Showing papers in "Journal of Gastroenterology and Hepatology in 1992"

Structural abnormalities of the cricopharyngeus muscle in patients with pharyngeal (Zenker's) diverticulum.

Abstract: Recent manometric and radiological studies suggest that the upper oesophageal sphincter has poor compliance in patients with a pharyngeal (Zenker's) diverticulum. To test the hypothesis that this phenomenon is related to structural changes within the cricopharyngeus muscle we examined, histologically, muscle strips from 14 patients with a Zenker's diverticulum and compared them with control tissue obtained at autopsy from 10 non-dysphagic individuals. The cricopharyngeus muscle from patients and controls differed from inferior constrictor muscle by virtue of type 1 fibre predominance and greater fibre size variability. Ragged red fibres and nemaline bodies are a normal finding in the cricopharyngeus. Marked differences were observed in the cricopharyngeus muscle of Zenker's patients which demonstrated fibro-adipose tissue replacement and fibre degeneration. It is concluded that these structural changes may account for the observed diminished upper oesophageal sphincter opening and dysphagia in patients with Zenker's diverticulum.

Ascending infection of the biliary tract after surgical sphincterotomy and biliary stenting

Abstract: It has been widely accepted that there is an ascending route of bacterial infection of the biliary tract but there is a lack of direct evidence. This hypothesis was tested in an animal experiment using the cat as an animal model. The implantation of biliary stents and surgical sphincterotomy were performed in these animals, with sham controls. Stents bypassing the sphincter of Oddi with the tip in the duodenal micro-organisms and the biliary tract was heavily contaminated. Blockage of these stents resulted in biliary obstruction. Stents implanted within the common bile duct, proximal to the sphincter were largely unaffected by biofilm formation. After surgical sphincterotomy the biliary tract was also contaminated but, in the absence of obstruction, the animals did not develop any symptoms. It was concluded that ascending infection by duodenal biliary reflux, via the sphincter of Oddi, is an important route of infection in the biliary system.

Carbon tetrachloride induced cirrhosis in rats: A useful tool for investigating the pathogenesis of ascites in chronic liver disease

Abstract: We have recently witnessed a renewed interest in the mechanisms of sodium retention in cirrhosis and in the treatment of ascites.’.’ This interest has been promoted by the advent of new technologies to assess the haemodynamic, renal and neurohumoral abnormalities present in cirrhotic patients, by the reintroduction of paracentesis as a safe therapeutic option3.‘ and by the use of simple and reproducible experimental models of hepatic cirrhosis. The present article reviews the usefulness of an experimental model of cirrhosis induced by carbon tetrachloride (CCI,) in the investigation of the mechanisms of ascites formation. Special emphasis is given to the different techniques of CC1, administration, the chronopathology of the liver disease, and the relationship between alterations in systemic haemodynamics, neurohumoral systems, and renal sodium and water metabolism.

Relationship between intensity of Opisthorchis viverrini infection and hepatobiliary disease detected by ultrasonography

Abstract: Twenty-four locality-, age- and sex-matched groups of village residents with no light, moderate and heavy Opisthorchis viverrini infection were examined by ultrasonography. Highly significant differences were observed between the groups in the relative size of the left lobe of the liver and the fasting and post-meal size of the gall-bladder. In addition, indistinct gall-bladder wall, the presence of gall-bladder sludge and strongly enhanced portal vein radicle echoes were most frequently observed in the heavily infected group. Two suspected cases of cholangiocarcinoma were identified from the heavy group. The results highlight the importance of intensity of infection on the frequency and severity of fluke-associated hepatobiliary disease.

Contrasting effects of butyrate on the expression of phenotypic markers of differentiation in neoplastic and non-neoplastic colonic epithelial cells in vitro.

Abstract: The in vitro effect of butyrate on expression of differentiation markers in colonic epithelial cells was assessed in the colon cancer cell line, LIM1215 and in epithelial cells isolated from a surgically resected histologically normal colon. Markers used to assess cell differentiation were: net glycoprotein synthesis ([3H]-glucosamine uptake) expressed relative to net protein synthesis ([14C]-leucine uptake), and the expression of the brush border glycoproteins (alkaline phosphatase and carcino-embryonic antigen) in cell homogenates calculated relative to cellular protein content. In response to 24 h exposure to 1 mmol/L butyrate, all markers significantly increased in LIM1215 cells whereas they all significantly decreased in isolated colonic epithelial cells under identical culture conditions. Similar effects were seen at butyrate concentrations of up to 4 mmol/L. Butyrate suppressed proliferation of LIM1215 cells but had no consistent effect on [3H]-thymidine uptake by, or DNA content of, normal epithelial cells. Additional experiments found no evidence of a toxic effect of butyrate at those concentrations nor of an alteration of cell responsiveness to butyrate due to the isolation process itself. In contrast to its differentiative effect on neoplastic cells, butyrate reduces the expression of phenotypic markers of differentiation in vitro in colonic epithelial cells from non-neoplastic mucosa.

A review of postgastrectomy bone disease.

Abstract: Postgastrectomy bone disease was a term devised to describe the metabolic disorders of bone which may follow a gastrectomy operation. Although the use of this operation has declined drastically in recent years, this metabolic bone disorder is still with us and may escape and confuse the unwary. These disorders may take the form of osteomalacia, osteoporosis in excess of normal ageing, or a combination of both. For screening purposes, regular estimations of plasma alkaline phosphatase levels identify patients who may be developing osteomalacia which can then be treated with calcium and vitamin D supplements. Numerically, osteoporosis in excess of ageing is a bigger problem and its prevention and treatment is at present unsatisfactory. Screening procedures for osteoporosis are reviewed, including the more recent methods of bone mineral density assessment. Osteopenia or demineralization occurs in both osteomalacia and osteoporosis therefore osteomalacia must be excluded before attributing any loss to osteoporosis. The present situation with regards to the prevention and treatment of osteoporosis is also reviewed.

A comparison of diagnostic tests to determine Helicobacter pylori infection.

Abstract: Twenty-five Helicobacter pylori positive and 25 H. pylori negative subjects as defined by culture and phase contrast microscopy of antral biopsy specimens obtained from routine upper endoscopy were studied. Antral biopsies were examined by rapid urease test, phase contrast microscopy, culture and histology. Venous blood was tested for H. pylori specific IgG antibodies by an ELISA technique. Within 7 days of endoscopy the patients also had a [14C]-urea breath test. The sensitivity and specificity of the rapid urease test was 92%, the breath test 96% and 100%, histopathology 96% and 91% and serology 96% and 88%, respectively. The [14C]-urea breath test performed over 1 h with sampling of subjects at 0, 0.5 and 1 h was an accurate and reliable method. Results expressed as counts per minute of the expired 14CO2 proved to be a simple method of assessing H. pylori status. A significant correlation between severity of histological antral gastritis and the amount of 14CO2 expired was observed. This study has shown that the non-invasive 14C-urea breath test and serology are highly sensitive and specific for the diagnosis of H. pylori infection.

Opisthorchis viverrini infection in northeast Thailand and its relationship to cholangiocarcinoma.

Abstract: There is strong epidemiological and experimental evidence supporting an important aetiological role for liver fluke infection in the development of cholangiocarcinoma (CHCA) in humans.’-24 However, compared with other experimental cancer models, little research has focused on the mechanisms of this relationship since the first inductions of CHCA in infected hamsters by Thamavit et ~ l . ~ . ’ ~ and Flavell and L ~ c a s . ” ’ ~ Fluke-associated CHCA is not widely discussed, although it has several advantages as a model for carcinogenesis. First, the influence of fluke infection on the susceptibility of bile ducts to malignancy appears to be very strong compared with most other known risk factors of human cancer. Cholangiocarcinoma occurs with a high frequency in infected p e ~ p l e , ’ ~ ’ ~ but only rarely in the absence of i n f e c t i ~ n . ~ ~ ? ’ ~ Bile duct carcinogenesis can be elicited relatively easily in fluke-infected hamsters under conditions where it does not occur in uninfected animals.’-15 Second, since Opisthorchis per se probably does not alter DNA directly, the enhanced susceptibility to carcinogens may closely mimic general pathways of malignancy not associated with biological agents. Research may therefore be widely applicable to human cancer. Third, unlike viruses and unknown aetiological agents, Opisthorchis can be eliminated by simple treatment with the drug, praziq~antel.”-’~ Thus the conditions thought to enhance cancer susceptibility can be assessed in the same individual in the presence and absence of one aetiological agent. This review highlights recent epidemiological literature concerning Opisthorchis and CHCA in humans in Northeast Thailand. An excellent review of Clonorchis sinensis was recently published by Rim.30 Since experimentally induced CHCA, which clearly identifies a role for Opisthorchis in carcinogenesis, is only briefly mentioned here, interested readers are directed to Flavell’ ’ and recent papers of Thamavit et al.14.15 In closing this review, we suggest areas for further research to elucidate the pathogenesis of this cancer by considering recent studies of inflammatory responses and carcinogenesis.

Effect of glycyrrhizin on lysis of hepatocyte membranes induced by anti-liver cell membrane antibody.

Abstract: Studies were made on why glycyrrhizin injection decreases the plasma aspartate aminotransferase (AST) and alanine aminotransferase activities in patients with chronic hepatitis.1 For this, rat hepatocytes were isolated, and incubated with antibody raised against rat liver cell membranes, and the effect of glycyrrhizin on their release of transaminase was investigated. Isolated rat hepatocytes released AST on incubation with anti-liver cell antibody in the presence of complement. At this time, their endogenous phospholipase A2 activity was increased. Cultured hepatocytes also released the transaminase in the presence of venom phospholipase A2. Glycyrrhizin suppressed the release of transaminase in the presence of either anti-liver cell membrane antibody or phospholipase A2. These results suggest that antibody treatment raised the phospholipase A2 activity in liver cell membranes, resulting in release of transaminases, and that glycyrrhizin suppressed this increase in phospholipase A2 activity and so inhibited the release of transaminase.

Significance of plasma glutathione determination in patients with alcoholic and non-alcoholic liver disease.

Abstract: Plasma glutathione levels were determined in 79 patients with various types of liver disease and 18 healthy controls in order to study their significance in the course of liver disease. Plasma was taken at the time of needle liver biopsy. A positive linear correlation was found between plasma and hepatic glutathione concentrations, as has been suggested in experimental animals. In patients with acute viral hepatitis, chronic hepatitis, non-alcoholic liver cirrhosis and alcoholic liver disease, plasma glutathione levels were significantly decreased compared with those in controls. Of importance is the fact that the plasma levels increased after recovery in patients with acute viral hepatitis and after abstinence from alcohol intake in patients with alcoholic liver disease. Determination of plasma glutathione may be valuable in the evaluation of liver disease, particularly in acute viral hepatitis and alcoholic liver disease in which the hepatic content of glutathione is suggested to be decreased. Such patients may be susceptible to oxidative stress and radical-related hepatic injury.

Effect of drinking on the outcome of cirrhosis in patients with hepatitis B or C

Abstract: Survival rates were calculated for 251 patients with cirrhosis of the liver but without hepatocellular carcinoma, primary biliary cirrhosis, or autoimmune cirrhosis who underwent laparoscopy during the past 21 years at the authors' hospital The survival rates were calculated by the Kaplan-Meier method Stored serum was assayed for hepatitis B surface antigen (HBsAg) and antibodies to the hepatitis C virus (HCV) Patients with alcoholic cirrhosis had significantly better survival rates than patients with HBsAg, HCV, or both Differences in survival rates between patients with hepatitis B and C were insignificant In both groups, habitual drinkers had a significantly lower survival rate The results suggested that alcohol accelerates liver damage in subjects with viral hepatitis

C-reactive protein and lactate dehydrogenase isoenzymes in the assessment of the prognosis of acute pancreatitis.

Abstract: The value of serum C-reactive protein, lactate dehydrogenase isoenzymes and erythrocyte sedimentation rate in predicting the outcome of acute pancreatitis was evaluated for 57 episodes in 54 patients. Serum C-reactive protein levels on day 2, 4 and 7 after admission were significantly higher in 19 episodes of severe attacks than in 38 episodes of mild attacks (13.71 +/- 9.68, 9.00 +/- 7.54, 6.02 +/- 3.83 vs 4.78 +/- 3.91, 3.30 +/- 3.61, 1.43 +/- 2.08 mg/dL; P less than 0.0001, P less than 0.005, P less than 0.0001, respectively). The sensitivity, specificity and accuracy of predicting a severe attack were 94, 76 and 82% using C-reactive protein greater than or equal to 8 mg/dL on day 2; 67, 92 and 84% using C-reactive protein greater than or equal to 5 mg/dL on day 7; and 59, 76 and 70% using Ranson's criteria greater than or equal to 3. Increases in LDH-4 and LDH-5 isoenzymes were found in both groups, with LDH-4 being slightly higher in severe attacks than in mild attacks. There was no significant difference of erythrocyte sedimentation rate between both groups. When compared with Ranson's criteria, lactate dehydrogenase isoenzymes and erythrocyte sedimentation rate, C-reactive protein is more valuable in the early assessment of the severity of acute pancreatitis.

Correlation between CA19-9 production in vitro and histological grades of differentiation in vivo in clones isolated from a human pancreatic cancer cell line (SUIT-2).

Abstract: The production of carcino-embryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) were investigated in 28 clones isolated from a human pancreatic cancer cell line (SUIT-2) and related to in vitro morphology of the clones and in vivo tumorigenicity. Clones of fusiform and polygonal cells could be morphologically distinguished in confluent cultures. There was no significant difference in CEA production between fusiform-cell clones (2.10 +/- 2.70 ng/L x 10(6) per 24 h) and polygonal-cell clones (6.01 +/- 7.30 ng/L x 10(6) per 24 h), but polygonal-cell clones had higher production of CA19-9 (1176.1 +/- 1628.4 U/L x 10(6) per 24 h) than fusiform (6.0 +/- 7.3 U/L x 10(6) per 24 h; P < 0.01). Production of CA19-9 in vitro correlated with the histological grade of differentiation in vivo in nude mice (r = 0.73, P < 0.001), but CEA production did not. The polygonal-cell clones developed well-differentiated carcinomas in vivo and produced significantly more CA19-9 (P < 0.001) than fusiform-cell clones, which generally developed into poorly differentiated tubular adenocarcinomas in vivo. This cell line may provide an appropriate system for further studies of the biology and therapy of pancreatic cancer.

Loss of heterozygosity on chromosome 16 in hepatocellular carcinoma

Abstract: In order to understand the molecular genetics of human hepatocellular carcinoma (HCC) a common chromosomal abnormality in HCC was examined using restriction fragment length polymorphism (RFLP) analysis. Sixty-eight HCC specimens were examined for loss of heterozygosity at 11 different chromosomal arms including 1p, 5p, 11p, 11q, 13q, 14q, 15q, 16p, 16q, 18q, and 19q. Losses were not detected on chromosome 1, 5, 14, 15 or 19, and the frequencies of losses were low (11–19%) for chromosomes 11, 13 and 18. In contrast, loss of heterozygosity was frequently observed for three different loci on chromosome 16, the HBA locus at 16p 13.3 (22%), the MT2 locus at 16q21–22.1 (15%) and the HP locus at 16q22.1–22.2 (39%). There was no remarkable difference in the frequencies of loss of heterozygosity at these loci among HBV related HCC, HCV related HCC and neither virus (NBNC) related HCC. Thus, the results indicate that at least three different genetic abnormalities in chromosome 16 are commonly observed in various HCC, and that this chromosome may have some important role(s) in recessive genetic changes which generate this tumour.

The role of hepatitis B virus in the development of primary hepatocellular carcinoma: Part I.

Abstract: Chronic infections with hepatitis B virus (HBV) of humans and animal hepadnavirus infections in their natural hosts are strongly associated with primary hepatocellular carcinoma (HCC). Although viral integrations are found in cells of many HCC, no general viral-specific hepatocarcinogenic mechanism for hepadnaviruses has been identified. In approximately one half of HCC in woodchuck hepatitis virus (WHV) infected woodchucks, viral integrations near the c-myc or N-myc genes have been reported which result in enhanced expression of the respective gene. Such host gene-specific insertional mutagenesis has not been found in HCC of other hepadnavirus infected hosts. Thus in humans, ground squirrels and ducks hepadnaviral integrations appear to be at different host chromosomal DNA sites in each HCC and few integrations have been found within or near any cellular gene. Other possible hepadnavirus-specific carcinogenic mechanisms that are being investigated include transactivation of cellular gene expression by an hepadnavirus gene product (e.g. the X-gene), and mutation of host genes by unknown hepadnavirus-specific mechanisms. It should be noted, however, that chronic hepadnavirus infection is associated with chronic necroinflammatory liver disease with hepatocellular necrosis and regeneration (sometimes leading to cirrhosis in humans), a pathological process that is common to numerous other risk factors for HCC. This suggests the possibility that this pathological process is hepatocarcinogenic irrespective of the inciting agent and the role of hepadnavirus infection is no different from that of other risk factors in causing chronic necroinflammatory liver disease.

Analysis of cost-effectiveness of different strategies for hepatocellular carcinoma screening in hepatitis B virus carriers.

Abstract: A mathematical model was used to calculate the efficacy of screening to detect hepatocellular carcinoma at a resectable stage in hepatitis B virus carriers. Data relating to tumour incidence, efficacy of screening tests and tumour growth times were obtained from a literature review. Various tests were costed according to charges currently prevailing at the authors' institution. The cost per early tumour detected is inversely proportional to tumour incidence. It is relatively low for populations with high incidences of hepatocellular carcinoma for example, male carriers over the age of 30. Both the costs and the proportions of early tumour detected increase with increasing frequency of screening. However, the use of ultrasonography at 10 monthly intervals or both ultrasonography and alpha-fetoprotein estimation at yearly intervals will detect 90% of tumours early at a cost of S$20,000 (US$11,800) per early tumour detected. The results would be significantly altered if tumour growth times were markedly different from those reported in the literature.

Inflammatory bowel disease: an uncommon problem in Singapore.

Abstract: Fifty patients with inflammatory bowel disease (ulcerative colitis, 40; Crohn's disease, seven; indeterminate colitis, three) treated in one gastroenterology unit in Singapore over a 10 year period were reviewed. Clinical features were similar to those described in Western patients. Of the three main races of Singapore it was found that Indians are more susceptible to these diseases than Chinese or Malays. A survey of all gastroenterologists in Singapore indicated a possible prevalence of 8.6 per 100 000 people for ulcerative colitis and 1.3 per 100 000 people for Crohn's disease. These prevalence rates are much lower than those reported for Western populations.

Field evaluation of a rapid, simple and inexpensive urease test for the detection of Helicobacter pylori.

Abstract: A modified rapid urease test (MRU test) for the detection of Helicobacter pylori was evaluated under field conditions during an endoscopic survey in rural India and compared with a commercially available urease test (CLO test) and with histology. Of 195 consecutive subjects who underwent upper gastrointestinal endoscopy, 153 (78.5%) were positive for Helicobacter pylori when tested by the CLO test and/or histology. The sensitivity and specificity of the MRU test relative to this was 97.4 and 95.2%, respectively when the test was read over a 3 h period. The MRU test was positive in 77.4, 89.0, 93.8 and 96.6% of cases at 1, 5, 20 and 60 min, respectively, compared with 2.7, 14.4,48.6 and 71.2% of cases for the CLO test at the same time. The accuracy of the MRU test was thus similar to that of other methods for the detection of Helicobacter pylori. Furthermore, it gave a positive diagnosis more rapidly than other tests, in most cases before the subject had left the endoscopy suite. The MRU test is extremely simple to prepare and read and costs less than E0.05 per test compared with 22.26 for a CLO test. It is suitable for use in clinical or epidemiological work and especially where cost factors are critical.

Presentation and role of peritoneoscopy in the diagnosis of tuberculous peritonitis.

Abstract: This study represents the clinical and laboratory features of 135 tuberculous peritonitis cases in whom peritoneoscopic investigation was used routinely. Disease was more common in women than men (1.5:1) and was most frequently encountered in the third and fourth decades in life. The most common presenting symptoms were abdominal distension (96%), abdominal pain (82%), weight loss (80%), weakness (76%), loss of appetite (73%) and fever (69%). The most common physical findings were ascites (96%), fever (75%) and abdominal tenderness (43%). One hundred and twenty-nine cases (95.5%) showed exudative type tuberculous peritonitis with variable amounts of ascites and filmy adhesions. In six patients (4.5%) the disease was of the plastic (dry) type. Peritoneoscopic investigations of 139 patients suggested tuberculous peritonitis but four cases showed histologically proven malignancy (3%). Laparoscopic diagnoses of the remaining cases were confirmed by histology (97%). The laparoscopic appearance of scattered yellowish-white nodules, approximately 1-5 mm in size, on the peritoneal surfaces, and filmy adhesions were suggestive of tuberculous peritonitis. A non-fatal colon perforation occurred as a major complication. After antituberculous therapy patients were followed for at least 1 year. Peritoneoscopy with simultaneous biopsy is the ideal and most accurate diagnostic modality in the diagnosis of tuberculous peritonitis.

Plasma abnormal prothrombin (PIVKA-II): a new and reliable marker for the detection of hepatocellular carcinoma.

Abstract: We evaluated the clinical usefulness of a protein induced by vitamin K absence, antagonist-prothrombin (PIVKA-II), in detecting hepatocellular carcinoma (HCC) specifically in patients with liver cirrhosis, and the possible correlation between levels of PIVKA-II and pathological features of HCC. Plasma levels of PIVKA-II and alpha-fetoprotein (AFP) were measured in 628 patients with various diseases, including 253 with liver cirrhosis and 116 with HCC. PIVKA-II was detected (greater than or equal to 0.1 arbitrary unit/mL) in 54.3% of HCC and the concentration showed a positive correlation with the tumour size. As a screening test for the detection of HCC, PIVKA-II produced values comparable with those of AFP with a sensitivity, specificity and validity of 52.8, 98.8 and 51.6% respectively. Sixteen of 45 patients (37%) with HCC who had low AFP (less than 100 ng/mL) levels were positive for PIVKA-II. No apparent relationship, however, could be found between the levels of PIVKA-II and the aetiology or pathological findings of HCC. These results suggest that PIVKA-II can be a reliable marker for detecting HCC in patients with liver cirrhosis.

Treatment of peptic ulcer disease with furazolidone.

Abstract: Furazolidone (FZ) has been used in China as a treatment of peptic ulcer disease for about 20 years. Clinical and experimental studies suggest that it has good short-term and long-term effects on both human and animal ulcers. The ulcer healing rate is related to the dosage and course of treatment. The healing rate of a high dose, 2 week course is about 70-75% and the relapse rate after 3 years is 9.5%. The adverse reactions to FZ are not severe, and are well tolerated in most patients. However the mutagenic studies of several biological systems indicate that it has a mutagenic effect, but the mutagenic and carcinogenic effects on humans and animals remain questionable, because FZ has been biotransformed into other metabolites. The mechanisms of FZ in the treatment of peptic ulcer disease are not fully understood, perhaps partly due to the monoamine oxidase (MAO) inhibitory reaction and partly to the antibacterial activity to Helicobacter pylori (HP). The long-term effects of FZ are still not clear.

The effect of chilli on gastrointestinal transit.

Abstract: The effects of chilli on gastrointestinal transit (gastric emptying, orocaecal transit, whole gut transit) were evaluated in eight healthy volunteers. In each subject, gastrointestinal transit of a standard test meal was measured on two separate days. On one of these occasions, 20 g of chilli powder was added to the meal. Gastric emptying was quantified with a radioisotopic technique, orocaecal transit by measurement of breath hydrogen concentrations and whole gut transit by counting the number of radio-opaque markers in the stool. The rate of gastric emptying was slower (P less than 0.05) and whole gut transit was faster (P less than 0.02) after the meal containing chilli, compared with the other meal. There was no significant difference in orocaecal transit. These results show that ingestion of chilli is associated with significant effects on gastric emptying and intestinal transit.

Gastrointestinal symptoms and masticatory dysfunction

Abstract: One hundred and forty-two female patients consulting a prosthodontic clinic for masticatory disturbances and suffering from mandibular ridge atrophy were systematically interrogated for the presence of digestive symptoms. Eight-five subjects (60% of the studied population) reported current digestive complaints; 32 had abdominal pain (burning sensation, bloating or cramps), 12 presented stool transit alteration (constipation or diarrhoea) and 41 reported both abdominal pain and stool transit abnormalities. A prospective evaluation of the digestive symptoms was obtained following surgical reconstruction of the atrophic mandibular ridge and insertion of functional dental prostheses to correct masticatory dysfunction. One year after jaw surgery, 62 of 73 patients (85%) initially complaining of abdominal pain reported symptomatic improvement of their condition, while a marked amelioration in stool habits was noted in 34 of 53 patients (64%) initially suffering intestinal transit alteration. The high incidence of digestive complaints in our patients with dental deficits and the improvement of these symptoms after jaw reconstruction support a case for masticatory failure in the development of digestive symptoms.

Gall-bladder sludge: lessons from ceftriaxone.

Abstract: Ceftriaxone-associated sludge has been a fascinating story. The occurrence is novel and unique. It has produced a model of gall-bladder sludge in humans. This phenomenon has taught us a great deal about biliary lipid and organic anion excretion by the liver, and the physical chemistry of calcium and calcium sensitive anions. It has added further insights into the pathophysiology of gall-bladder sludge formation. It points to a combination of a hepatic effect where the liver secretes a biochemically abnormal bile, and a gall-bladder effect which provides an environment for precipitation, in order for sludge to develop. The precipitated calcium ceftriaxone has prompted us to re-evaluate the imaging criteria for the diagnosis of gall-bladder sludge versus gallstones. Above all, the rapid onset and rapid disappearance of ceftriaxone sludge has mirrored in a compressed, encapsulated form, the natural history of gall-bladder sludge. It has reminded us that, like gallstones, biliary sludge is usually benign and asymptomatic. However just because it is smaller than gallstones does not mean it cannot cause problems. It can disappear or it can become a calcium ceftriaxone gallstone.

Hypoechoic lesions in the 'bright liver': a reliable indicator of fatty change. A prospective study.

Abstract: The accuracy of ultrasonographic diagnosis of hypoechoic focal fatty change in the 'bright liver' was evaluated in 40 lesions found in 35 patients followed up for a mean period of 37.8 months. Patients with ultrasound and laboratory findings suggesting liver cirrhosis were excluded from the study. All patients underwent a blind liver biopsy in order to verify the diagnosis of diffuse disease suggested by the finding of 'bright liver'. No guided biopsy was performed on the focal lesions in order to establish the accuracy of ultrasound alone in recognizing focal fatty change. Clinical, haematologic and echographic follow-up confirmed the diagnosis in all cases. All histological specimens revealed liver steatosis, indicating a 100% sensitivity of ultrasonography in identifying non-cirrhotic fatty liver with an accompanying focal change. Increased echogenicity and hypoechoic focal changes are reliable indicators of fatty infiltration, making ultrasonography an acceptable, non-invasive method for the diagnosis of liver steatosis.

Striking variability of hepatic copper levels in fulminant hepatic failure

Abstract: Two cases of acute hepatic failure are reported in which the diagnosis of Wilson's disease was considered because of low serum ceruloplasmin, low serum copper levels and high 24 h urinary copper. Case 1 had Kayser-Fleischer rings, haemolysis and a high 24 h urinary copper, and so Wilson's disease was confidently diagnosed. Case 2 had high urinary copper excretion, but [64Cu] study indicated a 24:2 h ratio of 0.7 and made the diagnosis of Wilson's disease uncertain. Both patients underwent orthotopic hepatic transplantation, and multiple biopsies were taken from the resected specimen in order to estimate hepatic copper levels. In both cases, hepatic copper levels revealed considerable variation: 0.8-5.2 mumol/g dry wt (case 1) vs 0.02-12.65 mumol/g dry wt (case 2). In case 1, only two of 14 levels were within the diagnostic range for Wilson's disease (greater than 4 mumol/g dry wt), whereas hepatic copper levels in case 2 were in the Wilsonian disease range in three of 16 specimens. These results were in contrast to uniformly high hepatic copper levels in one patient with established cirrhosis secondary to Wilson's disease and two cases of primary biliary cirrhosis. This report indicates that hepatic copper levels vary greatly in acute liver failure, and that estimates from a single biopsy specimen may be misleading as to the cause of the underlying liver disease.

Duplex-Doppler assessment of cirrhosis in patients with chronic compensated liver disease.

Abstract: Portal venous flow velocity (PFV) was measured with duplex-Doppler equipment in 50 normal subjects and in 117 patients with suspected chronic liver disease who showed no evidence of decompensation such as ascites, hepatic encephalopathy, jaundice or oesophageal bleeding. All the patients underwent percutaneous liver biopsy which demonstrated non-cirrhotic liver disease in 58 cases (CH-patients: steatosis 8, persistent chronic hepatitis 8, active chronic hepatitis 42) and liver cirrhosis in the other 59 cases (LC-patients). The normal subjects and the CH-patients had similar values of max-PFV and mean-PFV (max-PFV 26.7 +/- 3.2 and 25.7 +/- 3.4 cm/s respectively; mean-PFV 22.9 +/- 2.8 and 22.4 +/- 3.8 cm/s respectively). The LC-patients' values (max-PFV 19.3 +/- 3.5; mean-PFV 16.9 +/- 2.9) were significantly lower than those of the normal subjects (P less than 0.001) and of the CH-patients (P less than 0.001). Considering the normal max-PFV to be in the range 20-33.1 cm/s (mean +/- 2 s.d. of the normal subjects, 95% confidence limits), max-PFV was reduced in 0/50 normal subjects, 1/58 CH-patients and 39/59 LC-patients (66.1% sensitivity; 98.2% specificity). In conclusion, the duplex-Doppler measurement of PFV is of great interest in the diagnostic study of patients with suspected chronic compensated liver disease and in the early diagnosis of cirrhosis. A low max-PFV is a reliable pointer to liver cirrhosis, whereas a normal max-PFV indicates a non-cirrhotic liver disease but is less probative. Each centre should standardize normal PFV values in order to establish their own threshold value for diagnosing liver cirrhosis.

Hepatitis C virus infection in chronic liver disease and hepatocellular carcinoma in Saudi Arabia.

Abstract: The prevalence of antibody to hepatitis C virus (HCV) was determined in 139 patients with chronic liver disease (CLD) and 42 patients with hepatocellular carcinoma (HCC) during one year at the Riyadh Military Hospital, Saudi Arabia. The anti-HCV was detected in 36 of 96 (37.5%) HBsAg-negative patients with chronic liver disease and six of 43 (13.9%) HBsAg-positive patients with chronic liver disease. In addition, 11 (42.3%) HBsAg-negative hepatocellular carcinoma patients and two of 16 (12.5%) HBsAg-positive hepatocellular patients had antibody to HCV. The anti-HCV prevalence was 1.5% in 4818 healthy blood donors and 1% in 385 antenatal patients. The overall HCV seropositivity of 30.4% in 181 liver disease patients (CLD and HCC) in Saudi Arabia is lower than that reported from European countries.

Prevalence of hepatitis C virus antibodies in chronic liver disease and hepatocellular carcinoma patients in India.

Abstract: The prevalence of antibodies to hepatitis C virus (HCV) was investigated in 129 patients with chronic liver disease (85 with chronic active hepatitis and 44 with cirrhosis) and 53 patients with hepatocellular carcinoma. The commercially available second generation anti-HCV enzyme immunoassay kit was used. Antibodies to hepatitis C virus were detected in 16.2% of the patients with chronic liver disease and in 15.1% with hepatocellular carcinoma. Of the HCV positive patients in all groups 51.7% were positive for hepatitis B virus (HBV) markers indicating present or past infection. Prevalence of HBV markers in all the three groups (CAH, cirrhosis and HCC) was higher as compared with anti-HCV prevalence. These results suggest that HCV infection may not be a major cause of chronic liver disease and hepatocellular carcinoma in India and indicate the presence of other aetiological agents.

A meta-analysis comparing the efficacy of omeprazole with H2-receptor antagonists for acute treatment of duodenal ulcer in Asian patients.

Abstract: A meta-analysis was performed on pooled data from five large double-blind studies (a total of 1057 patients), which were conducted in Asia to compare the effects of omeprazole with H2-receptor antagonists (H2-RA) in duodenal ulcer. As each study followed the same protocol and data evaluation procedures, a detailed analysis of ulcer healing, symptom relief and influence of prognostic factors across the data was possible. Patients received omeprazole 20 mg om or standard doses of H2-RA for a minimum of 2 and a maximum of 4 weeks, depending on healing (as verified by endoscopy). All efficacy analyses were based on per protocol data. The mean healing rates at 2 weeks were 72% for omeprazole and 42% for H2-RA (difference 30%; 95% CI: 24-36%; P 10 mm) taking longer to heal than small ulcers. There was no significant influence of smoking and alcohol drinking on ulcer healing. Patients on omeprazole experienced significantly less epigastric pain after 2 weeks than those on H2-RA, 79% of them being completely symptom-free on omeprazole compared with 65% on H2-RA. The incidence of adverse events was approximately 5% on each treatment and profiles were similar for each drug. It is concluded that omeprazole, even in the presence of adverse prognostic influences, results in significantly better healing of duodenal ulcer and relief from symptoms than H2-RA.