Manganese and copper levels in patients with primary biliary cirrhosis and primary sclerosing cholangitis

The liver and the biliary tree form the main excretory route of manganese (Mn) and copper (Cu). Cholestasis, can lead to the accumulation of these trace elements in the organism, resulting in toxicity to the basal ganglia of the central nervous system. The aim of our study was to reveal the influence of long-term cholestasis on the Mn and Cu levels in the blood of patients with primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC). We recruited patients with PBC (n = 20) and PSC (n = 32). A control group (n = 40) was also set up. We also examined serum bile acid concentrations and liver enzyme activities. We did not observe any significant differences in any of these parameters between the PBC and PSC groups. The Mn and Cu levels in the PBC and PSC patients differed significantly from the that in the control group (p < 0.0001 and p < .021, respectively). Patients in whom the laboratory cholestasis markers normalized during ursodeoxycholic acid treatment (18/52;35%) presented with significantly lower levels of Mn and Cu (p = .015 and p = .012, respectively). Ten PSC patients showed normal levels of Mn and Cu six months after liver transplantation. Fine tremors, rigidity, dysarthria, and hypomimia were reported in nine (23%), eight (20%), four (10%), and eight (20%) patients, respectively. In addition to monitoring the cholestasis levels, liver function, and Mn and Cu levels during the long-term treatment of PBC and PSC patients, it is important to also regularly monitor the occurrence and development of extrapyramidal symptoms of Parkinson's-like syndromes.

Liver transplantation as potential curative method in severe hemophilia A: case report and literature review

The authors present clinical case of orthotopic liver transplantation for cirhosis due to chronic viral hepatitis C in a subject with severe hemophilia A. Preoperatively performed pharmacokinetic study with recombinant F VIII confirmed satisfactory in vivo recovery of 2.1 %. A bolus application of 52 units F VIII/kg body weight with target F VIII activity over 100.0 % was administred shortly before the transplantation started. Totally, 30 000 units of recombinant F VIII, 3 thrombocyte concentrates, 2 erythrocyte concentrates, 5 units of virally inactivated plasma, 1 unit of fresh frozen plasma and 3 500 antithrombin units were used. There were no perioperative or postoperative bleeding complications, F VIII substitution was stopped on postoperative day 3. The patient was discharged on twentieth postoperative day.

Use of idarucizumab in clinical practice: a case report

Budd-Chiari syndrome is a serious condition which in chronic course leads to the development of liver cirrhosis. Anti-coagulant treatment of this syndrome is fully indicated and in the treatment can be used dabigatran. Advanced cirrhosis of the liver due to this disease can be an indication for a liver transplant. In this case, it is a great advantage the existence of an antidote to dabigatran (idarucizumab) in order to adjust the coagulation ratios and prevent bleeding disorders. Referred to a case report describes the first experience with idarucizumab in context with liver transplant in a patient with Budd-Chiari syndrome.

[First experience with elbasvir/grazoprevir fixed-dose combination in real-life practice in the Czech Republic]

Hepatitis C virus infection (HCV) is one of the leading causes of chronic liver disease worldwide. The new fixed-dose combination of the highly potent second wave first generation NS5A inhibitor elbasvir (50 mg) and the second generation protease inhibitor grazoprevir (100 mg) is contained in the drug Zepatier. This combination is indicated for the treatment of patients chronically infected with HCV genotypes 1 or 4. Between June and August 2017, the treatment was initiated in 22 patients with chronic viral hepatitis C, with 17 patients being treated in the Department of Infectious Diseases University Hospital Brno and five patients in the Center of Cardiovascular and Transplant Surgery in Brno. All patients were infected with HCV subtype 1b. In all cases, the duration of Zepatier monotherapy (without simultaneous ribavirin administration) was 12 weeks. At the moment, only preliminary results are available. All 22 patients achieved end-of-treatment virologic response. In nine patients, it was already possible to evaluate the virologic response at four weeks after the end of treatment, with sustained virological response (SVR12) was observed in all these patients. The most common complaints were fatigue (3 patients, 14 %) and headache (2.9 %). These problems were not serious and did not interfere with normal daily activities of treated persons.

[Viral hepatitis C and organ transplantation]

At the Centre for Cardiovascular and Transplantation Surgery, Brno (CKTCH), a total of 638 liver transplantations were performed from the beginning of the transplantation programme on 2/2 1983 to 1/1 2017. Of the overall number of 638 transplantations indicated based on cirrhosis with chronic hepatitis C (HCV), 68 patients (11 %) underwent liver transplantation. Patients with HCV diagnosis were treated both while on the waiting list and after liver transplantation (LT). There was interferon as well as interferon-free therapy used during the treatment. 15 patients received interferon therapy after LT with only 2 of them achieving a sustained virological response 2/15 (13 %). 28 patients received interferon-free therapy after LT. A sustained virological response (SVR 12) was reached by 26/28 (93 %) patients.Key words: liver transplantation - viral hepatitis C.

[Infectious complications related to liver transplants]

Infection is a feared complication in the process of transplantation. The study discusses sources of infection, screening of infection and risk factors for infection, time occurrence of individual infections during the peritransplantation and posttransplantation course. It describes the most frequent forms of bacterial, viral and mycotic infections. It specifies efficient prophylactic measures that considerably reduce the risk of infection following liver transplantation.Key words: bacterial infection - cytomegalovirus (CMV) - EB virus (EBV) - hepatitis B (HBV) - hepatitis C (HCV) - liver transplantation - mycotic infection prophylaxis - risk factors - viral infection.

[Real data o viral hepatitis C therapy in the Czech Republic]

We reported the first real data about efficacy of interferon-free therapy of chronic hepatitis C in the Czech Republic. Patients were treated with combined therapy of paritaprevir/ritonavir + ombitasvir + dasabuvir with or without ribavirin. There were 109 patients, predominantly men - 62 (57 %), most of them infected by genotype 1b - 101 patients (93 %), minority infected by genotypes 1a (6/109, 5 %) and 4 (2/109, 2 %). Both treatment-naive (43/109, 39 %), and treatment-experienced patients (66/109, 61 %) were treated. Sustained virological response 12 weeks after therapy termination (SVR12) was 100 %, with exclusion of patients with other reason than virological treatment failure.Key words: dasabuvir - chronic hepatitis C - ombitasvir - paritaprevir/rinonavir - ribavirin.

[Tumours and liver transplants]

Liver transplantation as a curative treatment method can be used for selected primary liver tumours, in particular for hepatocellular carcinoma and rather rare semi-malignant tumours such as epithelioid hemangioendothelioma, further for infiltration of liver by metastatic neuroendocrine tumours (provided that metastases are only located in the liver and the primary tumour was removed) and for benign tumours (hemangiomas and adenomas) with oppression symptoms and size progression. Cholangiocarcinoma is not indicated for liver transplantation at the CKTCH Brno. In recent years liver transplants for hepatocellular carcinoma have increased and hepatocellular carcinoma has also been more frequently found ex post, in the explanted livers. Liver transplantation is indicated in selected patients with a good chance of long-term survival after liver transplantation (a generally accepted limit is 5 year survival of 50 % after transplantation). By 20 March 2015 there were liver transplants carried out on 38 patients - in 25 of them was hepatocellular carcinoma diagnosed before transplantation and in 13 it was found in the liver explants. 5 year survival following transplantation is reached by 53 % of this cohort. 32 % patients suffered from chronic hepatitis C. The longest surviving (32 years) patient at CKTCH Brno had liver transplanted for a big fibrolamellar hepatocellular carcinoma, which points to the prognostic significance of tumour histology: the criterion only considered in some indication schemes for practical reasons. Benign liver tumours (adenomatosis, cystadenoma, hemangioma with oppression symptoms) are rather rare indications and the transplantation results are favourable. 4 patients underwent transplantation for infiltration of liver by carcinoid, tumour recurrence occurred in one.

[Liver transplant indication and waiting list inclusion]

The authors have presented an overview of indications and inclusion of patients to the liver transplant waiting list in the Brno transplant centre over a period of 30 years from the first liver transplant performed in the Czech Republic (the then Czechoslovakia). The first clinical liver transplant in the Czech Republic was performed on 2 February 1983. Indication for the transplant was a malignant liver tumour. For a period of 30 years (from 2 February 1983 to 15 January 2013) a total of 592 patients were placed on the waiting list and a total of 453 liver transplants were performed. An urgent liver transplant was carried out in 32 patients over the same period of time.

[Liver transplant outcomes in Brno]

The first liver transplant in the former Czechoslovakia took place in Brno on 2 February 1983; the patient concerned has lived for more than 30 years with a normally functioning liver and is one of the longest surviving patients after a liver transplant in Europe. The Cardiovascular and Transplantation Surgery Centre (CTSC) in Brno has experienced an increased development in the area of liver transplants since the mid  1990s. At present, about 30 patients a year undergo a transplantation, with 451 liver transplants in total as of 31 December 2012. The primary indication concerns liver cirrhosis of various etiologies, with an increasing number of cases of cirrhosis resulting from hepatitis C. Urgent liver transplants (for acute liver failure or primary dysfunction of first liver graft) amount to 11% of cases. There were 18 retransplants performed as of 31 December 2012, with 50% five year survival. The primary graft dysfunction was present in 7 patients (i.e. 1.5%). The 1 year survival rate of all patients after a liver transplant performed in CTSC is 92%, 5 year survival rate is 80%, and 10 year survival rate is 71%. Currently the parameters such as recipients age, donors age, and transplant waiting time has been statistically increasing; small recipients with a body weight below 70 kg especially have to wait for a significantly longer period of time (waiting median of 178 days). In CTSC Brno 14 combined simultaneous transplants (13 transplants of liver + kidney and one combined simultaneous transplants of liver + heart + kidney in 2005) have been performed as of 31 December 2012.

[Interventional radiology options to address certain complications of the orthotopic liver transplant]

At the clinic of imaging method St. Annas University Hospital solved complications arising after ortotopic liver transplantation. For more than 15 years of cooperation with CKTCH Brno intervention was performed on both the arterial and venous system, but most on the biliary tract. The order was a unit patients, which correlates with other comparable work. In the years 1998- 2013 we conducted one intervention on arterial bed, 3× intervention in hepatic venous system and we solved biliary complications in 7 transplant. .

[Liver transplants in viral hepatitides]

The authors present their own results of liver transplants over the last 30 years (from 2 February 1983 to 31 December 2012). For the respective period, 451 patients underwent a transplant in the Brno Transplantation Centre. Ten out of 451 patients (2.2%) underwent transplants for the indication of cirrhosis caused by viral hepatitis B in the Brno Transplantation Centre. The first liver transplant indicated due to viral hepatitis B was performed in 1994. Out of the ten patients, 3 died (30%). Forty  one out of 451 patients (9%) underwent liver transplant for cirrhosis caused by viral hepatitis C. The first liver transplant indicated due to viral hepatitis B was performed in 1991. A total of 21 patients out of 41 (51%) were treated with antiviral therapy; 27 out of 41 (66%) developed a recurrence after the liver transplant. Out of the 41 patients who underwent a liver transplant for viral hepatitis C indication, a total of 15 (36.6%) died.

[Liver transplants in tumours and alcoholic cirrhoses]

The treatment of hepatocellular carcinoma requires a multidisciplinary approach; liver transplant is suitable only in the minority of strictly selected patients. The CSTC Brno applies the so  called Milan criteria. As of 31 December 2012 the CSTC Brno performed liver transplants in 16 patients with hepatocellular carcinoma in cirrhosis, with a five year survival rate of 40% and a 10 year survival after transplant of 20%. It is a paradox that the longest living (30 years) patient of CSTC Brno underwent the transplant for a large fibrolamellar hepatocellular carcinoma, which emphasises the prognostic significance of the tumour histology -  criterion taken into account for practical reasons only in some indication schemes. Liver transplant for cholangiocarcinoma is no longer being carried out in CSTC. Five patients underwent this operation in the past and the longest living one survived for four years after the transplant. Benign liver tumours (adenomatosis, cystadenoma, hemangioma with compression symptoms) are rather rare indications and transplant results are positive. Four patients were transplanted for liver carcinoid, with one patient experiencing recurrence. The most frequent compact indication for liver transplant in CSTC Brno concerns alcoholic cirrhosis (24%, 108 patients); the survival rate of these patients after transplant is very good (81% 5 year survival and 68% 10 year survival). Likewise, efforts are made to select patients with a low risk of alcohol abuse after the transplant, which is, however, not very successful. The recurrence of some kind of alcohol abuse occurred in 26% transplanted patients, while seven died of alcoholic cirrhosis of the graft.

Immunoglobulin G4-related cholangitis: a variant of IgG4-related systemic disease

IgG4-related sclerosing cholangitis as part of IgG4 systemic-related diseases is commonly associated with autoimmune pancreatitis. Major clinical manifestations of IgG4-related sclerosing diseases are apparent in the organs in which tissue fibrosis with obstructive phlebitis is pathologically induced. IgG4-related sclerosing cholangitis is included within the heterogeneous group of 'sclerosing cholangitis'. Sclerosing cholangitis may be associated with choledocholithiasis, infection or biliary malignancies. Sclerosing cholangitis of unknown etiology is called primary sclerosing cholangitis (PSC). Conservative therapy of PSC is usually unsuccessful, the disease involves extra- and/or intrahepatic biliary tree, and the end point of this disease is liver cirrhosis. Typically, PSC is identified at the age of 30 to 40 years, and the disease is frequently associated with inflammatory bowel diseases. On the other hand, IgG4-related sclerosing cholangitis is not associated with inflammatory bowel diseases. In patients with IgG4-related sclerosing cholangitis, a first symptom can be obstructive jaundice, whereas obstructive jaundice is rarely present in PSC. Clinically, patients with IgG4-related sclerosing cholangitis are older at diagnosis compared to patients with PSC. A typical diagnostic feature of IgG4-related sclerosing cholangitis is elevation of serum immunoglobulin G4. In patients with IgG4-related sclerosing cholangitis, response to steroid therapy is high; in patients with PSC corticosteroid therapy is unsuccessful. Histochemically abundant infiltration of IgG4-positive plasma cells is detected in the biliary duct wall. Histologically, we can identify dense lymphoplasmacytic infiltration of the bile duct wall, transmural fibrosis, lymphoplasmacytic infiltration and fibrosis in the periportal area of the liver - a typically obliterative phlebitis. The biliary epithelium is usually intact in contrast to PSC, where mucosal erosion is often present. Steroids are the first-choice therapy of IgG4-related sclerosing cholangitis. In the literature, cholangiocarcinoma in patients with IgG4- related sclerosing cholangitis was not described, whereas cholangiocarcinoma develops in up to 10-30% of patients with PSC.

[Liver function assessment in oncology practice]

The overall condition and prognosis of a patient can be affected by impaired liver function. It applies to anticancer pharmacotherapy, liver surgery and radiological interventions. The liver condition is usually assessed by common laboratory tests and clinical examination in daily practice. Liver tests consist of aminotransferases - alanine transaminase, aspartate transaminase, bilirubin, alkaline phosphatase, gamma glutamyl transpeptidase, lactate dehydrogenase, albumin and prothrombin time, less frequently prealbumin and cholinesterase. The alkaline phosphatase and aspartate transaminase are markers of a liver damage, the alkaline phosphatase and gamma glutamyl transpeptidase are most useful as markers for cholestatic liver injury. Albumin, prealbumin, cholinesterase and prothrombin time are the markers of synthetic liver function. Bilirubin and bile acids are related to the liver transport and excretory capacity. The Child-Pugh score is used to assess prognosis of chronic liver disease, mainly cirrhosis. The examination of liver function using indocyanine green helps to determinate the extent of possible liver resection. A mathematical analysis of dynamic cholescintigraphy and a calculation of hepatic extraction fraction enables quantification of liver function. Other liver function tests are of little use in oncology.

[The influence of some factors on presence of varices and variceal bleeding in liver cirrhosis patients]

STUDY AIM

The aim of the study was to identify non-invasive investigations that would provide a sufficiently reliable prediction of the presence of varices in patients with liver cirrhosis (LC) and identification of patients in a risk of variceal bleeding.

PATIENT SAMPLE AND METHODOLOGY

As part of a prospective evaluation, 165 patients with alcoholic LC admitted to the Department of Internal Hepatology and Gastroenterology of the Medical School, Masaryk University in Brno between 2007-2009 were divided according to the presence of varices and variceal bleeding into three groups: I. patients with LC and varices with no variceal bleeding (N = 50), II. patients with LC with no varices and thus no variceal bleeding (N = 51), III. patients with LC and varices with confirmed variceal bleeding (N = 64). A statistical evaluation was performed of a range of haematological and biochemical parameters, spleen size and a thrombocyte, leucocyte and erythrocyte count to spleen size ratio.

RESULTS

Patients with varices (groups I and III) had, compared to patients with no varices (group II), a significantly larger spleen, lower thrombocyte count, lower plasma fibrinogen level, extended prothrombin time (higher INR), lower plasma GGT activity and lower erythrocyte, leucocyte and thrombocyte count to spleen size ratio. In the present cohort, statistically significant factors for the presence of variceal bleeding included lower erythrocyte count and lower level of haemoglobin, i.e. the expected effect of bleeding, lower fibrinogen serum levels, lower serum ALP activity, lower total serum protein and serum albumin, higher plasma levels of uric acid and lower leucocyte or erythrocyte count to spleen size ratio.

CONCLUSION

Using common haematological and biochemical parameters together with spleen size enables, even without endoscopic examination, highly reliable prediction of the presence of varices and identification of patients in a high risk of variceal bleeding. When these non-invasive methods are used, it is possible to eliminate the need for the invasive endoscopic examination that is frequently poorly tolerated by the patients and economically demanding.

[Immunoglobulin G4-associated cholangitis]

Autoimmune LgG4- associated cholangitis is a new entity among the liver and biliary tree disorders, classified among the so-called IgG4-related diseases. Even though prognosis of this disease is unclear, this type of sclerosing cholangitis is not being linked to a carcinoma. Clinical and laboratory data differ slightly from the findings associated with the usual primary sclerosing cholangitis and it is mainly the high IgG4 level and hyperbilirubinaemia that supports the diagnosis ofautoimmune disease. Unlike primary sclerosing cholangitis, this disease is not associated with a malignant prognosis and steroids represent an effective treatment. Combination of steroids with azathioprin is a possible alternative in case of a relapse. Patient's response to steroid therapy is a diagnosis-supporting criterion. This disease should always be considered as part of differential diagnosis of primary sclerosing cholangitis, especially when autoimmune aberrations or other autoimmune diseases are present. Long-term evaluations of these patients are so far lacking and thus studies on larger patient samples are required.

[The case of familial adenomatous polyposis and a proposal for the system of dispensarisation]

We present a case of a 46 years old female with familial adenomatous polyposis of the colon. The adenocarcinoma had been treated using all available oncology therapeutic modalities. Late post-radiation changes caused ileus that required acute surgical revision, and formation of difficult-to-define enterovesical fistula that led to recurring urosepsis. When the conservative methods, including enteral and, subsequently, home total parenteral nutrition, were unsuccessful, the patient underwent successful surgery with resection of the affected intestinal loops, part of the bladder, evacuation of an abscess in the small pelvis and terminal jejunostomy. As a result of this procedure, the patient is now able to take food per os without infectious complications. The resulting short bowel syndrome is managed by administration of additional parenteral nutrition and registration of the patient for intestinal transplantation is being considered.

[Ascites in Mulibrey syndrome]

The authors describe a case of 22 years old adult male with Mulibrey syndrome. This is an autosomal recessive hereditary disease that manifests through multiple malformations. Diagnosis of Mulibrey syndrome in the present case was first based on clinical signs (facial dysmorphia, growth disorder, muscle hypotrophy) and was later confirmed by genetic examination. At the age of 18 months, the patient underwent surgery for Wilms' tumour followed by cytostatic therapy. Facial, neck and lower extremities oedemas started to occur from the age of 11 years when diastolic ventricular dysfunction was also diagnosed. Pericardiectomy was performed at the age of 13 with no significant clinical effect. Significant ascites dominated the clinical picture and required repeated paracentesis at the age of 15 years. Subjective complaints improved when adequate diuretic therapy was introduced and ascites was managed with conservative therapy without the need for further paracentesis.

[Bacterial infection and its relation to the genesis and course of varicose hemorrhage]

Acute hemorrhage from esophageal varices due to portal hypertension is a frequent and serious complication of liver cirrhosis. Bacterial infection may be one of the factors influencing such hemorrhage. Endotoxins may increase portal tension and at the same time result in primary hemostasis disorder, thus becoming one of the causes of hemorrhage. The authors of the paper compared the incidence of bacterial infection in 53 patients with varicose hemorrhage due to portal hypertension with 62 patients with liver cirrhosis and portal hypertension without varicose hemorrhage. At least one pathogen was found in considerable 61.1% of the total of patients in the liver cirrhosis group, while the difference between the two groups was but insignificant. No statistically significant difference was found between the group of patients with hemorrhage and those without hemorrhage in terms of presence of bacterial infection in hemoculture, urine, throat, faeces and ascites, nor was there a difference in the etiology of the G+ bacteria, G- bacteria or fungi and yeast infectious agents in the hemoculture, urine, throat, faeces and ascites in either of the groups. No statistically significant difference was found in comparing the patients with a recurrence of hemorrhage (or with mortality) and with infection with those without recurrence of hemorrhage. Bacterial infection was more often found in patients with a recurrence of hemorrhage (75%) as compared with those without any recurrence (52%), and also in patients who died bacterial infection was proven more often than in those who survived (61.9% vs. 58.1%, respectively). There was no difference in morbidity or recurrence of hemorrhage between the patients treated with norfloxacin and ampicilin/sulbactam. No statistically significant difference was recorded between the 1st and 5th day in terms of decrease in bacterial infection. A significant difference was found in the urine etiological agent, where a significant increase in the share of fungal and yeast urine infection (p = 0.011) was recorded after the application of the therapy, as well as a drop in urine infection caused by the G- bacterial agent (p = 0.057).

[Atypital localisation of pyoderma gangraenosum in patient with ulcerative colitis]

The authors present a case of 61-year-old man with ulcerative colitis and with extraintestinal manifestation of the disease in the form of pyoderma gangraenosum. Multiple skin defects, which developed in atypical localisation (extensive affection of facial and hairy parts of the head) in patient with chronically active form of ulcerative colitis were complicated with bacterial contamination of methicilin-resistant strains of Staphylococcus aureus. After application of the parenteral feeding, corticotherapy and targeted antibiotic therapy the subjective and objective status of the patient markedly improved, stool frequency was reduced, admixture of blood in the stool disappeared, temperatures fell back and there was a decrease in activity of non-specific bowel inflammation in laboratory findings. However endoscopic examination of the intestine confirmed the finding of chronically active ulcerative colitis with ulcerations and bridging polyps. Patient was indicated to total colectomy, but he refused it.

Bacterial infection and acute bleeding from upper gastrointestinal tract in patients with liver cirrhosis

BACKGROUND/AIMS

Acute bleeding from the upper gastrointestinal tract is a common and serious complication of liver cirrhosis. It is believed that bacterial infection may be the immediate cause of the bleeding and the latest meta-analyses show that bacterial infection is an independent predictive factor of the failure to stop bleeding.

METHODOLOGY

The authors evaluated the presence of bacterial infection (blood, urine, throat and ascitic fluid) in 35 consecutive patients with liver cirrhosis and acute bleeding with portal hypertension and compared these results with a group of 35 patients with liver cirrhosis with portal hypertension without acute bleeding.

RESULTS

According to the results obtained, there is a statistically higher incidence of bacterial infection among patients with acute bleeding with portal hypertension (25 of 35 patients, 71%) than among patients with liver cirrhosis and portal hypertension without acute bleeding (14 of 35 patients, 40%, p < 0.01). The incidence of bacteriological findings in blood and throat samples is statistically higher in patients with acute bleeding as opposed to the control group (p < 0.05).

CONCLUSIONS

These results confirm the necessity of administering antibiotic prophylaxis to all cirrhotic patients with variceal bleeding, not just to those with confirmed infection or symptoms thereof.

[Acute oesophageal necrosis]

The case of acute oesophageal necrosis in 56-year-old patient with tumor dissemination is presented. Acute endoscopy was performed after several hours lasting haematemesis and melena. Endoscopy revealed acute oesophageal necrosis in more than 2/3 of the oesophagus. Patient was treated with proton pump blockers and the total parenteral sustenance was introduced. Three days after the hospital admission the patient died in the septical metabolic disorder resulting from a disseminated spinocellular carcinoma of cervix uteri. Autopsy confirmed necrosis of oesophageal mucosa penetrating into the muscularis mucosae. Acute oesophageal necrosis is a rare disease, which is characteristic by the endoscopic finding of "black oesophagus", histological image of mucous membrane necrosis and by unknown aetiology. The article gives an overview of contemporary knowledge on the clinical, endoscopic and histologic images. The finding of "black oesophagus", which has been reported by several endoscopic units, has highly heterogeneous origin and it represents 0.0125 % (Moreto) till 0.28 % (Augusto) of cases. Our department has recorded 2 cases from 24271 of endoscopies performed in the last 8 years.

Hepatitis D

Hepatitis D virus (HDV) is a small, RNA-containing virus that requires the concomitant presence of Hepatitis B virus (HBV) in an obligate manner for its survival and pathogenicity. HDV infection is very uncommon in Czech Republic. The results of antiviral therapy of hepatitis D patients are not satisfactory. Alpha-interferon (alpha-IFN) in high doses (9-10 MU three times a week for 12 months) is usually recommended.

[Factors participating in development of bleeding varices in portal hypertension. Part II: Possible impact of kidney damage and malnutrition, mortality]

An acute bleeding from oesophageal varices as a result of portal hypertension is a frequent and serious complication of liver cirrhosis. The development of oesophageal varices and their rupture depends on the portal pressure. However, a range of other factors can contribute to a development of bleeding and its negative prognosis. A sample of 46 patients admitted for the acute bleeding has been compared to 48 cirrhosis patients hospitalised for other conditions in this work. There were significantly higher levels of nitrogenous matters in bleeding patients (urea 14.1 mmol/l vs. 7.78 mmol/l, p < 0.01, creatinine 129.8 micromol/l vs. 106.04 micromol/l, p = 0.09). Perhaps it can't be said that impaired renal functions alone increase the risk of bleeding. From this point of view they could rather be seen as definite prognostic markers of the degree of portal hypertension. Moreover, there was a decreased level of total proteins in bleeding patients (60.7 g/l vs. 69.9 g/l, p < 0.01) at a mild nonsignificant decrease of albumin (26.64 g/l vs. 28.51 g/l). Cirrhotic patients are known to suffer from malnutrition and there is a possibility that malnutrition can contribute to development of bleeding. A prognostic marker of mortality was a considerable impairment of liver function (bilirubin 97.4 micromol/l vs. 57.4 micromol/l; p = 0.1 and prolonged prothrombin time 1.99 INR vs. 1.56 INR; p = 0.09) and impaired kidney function (creatinine 166.7 micromol/l vs. 114.9 micromol/l, p = 0.09). Therefore a care of a good renal function must be a part of the complex care of bleeding patients.

[Factors participating in development of bleeding varices in portal hypertension. Part I: bacterial infection and comparison of intravenous and peroral antibiotics effects--a randomised study]

An acute bleeding from oesophageal varices as a result of portal hypertension is a frequent and at the same time serious complication of cirrhosis of the liver. One of factors influencing this bleeding can be a bacterial infection. Endotoxines can increase portal pressure and so participate in development of bleeding and simultaneously deteriorate a patient's prognosis. An antibiotic treatment is a part of a treatment algorithm, however what antibiotics to administer and in what manner is unclear. A group of 46 patients who were admitted to a hospital for an acute bleeding from varices has been compared in the study to 48 cirrhosis patients hospitalised for other reasons. An infection incidence was high in both groups (63.0 % vs. 54.2 %), bleeding patients had more often positive hemoculture (17.3 % vs. 8.6 %), and statistically significantly more often positive findings in throat swab culture (36.9 % vs. 17.3 %, p = 0.04) which is an evidence of an increased pathology colonisation of these patients. Bleeding patients were randomised for peroral norfloxacin administration (n = 25) or an intravenous administration of a combination of ampicilin and sulbactam (n = 21). There was no difference in survival of both groups. Due to a high number of bacterial infections antibiotics administration has been indicated in these patients. Intravenous administration is probably of the same effect as peroral administration.

[What risk is a health care worker infected with hepatitis B or C virus for his patients?]

Presently, there are no legislative standards in the Czech Republic banning health care workers with chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection to do activities with a risk of the transmission of these viral infections to patients (surgeries and other invasive interventions). In a range of developed countries in the world individuals with chronic HBV infection, HBeAg positive individuals, have a restricted access to the risk interventions. A quantitative assessment of viremia is important in the health care workers infected with HBeAg-minus mutant of the virus. There are particular critical viremia values set up (serum HBV DNA levels) which exceeding in the health care workers leads to banning them to do the risk interventions. In cases of proved transmission of hepatitis B infection from a health care worker to a patient, the ban of doing risk interventions is a rule. Transmission of HCV infection from a health care worker to a patient is much less probable so the individuals with chronic hepatitis C are usually not forbidden to make invasive procedures. An exception are cases when there was a patient infected by a particular health care worker in the past. There are various attitudes to the health care workers with chronic HBV or HCV infection in various countries of the world. A necessity to reach a definite consensus is necessary. The first step to it are common recommendations of 12 European countries and the USA which are repeatedly cited in the text. We can expect that these problems will have to be solved very soon in the Czech Republic too.

[Large-droplet liver steatosis in celiac disease]

Authors monitored a case of a 25 years old woman who was admitted for swelling of lower limbs. Laboratory results showed hypoproteinemia, elevation of liver enzymes, and prolonged prothrombin time. Ultrasound examination proved hepatomegalia with diffusely hyperechogenic liver without central lesion. Computer tomography confirmed hepatomegalia with diffusely hyperechogenic liver and a suspicion of liver steatosis was expressed. Liver biopsy confirmed serious diffuse large droplet steatosis of unclear genesis. Carried out examinations excluded infectious and autoimmune liver diseases, metabolic diseases, and congenital liver diseases (Wilson's disease, porphyria, haemochromatosis etc.). Laboratory results showed gliadin, endomysin, and reticulin antibodies. An enteroscopy picture showed villi decrease. Histology examination of a biopsy specimen confirmed total villi atrophy with non-differentiated enterocytes and round-cell cellulisation of epithelium and proprium. Histology and histochemical findings were distinct proves of coeliac disease. A patient was prescribed a gluten free diet. Her metabolic parameters (normalisation of albumine levels, prothrombine time, and trace elements) and anino transferase levels gradually improved. This case documents development of a serious liver disorder as a result of malnutrition which developed in a young woman as a result of unrecognised coeliac disease.

[Procalcitonin as an indicator of infection in patients with liver cirrhosis]

Incidence of bacterial infections in hospitalised patients with liver disease is high. Due to a liver dysfunction immune reactivity is significantly impaired and bacterial infections are more frequent. Also incidence of nosocomial infections is higher in patients with liver disease compared to patients hospitalised for other conditions. To make a differential diagnosis of infectious and non-infectious aetiology of an inflammation is very difficult. Characteristic laboratory tests for bacterial infection include test of a number of leucocytes in peripheral blood, differential count of leucocytes, erythrocyte sedimentation, procalcitonin, C-reactive protein, tumor necrosis factor alpha, interleukin-1, interleukin-6, interleukin-8, and complement fragment C3a. Clinically the most significant are C-reactive protein test and procalcitonin test. Procalcitonin is a protein, a calcitonin precursor, which is in healthy individuals produced by cells of thyroid gland. A half-life of procalcitonin in serum is 20-24 hours which makes it suitable for daily monitoring and enables to control a course of treatment and to distinguish bacterial infection from other types of inflammations. Procalcitonin levels rise in bacterial, parasite, and yeast infections. Elevated procalcitonin levels appear only in inflammations of an infectious etiology with systemic signs. In patients with liver cirrhosis bacterial infections are more frequent. They usually include spontaneous bacterial peritonitis, infection of the respiratory system, urinary infections, and bacteremia. A timely proof of a bacterial infection and an appropriate and effective antibiotic therapy lead to an improvement of the general state of a patient and to his/her better prognosis. Procalcitonin determination is appropriate for diagnosing infections and control of treatment.

[Successful treatment of chronic hepatitis C in hemophiliacs based on historical development of therapeutic protocols]

Chronic infection with hepatitis C virus is very frequent among hemophilic patients in all developed counties, including the Czech Republic. Because of a possibility of developing serious terminal stages of infection, liver cirrhosis and hepatocellular carcinoma, the tendency in treatment of patients with chronic hepatitis C is to start it as soon as possible and thus reduce the probability of developing these advanced stages of disease which are difficult to treat. Treatment of hemophilic patients with chronic hepatitis C started in the Department of Infectious Diseases, University Hospital Brno Bohunice, in 1996. Used treatment schemes have reflected historical evolution of treatments used to treat chronic hepatitis C. Initially, alpha-interferon (IFN) was administered in monotheraphy (6 patients), later, since 1999, a combination of alpha-IFN and ribavirin was administered (13 patients), and since 2001 a combination of pegylated interferon (PEG-IFN) and ribavirin (3 patients) was administered. In all the patients the individual treatments took 12 month. Sustained negativization of HCV RNA in serum has not been achieved in any patient treated only with alpha-IFN. In patients who were administered the combination of alpha-IFN and ribavirin this effect appeared in 4 from 7 cases without history of treatment with alpha-IFN (57%), one from 2 relapses and one from 3 non-responders. The combination PEG-IFN and ribavirin was effective in the only one patient who relapsed after alpha-IFN and ribavirin and in one from the two non-responders to this combination. The tolerance and safety of treatment was good in haemophilia patients and could be fully compared to those in other patients with chronic hepatitis C.

Treatment of chronic hepatitis C in hemophilic patients

Chronic hepatitis C infection is common among hemophiliacs in all the developed countries. Since 1996, only alpha-interferon (alpha-IFN) in monotherapy has been used for the treatment of chronic hepatitis C in hemophiliacs (6 patients). In Czech Republic a combination therapy with alpha-IFN and ribavirin has been used since 1999 (13 patients). Finally, a combination therapy with pegylated alpha-IFN (PEG-alpha-IFN) and ribavirin is being used since 2001 (still 3 patients). In all cases, the treatment lasted 48 weeks. A sustained virological response (SVR, defined as an undetectable serum HCV RNA level 24 weeks after the treatment was completed) was not achieved in any of 6 patients treated with alpha-IFN alone. A combination therapy with alpha-IFN and ribavirin yielded better results: four of eight patients still untreated with alpha-IFN (naive patients), one of two relapsers, and one of three non-responders to previous alpha-IFN monotherapy achieved SVR. So far the combination therapy with PEG-alpha-IFN and ribavirin has been used only in 3 patients. SVR was achieved in one patient who had relapsed after the combination therapy with IFN-alpha and ribavirin, and in 1 of 2 non-responders to this therapy. We conclude that the efficacy and tolerability of the treatment of chronic hepatitis C in hemophiliacs did not differ from that of chronic hepatitis C in other patients.

[Antibiotic prophylaxis in patients with acute hemorrhage due to portal hypertension--personal experience]

Acute bleeding from upper part of gastrointestinal tract is a frequent and serious complication affecting 20 to 60% of patients with liver cirrhosis and portal hypertension. It is associated with a high death rate of 30 to 50% and a frequent relapse of bleeding occurs in up to 40% of these patients. The most recent meta-analyses have shown that bacterial infection is an independent factor in the failure of blood hemostasis and significantly influenced mortality in these patients. The authors investigated 25 patients with acute bleeding from the upper part of gastrointestinal tract due to portal hypertension in patients with liver cirrhosis. Irrespective of the proved bacterial infection the patients were given antibiotic prophylaxis. In 13 patients the authors administered norfloxacin orally and 12 patients were treated intravenously with ampicilin/sulbactam. The prophylaxis of the bleeding cirrhotic patients by norfloxacin (orally) resulted in a statistically significant prevention of early relapse as compared with the therapy by ampicilin/sulbactam (intravenously). The death rate reached 40% in spite of the antibiotic prophylaxis. There was no significant difference in the death rate between the two groups with different treatments.

Unusual Bochdalek hernia in puerperium

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

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

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

Efficacy of alpha-interferon therapy of chronic hepatitis patients infected with wild type hepatitis B virus and HBEAG-minus mutant

The aim of this study was to evaluate the efficacy of alpha-interferon (alpha-IFN) treatment of 56 chronic hepatitis B (HB) patients positive for HB e antigen (HBeAg), which were previously not treated with alpha-IFN (group A). Seven of them, which did not respond to initial alpha-IFN treatment, were subjected to additional treatment with alpha-IFN (group B). Another 7 patients with chronic HB caused apparently by an HBeAg-minus HB virus (HBV) mutant represented group C. In the alpha-IFN treatment, 5 megaunits (MU) of alpha-IFN were administered subcutaneously three times a week for six months. A trend of improvement of important markers of the disease in the treated patients could be seen with increasing time after completion of the treatment even though it was not statistically significant. In group A, the absence of serum HBV DNA was found in 43% of the patients at the end of the treatment, in 41% 6 months later, and in 46% 12 months later. At the same time intervals group A showed negative HBeAg in 36%, 39% and 46%, positive anti-HBeAg in 36%, 38%, and 46%, negative HBsAg in 9%, 11%, and 14%, and normal level of alanine transaminase (ALT) in 23%, 39%, and 44%, respectively. A trend toward better results of alpha-interferon therapy for the group A patients displaying lower baseline viremia and higher ALT activity could be seen; however, this relationship was not statistically significant. Groups B and C were too small for statistical analysis. Nevertheless, 4 of 7 patients of group B were negative for HBV DNA 12 months after the treatment and HBV DNA was eliminated during the treatment in all patients of group C; however, 3 patients relapsed after the treatment.

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

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

[The SEN virus--will there be another letter in the alphabet of viral hepatitis?] ]

The SEN virus (SENV) is a small nonenveloped single-stranded DNA virus which is probably a circovirus. By phylogenetic analysis it is possible to differentiate genotypes SENV A-H. The pathway of transmission of infection is not known so far but the infection by this virus is frequent in recipients of blood transfusions and liver grafts and in intravenous drug addicts. This suggests possible parenteral transmission of infection. Other routes of transmission of the infection are also possible as the virus can be detected also in a significant proportion of young subjects without the risk of parenteral infection in the case-history. Whether SENV causes hepatitis has not been proved unequivocally so far. The prevalence of this infection does not differ significantly in patients with different liver diseases, acute or chronic viral or non-viral. SENV infection very probably does not influence the course of chronic hepatitis C.

[Barrett's esophagus]

Barrett's oesophagus is a premalignant metaplastic change of the oesophageal mucosa. Due to its relationship with oesophageal reflux disease and the development of adenoma-carcinoma of the oesophagus the problem arouses increasing interest. In the wide pathogenesis of the disease most probably the composite effect of the refluxed HCl content and duodenal juices play a part. In the diagnosis in addition to fundamental methods--endoscopy and histology--increasingly chromoendoscopy and fluorescent endoscopy are involved. Dispensarization of patients is essential and depends on the degree of pathohistological epithelial changes. Treatment of Barrett's oesophagus can be divided into conservative, where the drug of choice are proton pump inhibitors, and surgical treatment. Promising is endoscopic ablation of the epithelium in combination with subsequent antisecretory therapy.

[Rifaximin in the treatment of hepatic encephalopathy]

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

[Spontaneous bacterial peritonitis in the Czech Republic]

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

[Pathologic gastroesophageal reflux in patients with bronchial asthma]

Gastrooesophageal reflux (GER) and asthma bronchiale are frequent diseases. Asthma affects some 3-10% of adults. Gastrooesophageal reflux is present in some 45-89% asthmatic patients. Symptoms of GER are not only gastrooesophageal, and recently increased attention is focused on extraoesophageal symptoms where in particular the relationship of GER and asthma or chronic cough is investigated. At our clinic we implemented a pilot study with the objective to monitor the presence of pathological GER in patients with asthma and to assess whether antireflux therapy will influence the respiratory complaints of the patients. The group was formed by 14 patients selected at random with different severity of asthma and different symptoms of GER. The patients had a baseline examination evaluating the presence of GER (24-hour pH metry) and pulmonary function (FEV1). In case of a pathological GER the patients were treated by antireflux therapy and then check-up examinations were made. It was found that after treatment of GER in patients with asthma in particular subjective symptoms improved such as cough and pyrosis which leads to a substantial improvement of the quality of life. On the other hand reflux treatment did not exert a basic effect on pulmonary functions and it was not possible to reduce the medication of asthma.

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

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

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

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

Autoantibodies to asialoglycoprotein receptor in chronic hepatitis C patients

The aim of this study was to determine the incidence of autoantibodies to asialoglycoprotein receptor (ASGPR, anti-ASGPR) in chronic hepatitis C patients and to characterize the anti-ASGPR-positive and anti-ASGPR-negative patients in more detail. A total of 79 chronic hepatitis C patients were screened for the presence anti-ASGPR by ELISA. Anti-ASGPR were detected in 11 (13.9%) patients. No significant differences were found between the anti-ASGPR-positive and anti-ASGPR-negative patients in age, alanine transaminase (ALT) activity, histological findings and response and tolerance to alpha-interferon (alpha-IFN) therapy. The male predominance in the anti-ASGPR positive group was statistically significant. It was surprising that other tested autoantibodies (antinuclear autoantibodies [ANA], smooth muscle autoantibodies [SMA], type 1 liver-kidney microsome autoantibodies [LKM-1], anti-thyroglobulin and thyroid microsome autoantibodies) and increased levels of immunoglobulins A, G and/or M were observed significantly more frequently in the anti-ASGPR-negative group.

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

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

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

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

[Therapy of ulcer disease using gastrinal-sucralfate produced in Czechoslovakia]

The authors present their experience with the use of the Czechoslovak preparation Gastrinal-Sucralphate in the treatment of 40 subjects with gastroduodenal ulceration. Moreover, they compared two forms of the drug--tablets and granulate. The healing effect of the drug is very high, in tablets 77.0%, in granulate as much as 89.5%. As far as tolerance is concerned, it was obviously better after the granulate, subjective side-effects were very rare. The drug does not affect any basic biochemical parameters which were monitored during administration of the drug.