Ablation of Barrett's epithelium by endoscopic argon plasma coagulation in combination with high-dose omeprazole

BACKGROUND

Barrett's esophagus is a premalignant condition induced by gastroesophageal reflux. The aim of this prospective study was to assess the efficacy of argon plasma coagulation in combination with high-dose omeprazole therapy to ablate nondysplastic Barrett's epithelium.

METHODS

In 73 patients with histologically confirmed Barrett's epithelium, argon plasma coagulation was used in combination with maximal acid suppression (omeprazole 40 mg three times a day). Histologic and endoscopic changes were evaluated at 6- and 12-month intervals.

RESULTS

In 69 of 70 patients (98.6%) complete squamous regeneration was achieved after a median of 2 argon plasma coagulation sessions (range 1 to 5). During a median follow-up of 12 months (range 2 to 51 months) there has been no relapse or evidence of the development of dysplasia under continuous acid suppression. Three patients (4.3%) developed a mild stricture of the distal esophagus that resolved after a single session of bougie dilation.

CONCLUSIONS

In our experience, argon plasma coagulation in combination with high-dose omeprazole treatment is an effective and safe technique for complete ablation of nondysplastic Barrett's epithelium. Restoration of squamous mucosa after argon plasma coagulation appears to be long-lasting.

Spontaneous regression of hepatocellular carcinoma confirmed by surgical specimen: report of two cases and review of the literature

Two cases with spontaneous regression of a histologically confirmed hepatocellular carcinoma (HCC) are presented. This rarely seen phenomenon of a spontaneous tumor involution is discussed and compared with the current literature. The clinical symptoms were very similar to that of a liver abscess. A 56-year-old male suffered from a multicentric, highly differentiated, trabecular HCC. First symptoms were epigastric pain, septic fever and arthritis. The tumor marker AFP was constantly normal and no hepatitis could be verified. A resection of the tumor was performed. In patient 2, a 74-year-old male, a multicentric, clear cell HCC was found. The patient had completely recovered from hepatitis type B and within the liver tissue no viruses could be identified. Clinical symptoms were mainly characterized by upper abdominal pain and septic fever. AFP was excessively elevated (3850 ng/ml) but returned to normal preoperatively. In both cases, the specimen showed a subtotal necrotic HCC with insignificant amounts of vital tumor cells. Neither patient had a liver cirrhosis macroscopically, however patient 2 had local periportal fibrosis histologically. After 24 and 41 months of follow-up, respectively, both patients are in good health

Very fast ultracentrifugation of serum lipoproteins: influence on lipoprotein separation and composition

A very short run time and small sample volumes in the separation of lipoproteins by preparative ultracentrifugation are needed for several investigations. Recently, a very fast sequential separation method was described that needs only 100 min for one run in a centrifugal field of 625,000 x g. We studied the influence of centrifugal fields of this dimension on lipoprotein separation and lipoprotein particle integrity using a Beckman Optima TLX ultracentrifuge with a TLA-120.2 rotor. Rotor speed (120/90/60/30.10(3) rev./min) and run time (100 min/3 h/6.7 h/27 h) were selected in such a way that the product of centrifugal field and run time remained constant. The first conditions correspond to the very fast ultracentrifugation (VFU) procedure with a centrifugal field of 625,000 x g. Thirty different plasma samples covering a wide range of lipid and protein concentrations were separated in the course of two centrifugal runs at densities of 1.006 and 1.063 kg/l which yielded very-low-density lipoproteins (VLDL), low-density lipoproteins (LDL), and the subnatant of low-density lipoproteins, including high-density lipoproteins (HDL) and concomitant sedimented plasma proteins. The major lipid components of the lipoproteins, triacylglycerols, free and esterified cholesterol, phospholipids and the apolipoproteins B and A-I, were estimated considering the masses of the tube contents after a slicing procedure. Measurements of lipids and proteins showed a very good recovery of better than 94% and 91%, respectively, and precision-within-series (coefficient of variation) of better than 4.2% and 6.5%, respectively. The effects of the rotor speed on the lipoprotein structure appeared to be weak. With increasing rotor speed, VLDL and LDL lipid constituents principally tended to decrease, whereas they increased in the subnatant of the LDL-run. The mean lipoprotein mass composition, considering the mass percentage of each measured particle constituent, did not show significant alterations. Total protein decreased in VLDL and in LDL and increased in the subnatant of the LDL-run. As checked by an enzyme-linked immunosorbent assay (ELISA) and sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE), the protein effects were due to nearly complete disappearance of contaminating plasma proteins, especially albumin as the major contamination of VLDL and LDL. The apolipoproteins (apo) B-100, A-I, E and C-I to C-III remained nearly unaffected. The main advantages of VFU were the very short run time (cumulative flotation time is 3.4 h) and the elemination of albumin without repeated runs. The procedure was suitable for the assessment of lipid and protein constituents in lipoproteins from very small plasma samples (500 microliters).

[Reversible thrombocytopenia due to digitoxin overdose]

A 65-year-old woman, known to have peptic ulcers, developed nausea and retching. Clinical examination demonstrated pain on pressure in the epigastrium with otherwise normative findings for age. Two gastric ulcers and gastritis with erosions were seen at endoscopy. The patient, who was being treated with digitoxin for heart failure, reported having taken up to four digitoxin tablets (0.07 mg each) daily because she had insomnia. The plasma digitoxin level was between 150 and 160 nmol/l (therapeutic range 17-33 nmol/l), while the ECG showed no signs of digitalis intoxication. Initially the platelet count was 40,000/microliter: there had been no history of thrombocytopenia or symptoms of abnormal haemostasis. Other laboratory tests were within normal limits. After digitoxin had been discontinued, the platelet count rose without further treatment to 373,000/microliter 3 weeks after hospital admission by which time the digitoxin level had fallen to 48.9 nmol/l. The gastrointestinal symptoms regressed completely on treatment with omeprazole (40 mg three times daily for 8 days) and ranitidine (150 mg twice daily).

Immunomodulating effect of ursodeoxycholic acid therapy in patients with primary biliary cirrhosis

Peripheral blood lymphocytes of 22 patients with primary biliary cirrhosis under ursodeoxycholic acid therapy were examined for selected lymphocyte activation markers. The percentage of dipeptidyl peptidase IV positive Peripheral blood lymphocytes of primary biliary cirrhosis patients by using immune- and enzyme-histochemical staining was found to be low (5-12%), with healthy controls exhibiting a normal range of 18-27%. After pokeweed mitogen stimulation in vitro the interleukin-2 production by peripheral blood lymphocytes in primary biliary cirrhosis patients was significantly decreased (3.135 pg/ml mean value), compared to healthy subjects (61.167 pg/ml mean value). After 4-20 weeks ursodeoxycholic acid treatment the dipeptidyl peptidase IV expression and IL-2 production were normalised. These results provide evidence for the immunomodulating effect of ursodeoxycholic acid.

[Dipeptidyl-peptidase IV of human lymphocytes in patients with primary biliary cirrhosis and UDCA therapy]

Investigations concerning changes of dipeptidyl-peptidase IV-positive (DP IV+) lymphocytes in the peripheral blood (PBL) were undertaken in 22 patients with primary biliary cirrhosis (PBC) under therapy with ursodeoxycholic acid (750 mg/day). We found that 4-8 weeks after therapy beginning the number of DP IV+ PBL was raised from a low initial suppressed level of 5-12% into a range of 18-33% corresponding to that of a healthy. Concurrently liver function parameters of the patients were improved significantly. The identity of DP IV+ and CDw26+ of peripheral T-cells could be shown by combination of the cytochemical DP IV-staining with the indirect immunofluorescence of the lymphocyte marker CDw26. These results show that the UDCA-therapy in patients with PBC has a direct effect on the immune system and a positive influence on the immuno-regulative capacity.

[Dipeptidyl peptidase IV of peripheral blood lymphocytes in patients with primary biliary cirrhosis]

Investigations concerning changes of dipeptidyl-peptidase IV-positive (DP IV+) lymphocytes in the peripheral blood (PBL) were undertaken in 22 patients with primary biliary cirrhosis (PBC) under therapy with ursodeoxycholic acid (750 mg/day). We found that after 4-8 weeks of therapy the number of DP IV+ PBL was raised from an initially low, suppressed level of 5-12% to 18-33% corresponding to the range observed in healthy subjects. Concurrently liver function parameters of the patients were significantly improved. The identity of DP IV+ CD 26+ peripheral T-cells could be shown by the combination of cytochemical DP IV-staining with the indirect immuno-fluorescence of the lymphocyte marker CD 26. These results show that the UDCA-therapy in patients with PBC has a direct effect on the immune system and a positive influence on the immuno-regulative capacity.

[Endoscopy in cholestasis]

The spectrum of causes of cholestasis ranges from microscopically recognizable damage to the parenchymal cells of the liver to obstruction of the ductus choledochus und papilla Vateri. Liver biopsy on the one hand and ERCP on the other therefore constitute the morphological methods that come closest to the pathological substrate. Obligatory sonography serves the restriction of diagnosis to a large extent. Laparoscopy is nearly always dispensable. Even in case of liver biopsy the therapeutic consequences should have an influence. Consequently, for transpapillary endoscopic methods in obstructive jaundice it is essential to remove the obstruction (papillotomy and extraction of the calculus or nasobiliary probe or intraluminal tube) if possible in one and the same session. The purely diagnostic ERC possibly causes dangerous cholangitis in mechanical icterus. Transpapillary and percutaneous transhepatic endoscopic methods are becoming more and more sophisticated and new indications are being discovered. However, the results of sonography and endoscopy in obstructive jaundice depend very much on the equipment available and experience of the investigator. He should realistically estimate what he is able to do as well as the patients' chances of recovery. In addition he should maintain contact to large departments of surgery and endoscopy.

[The significance of internal medicine intensive care within the complex of intensive medicine. Discussion contribution to the structural and professional classification in adult intensive medicine]

The development and establishment of intensive care units for adult patients requires a far-reaching subdivision into surgical and conservatively oriented intensive care for qualitative and quantitative reasons. Insufficiently substantiated claims to monopolization of intensive care techniques that are polemically asserted have to be strongly contradicted. The present paper is concerned with approved structural concepts of intensive care developed by Deutsche Krankenhausgesellschaft and various medical societies. They are supplemented by personal experience in the field of internal intensive care.

Prophylactic endoscopic sclerotherapy of esophageal varices--a prospective randomized trial

Sixty-three patients with degree III or IV esophageal varices and the so-called red color sign, but without previous bleeding were randomly assigned to either prophylactic sclerotherapy (PST) (n = 30) or to a control group (n = 33). In 58 cases the portal hypertension was caused by liver cirrhosis (40% alcoholics). The two groups were comparable with respect to demographic data and endoscopic appearance, causes and severity of liver damage. Sclerotherapy was performed as combined intra-and paravariceal injections of 2 or 3% polidocanol. All patients, both in the treatment and in the control groups, who bled from varices after randomization, received sclerotherapy until the varices were eradicated, and remained in their groups. After a mean follow-up of 44.5 months, the bleeding rate in the PST group was significantly lower (30% vs 75%, p less than 0.01). The difference became significant from the second year onward. Fourteen patients of the PST group and 19 of the controls died (4 and 14, respectively, p less than 0.05 as a result of the bleeding). Life table analysis (Kaplan-Meier) revealed no differences in survival between the two groups. At the present time PST cannot yet be recommended as a method for clinical routine use.

[Immunohistologic findings in the liver, spleen, brain and skeletal muscles in fatal cholestatic viral hepatitis (following double infection with hepatitis B and non-A/non-B?)]

We report immunohistological findings in liver, spleen, brain, and skeletal muscle of a 23-year-old woman with hepatitis nonA/nonB caused by contaminated anti-D-globulin. She died in a liver coma. At autopsy, a chronic liver dystrophy with cirrhosis was diagnosed. The necrotic areas of the liver showed a collapse of the reticulin framework, newly formed collagen fibres, and diffuse inflammation with immunohistological evidence of IgG, CIq, C9, and fibrinogen. C4 and C9 could be localised in bile thrombi and in the cytoplasm of pseudotubular transformed hepatocytes. In addition, C9 was found in blood vessel walls. A local distribution of HBsAg was found in the cytoplasm and/or the periphery of liver cells. HBcAg could not be detected in any of 5 different regions of the liver. A serum with antibodies to acute phase antigen of nonA/nonB hepatitis stained the cytoplasm and nuclei of (mostly intact) liver cells focally and their cell membranes diffusely. Patchy deposits of IgA and IgM were demonstrated in liver, brain und spleen. Circulating antibodies to cell nuclei and smooth muscle reacted with the patient's own liver and brain but not with spleen and skeletal muscle.--It is suggested that the manifold immunohistological findings in this patient are an expression of the vain attempt of the organism to clear away antigenic material, probably induced by different hepatitis viruses.

[Clinical and internal medicine therapy of biliary tract diseases]

Symptomatology, clinical diagnosis and medicamentous therapy of diseases of the biliary ducts are described. The treatment with chenodesoxycholic acid is reserved to special cases of cholecystolithiasis. Its prerequisites are proved pathophysiologically. In the cholelithiasis of older patients who underwent a cholecystectomy the endoscopic papillotomy is the therapy of choice, as it is verified by several representative publications and own experiences with up to now 60 patients.

[Comparative study on the diagnostic value of direct and indirect cholangiography]

The examinations contain the findings of the endoscopic retrograde cholangiopancreaticography in 600 patients, the date of a controlled comparative study intravenous cholangiotomography versus endoscopic retrograde cholangiography in 45 patients undergoing endoscopic retrograde cholangiopancreaticography and the results of the percutaneous transhepatic cholangiography in 54 patients. In anicteric patients and after subsidence of the clinical symptoms the optimum use of the intravenous cholegraphy with tomography is to be demanded. It is able multiply to clarify the diagnosis. The terminal part of the choledochus deserves particular consideration. In obstructive jaundice the percutaneous transhepatic cholangiography is essentially more successful and simpler than the endoscopic retrograde cholangiography.

[Laparoscopy--current aspects]

A short survey is given on description and evaluation of progress and developmental trend of laparoscopy. Important technical improvements are the cold light via the glass fibre light conductor, optics of high value, the colour photography with electronic flash-light, colour films and colour television, new accessory instruments and belongings. Now as ever hepatomegaly and splenomegaly, jaundice, ascites, portal hypertension, suspicion of cirrhosis and metastases are regarded as main indications. The laparoscopy deserves a greater consideration in unclear abdominal symptoms, in gynaecological diseases, for the proof of the affection of liver and spleen in lymphogranulomatosis, sarcoidosis, tuberculosis (with aimed liver biopsy). The endoscopic retrograde cholangiopancreatography in the differential diagnosis of the jaundice competes with the laparoscopy, but it is not able to supersede it. The laparoscopic judgment of the pancreas and the importance of visible changes of the fine structed. Among the contraindications of the laparoscopy the hiatal hernia has lost its significance.