Pain attacks in non-complicated and complicated gallstone disease have a characteristic pattern and are accompanied by dyspepsia in most patients: the results of a prospective study

OBJECTIVE

The cardinal indication for surgical treatment of gallstones is pain attacks. However, following cholecystectomy, 20% of patients remain symptomatic. It is unclear to what extent post-cholecystectomy symptoms can be ascribed to persistence of preoperative symptoms or to new pathology. The pain and digestive pattern in gallstone patients has not been defined in a recent setting with ultrasonography as the diagnostic method. The aim of this study was to characterize a pain pattern that is typical for gallstone disease and to describe the extent of associated dyspepsia.

MATERIAL AND METHODS

A total of 220 patients with symptomatic gallstone disease including complicated disease (acute cholecystitis and common bile duct stones) were interviewed using detailed questionnaires to disclose pain patterns and symptoms of indigestion.

RESULTS

All patients had pain in the right upper quadrant (RUQ) including the upper midline epigastrium. The pain was localized to the right subcostal area in 20% and to the upper epigastrium in 14%, and in the rest (66%) it was more evenly distributed. An area of maximal pain could be defined in 90%. Maximal pain was located under the costal arch in 51% of patients and in the epigastrium in 41%, but in 3% behind the sternum and in 5% in the back. The pain was referred to the back in 63% of the patients. The mean visual analogue scale (VAS) score was very high: 90 mm on a 0-100 scale. A pattern of incipient or low-grade warning pain with a subsequent relatively steady state until subsiding in the same fashion was present in 90% of the patients. An urge to walk around was experienced by 71%. Pain attacks usually occurred in the late evening or at night (77%), with 85% of the attacks lasting for more than one hour and almost never less than half an hour. Sixty-six percent of the patients were intolerant to at least one kind of food, but only 48% to fatty foods. Symptoms of functional indigestion (gastroesophageal reflux, dyspepsia or irritable bowel symptoms) were seen in the vast majority in association with attacks.

CONCLUSIONS

Gallstone-associated pain follows a certain pattern in the majority of patients. The pain is located in a defined area with a point of maximum intensity, is usually referred, and occurs mainly at night with duration of more than one hour. The majority of patients experience functional indigestion, mainly of the reflux type or dyspepsia.

Quality of life in patients with subjective food hypersensitivity: applicability of the 10-item short form of the Nepean Dyspepsia Index

The aim of this study was to investigate quality of life and applicability of the 10-item short form of the Nepean Dyspepsia Index (SF-NDI) in patients with subjective food hypersensitivity. Fifty-two adult patients and 120 controls were examined using three questionnaires: Quality of life Nepean Dyspepsia Index (NDI), Gastrointestinal Symptom Rating Scale (GSRS), and Ulcer Esophagitis Subjective Symptoms Scale (UESS). To document psychometric properties, 20 of the patients filled in the SF-NDI questionnaire once more 4 weeks later. Patients had poor quality of life compared with controls from health care workers or general population (P < 0.001). Scores on SF-NDI were significantly correlated with scores on the GSRS (r = 0.34, P = 0.02) and UESS (r = 0.41, P = 0.003). The SF-NDI performed very satisfactorily, with a high reliability, construct validity, and responsiveness. Patients with subjective food hypersensitivity have considerably reduced quality of life. The SF-NDI provides reliable, responsive, and clinically valid measures of quality of life in these patients.

Altered dopamine D2 receptor function in fibromyalgia patients: a neuroendocrine study with buspirone in women with fibromyalgia compared to female population based controls

BACKGROUND

To what extent fibromyalgia belongs to affective spectrum disorders or anxiety spectrum disorders remains disputed. Buspirone induces a hypothermic response, which most likely is due to 5-HT(1A) autoreceptor stimulation, and growth hormone (GH) release, which probably is related to postsynaptic 5-HT(1A) receptor stimulation. The prolactin response to buspirone has been suggested to be mediated through dopamine (DA) antagonistic effects.

OBJECTIVES

Based on the assumption that fibromyalgia is more strongly related to stress and anxiety than affective spectrum disorders, we hypothesized that compared to population controls, fibromyalgia patients should demonstrate an increased prolactin response (DA sensitivity) to buspirone challenge test, but no difference in hypothermic response or GH release (5HT sensitivity).

METHOD

A 60-mg dose of buspirone was given orally to 22 premenopausal women with fibromyalgia and 14 age and sex matched healthy control subjects. Core body temperature, growth hormone and prolactin levels were analyzed at baseline and after 60, 90, and 150 min.

RESULTS

Fibromyalgia patients showed an augmented prolactin response to buspirone compared to controls. Temperature and growth hormone responses did not differ from controls.

CONCLUSIONS

Dopaminergic rather than serotonergic neurotransmission is altered in fibromyalgia, suggesting increased sensitivity or density of dopamine D(2) receptors in fibromyalgia patients. Stress and anxiety is an important modulator of dopaminergic neurotransmission. Our results suggest that fibromyalgia is related to anxiety and associated with disturbance in the stress response systems.

Changes in food tolerance and lifestyle after eradication of Helicobacter pylori

BACKGROUND

It is known that patients with peptic ulcer disease (PUD) often have an unhealthy lifestyle that results in increased mortality because of smoking-related diseases. No thorough study has been done to see what changes, if any, the patient makes to lifestyle after eradication of Helicobacter pylori.

METHODS

One-hundred-and-eighty-three patients were enrolled in an open-endoscopy setting; 58% had PUD and 42% gastritis and/or duodenitis (G/D). They filled out a lifestyle questionnaire before the start of anti-Helicobacter therapy and again 1 year later.

RESULTS

The prevalence of food intolerance decreased from 71% to 44% among patients with PUD (P < 0.0001) and from 76% to 63% among patients with G/D (P = 0.09). Tolerance improved for coffee, orange juice, fried foods, spicy foods and fruits. There was no significant change in smoking or alcohol consumption after eradication. Coffee and tea consumption was unchanged. Milk consumption decreased from 4.2 dL/day to 3.3 (P = 0.01). The number of meals decreased from 3.5/day to 3.4 (P = 0.005) and snacking from 1.3 snacks/day to 1.1 (P = 0.02). Consumption of fruit increased from 4.0 to 4.3 times/week (P = 0.04), but the frequency of meat, fish, vegetables, spicy foods, salty foods, sweets and cakes did not change. The time spent on each meal was unchanged. There was no change in the time spent exercising. There were few significant differences between PUD and G/D patients.

CONCLUSIONS

Food was better tolerated, but there were no major changes in lifestyle after eradication of H. pylori. Patients therefore do not abuse the privilege of a more tolerant digestion by indulging in a more unhealthy lifestyle.

Patients with endoscopic gastritis and/or duodenitis improve markedly following eradication of Helicobacter pylori, although less so than patients with ulcers

BACKGROUND

It is well documented that dyspepsia in patients with peptic ulcer disease (PUD) improves markedly after eradication of Helicobacter pylori, while rarely does it improve in patients with functional dyspepsia. There is a large group of H. pylori-infected patients who do not qualify for either diagnosis, but in whom eradication may be considered. The aim of this study was to compare symptom severity, change in gastrointestinal symptoms 1 year after eradication and satisfaction with therapy between PUD patients and patients with endoscopic diagnoses of gastritis and/or duodenitis (G/D patients).

METHODS

The patients were randomized to one of four triple regimens containing ranitidine bismuth and metronidazole, and either oxytetracycline or spiramycine. Eradication was assessed with the 14C-urea breath test. GI symptoms were evaluated using the Gastrointestinal Symptom Rating Scale (GSRS) and the Ulcer Esophagitis Subjective Symptoms Scale (UESS) questionnaires.

RESULTS

One-hundred-and-eighty-three patients were recruited from GI outpatient clinics. Patients with PUD and G/D had similar severity of symptoms before eradication therapy. One year after H. pylori eradication, 99% of the PUD patients and 75% of the G/D patients felt better regarding their main upper GI complaint. Abdominal pain score decreased by 48% as measured by GSRS and by 78% as measured by UESS in the PUD group and by 25% and 47%, respectively, in the G/D group. Reflux symptoms decreased by 41% and 63% in PUD patients and by 28% and 45% in G/D patients; indigestion by 30% and 47% in PUD and by 20% and 34% in G/D; eating discomfort by 60% in PUD and by 35% in G/D. Sleep quality score improved by 68% in PUD and by 41% in NU patients. Constipation decreased by 22% in the PUD group. All these differences in symptoms were highly significant compared to baseline. Diarrhoea was unchanged.

CONCLUSIONS

Abdominal pain, reflux symptoms, indigestion and the ability to eat and sleep improved in both PUD and G/D patients 1 year after H. pylori eradication. Chronic diarrhoea was not induced. Abdominal pain improved significantly more in PUD than in G/D patients. Further study of the effect of H.pylori eradication in G/D patients is warranted.

Vagal tone and meal-induced abdominal symptoms in healthy subjects

BACKGROUND/AIMS

Patients with functional dyspepsia often have meal-induced dyspeptic symptoms and low vagal tone. We examined whether these variables are related in healthy subjects.

METHODOLOGY

In 40 healthy subjects vagal tone and abdominal symptoms were recorded before and after a 500-ml soup meal ingested in 1 and 4 min on separate visits. Vagal tone was indexed by respiratory sinus arrhythmia (RSA).

RESULTS

Scores for nausea and discomfort were higher when the soup was ingested in 1 min as compared with 4 min (nausea: p = 0.02; discomfort: p = 0.04). There was no difference in fullness or abdominal pain. RSA was unrelated to meal-induced symptom scores. RSA varied with respiration and body position: It was highest while breathing deeply in the sitting position (24.0 beats/min). With normal breathing RSA was highest in the supine position (9.0 beats/min), lower while sitting (7.0 beats/min) and lowest while standing (6.2 beats/min).

CONCLUSIONS

Epigastric discomfort in response to rapid ingestion of a test meal in healthy subjects was not related to vagal tone as indexed by RSA. Vagal tone varied with breathing pattern and body position. It is possible that increasing vagal tone by such measures can be beneficial in the treatment of patients with functional dyspepsia.

Factors explaining variance in perceived pain in women with fibromyalgia

BACKGROUND

We hypothesized that a substantial proportion of the subjectively experienced variance in pain in fibromyalgia patients would be explained by psychological factors alone, but that a combined model, including neuroendocrine and autonomic factors, would give the most parsimonious explanation of variance in pain.

METHODS

Psychometric assessment included McGill Pain Questionnaire, General Health Questionnaire, Hospital Anxiety and Depression Rating Scale, Eysenck personality Inventory, Neuroticism and Lie subscales, Toronto Alexithymia Scale, and Multidimensional Health Locus of Control Scale and was performed in 42 female patients with fibromyalgia and 48 female age matched random sample population controls. A subgroup of the original sample (22 fibromyalgia patients and 13 controls) underwent a pharmacological challenge test with buspirone to assess autonomic and adrenocortical reactivity to serotonergic challenge.

RESULTS

Although fibromyalgia patients scored high on neuroticism, anxiety, depression and general distress, only a minor part of variance in pain was explained by psychological factors alone. High pain score was associated with high neuroticism, low baseline cortisol level and small drop in systolic blood pressure after buspirone challenge test. This model explained 41.5% of total pain in fibromyalgia patients. In population controls, psychological factors alone were significant predictors for variance in pain.

CONCLUSION

Fibromyalgia patients may have reduced reactivity in the central sympathetic system or perturbations in the sympathetic-parasympathetic balance. This study shows that a biopsychosocial model, including psychological factors as well as factors related to perturbations of the autonomic nervous system and hypothalamic-pituitary-adrenal axis, is needed to explain perceived pain in fibromyalgia patients.

Chemical control of Penthaleus major (Acari: Prostigmata) in hayfields in Iceland

The plant parasitic mite Penthaleus major (Dugès) occurs as a pest on perennial grasses in hayfields in Iceland, northern Norway, and southern Greenland. In these areas it appears as a summer phenomenon, contrary to more southern locations, where it appears as a pest on winter crops. Up to 500 individuals of P. major were collected per day in pitfall traps. Spring application of 44 ml/ha of permethrin and 5 ml of deltamethrin significantly reduced but did not eliminate the populations of P. major the following weeks. In addition to this immediate effect, spring application also decreased the mite populations in the fall and even the following spring. Additional effects might be obtained by earlier spring application. Despite a significant reduction in mite populations and reduction in visible plant damage, significant differences on dry matter yield were rarely registered. A side effect of application was a small but significant reduction in potassium-content of the yield, and the reduction in mite population was accompanied by a corresponding reduction in the number of spiders.

Controversies in dyspepsia

Even in the absence of visible lesions like an ulcer, cancer or oesophagitis, patients with functional dyspepsia may complain of severe dyspeptic symptoms and have a poor quality of life. Characteristically, these patients also often have a low estimate of their own health and have complaints from several organ systems. The cause of the disease is not known. Both central nervous system and gastric disturbances appear to be involved, and their relative importance is controversial. There is no clear beneficial effect of acid suppression or H. pylori eradication although effects of such therapy may be seen in minor subgroups. New findings emphasise the importance of distinguishing between functional dyspepsia and gastro-oesophageal reflux disease, which exhibit completely different gastric accommodation patterns to a meal and have very different therapeutic potential. The effect of drugs like glyceryl trinitrate, glucagon, sumatriptan and buspirone which all concomitantly improve symptoms and gastric accommodation support the important role of abnormal gastric accommodation to meals in patients with functional dyspepsia. A hypothetical model for the pathogenesis of functional dyspepsia is presented. It incorporates four established abnormalities: various psychological abnormalities, low vagal tone, impaired gastric relaxation, and visceral hypersensitivity, in a logical interplay along the brain-gut axis.

[Educational level, occupation and income of those who became disability pensioners in Iceland in the year 1997.]

INTRODUCTION

All claims for disability benefits in Iceland are managed by the State Social Security Institute of Iceland. The decision to grant a claimant disability benefits was until September 1999 mainly based on medical certificates but social and economic factors were also taken into consideration. As information on social and economic conditions in medical certificates is limited it was decided to investigate these factors particularly. In this paper a comparison of educational level, employment, and income is made between new recipients of disability benefits and a random sample of the Icelandic nation.

MATERIAL AND METHODS

All new recipients of disability benefits (full disability pension, partial disability pension and rehabilitation pension) in 1997 were contacted by phone and asked to answer a questionnaire. Their answers were compared with those obtained in a national survey carried out by the Institute of Social Sciences at the University of Iceland in 1996 and 1997 with a sample representing accurately the Icelandic population in terms of gender, age and place of residence. Information about average income of disability pensioners was obtained and compared to that of people in employment.

RESULTS

Educational level of those receiving disability benefits was considerably lower than expected in comparison with the population and unskilled workers were overrepresented. Contrary to what might be expected a larger proportion of the recently disabled have been employed at some time than is the case for the national sample, even though 63.6% of the new disability pensioners were women. Considerable number of those receiving disability benefits were still in employment, particularly those with partial disability pension. Mean monthly income of Icelanders participating in the labour market was almost twice that received by those on disability benefits.

CONCLUSIONS

Since lower educational level and more restricted employment opportunities characterize disability pensioners as compared to the nation, it seems likely that more varied occupational rehabilitation and educational opportunities could improve the situation of those who have had to leave the labour market because of ill health, lack of education and poor working conditions.

[Hepatocellular carcinoma in Iceland.]

INTRODUCTION

The incidence of hepatocellular carcinoma (HCC) varies throughout the world, being relatively low in Northern Europe (less than five per 100,000 population) where the majority of the patients have cirrhosis. In Iceland the prevalence of viral hepatitis and cirrhosis, the main risk factors for HCC, is lower than reported in many other countries. The aim of our study was to investigate the incidence and etiology of HCC in Iceland.

MATERIAL AND METHODS

All patients diagnosed with HCC in Iceland in 1984-1998 were included in the study. Histologic diagnosis was required for inclusion. Patients were identified from the Icelandic Cancer Registry and by reviewing autopsy and histopathology reports. Further information was obtained from medical records.

RESULTS

A total of 71 cases of HCC were identified, 51 males and 20 females. The mean age for males was 69.3 years (18-95) and 73 years (52-89) for females. The age-standardized annual incidence rate of HCC was 1.08/100,000 (males 2.10, females 0.67). The incidence did not increase significantly during the study period. Alcohol abuse (15.5%) and hemochromatosis (11%) were the most common risk factors. Twenty-three (32%) had cirrhosis but 39 (55%) had no known risk factors. Of 55 cases where non-neoplastic tissue was available for examination, 27 had liver disease.

CONCLUSIONS

1) The incidence of HCC in Iceland is lower than reported in other countries. 2) Alcohol abuse and hemochromatosis are the most common risk factors. 3) The ratio of patients with cirrhosis is low.

Outbreak of Potato Late Blight and First Report of Mating Type A2 and Metalaxyl Resistance of Phytophthora infestans in Iceland

Late blight caused by Phytophthora infestans (Mont.) de Bary was endemic on potato in Iceland from about 1890 until 1961. Probably because of a cooler climate in the 1960s, the disease disappeared and there were no epidemics until 1990 and 1991. Late blight was not found in the period 1992 to 1998 even though the weather conditions were favorable for epidemic development in some of the years. Lack of initial inoculum was probably the limiting factor for an epidemic in Iceland some years. During the summer of 1999, late blight reappeared in Iceland. In August 1999, potato leaves with single lesions of late blight were sampled from two locations and sent to the Norwegian Crop Research Institute. Isolates were trapped by placing infected leaves under tuber slices in petri dishes. Pure cultures were made by picking small pieces of mycelium from the upper side of the potato slice after 7 to 10 days incubation at 15°C and plating them onto modified rye B agar with antibiotics (1). Sixteen isolates maintained on rye B agar were paired with reference isolates of mating types A1and A2 and examined for oospores at the hyphal interfaces between the isolates (1). One isolate was typed as A2 and 15 isolates were A1. Response to metalaxyl was determined for 13 isolates in vitro (1) on rye B agar amended with 5 mg/l metalaxyl-m. One of the A1 isolates was metalaxyl-resistant and 12 isolates, including the A2 isolate, showed intermediate resistance to the fungicide. These data show that the "new" population of P. infestans is now present in Iceland as in the other Nordic countries (1). Iceland imports some seed potatoes each year, mainly from the Netherlands. Imported seed potatoes were probably the source of initial inoculum in 1999 in Iceland. In the future, oospores in the soil might be an additional inoculum source in Iceland since both mating types are now present. Reference: (1) A. Hermansen et al. Plant Pathol. 49:11, 2000.

Genotype-phenotype interactions in Wilson's disease: insight from an Icelandic mutation

Wilson's disease, an autosomal recessive disorder of copper transport, usually presents with symptoms from the liver or central nervous system. Rarely, the initial manifestation is fulminant hepatic failure. The abnormal gene (ATP7B) is located on chromosome 13q and encodes a copper-transporting ATPase. A large number of mutations have been reported. We describe a previously healthy 16-year-old girl who presented with fulminant hepatic failure. The girl died within 24 h of admission to a hospital from refractory shock. Autopsy revealed cirrhosis and widespread necrosis of the liver. The copper content of the liver was markedly increased (975 micrograms/g dry weight), strongly suggesting a diagnosis of Wilson's disease. Genetic studies revealed that the girl was homozygous for the mutation 2007 del7, which is the mutation found in all Wilson's disease patients previously identified in Iceland. This is the first known case of fulminant hepatic failure due to Wilson's disease in Iceland. Despite the same mutation, the clinical picture is vastly different from other Icelandic patients with Wilson's disease, who all presented with relatively late-onset neurological disease. This suggests that factors other than the specific mutation have significant impact on the phenotype of the disease.

[Changes in the prevalence of disability pension in Iceland 1976-1996.]

OBJECTIVE

To determine changes in the prevalence of disability pension in Iceland and to describe the distribution of those receiving disability pension according to gender, age and main diagnoses between the years 1976 and 1996.

MATERIAL AND METHODS

The study includes all those receiving disability pension on the 1st of December in the years 1976 and 1996 as ascertained by the disability register at the State Social Security Institute of Iceland. There are two levels of disability pension, full disability pension (disability assessed as being more than 75%) and reduced disability pension (disability assessed as being 50% or 65%). Information on age and gender distribution of the Icelandic population was obtained. Age-standardized risk ratio between the years 1976 and 1996 was calculated for both pension levels combined and for full disability pension alone.

RESULTS

There was no significant change in crude prevalence rate for both pension levels combined between the years 1976 and 1996, when the increase in the population was accounted for but without paying attention to changes in gender or age distribution. However, the standardized risk ratio showed a significantly decreased risk for both pension levels combined both for men and women in the year 1996 as compared with the year 1976, the age-standardized risk ratio being 0.95 and 0.93 respectively. It also showed a significant change between pension levels with an increased risk of full disability pension and a decreased risk of reduced disability pension. The increase in full disability pension was noted for both males and females and was largely independent of age. There was a significant increase in full disability pension in most disease categories. Disability due to diseases of the nervous system and sense organs and injury and poisoning increased amongst women only. A significant decrease in full disability pension due to infections and diseases of the digestive system occurred in both men and women.

CONCLUSION

The prevalence of a disability pension amongst men and women in the year 1996 as compared to the year 1976 was significantly decreased when changes in population size and age distribution had been accounted for. This is particularly interesting because unemployment was increasing just prior to the year 1996. The prevalence of full disability pension had however significantly increased in 1996 compared with 1976. A plausible explanation for the observed change in disability pension levels is a pressure from the labour market, with increasing unemployment and competition. Also, the introduction of a disability card for those with full disability pension in 1980, which granted lower price for medication and the services of physicians, is likely to have increased the pressure for the higher level of disability pension (full disability pension). It seems unlikely that the increase in full disability pension and the decrease in reduced disability pension is due to a deterioration of health of the Icelandic population. Increased disability due to injury and poisoning amongst women is probably a result of their increased participation in the labour market. The decrease in disability due to infections is a result of a reduction in the number of cases of tuberculosis and poliomyelitis. The decrease in disability due to diseases of the digestive system is probably a result of improvement in the treatment of oesophageal reflux and peptic ulcer.

[Thyrotoxicosis and coexistent diseases in atrial fibrillation.]

OBJECTIVE

To evaluate the prevalence of thyrotoxicosis and coexistent diseases in patients with atrial fibrillation admitted to a general medicine ward.

MATERIAL AND METHODS

All patients with the discharge diagnosis of atrial fibrillation were studied. The study design was retrospective for the years 1993-1994 and prospective from April 1995 through December 1997. Information on thyroid function tests was obtained from medical records in the retrospective part, but TSH, T4 and T3 were measured for patients admitted during the prospective part. Coexistent diseases were recorded.

RESULTS

Atrial fibrillation was diagnosed in 167 patients (58 in the retrospective part and 109 in the prospective part). Males were predominant (59.3%) and the average age was 73.7 years (span 26-100). Adequate information on thyroid function tests was available for 135 patients (58.6% of the retrospective part and 92.7% of the prospective part). 24 (17.8%) had abnormal thyroid function tests, predominantly women (71%). Ten had an isolated elevation of TSH, seven an isolated depression of TSH, two hypothyroidism and five other abnormalities. Hypertension was the most common coexistent disease (76 of 167 patients (45.5%). Ischemic heart disease was found in 44 (26.3%) and valvular heart disease in 27 (16.2%). No known coexistent disease was found in 32 (19.2%).

CONCLUSIONS

1) Thyrotoxicosis is rare in patients with atrial fibrillation who are admitted to a general medicine ward. Routine measurement of thyroid function tests in this patient population is therefore not warrented. 2) Unspecific abnormalities of thyroid function tests are common and are most likely due to diseases outside the thyroid gland or medications. 3) Hypertension, ischemic heart disease and heart valve disease are the most common coexistent diseases in this group of patients.

Fibromyalgia is associated with panic disorder and functional dyspepsia with mood disorders. A study of women with random sample population controls

BACKGROUND

We compared ICD-10 psychiatric disorders in female patients with fibromyalgia (n=45) or functional dyspepsia (n=18) with age-matched random sample controls (n=49).

METHOD

Version 2 of The Schedules for Clinical Assessment in Neuropsychiatry (SCAN) was used for present state examination and lifetime diagnoses.

RESULTS

Current psychiatric disorders (somatoform pain disorder and specific phobia omitted) were diagnosed in 80% of fibromyalgia patients (OR=8.3), 83% of functional dyspepsia patients (OR=10.3) and 33% controls. Among fibromyalgia patients 27% had lifetime panic disorder. Lifetime mood disorders were found in 83% of functional dyspepsia patients. First-degree relatives with psychiatric disorder were found in 16% of the fibromyalgia patients, 50% of functional dyspepsia patients and 20% of controls.

CONCLUSIONS

Fibromyalgia is associated with panic disorder and functional dyspepsia with mood disorders in substantial subgroups. Psychiatric symptoms and somatic complaints are closely related in these disorders.

[Liver transplantaion.]

In recent years, liver transplantation has become the treatment of choice for end-stage liver disease. Chronic viral hepatitis, alcoholic cirrhosis and chronic cholestatic diseases are the most common liver diseases requiring transplantation. Complications of cirrhosis such as variceal bleeding are important indications. Prognostic survival models are also used to determine the optimal timing of transplantation. Pretransplant evaluation is designed to assess the patients general health and the condition of the vital organs. The operation is complicated but most patients recover rapidly. Postoperative complications such as hepatic artery thrombosis may require retransplantation. Following transplantation, the patient is maintained on a regimen of immunosuppressive medications. Acute cellular rejection is common but usually responds to additional immunosuppression. One and five years survival has increased to 80-90% and 65-70% respectively. Recurrent liver disease is a common problem but rarely affects short term survival. Several Icelandic patients have undergone liver transplantation. Indications are similar to other European countries.

Therapy and diagnostic tests used for Helicobacter pylori infection in the Scandinavian countries in 1998

BACKGROUND

We wanted to ascertain how Helicobacter pylori infection is managed in Scandinavia.

METHODS

A one-page questionnaire with seven questions was mailed in April 1998 to 1718 gastroenterologists in Finland, Denmark, Norway, and Sweden (excluding Swedish surgeons).

RESULTS

The questionnaire was returned by 36%. Antimicrobials were used by 99% for peptic ulcer associated with H. pylori, by 67% for mucosa-associated lymphoid tissue lymphoma, by 27% before long-term therapy with a proton-pump inhibitor (PPI), by 16% for non-ulcer dyspepsia, by 11% for reflux disease, and by 11% for other indications. In Finland several conditions other than ulcer were treated more frequently than in the other countries. The commonest primary therapy is PPI triple therapy (94%), followed by bismuth-based (11%), 'other' (2%), and PPI dual therapy (0.2%). Primary bismuth-based therapy was almost completely limited to Norway. The commonest secondary therapy for failures was also PPI triple therapy (71%), followed by bismuth-based (41%), 'other' (10%), and PPI dual therapy (1%). Clarithromycin for primary therapy was used much less frequently in Finland than in the other countries. Follow-up to ascertain whether eradication is successful was done always or often by 90% in Finland, 63% in Norway, 62% in Sweden, and 21% in Denmark and by 61% of the internists and 42% of the surgeons. The commonest method to confirm eradication was gastroscopy (69%), followed by the breath test (52%) and serology (11%).

CONCLUSIONS

In Scandinavia H. pylori associated with peptic ulcer disease is treated with antimicrobials by virtually all gastroenterologists. PPI triple therapy is the commonest regimen for primary and secondary eradication. PPI dual therapy has essentially disappeared. Fifty-four per cent confirm eradication always or often, with gastroscopy being the commonest method.

On demand therapy of reflux oesophagitis--a prospective study of symptoms, patient satisfaction and quality of life

BACKGROUND

In patients with low-grade reflux oesophagitis adequate symptom control is the aim of treatment. Effervescent tablets alleviate heartburn more rapidly than ordinary tablets.

AIM

To investigate symptom control, patient satisfaction, health-related quality of life and disease progress when ranitidine 150 mg effervescent tablets were offered as on demand treatment. We also wanted to investigate whether any biological or psycho-social factor could predict patient satisfaction.

METHOD

Consecutive patients with endoscopically verified reflux oesophagitis grade I-II were followed up for 12 months. 24 h pH-metry, disease history, symptoms and several psycho-social factors were registered at baseline and 12 months follow-up.

RESULTS

Eighty-one patients were included. Mean age was 50.7 years (range 21-82), 63% were men. Mean tablet consumption was 1.21 per day (range 7-1016 tablets/year). At the 1-year follow-up discomfort resulting from reflux symptoms was significantly reduced (P<0.001), and the patients' social and vocational life improved. Eighty-four percentage of the patients were satisfied with the treatment. 24 h pH-metry or number of reflux episodes did not change. We did not find any factors able to predict patient satisfaction.

CONCLUSIONS

On demand therapy with ranitidine effervescent tablets was well accepted by the majority of patients with reflux oesophagitis grade I. Even though the number of reflux episodes did not change, the patients experienced less discomfort due to reflux symptoms, and their social and vocational life was better. There was no significant progression of the disorder during the 1-year follow-up. No predictive factor for patient satisfaction was found.

Spiramycin is comparable to oxytetracycline in eradicating H. pylori when given with ranitidine bismuth citrate and metronidazole

BACKGROUND

We have consistently achieved about 90% eradication of H. pylori with liquid bismuth, metronidazole and oxytetracycline.

AIM

To test eradication and adverse events of ranitidine bismuth citrate (RBC) when given with metronidazole and either oxytetracycline or spiramycin.

METHODS

One hundred and eighty-three patients were randomized to one of four 10-day regimens: RBC400OM: RBC 400 mg b.d., oxytetracycline 500 mg q.d.s.; RBC400SM: RBC 400 mg b.d., spiramycin 1 g q.d.s.; RBC200OM: RBC 200 mg q.d.s., oxytetracycline 500 mg q.d.s.; RBC200SM: RBC 200 mg q.d.s., spiramycin 1 g q.d.s. Additionally, all patients received metronidazole 400 mg q.d.s. A 14C-urea breath test was performed at 8 weeks.

RESULTS

Intention-to-treat eradication rates were 94%, 91%, 94% and 89% with RBC400OM, RBC400SM, RBC200OM and RBC200SM, respectively (P = 0.81). Eradication was significantly higher in ulcer patients (97%) than in those with diagnoses other than ulcer (86%) (P = 0.009). There was a strong tendency to better eradication among those who had never smoked (100%) compared with ex-smokers (93%) and smokers (89%) (P = 0.06). Fifty-three per cent experienced at least one moderate or severe adverse event, and women had more adverse events than men (P = 0.0002).

CONCLUSIONS

All four regimens had comparable efficacy and adverse events. Eradication was significantly better in ulcer patients but there was a trend to better eradication in those who smoked less, used less alcohol and exercised more. Adverse events were frequent, perhaps because of the large dose of metronidazole used, but few patients stopped treatment.

In vitro evaluation of three-dimensional ultrasonography based on magnetic scanhead tracking

The objective of this study was to evaluate the accuracy and precision of a magnetic position sensor system for acquisition of three-dimensional (3D) ultrasound images in volume estimation of phantoms in vitro. Installation of either 0.9% solution of saline at 37 degrees C or distilled water at 20 degrees C to a condom was performed. Scanning was performed either by a continuous or stepwise acquisition. This 3D ultrasound system demonstrated good correlation (r = 0.99-1.0, n = 8) between estimated (EV) and true volumes (TV). The errors were in the range 1.3%+/-0.3% (SEM) to 1.9%+/-0.6%, independent of sound velocity. Scanning through a porcine abdominal wall positioned at the fluid surface yielded a systematic underestimation of the volume: mean (EV - TV) = -7.2+/-0.8 ml. Eight repeated scans of the same volume yielded a coefficient of variation of 1.1%. Interobserver error of the tracing procedure was 2.6%+/-0.9%. This 3D ultrasound system gave high accuracy and precision in volume estimation in vitro, and yielded low interobserver error. A change in ultrasound velocity of approximately 60 m/s did not influence the accuracy significantly. Scanning through an abdominal wall underestimated volumes slightly.