoholic beverages, especially of white wine, triggered increased acidic GER, both in healthy participants and patients with reflux disease. In contrast, no relevant DGER was found after intake of alcoholic beverages.

CONCLUSIONS & INFERENCES

Fiber-optic bilirubin monitoring can be used for DGER monitoring in combination with alcoholic beverages, except with red wine. Low-proof alcoholic beverages are a strong trigger of GER, but not of DGER, both in healthy subjects and patients with reflux disease.

Influence of gender and age on anorectal function: normal values from anorectal manometry in a large caucasian population

INTRODUCTION

In the literature, data on the effects of gender and age on the pressure data of anorectal manometry differ. Possible reasons are investigation of only small numbers of healthy people and comparison of only 2 groups with large age differences. In addition, data about the influence of gender or age on anorectal sensation are sparse. Therefore, the aim of the present study was to determine the influence of gender and age on anorectal manometry in a large healthy female and male cohort spanning a great age range.

METHODS

Anorectal manometry was performed in 72 women and 74 men with a median age of 64 years in both groups (ranges: women 22-90 years; men 23-88 years). We determined mean anal resting and squeeze pressure as well as minimal rectal balloon volume for perception and for urge/desire to defecate. The Mann-Whitney U test was used to analyze for gender differences, regression analysis to search for age influences.

RESULTS

Squeeze pressure (p = 0.007) and perception threshold (p < 0.001) are significantly lower in females, while the mean resting pressure and urge threshold are similar in females and males. Mean resting pressure (women p < 0.0001; men p = 0.03) and mean squeeze pressure decrease (women p < 0.0001; men p = 0.004) with age. An age-related increase in sensory thresholds (= decreased rectal sensitivity) is only seen in females (perception threshold p = 0.01; urge threshold p = 0.04).

CONCLUSION

Most of the parameters measured by anorectal manometry (anal canal pressure, sensory thresholds) are influenced by gender and age. Therefore, the results of anorectal manometry must be interpreted in relation to sex- and age-adapted normal values.

[Mesenteric inflammatory veno-occlusive disease (MIVOD)--an underdiagnosed disease?]

Mesenteric, inflammatory veno-occlusive disease is an entity of unknown incidence and aetiology. Inflammation and necrosis of mesenteric veins leads to severe ischaemic damage of an intestinal segment. The clinical and endoscopic presentation can be ambiguous. However, modern multiphasic contrast-enhanced computed tomography allows early diagnosis, when characteristic features are considered. As local resection is the only known cure with minimal risk of recurrent disease, knowledge of this rare disease entity can spare our patients a risky delay of resection and erroneous therapeutic approaches.

[Metabolic disturbances in liver cirrhosis (part 2), hepatogenous diabetes: diagnostic aspects and treatment]

Uip to 20% of patients with liver cirrhosis develop hepatogenous diabetesdue to the hepatocellular functional loss and insulin resistance. Optimizing diabetic metabolic conditions is not only important to avoid typical late complications of diabetes, but also cirrhosis-associated complications e.g. gastrointestinal bleeding, hepatic encephalopathy or the occurence of hepatocellular carcinoma. So far there have beenno recommendations orguidelines for the diagnosis and treatmentof hepatogenous diabetes. The medical teatment of a diabetic condition is mainly influenced by its side effects. The risk of hypoglycemia must be considered carefully during drug treatment, especially in patients with chronic alcohol abuse. Suitable oral antidiabetics are glinides and short-acting sulfonylureas or possibly meal-related insulin administration with short-acting insulins or rapid-acting insulin analogues. Biguanide and PPAR-gamma agonists are contraindicated because of side effects in liver cirrhosis. Regarding basic treatment, an adequate daily energy and protein supply should be ensuredbecause the majority of patients with liver cirrhosis are malnourished.

Small bowel motility in functional chronic constipation

In functional constipation, three pathophysiological subgroups have been identified: slow-transit constipation (STC); normal-transit constipation (NTC) and outlet delay (OD). Extracolonic manifestations, especially disturbed small bowel motility, are well known to occur in STC, but have rarely been studied in NTC and OD. To perform 24-h-ambulatory jejunal manometry in a large prospective series of clinical patients with chronic constipation of all subtypes. A total of 61 consecutive patients, referred to our tertiary gastroenterologic centre for chronic constipation (48 female, 13 male; mean age 57 (range 20-87) years), underwent jejunal 24-h-ambulatory manometry (standardized meal) after a transit-time study (radio-opaque markers), anorectal manometry, defecography and colonoscopy. Computerized and visual analysis by two independent observers was compared with the normal range of manometric variables, defined by data previously obtained in 50 healthy subjects (Gut 1996;38:859). Five patients were excluded from the study because of coexistence of OD and STC. No patient with OD (n = 8), but all patients with STC (n = 32) and 94% of patients with NTC (n = 16) showed small bowel motor abnormalities; both in postprandial response and fasting motility. The abnormal findings ranged from severe disturbances with complete loss of MMC to subtle changes of contraction parameters that could only be assessed by computerized analysis. No significant differences between STC- and NTC-patients were found. Most findings pointed to an underlying enteric neuropathy. Intestinal prolonged-ambulatory manometry adds valuable information to the pathophysiologic understanding of functional chronic constipation of STC- and NTC-type, however there are no distinct manometric features to differentiate between both.

[Metabolic disturbances in liver cirrhosis (part 1)--hepatic osteopathy and malnutrition]

Medical treatment of patients with liver cirrhosis consists mainly of symptomatic therapy of associated complications. Apart from the classical complications of cirrhosis, e. g. ascites, portal hypertension or hepatic encephalopathy, other frequent complications are neglected in everyday medicine. The incidence of metabolic disturbances seems to be similar to the prevalence of classical complications of liver cirrhosis, such as portal hypertension or ascites. Osteoporosis is an important manifestation of hepatic osteopathy, especially in chronic cholestatic diseases and in candidates for liver transplantation, which necessitates timely adequate diagnostic test (e. g. osteodensitometry) and treatment (pre-emptive and causal). Malnutrition, especially when related to protein- and energy supply, is very common in patients with liver cirrhosis and has prognostic significance regarding mortality and complication rates. A sufficient daily energy and protein supply should be ensured, one which is higher than that for the normal population. Additional substitution of vitamins and trace elements is indicated when symptoms of deficiency became apparent.

[Hepatogenous diabetes - diagnostics and treatment]

BACKGROUND

Patients with liver cirrhosis develop frequently disturbances of glucose metabolism e. g. glucose intolerance or hepatogenous diabetes which are caused by the hepatocellular functional loss and insulin resistance due to chronic liver disease.

DISCUSSION

Until now there are no recommendations comparable to guidelines on the diagnosis of and therapy for hepatogenic diabetes. Regarding basic treatment a sufficient daily energy and protein supply should be guaranteed since the majority of patients with liver cirrhosis are malnourished. The risk of hypoglycaemia must be considered carefully under pharmacological treatment of hepatogenous diabetes. Biguanide and PPAR gamma agonists are contraindicated due to side effects in liver cirrhosis. Suitable oral antidiabetics are glinides and short-acting sulfonylureas. If a sufficient diabetes adjustment does not succeed by oral antidiabetics a prandial insulin therapy using short-acting insulins or rapid-acting insulin analogues should be applied.

CONCLUSION

Optimisation of diabetic metabolic conditions is not only important to avoid typical diabetic late complications but also cirrhosis-associated complications, e. g., gastrointestinal bleeding, hepatic encephalopathy or the occurrence of hepatocellular carcinoma.

[Summary of the annual meeting of the German society for neurogastroenterology and motility, March 28 - 30, 2008 at Castle Hohenkammer]

The annual meeting of the German Society for Neurogastroenterology and Motility was held at Castle Hohenkammer from 28th to 30th of March 2008 with C. Pehl (Vilsbiburg) as chairman. The members of the Society study the function of the enteric nervous system, gastrointestinal motility, and functional disturbances of the GI tract. Basic researchers as well as clinical scientists are members of the Society and discussed together their results at this meeting. Results from thirty-six working groups from different European countries, USA, and Egypt were presented at the annual meeting. In addition, Prof. Mark Fox (Switzerland/United Kingdom) gave a review lecture entitled "New technologies to evaluate esophageal function".

[Nutrition in liver cirrhosis: diagnostic aspects and treatment]

Malnutrition is very common in patients with liver cirrhosis and includes especially protein-calorie malnutrition. The pathophysiological reasons vary and are caused by metabolic modifications and characteristics of enteral absorption and digestion cause by the cirrhosis. Malnutrition contributes to overall mortality and complication rate of the chronic liver disease. An adequate daily energy and protein supply should be ensured in patients with liver cirrhosis, which is higher than that in the normal population, because of higher amino-acid turnover. Ascites may benefit from daily low-salt fluid intake. Nutritional substitution of vitamins and trace elements is indicated when symptoms of deficiency occur.

[Acute renal failure in patients with liver cirrhosis--what to do? An update]

A lot of patients suffering from liver cirrhosis show a decreased renal perfusion and glomerular filtration rate. An impaired renal function is the result of complex e.g. hemodynamic disturbances, resulting of the chronic liver disease. This explains its disposition to renal dysfunction and the higher incidence of acute renal failure in liver cirrhosis. In the case of renal failure hepatorenal syndrome, apart from prerenal, renal and postrenal causes, should be included in the differential diagnosis especially when signs of portal hypertension are apparent regarding its high mortalityand fatal prognosis requiring an immediate therapeutically approach. Special attention must be due to preventive strategies to avoid renal deterioration. This includes simple steps e.g. a careful election of medication but also an adequate therapy of infection-associated complications in patients with liver cirrhosis.

[Cholestatic hepatitis in situs inversus abdominalis]

A 75 year old patient was admitted to hospital due to painless jaundice and fatigue. Patient's history was not remarkable for chronic viral hepatitis, autoimmune hepatitis, hereditary metabolic disorders or a hepatotoxic damage. Laboratory tests revealed significant elevation of the parameters of cholestasis and aminotransferase activity, a significantly elevated titer of both antinuclear (ANA) and antimitochondrial (AMA) antibodies. Abdominal ultrasound and computertomography showed no mechanic cholestasis nor tumorous process but a situs inversus abdominalis of the abdominal parenchymatous organs. Portal and periportal inflammation, consistent with autoimmune hepatitis, was diagnosed histologically after performing laparoscopic liver biopsy. Regarding the significantly elevated cholestatic parameters and the positive AMA-autoantibodies AIH-PBC overlap syndrome was highly probable so medical treatment including both ursodeoxycholic acid and immunosuppressive therapy with corticosteroids and azathioprine was started resulting in a continous downward tendency of liver enzymes and an improvement of the patient's clinical condition. Finding the correct diagnosis and therapy of autoimmune liver disease is not always easy and unproblematic. Regarding its sometimes fatal progression and good response towards medical treatment prompt diagnosis and institution of autoimmune hepatitis--alone or combined as PBC/AIH overlap syndrome--should not be deferred. Laparoscopic liver biopsy should be the method of choice in patients's with situs inversus abdominalis regading the variable anatomy.

Invasive und nichtinvasive Diagnostik der Hypovolämie bei akuter Pankreatitis

Severe acute pancreatitis leads to a dramatic fluid loss in the intraperitoneal space which may result in circulatory decompensation. Sequestration of fluid can amount up to 40 percent of the circulating blood volume. The amount of fluid and electrolyte replacement is often misjudged leading to a higher rate of complications and a higher mortality rate of the disease. Furthermore, subsequent and adequate fluid resuscitation seems to influence the prognostic course of the disease by improving the perfusion and oxygenation of the pancreas. Otherwise volume overload may cause cardiopulmonary decompensation in the case of synchronous cardiopulmonary comorbidities. Therefore, an important part of treatment relies on careful haemodynamic monitoring, if necessary managed in an intensive care unit. Usually most patients with acute pancreatitis will be treated on a non-intensive medical ward which allows a differentiated and continuous haemodynamic monitoring only to a limited extent. Apart from monitoring circulatory parameters and measuring central venous pressure, there are other clinical methods, laboratory tests and radiological diagnostic procedures to determine the amount of intravascular fluid deficit and the individual volume demand of patients with acute pancreatitis. Prospective clinical trials for evaluation of pancreatitis-specific volume management do not exist so far. The aim of this review is to provide background information on invasive and non-invasive diagnostic methods for detection of circulatory hypovolemia in acute pancreatitis.

„Das iatrogene akute Koronarsyndrom” - 59-jähriger Patient mit Adenokarzinom des Colon ascendens und Stenokardien unter adjuvanter Chemotherapie mit 5-Fluorouracil

Fluorouracil-associated cardiotoxic adverse events represent a relevant but underestimated problem in 5-fluorouracil treatment. After right hemicolectomy for adenocarcinoma of the rightsided colonic flexure a 59-year old patient was referred to our hospital for adjuvant chemotherapy according to MOSAIC-protocol with oxaliplatin and 5-fluorouracil. The patient's history was unremarkable for any cardiopulmonary disease and for any cardiovascular risk factors. 24 hours after completing the first cycle the patient was readmitted to our emergency department because of thoracic pain combined with significantly elevated cardiac enzymes and ischaemic changes in ECG. Coronary angiography was performed revealing no coronary artheriosclerosis. Clinical symptoms and pathological ischaemic serum parameters returned to normal range within 12 hours. Diagnosis of 5-FU-induced acute coronary syndrome could be made. Because of the high rate of recurring cardiotoxicity the patient's chemotherapy was modified to an alternative regimen containing raltitrexed instead of 5-fluorouracil. Immediate diagnosis of 5-FU-induced cardiotoxicity and differentiation from preexisting coronary heart disease is still a major problem in daily oncological practice.

[Severe intrahepatic cholestasis in a 66-year old male patient with medically treated atrial fibrillation]

A 66-year-old male was admitted to hospital due to painless jaundice. Because of ischemic cardiomyopathy with paroxysmal atrial fibrillation as well as recurrent ventricular tachycardias and fibrillation he was treated with phenprocoumon and amiodarone (200 mg per day) for 2 years. Laboratory tests revealed significant elevation of the parameters of cholestasis and aminotransferase activity. Serological tests excluded infectious, autoimmune or metabolic liver diseases. Abdominal ultrasound and ERCP showed no mechanic cholestasis nor tumor of the pancreas. Cardiac congestive disease was also excluded. Severe intrahepatic cholestasis, consistent with drug-induced hepatotoxic damage, was diagnosed histologically. After discontinuing phenprocoumon the liver enzymes further increased. When amiodarone was stopped, however, laboratory parameters showed a continuous downward tendency. For prevention of malignant cardiac arrhythmia the patient received an atrioventricular defibrillator. Intrahepatic cholestasis is a rare presentation of amiodarone-induced hepatic toxicity. Liver damage can even occur after the drug has been taken for prolonged periods without any problems.

[A 67-year-old patient with diarrhoea and constipation without any pathological findings in virtual colonoscopy]

Virtual colonoscopy provides a computer-simulated endoluminal perspective of the air-filled, distended colon using modern CT scanning (spiral CT). According to recent studies the sensitivity and specificity of this technique are high for adenomatous polyps > or = 10 mm. A 67-year-old patient was admitted to our hospital because of diarrhoea and constipation, associated with abdominal pain in the lower right abdomen. Prior to admission the patient had undergone virtual colonoscopy in a specialised radiological practice which had detected no abnormalities apart from colonic diverticulosis. However, conventional video-colonoscopy revealed a subtotal circular malignant stenosis in the region of the right colonic flexure. A poorly differentiated adenocarcinoma was diagnosed histologically. Staging showed peritoneal carcinosis with infiltration of the right ureter and lymphangiosis carcinomatosa of the pectoral lobe of the left lung. After right hemicolectomy because of metastasised carcinoma of the ascending colon (pT4pN1pM1) we started palliative chemotherapy with oxaliplatin, 5-fluorouracil and leucovorin. The risk of misdiagnosis by virtual colonoscopy is clearly increased in patients with subtotal tumour stenosis of the ascending colon. Conventional video-colonoscopy remains the gold standard for the diagnosis of colorectal carcinoma.

[Unclear liver fibrosis in a 42-year-old patient with polycythemia vera]

A 42-year-old patient was admitted to hospital because of ascites and polyglobulia. Laboratory tests revealed reduced liver function and a significant elevation of all three hematopoietic cell lines. Liver fibrosis and polycythemia vera were diagnosed by histologic examination. The most frequent causes for liver fibrosis were serologically excluded. Ultrasound combined with Doppler imaging revealed an obstruction of the right hepatic vein, which was indicative of Budd-Chiari syndrome. BCS can occur under fulminant and nonfulminant conditions, which can result in progressive damage of the liver. Phlebotomy and combined therapy with low-dose aspirin and anagrelide achieved permanent reduction of the elevated blood parameters. In the follow-up the patient's clinical course was stable without hepatic decompensation.

[Pyogenic liver abscess in chronic alcoholic pancreatitis]

HISTORY AND ADMISSION FINDINGS

A 44-year-old patient was transferred for further treatment of pyogenic liver abscess and a severe attack of a chronic pancreatitis for strong upper right quadrant abdominal pain and recurring fever.

INVESTIGATIONS

Laboratory results revealed a significant inflammatory constellation. Abdominal ultrasound was performed which showed a big pyogenic abscess in the right lobe of the liver. Escherichia coli and Enterococcus faecalis could be isolated from abscess aspirates. Endoscopic retrograde cholangiography (ERC) without access of the pancreatic duct showed stenosis of the Ductus hepatocholedochus which was treated with a biliary endoprothesis.

DIAGNOSIS, TREATMENT AND COURSE

Antibiotic treatment and percutaneous drainage led to complete remission of the abscess. A few days after discharge the patient returned with identical clinical symptoms. Abdominal ultrasound showed recurrence of the abscess. Because of excessively high pancreatic amylase in aspirated abscess material the patient underwent endoscopic retrograde cholangiopancreaticography (ERCP). There, a pancreatico-hepatic fistula was seen, probably the result of necrosis caused by a severe acute attack of the chronic pancreatitis. After insertion of a naso-fistular drainage, continous rinse and appropriate antibiotic therapy both abscess and fistula completely disappeared without recurrence.

CONCLUSION

The rare case of a pancreatic fistula should be considered when a pyogenic liver abscess follows an episode of acute pancreatitis or attack of chronic pancreatitis. Determination of pancreatic amylase in aspired abscess material can be an important step towards correct diagnosis.