The measure of life-time alcohol consumption in patients with cirrhosis: reproducibility and clinical relevance

Our aims were to design a reproducible method of measuring life-time alcohol consumption in patients with cirrhosis, and to assess the risk of liver decompensation associated with alcohol intake using a case-control design and a multivariate analysis. We studied 439 patients ("cases") with decompensated cirrhosis, and 233 with compensated cirrhosis ("controls"). Mean life-time daily amount and duration of alcohol intake were measured by a standardized questionnaire, whose reproducibility, assessed by interviewing 75 relatives, was 70% for daily alcohol intake and 84% for duration of intake. Better reproducibility was found by re-interviewing patients at discharge from hospital. Daily alcohol intake was significantly higher in males, younger patients and patients with liver decompensation. After stratification according to the average life-time daily alcohol intake, we found a significant increase in the risk of liver decompensation from 125 g ethanol intake per day onwards. No association was found between duration of alcohol intake and risk of liver decompensation. We conclude that alcohol intake can be reliably and reproducibly measured: in patients with cirrhosis, increased alcohol intake is associated with increased risk of liver decompensation, with a significant dose-effect above a daily intake of 125 g ethanol.

Prolonged gastric pH monitoring in responder and nonresponder duodenal ulcer patients: response to placebo and to H2-blocker administration

We evaluated the circadian pattern of gastric acidity by prolonged intraluminal pHmetry in 15 "responder" and 10 "nonresponder" duodenal ulcer patients after nocturnal administration of placebo, ranitidine, and famotidine. Acidity was measured during predefined periods under the different drug regimens in the two groups of subjects, and a comparison was performed both within and between groups. With placebo, significantly lower median 24-h pH values were detected in patients with resistant ulcer than in responders (1.13 versus 1.63). On the contrary, no statistical difference was detected between the two groups during any time of day after administration of either ranitidine or famotidine. Within each group, no significant difference was noted between the two different H2-blockers. Thus, our data suggest that patients with resistant duodenal ulcer display an increased gastric acidity in control conditions but a "normal" response to administration of antisecretory drugs.

Daily gastric pH in controls and in duodenal ulcer patients: basal condition and response to treatment

Gastric pH was monitored, by means of a computerized system, in healthy controls (C) and in patients with active duodenal ulcer (ADU) and inactive duodenal ulcer (IDU). The test was performed before treatment and during administration of a single dose of ranitidine 150 mg, cimetidine 400 mg, and pirenzepine 50 mg, in random sequence at 12-h intervals, (10 am, 10 pm). Under basal conditions, progressively lower median pH values were detected in ADU and IDU patients, compared with controls. A significant difference was found between C and ADU during daytime (1.38 vs. 0.85), nighttime (1.29 vs. 0.81), and 24 h (1.35 vs. 0.81) and between C and IDU during 24 h (1.35 vs. 1.11). However, no statistical difference was observed between patients with active and inactive ulcer disease. Administration of ranitidine and cimetidine significantly increased gastric pH during nighttime but not during daytime. Ranitidine, at the doses studied, proved to be more potent than cimetidine in suppressing gastric acidity. Gastric pH was unaffected by pirenzepine in most cases.

Diagnostic value of serum immunoreactive conjugated cholic or chenodeoxycholic acids in detecting hepatobiliary diseases. Comparison with levels of 3 alpha-hydroxy bile acids determined enzymatically and with routine liver tests

The diagnostic value of the enzymatic fluorometric method for total serum bile acids (TSBA) and for radioimmunoassay measurement for conjugated cholic acid (CCA) or chenodeoxycholic acid was compared with that of routine liver function tests in 223 patients with liver disease, 88 healthy subjects, and 118 patients affected by other diseases. The value of the tests for screening in the general population was assessed by simulation, using estimates of disease prevalence. TSBA was significantly more sensitive (78%) but less specific (94%) than CCA (sensitivity of 69%, specificity of 98%). Aspartate aminotransferase was nearly as sensitive (74%) as TSBA, but significantly less specific (93%) than CCA. CCA provided the highest positive predictivity (98%), even in a screening simulation (32%). With the use of sequential aspartate aminotransferase measurement followed by CCA, this value rose to 100%. This test procedure appears to be the best screening method for liver diseases available at present.

Comparison of ranitidine and sucralfate in the long-term treatment of duodenal ulcer

We evaluated long-term treatment with either ranitidine (R) or sucralfate (S) in the prevention of duodenal ulcer recurrences. Fifty-nine patients with healed ulcers were randomly allocated to maintenance treatment with 150 mg R nightly or 2 g/day S. By using a life table analysis, the calculated probable remission rates at 4, 8, and 12 months were 90, 85, and 53% with R, respectively, and 62, 62, and 53% with S, respectively. These differences were not significant at any interval. In both groups ulcer relapse was independent of sex, smoking habit, and alcohol and coffee consumption, whereas a history longer than 5 years was significantly related to a higher probability of recurrence. No relevant clinical or biochemical side effects were encountered with either drug, but compliance rate was higher in the R group. R and S are equally effective in preventing duodenal ulcer relapse over a 1-year period of maintenance treatment, although R proved to be more effective in preventing early relapse.

Presence and origin of IgA1- and IgA2-containing circulating immune complexes in chronic alcoholic liver diseases with and without glomerulonephritis

Levels of IgA-containing circulating immune complexes (IgAIC) and their content of IgA1 and IgA2 subclasses were determined in chronic alcoholics with various degrees of liver damage and with or without associated glomerulonephritis. In patients with chronic alcoholic liver diseases, significantly increased IgAIC mean values were found independent of the presence of renal involvement, while in chronic alcoholics without biochemical evidence of liver damage IgAIC levels were normal. Both IgA subclasses were evidenced in IgAIC with an IgA pattern similar to that found in secretions, in agreement with the impaired liver clearance of IgAIC derived from intestinal mucosa. Nevertheless, no significant correlation between IgAIC and markers of hepatocytolysis or of cholestasis was found. One cannot therefore rule out the hypothesis of increased IgA synthesis in alcoholic liver disease due to abnormal alimentary antigen challenge and pathologic lymphocytic responsiveness. Finally, high IgAIC levels were found not only in patients with IgA glomerular deposits, but also in patients without clinical evidence of renal involvement.

Pulmonary involvement in chronic pancreatitis

Although the association between acute pancreatitis and pleuropulmonary damage is well documented, so far no information on lung function in patients with chronic pancreatitis is available. In this study functional, radiological, and clinical investigations have been carried out in 42 patients affected by chronic calcific pancreatitis (CCP) and in 50 controls in a case-control study. An impairment of pulmonary diffusing capacity has been detected in CCP patients, while all the parameters of ventilatory function were not different from controls. This finding suggests the presence of early lung parenchymal damage in chronic pancreatitis secondary to either emphysema or pulmonary fibrosis.

[Clinico-pathological study of a case of alpha chain disease]

A case of alpha-chain disease is presented. Diagnosis was clinched by the discovery of typical heavy alpha-chains on analysis of serum proteins. The clinical picture included non-gluten-dependent semi-coeliac malabsorption, Hippocratic fingers, flattened villi, plasma cell infiltration of the jejunal mucosa, alpha- and beta-globulin dysprotidaemia, and abdominal masses; these signs are indicative of, but not conclusive evidence of alpha-chain disease. The presence of Coccidioides organules in the mucosa and glandular tuberculosis rises aetiopathogenetic questions that suggest that due attention be given to microbiological examination. Rapid progression to neoplasia following immunodepressive management underscores the risks associated with the administration of immunodepressors in patients with immunitary deficiencies. It is still not clear whether alpha-chain disease should be regarded as a self-perpetuating immunoproliferative disease, or as a form neoplasia ab initio, with a protracted, though of inevitably fatal, course.