The effect of pancreatic enzyme supplementation in patients with steatorrhoea after total gastrectomy

OBJECTIVE

To assess the influence of pancreatic enzyme supplementation on symptoms, energy intake, bowel habits, and fat malassimilation in patients after total gastrectomy.

DESIGN

A prospective, double-blind, randomized, parallel, placebo-controlled, multi-centre trial.

SETTING

Institutionalized patients in three gastroenterological rehabilitation clinics.

PARTICIPANTS

52 institutionalized patients with a faecal fat output > or = 14 g/day, operated on for malignant gastric disease a median of 198 days (interquartile range (IQR) 47-608) previously, and free from recurrence and/or metastasis.

INTERVENTIONS

Nine sachets of pancreatic enzymes per day (each containing lipase 36,000, amylase 27,000, protease 2400 FIP (Federation International Pharmaceutique)) or identical-looking placebo were given for 14 days.

MAIN OUTCOME MEASURES

Abdominal symptoms, energy intake, bowel habits and fat malassimilation.

RESULTS

After treatment, patients on enzyme therapy felt better overall (P = 0.006), but no improvement of a specific symptom could be identified. During the intervention, the median kilojoule intake per kilogram body weight was 9% higher in the placebo group (170.8 (IQR 146.9-202.6)) than in the enzyme-treated group (157.0 (IQR 134.8-170.4)) (P = 0.03). Enzyme treatment did not result in a significant difference between the placebo and the enzyme-treated group regarding bowel habits or fat malassimilation.

CONCLUSIONS

The effect of high-dose pancreatic enzymes supplementation on symptoms and steatorrhoea after total gastrectomy is marginal and does not justify its routine use.

Determinants of medico-social functioning after total gastrectomy

AIM

To describe medico-social functioning after total gastrectomy and the factors determining it.

PATIENTS AND METHODS

In three medical rehabilitation centres, 173 consecutive patients (female/male = 62/111) after potentially curative total gastrectomy for gastric malignancy 206 days earlier (median, interquartile range = IQR 56-644) were evaluated for different pre- and post-operative parameters with potential influence on post-operative medico-social functioning as measured with the Edinburgh Rehabilitation Status Scale (ERSS). Parameters evaluated were: gender, age, time since operation, tumour stage, type of operation, clinical centre of admittance, haemoglobin, ferritin, albumin, presence of small bowel bacterial overgrowth, rapid oro-coecal transit, dyspepsia, early satiety, reflux, dysphagia, vomiting, a symptom based score, body mass index in health, at operation and on admission, weight loss since operation, calorie intake, bowel habits, and fat malassimilation. Independent influential factors for the ERSS were identified in a linear regression analysis.

RESULTS

The median ERSS-score was 4 (IQR 2-6) on a scale from 0 (best) to 28 (worst). There was a significant difference in the ERSS-scores between the three different clinics. The ERSS-scores improved significantly with time since operation (ca. 22% per year). ERSS-scores were higher in patients with intestino-oesophageal reflux (+71%), with dyspepsia (+65%), or with dysphagia (+62%).

CONCLUSION

Medico-social functioning was acceptable in this patient population. After total gastrectomy, dyspepsia, dysphagia, and intestinal reflux into the oesophagus need special attention.

Antimitochondrial antibody profiles in primary biliary cirrhosis distinguish at early stages between a benign and a progressive course: a prospective study on 200 patients followed for 10 years

In recent retrospective studies, it was shown that subtypes of antimitochondrial antibodies (AMA) can help to discriminate between a benign [only anti-M9 and/or anti-M2 positive by enzyme-linked immunosorbent assay (ELISA)] and a rather progressive course (anti-M2, -M4 and/or -M8 positive). According to different constellations of these AMA subspecificities in ELISA and complement fixation test (CFT), four AMA profiles (A-D) were defined. In 1984 we started a prospective study based on 200 PBC patients with known AMA profiles in order to correlate the antibody pattern with the clinical outcome. Progression was defined primarily as the necessity of liver transplantation and death due to hepatic failure or variceal bleeding. At entry, 18 (9%) of the 200 patients had AMA profile A (only anti-M9), 57 (29%) profile B (only anti-M2 with or without anti-M9), 74 (37%) profile C (anti-M2 in association with anti-M4/-M8 by ELISA), and 51 (26%) profile D (anti-M2/-M4/-M8 by ELISA and CFT). At the beginning of the study, 177 patients had PBC stage I/II. During the observation period of ten years, ten patients died and in 18 orthotopic liver transplantation (OLT) was performed; all these patients belonged to profile C/D. Furthermore, 44% of the patients with profile C and 31% of the patients with profile D progressed to late stages, as defined by histology and clinical manifestations such as portal hypertension and increase of bilirubin, while only one of the patients with profile B and none of the profile A-patients developed late stage PBC. A significant increase of bilirubin was observed only in C/D-patients. AMA profiles did not change during the follow-up. In conclusion, AMA profiles discriminate between a benign and a progressive course of PBC already at early stages.

Total gastrectomy: the influence of preserved duodenal transit and of pouch reconstruction on abdominal symptoms, nutrient assimilation, and medico-social functioning

BACKGROUND/AIMS

The aim of this retrospective study was to establish whether patients with different reconstruction after total gastrectomy (duodenal bypass without pouch (subgroup Ia, n = 88); duodenal bypass with pouch (subgroup Ib, n = 27); continuous duodenal transit (subgroup II, n = 27)) differ concerning abdominal symptoms, nutrient assimilation, and medico-social functioning.

METHODS

The 142 patients (49 females, 93 males; mean age 57.2 years, (95% confidence interval 55 to 59)) after potentially curative total gastrectomy for gastric malignancy 500 days earlier (mean: 95% confidence interval 334 to 666) were evaluated for abdominal symptoms, biochemical and haematological parameters, endoscopic findings, small intestinal bacterial overgrowth, oro-caecal transit time, objective signs of malassimilation, and the degree of medico-social functioning.

RESULTS

There were no significant differences between the subgroups in any of the parameters examined.

CONCLUSION

In this study, neither subjective nor objective patient data support preference for any single mode of the examined reconstructions after total gastrectomy. However, small patient numbers, unstandardised reconstruction procedures and a recruitment bias might influence these findings.

Small bowel bacterial overgrowth in patients after total gastrectomy

The aim of this study was to elucidate the consequences of small bowel bacterial overgrowth (SBBO) after total gastrectomy. A total of 127 patients, evaluated for SBBO with a radiographically controlled H2-breath test (subgroup I, without SBBO, n = 80; subgroup II, with SBBO, n = 47) after potentially curative total gastrectomy for gastric malignancy, were uniformly evaluated. Mean time since operation was significantly shorter in subgroup II than in subgroup I [370 days, confidence interval (CI) 96-645 days, vs. 687 days, CI 397-976 days; P < 0.01]. Controlling for this difference, there were no other significant differences in symptoms and signs between the subgroups except for the medico-social functioning measured with the Edinburgh Rehabilitation Status Scale (ERSS). The mean ERSS showed significantly better medicosocial functioning in subgroup I than in subgroup II [3.7 (CI 2.2-5.2) vs. 5.1 (CI 3.0-7.0); P < 0.05]. After total gastrectomy, patients without SBBO did not differ significantly from patients with SBBO in most parameters. Medicosocial functioning was significantly poorer in the latter.

Nutrient malassimilation following total gastrectomy

BACKGROUND

The aim of the study was to elucidate the degree and the pathophysiology of abdominal symptoms, malnutrition and malassimilation after total gastrectomy.

METHODS

In 174 consecutive patients, with potentially curative total gastrectomy for gastric malignancy, subjective symptoms and objective parameters of malassimilation were evaluated.

RESULTS

Abdominal symptoms were present in 86% of the patients. In spite of a high daily calorie intake (median 37.8 kcal/kg body weight) mean body mass index had been decreasing since good health. Anaemia was found in 46%, sideropenia in 31% and oesophagitis in 26%. Mean faecal fat excretion was 17.4 (1.4) g/day and mean fat malassimilation 14.8% (1.1) of the intake. A shortened small-bowel transit was measured in 21.7% of the patients, and bacterial overgrowth was present in 37.7%.

CONCLUSIONS

Malassimilation post total gastrectomy seems to be multifactorial. Shortened small-bowel transit and subsequent dyssynchrony of pancreatic enzyme supply seem to be of major importance.

[Lidocaine elimination and MEGX formation after oral lidocaine administration--a practicable test for assessment of quantitative liver function]

Oral load with 200 mg Lidocain was performed in 370 patients with chronic liver disease. The 120- and 240-minute Lidocain plasma concentrations as well as the 30- and 60-minute MEGX plasma concentrations, main metabolite of Lidocain, were measured by means of gas chromatography and with the commercial TDX test from the firm Abbott. No side effects caused by the load were observed and all of the patients resorbed Lidocain. Peak concentrations were found both for Lidocain and for MEGX in the 60-minute tests. Patients with liver cirrhosis of different aetiology showed significantly higher Lidocain plasma concentrations and lower MEGX values than patients with chronic non-cirrhotic liver disease. The differentiation of these two groups of patients was most successful via the determination of the 240-minute Lidocain plasma concentration. Oral load with 200 mg Lidocain has turned out to be a practicable and meaningful test for the estimation of the Cytochrom P450-dependent liver function.

Caffeine elimination in cirrhotic and non-cirrhotic liver disease of different etiology

Caffeine elimination was studied in 419 patients with cirrhotic and noncirrhotic liver disease of different etiology (hepatitis B virus infection n = 79; hepatitis NANB virus infection n = 74; ethanol-induced liver damage n = 143; primary biliary cirrhosis I-IV n = 63; cryptogenic liver cirrhosis n = 60) following oral administration of 366 mg caffeine. Caffeine clearance in the control group was 69 +/- 33 ml/min (age-matched healthy volunteers and patients without liver disease). Caffeine clearance in acute hepatitis B (70 +/- 60 ml/min) chronic persistent hepatitis B (81 +/- 56 ml/min), chronic aggressive hepatitis B (107 +/- 66 ml/min), posthepatitic liver cirrhosis B (84 +/- 62 ml/min), acute hepatitis NANB (94 +/- 69 ml/min), chronic persistent hepatitis NANB (122 +/- 60 ml/min), chronic aggressive hepatitis NANB (87 +/- 52 ml/min) and posthepatitic cirrhosis NANB (59 +/- 26 ml/min) is not reduced in comparison with controls. In patients with alcoholic fatty liver (127 +/- 71 ml/min, p < 0.05) caffeine clearance is enhanced, in alcoholic hepatitis (57 +/- 72 ml/min) comparable to controls and in alcoholic cirrhosis reduced (36 +/- 44 ml/min, p < 0.05). In primary biliary cirrhosis I-IV caffeine clearance is higher than in controls (117 +/- 59 ml/min, p < 0.05). In cirrhotic liver disease of different origin caffeine clearance is inversely related to the serum bilirubin level. However, the absolute value is determined in addition by the underlying disease.(ABSTRACT TRUNCATED AT 250 WORDS)

[Drug clearance as a decision aid for further invasive liver diagnosis--studies with hexobarbital as a model substrate]

The clearance of a drug predominantly metabolized in the liver may serve as an estimate of quantitative liver function. In 260 consecutive patients presenting with a history of liver disease and abnormal laboratory findings but without a current definite diagnosis we have measured the clearance of hexobarbital and investigated if low values in patients are able to support the decision for an invasive diagnostic procedure such as needle biopsy or laparoscopy. 250 mg of hexobarbital was given orally to the patients between 8 and 10 hrs p.m. 12 hrs later blood samples were taken. Hexobarbital was determined by gas chromatography with N-selective detection, and a single point clearance was calculated. We recommended liver biopsy or laparoscopy to all patients with a hexobarbital clearance below 2.7 ml/min/kg body weight (normal 2.66-5.34 ml/min/kg). 73 out of 260 patients showed a reduced hexobarbital clearance. In 44 patients blind liver biopsy (n = 14) or laparoscopy (n = 30) was performed, 29 patients refused an invasive diagnostic procedure. 17 out of 26 patients with the tentative diagnosis chronic hepatitis had already an incomplete or complete liver cirrhosis. In 11 out of 18 patients with the tentative diagnosis alcohol toxic liver injury we found a progressive portal fibrosis or complete liver cirrhosis. Reduced drug clearance reflecting quantitative liver function can be an indicator of advanced liver disease, thus adding substantially to the decision for further invasive diagnostic procedures.

[Clinical importance of organ-specific antibodies in ulcerative colitis and Crohn disease]

In 479 patients with chronic inflammatory intestinal diseases and other abdominal diseases autoantibodies against intestinal goblet cells and exocrine pancreas were determined by indirect immunofluorescence. In ulcerative colitis 17% had serum antibodies against intestinal goblet cells, in Crohn's disease 26% against exocrine pancreas. Autoantibody prevalence and level of the titre were dependent on the inflammatory activity of both diseases but independent on the therapy. In Crohn's disease high level of titres of antibodies against exocrine pancreas we found in cases with multiple complications. Antibodies titres against intestinal goblet cells in ulcerative colitis and against exocrine pancreas in Crohn's disease exceeding 1:100 improved the diagnostic decision. Besides clinical states, endoscopic and histological findings a positive result of the antibody investigations had to be considered for final diagnosis.

[One point determination of oral caffeine clearance in patients with liver diseases]

Caffeine clearance has been determined in 117 volunteers and patients (including 27 patients with liver cirrhosis) after oral application of 366.1 mg caffeine according to conventional pharmacokinetic methods (Cl = D/AUC). The resulting clearance values can be estimated with adequate accuracy from the plasma concentration at 12h for a concentration range of 2.0 to 6.5 mg/l according to Cl max = Doses/C 12h x t 12h x e and for concentrations higher than 6.5 mg/l according to Cl = Vd x (1n (D/Vd) - 1n C 12h/t 12h Vd is estimated from body weight as Vd = 0.42 x BW. "One - point" - estimation does not provide reliable data for plasma concentrations below 2.0 mg/l.

Influence of smoking on caffeine elimination in healthy volunteers and in patients with alcoholic liver cirrhosis

The effect of smoking on caffeine elimination was measured in 7 healthy volunteers and in 18 smoking and in 30 nonsmoking patients with alcoholic liver cirrhosis following oral application of 366 mg caffeine. In an intraindividual experiment in smoking health probands, caffeine clearance decreased from 118 +/- 33 to 77 +/- 22 ml per min (p less than 0.05) after abstaining cigarette smoking for 3 weeks. In a control group without liver disease (8 smokers, 15 nonsmokers), we found a caffeine clearance of 114 +/- 40 ml per min in smokers and 64 +/- 20 in nonsmokers (p less than 0.05). Smoking and nonsmoking patients with alcoholic liver cirrhosis did not differ with respect to clinical and laboratory data and hexobarbitone elimination. However, caffeine clearance was 63 +/- 63 ml per min in smoking patients compared to 34 +/- 49 ml per min in nonsmokers (p less than 0.05). Fasting plasma concentrations of caffeine were higher in nonsmokers (5.1 +/- 6.2 micrograms per ml) than in smokers (2.1 +/- 4.5 micrograms per ml, p less than 0.05). We conclude that smoking habits have to be taken into account if caffeine is used as a model compound for measuring quantitative liver function.

Disposition of nitrendipine in patients with chronic liver diseases

Metabolism of nitrendipine occurs principally in the liver. Therefore, an alteration of pharmacokinetics has to be discussed in patients with hepatic impairment. To evaluate steady-state plasma concentrations and pharmacokinetics, a low dose of nitrendipine (5 mg/day for 3 weeks) was administered orally to patients with different chronic liver diseases (fatty liver, n = 3; chronic hepatitis, n = 2; and cirrhosis of the liver, n = 5). Nitrendipine plasma concentrations were analyzed by using a gas-liquid chromatography procedure. Twenty-two days after beginning the study, steady-state plasma concentrations were lower than 1.0 microgram/L in one patient without liver disease and in seven patients with chronic liver diseases, in contrast to three patients with alcoholic cirrhosis (5.5, 1.3, and 2.9 micrograms/L). The maximum concentration (Cmax) was 2.3 micrograms/L in the patient without liver disease and 8.3 +/- 3.9 micrograms/L in the hepatic patients. The elimination half-life was prolonged in three of five patients with cirrhosis of the liver (35, 67, and 43 h), whereas in the other patients the half-life was in a normal range (4.2-21.3 h). The area under the concentration-time curve (AUC) was enhanced in three patients with liver cirrhosis (387, 69, and 126 h/micrograms/L); in the other seven hepatic patients, results were normal (35-49 h/micrograms/L). There were no alterations observed in any patient in blood pressure and laboratory data. Oral administration of a low dose of nitrendipine resulted in slightly enhanced steady state plasma concentrations only in patients with advanced cirrhosis of the liver. The half-life, AUC, and bioavailability also seem to be altered only in a more severe state of liver disease.

Factors influencing the caffeine test for cytochrome P 448-dependent liver function

Liver functions in patients with liver disease can be estimated by caffeine clearance. Our data, however, demonstrate the additional influence of factors other than liver disease on the caffeine test. Smoking enhances caffeine clearance in both healthy volunteers and patients with severe hepatic disorders, whereas co-medication with mexiletine strongly inhibits caffeine elimination.

[Effect of a fiber-rich diet on digoxin resorption]

In five female healthy volunteers the influence of dietary fiber (wheat bran or carob seed flour) on absorption of digoxin was investigated. Five minutes after ingestion of a formula diet alone or in combination with wheat bran or carob seed flour 0,8 mg beta-acetyldigoxin was given per os. The plasmaconcentration-time curve over eight hours, the area under curve and the cumulative urinary excretion were not changed significantly. It was concluded that there is no influence of dietary fiber on rate or degree of digoxin-absorption.

Effects of cytostatic drugs on plasma level and renal excretion of beta-acetyldigoxin

Mucosal defects decrease digoxin absorption in patients with malabsorption syndromes. Since the intestinal mucosa can be damaged by cytostatic drugs, we investigated their effects on digoxin plasma levels and urinary digoxin excretion. In six patients with malignant lymphoma who received 0.8 mg beta-acetyldigoxin before and 24 hr after treatment with a combination of cyclophosphamide, oncovin, procarbazine, and prednisone (COPP) or cyclophosphamide, oncovin, and prednisone (COP), plasma digoxin concentrations were measured 0 to 8 hr after the dose and areas under the plasma concentration-time curves were calculated. In 15 patients on 0.3 mg of beta-acetyldigoxin daily, plasma glycoside concentrations and renal excretion were measured daily before and after COPP, COP, cyclophosphamide, oncovin, cytosine-arabinosine, and prednisone (COAP), or adriamycin, bleomycin, and prednisone (ABP) treatment schemes. The diminished steady-state glycoside plasma concentrations and daily renal glycoside excretion during the 24 to 168 hr after the cytostatic drug established reversible impairment of digoxin absorption. The delayed time to peak after a single dose of digoxin during cytostatic drug therapy shows that extent and rate of digoxin absorption are reduced. To maintain adequate control of digoxin therapy in patients treated with cytostatic drugs, plasma levels should be monitored.

Pharmacokinetics and metabolism of theophylline in patients with liver diseases

In patients with acute hepatitis, cholestasis, and compensated or decompensated liver cirrhosis the kinetics and urinary excretion of theophylline and metabolites were investigated following intravenous administration (193 mg). Significant decreases of plasma clearance and a prolongation of the plasma elimination half-life were found only in cases with decompensated liver cirrhosis and to a lesser extent in cases of acute hepatitis. The metabolite pattern in urine was changed in all disease groups compared to controls, i.e., increased excretion of 1-methyl uric acid and a concomitant decrease of 1,3-dimethyl uric acid and particularly of 3-methylxanthine. These results allow the following conclusions. In liver disease the 1-demethylation of theophylline is inhibited; this inhibition appears to be compensated by a shift towards 1-methyl uric acid formation. The monitoring of plasma levels of theophylline is indicated, especially in therapy of patients wtih decompensated liver cirrhosis.

[Drug metabolism in patients with liver disease (author's transl)]

Patients with acute hepatitis and patients with compensated or decompensated cirrhosis of the liver have a decreased plasma clearance of hexobarbital. This however could not been demonstrated in patients with intra- or extrahepatic cholestasis and patients with primary biliary cirrhosis of the liver. The plasma clearance of methohexital, - a high clearance drug - is not changed in the same way. Also there is no evidence as yet, that patients with liver disease and without a collateral portal circulation do have an increased bioavailability of oral high clearance drugs.

Disposition of hexobarbital in intra- and extrahepatic cholestasis in man and the influence of drug metabolism-inducing agents

The pharmacokinetics of intravenously infused hexobarbital was studied in 10 patients with intrahepatic cholestasis and in 9 with extrahepatic biliary obstruction. The results were compared with those obtained in 16 healthy young volunteers and 5 older patients with normal liver function. After infusion, the plasma concentrations showed a rapid initial decline (alpha-phase) and subsequently a slower decrease (beta-phase). The half-life of a latter phase was 323 +/- 84 min in the healthy group, 357 +/- 151 min in the patients with intrahepatic cholestasis and 344 +/- 115 min in the group with biliary obstruction; the clearances were 3.41 +/- 0.90, 4.08 +/- 1.95 and 3.81 +/- 1.97 ml x min-1 x kg-1, respectively. The differences were not statistically significant. The mean volume of the central compartment of distribution and the steady state volume of distribution were not significantly different. In two patients hexobarbital clearance during cholestasis was greater than after it had subsided. After treatment of 11 patients with cholestasis with drug metabolism-inducing agents (phenobarbital, rifampicin or phenytoin), the half-life of hexobarbital was significantly shortened and the mean value of hexobarbital clearance was more than doubled.

Chiba-needle percutaneous cholangiography - a method without risk to the patient?

This critical review of PTC with the skinny needle was prompted by an unexpected complication - an intrahepatic hematoma. A negative PTC does not exclude the presence of dilated bile ducts. In the case of an obstructed biliary tree, bile leakage occurs in approximately 5%. Even after the Chiba needle or other techniques have become established, peritoneoscopy is still of value in the diagnosis of cholestasis. Thus, this method is not without some risk and optimistic reports should be judged with a certain reserve.

Alternative transport pathways of cholephilic 14C-hexobarbital metabolites in rats with experimental hepatitis and cholestasis

Object of the investigation was to find out whether otherwise cholephilic metabolites are excreted via an alternative pathway into urine in experimental liver disease. Intraduodenal application of 14C-labelled hexobarbital in rats is followed by an immediate biliary excretion of metabolites in the range of 400 microgram/100 g bw/h. Using TLC these metabolites can be separated into a polar fraction (about 80% of total) and a non-polar fraction. Phenobarbital treatment leads to a decrease of the total biliary excretion of metabolites to about 200 microgram/100 g bw/h, the metabolite pattern remaining unchanged. Animals with a mild form of GalN-hepatitis had a moderate reduction of bile flow and a total metabolite output of 40 microgram/100/gbw/h. The metabolite pattern showed a decrease mainly of the polar fraction. In animals with an early stage of ANIT cholestasis a 50% reduction of bile flow was associated with a total metabolite excretion of only 20 microgram/100 g bw/h and polar metabolites were nearly absent. In both types of experimental liver disease in corresponding urine samples otherwise cholephilic metabolites appeared. The results obtained show that clinically moderate stages of experimental liver disease lead to a significantly diminished output especially of polar 14C-hexobarbital-metabolites into the bile, which can, therefore, appear in the urine instead.

The effect of dietary fiber on postprandial serum digoxin concentration in man

The postprandial digoxin concentrations in serum were measured for 4 hr by radioimmunological assay in six healthy volunteers who had received 0.8 mg beta-acetyldigoxin by the oral route. Digoxin was given together with a formula diet containing as admixture, respectively, wheat bran, microcrystalline cellulose, pectin, carrageenan, and carob seed flour. The various additions did not reduce the mean digoxin concentrations in serum. After carob seed flour, the concentrations were significantly (P less than 5%) higher, as compared to the control. After microcrystalline cellulose, pectin, and wheat bran the mean peak concentrations were reached later than in the control state.

[Methohexital clearance in patients with acute hepatitis (author's transl)]

Pharmacokinetics of methohexital were studied in patients with acute hepatitis and after a treatment period either with "essential phospholipids" or phenobarbital. During the acute phase the distribution of methohexital was significantly altered. No change had been observed in the methohexital clearance. During remission the distribution of methohexital was in a normal range. After treatment with phenobarbital the methohexital clearance increased significantly whereas no change was observed after treatment with "essential phospholipids".

[Fiberendoscopic injection therapy of bleeding gastrointestinal lesions (author's transl)]

In 28 patients with acute gastrointestinal bleeding emergency fiberendoscopy was combined with aethoxysclerole (1%) injection of the bleeding lesion with purpose to controll haemorrhage. In 61% of 31 proceudres done in patients with oesophageal varices (n = 19) haemorrhage was controlled, and in further 16% deminuation of bleeding intensity was noted. In the remaining cases (n = 7) the procedure was ineffective. Only patients with Child C liver cirrhosis having oesophageal varices stages III and IV finally died because of uncontrolled haemorrhage. In 9 patients with bleeding from other lesions (gastric erosions and ulcers, Mallory-Weiss-Syndrome, erosio simplex Dieulafoy) haemorrhage was controlled in 8 patients. The method is practicable and efficient, but does not determine better the final outcome of patients with livercirrhosis Child C having oesophageal varices stages III and IV. In other cases tube treatment was avoided. The operation lethality within the series was 1,5%.

[Studies on drug metabolism in obese men and mice (author's transl)]

In 7 obese patients with an overweight of 53 +/- 19% of Broca we found a 2-fold enlarged apparent volume of distribution and a nearly 2-fold prolonged elimination halflife of hexobarbital; the hexobarbital plasma clearance however, which is nearly identical with the metabolizing capacity of the liver for hexobarbital, was not decreased. Phenobarbital induced the microsomal drugmetabolizing enzyme system in the fatty liver of genetically obese mice in the same way 2-3-fold as in the non-fatty liver of the lean littermates.

[Percutaneous transhepatic--versus endoscopic retrograde cholangiography in the differential diagnosis of cholestasis? (author's transl)]

Since the introduction of the Chiba needle the percutaneous transhepatic cholangiography (PTC) became an established method in the differential diagnosis of cholestasis beside the endoscopic retrograde cholangiography (ERC). From the clinical point of view it is sometimes difficult to decide which of these two techniques should be preferred. In case of absolute or relative contraindications or in case of failure of one of the two methods ERC and PTC can be used alternatively. In all other cases we feel that the PTC by means of the Chiba needle is superior because of easier technical handling and higher success rate. In addition PTC is less trying for the patients. However on the basis of our own experience is should be stressed, that even by using skinny needles there is danger of bile leakage, which necessitates an immediate surgical intervention in the presence of biliary obstruction.

[Bioavailability of Ce-Ferro forte. Comparative iron load test (author's transl)]

The intraindividual relative bioavailability of three oral iron preparations was investigated in 9 male and 3 female healthy volunteers. After an overnight fast each of the volunteers took 110 mg Fe++ in a weak gelatine capsule soluble within the duodenum (Ce-Ferro forte) or 105 mg and 100 mg Fe++ respectively in commercial preparations. Care was taken that a 3 days interval took place between the investigations. Before taking and 1/2, 1, 2, 4, 6, 8 and 12 hrs. after taking the iron capsule, blood was withdrawn into heparinized test tubes and plasma iron concentrations were determined using an atomic absorption spectrophotometer. After taking Fe++ sulfate in a weak gelatine capsule (A), the mean plasma iron increased significantly higher in comparison to preparation B in the 2nd and in the 4th hour and in comparison to preparation C in the 1st hour. The area under curve of iron increase was 531 +/- 329 (SD) after A, 415 +/- 327 And 414 +/- 390 after B and C respectively without significant changes. From these data was concluded that Fe++ sulfate in a duodenal soluble weak gelatine capsule has a beter bioavailability than the 2 other preparations investigated.

Influence of corticosteroid on hexobarbital and tolbutamide disposition

The influence of 10 days' prednisone treatment on the disposition of hexobarbital and tolbutamide was studied in 7 healthy male volunteers. No significant changes in the pharmacokinetic parameters of the two drugs became apparent, which indicates that prednisone pretreatment does not affect their metabolic activities.

[Pharmacokinetics of digoxin and methyldigoxin in patients with acute hepatitis (author's transl)]

After i.v. application of 3h-digoxin or 3H-methyldigoxin to 5 healthy volunteers and 5 patients with acute hepatitis, respectively (0.75 mg daily for 3 days and 0.375 for the following 2 days) total radioactivity in urine and plasma were determined. Chloroform-soluble and -insoluble glycosides were separated and the chloroform-soluble fraction was determined by TLC. 3 days after methyldigoxin application plasma levels reached toxic values in the patient group (2.73 +/- 0.48 ng/ml), whereas in patients receiving digoxin a mean plasma level of 0.91 +/- 0.21 ng/ml was obtained. During the first 24 hours following administration of digoxin 44 +/- 12% of the dose were recovered in urine of control subjects and 48 +/- 13% in patients with acute hepatitis, after methyldigoxin 34 +/- 5% and 34 +/- 8%, respectively. Metabolism of digoxin in patients with acute hepatitis was unaltered, whereas a diminished demethylation rate of methyldigoxin could be observed. 16 patients with acute hepatitis and 7 healthy volunteers received unlabelled digoxin p.o. as maintenance dose. Plasma glycoside concentrations were studied by radioimmunoassay. The average glycoside plasma concentrations were 0.59 +/- 0.21 ng/ml and 0.63 +/- 0.24 ng/ml, respectively.

[Metabolism of hexobarbital in patients with acute hepatitis and cirrhosis (author's transl)]

16 patients with acute hepatitis, 18 patients with cirrhosis and a total of 21 volunteers and patients with normal liver function received 7.32 mg/kg hexobarbital by linear intravenous infusion within 60 min. Hexobarbital was determined gaschromatographically in serial blood samples and the hexobarbital-clearance was calculated from the plasma concentration curve versus time. Additional experiments were performed in rats suffering from so called "galactosamine hepatitis". In half of the patients with acute hepatitis a normal hexobarbital clearance could be found. In the other patients this was distinctly reduced but not correlation was found to other liver function tests. Patients with cirrhosis were subdivided into two groups. The patients in group 1 were well compensated. The patients in group 2 had a decompensated state with ascites and oesophageal varices. In nearly all patients with cirrhosis the hexobarbital-clearance was diminished. This was more pronounced in group 2. Ketohexobarbital excretion in healthy subjects was in the range of 40-60% of dose. Patients with acute hepatitis excreted only 10-20% of dose and patients with liver cirrhosis only about 5% of dose. In rats with "galactosamine hepatitis" hexobarbital clearance in vivo was distinctly reduced and this could be explained by diminished microsomal cytochrome p 45- and hexobarbital oxidation rate.

Stimulation of drug metabolism by rifampicin in patients with cirrhosis or cholestasis measured by increased hexobarbital and tolbutamide clearance

Eleven patients with hepatic cirrhosis or cholestasis were treated with rifampicin for 7 to 132 days. Ten patients received hexobarbital (7.32 mg/kg) and five received tolbutamide (20 mg/kg) by i.v. infusion prior to and after rifampicin treatment; plasma concentrations of the two test compounds were determined during and after infusion. The average elimination half-life of hexobarbital had decreased from 624 to 262 min and that of tolbutamide from 292 to 160 min following rifampicin treatment. It was calculated that the metabolic clearance of hexobarbital had increased more than two-fold and that of tolbutamide almost two-fold. The results suggests that rifampicin is able to stimulate hepatic drug metabolism in patients with liver disease. It was apparent in general that the induction did not lead to improvement of hepatocellular function during disease as judged by laboratory findings.

Influence of rifampicin on drug metabolism: differences between hexobarbital and antipyrine

Six healthy volunteers were treated with 1,200 mg of rifampicin daily for 8 days. Before and immediately afterward each received indocyanine green, hexobarbital, galactose, and antipyrine by intravenous infusion on 3 consecutive days. The plasma concentrations of the drugs were determined several times after infusion. The average elimination half-life of hexobarbital had decreased from 407 to 171 min and its metabolic clearance had increased almost threefold. In contrast, the average elimination half-life of antipyrine was virtually the same on both occasions (6.9 and 7.2 hr) and there was no change in metabolic clearance. In a tuberculous patient treated with rifampicin the antipyrine elimination rate was unaffected. Rifampicin did not influence indocyanine green clearance or galactose elimination capacity. Serum gamma glutamyl transferase was not affected but urinary D-glucaric acid excretion was increased during rifampicin treatment. The experiment with hexobarbital was repeated after 2 weeks in all subjects; half-lives and clearance values had returned to near control values. It appears that rifampicin is a selective inducer of oxidative drug metabolism in man.

Pharmacokinetic interactions with rifampicin

Rifampicin, a potent antituberculosis agent, is frequently combined with other antituberculosis drugs, or with drugs belonging to entirely different classes which may be required during a long period of antituberculous treatment, and therefore has a potential for drug interactions of practical clinical importance. The absorption of rifampicin is markedly decreased when it is simultaneously administered with para-aminosalicylic acid granules, due to adsorption by an excipient, bentonite. Several clinical observations and investigations have indicated that rifampicin itself accelerates the metabolism of various other compounds, including oral anticoagulants, the contraceptive pill, oral hypoglycaemic agents and digitoxin. Rifampicin seems to be a potent inducer of drug metabolism in humans and it causes a proliferation of the smooth endoplasmatic reticulum and an increase of cytochrome P450 content in the liver. It also increases its own rate of desacetylation. However, of the test compounds hexobarbitone and tolbutamide, the metabolic clearance increased 2-to 3-fold following rafampicin treatment, whereas antipyrine clearance was unaltered. This indicates that there is a certain selectivity in the enzyme induction effect of rifampicin, although it reamins unclear which compound will and which will not be affected. Rifampicin may also possibly interfere with hepatic uptake of other compounds, but the clinical significance of this type of interaction has not been clearly demonstrated; On the other hand, oral probenecid significantly increases the serum level of rifampicin, probably due to a similar depression of hepatic uptake.

Induction of drug metabolism in man after rifampicin treatment measured by increased hexobarbital and tolbutamide clearance

Five healthy volunteers took 1.2 g rifampicin daily for 8 days, and before and afterwards each received hexobarbital (7.32 mg/kg) and tolbutamide (20 mg/kg) by i.v. infusion on two consecutive days. The plasma concentrations of the two drugs were determined during and after infusion. The average elimination half-life of hexobarbital had decreased from 325 to 122 min and of tolbutamide from 418 to 183 min following rifampicin treatment. It was calculated that the metabolic clearance of hexobarbital had increased about three-fold and that of tolbutamide more than two-fold. Significant changes in the distribution kinetics of the two drugs were not observed. The results suggest that rifampicin is capable of inducing drug metabolism in man, which leads to an increased rate of elimination of drugs that undergo biotransformation in the liver.

Pharmacokinetics of hexobarbital in acute hepatitis and after apparent recovery

The pharmacokinetics of hexobarbital were studied in 13 patients with acute hepatitis. Hexobarbital sodium was administered by zero order intravenous (iv) infusion, and plasma concentrations were determined regularly by gas chromatography. For each patient the data were fitted according to 2-compartment kinetics. The results were compared to those obtained for 14 healthy volunteers. The elimination half-life of hexobarbital was 490 +/- 186 min in the hepatitis patients and 261 +/- 69 min in the control group. Clearance was significantly reduced in the hepatitis group, whereas the volume of distribution at steady state was not significantly altered. For some patients the initial distribution volume was reduced. In 6 patients the experiment with hexobarbital was repeated after apparent recovery from hepatitis as judged by normal transaminase and bilirubin levels. Generally the half-life of hexobarbital was shorter and the clearance value was higher than during the acute illness, but the values had not yet returned to normal. Clinical recovery from liver disease is not accompanied by corresponding recovery of drug-metabolizing capability.

[Cholestatic jaundice after taking the laxative Normolaxol]

Report on two cases of jaundice developing shortly after ingestion of a new laxative, Normolaxol (quinolylmethylenediphenol). Clinical and morphological aspects of the acute cholestasis are described and discussed regarding differential diagnosis and pathogenesis.

Pharmacokinetics and metabolism of digoxin- and beta-methyl-digoxin-12aplha-3 H in patients with acute hepatitis

Pharmocokinetics and metabolism of digoxin and beta-methyldigoxin have been studied in patients with acute hepatits after intravenous administration of both H-labeled glycosides. In contrast to digoxin, the rate of decline of radioactivity after administration of beta-methyldigoxin was significantly retarded in patients with acute hepatitis. The increase in plasma concentration after beta-methyldigoxin to patients with acute hepatitis is probably related to decreased demethylation.

Pharmocokinetics of hexobarbital in man after intravenous infusion

The plasma levels of hexobarbital in humans were determined during and after a 30-min or 60-min zero-order intravenous infusion. Hexobarbital kinetics could be described by conceiving the body to exhibit two compartments. The plasma concentrations were fitted to the postinfusion equation and the parameters intrinsic to the two-compartment open model were estimated. The elimination half-life varied considerably among the 14 individuals (160-441-min), which could mainly be explained by the greatly varying metabolic clearance of the compound (123-360 ml/min). The apparent volume of distribution per kilogram of body weight was relatively constant (1.10 plus or minus 0.12 liters/kg).