[Saccharomyces boulardii in the treatment and prevention of antibiotic-associated diarrhea]

BACKGROUND

Antibiotic-associated diarrhea (AAD) is the most frequent side effect of antibiotic therapy. Clinical signs and symptoms comprise mild and self-limiting courses of diarrhea as well as life threatening courses like pseudomembranous colitis or toxic megacolon. Therapy is symptomatic, antidiarrheal drugs like Saccharomyces boulardii are the therapy of choice.

METHOD

Available studies on S. boulardii in the prevention of AAD are presented as a review.

RESULTS

In 14 out of 17 studies including 4,627 patients the administration of S. boulardii achieved a protective effect between 43.7% and 87.3%. A meta-analysis (5 studies, 1,076 patients) showed a significant reduction of the risk to develop an AAD from 17.2% to 6.7%,in a furthermeta-analysis (4 studies on eradication of H. pylori, 1,215 patients) the significant reductionwasfrom 12.2% to 5.6%.

CONCLUSIONS

There is very good evidence for the yeast S. boulardii to be effective in the prevention of AAD especially in hospitalized adults. The simultaneous administration of S. boulardii to antibiotics resulted in a significant reduction to develop AAD by more than half.

[Diarrhea after vascular reconstruction of an abdominal aortic aneurysm]

HISTORY AND CLINICAL FINDINGS

A 60-year-old man had a dacron aortofemoral bypass graft inserted to replace a ruptured infrarenal aortic aneurysm rupture. He subsequently had tachyarrhythmic atrial fibrillation with heart failure, NYHA class IV, and diffuse abdominal pain associated with watery diarrhea.

INVESTIGATIONS

Stool tests merely demonstrated Candida albicans. Abdominal ultrasound revealed intestinal loops with thickened walls and decreased peristalsis. Coloscopy demonstrated a retroperitoneal intestinal perforation with abscess formation resulting from ulcerative necrotizing rectosigmoid colitis which had also uncovered the vascular prosthesis near the abscess cavity.

DIAGNOSIS

Ischemic transmural necrotizing rectosigmoiditis with retroperitoneal intestinal perforation.

TREATMENT AND COURSE

The rectosigmoid colon was resected and an end-colostomy made with closure of the rectal stump (Hartmann's operation). The uncovered right limb of the vascular graft was covered completely and was discharged, being now mobile using a walking frame. There was no evidence of infection in the dacron prosthesis.

CONCLUSION

A transmural progression of an ischemic colitis should be considered as a late sequela after emergency vascular reconstruction of the abdominal aorta. Even if symptoms are mild, early postoperative sigmoidoscopy is indicated.

[Diarrhea in a patient with Down syndrome and endemic sprue]

BACKGROUND

Down syndrome is associated with disorders such as celiac disease, hypothyroidism, and insulin-dependent diabetes mellitus. In patients with mono- or oligosymptomatic celiac disease the time interval between the onset of symptoms and diagnosis often is unacceptably long.

CASE REPORT

A female patient with Down syndrome is presented who had acute watery diarrhea, which spontaneously ceased but recurred after a few days. After endoscopic and histologic evaluation and measurement of gliadin, endomysium, and reticulin antibodies celiac sprue was diagnosed. Further investigation showed findings of autoimmune hypothyroidism and secondary hyperparathyreoidism. After the patient was put on a gluten-free diet her state quickly improved.

CONCLUSION

Associations between Down syndrome and autoimmune diseases exist. Patients with acute gastrointestinal symptoms should be evaluated as to celiac disease. The time interval between the onset of symptoms and diagnosis of celiac disease can be shortened, if all diagnostic tools are used at the appropriate time.

[Motility disorders of the esophagus in patients with apoplectic infarct during the acute illness phase]

BACKGROUND

Prolonged oropharyngeal dysphagia occurs in up to 45% of patients presenting with a unilateral hemiplegic stroke. The aim of this study was to investigate esophageal motility in patients with hemiplegic stroke and to evaluate, whether detected motility disorders improve within 10 days after the beginning of symptoms.

PATIENTS AND METHODS

Fifteen patients with hemiplegic stroke and dysphagia underwent esophageal manometry within the first 2 days after admission to the hospital and 10 days later. Eighteen healthy volunteers served as controls.

RESULTS

The following parameters showed no significant differences between the 2 study days (day 2: day 10: controls, p-value [comparison with controls]): resting pressure of the lower esophageal sphincter: 21 +/- 3 mm Hg: 20 +/- 3 mm Hg: 18 +/- 2 mm Hg, NS, contraction amplitude: 67 +/- 8 mm Hg: 72 +/- 11 mm Hg: 78 +/- 9 mm Hg, NS, duration of contraction: 4.2 +/- 1.0 s: 4.2 +/- 0.9 s: 2.2 +/- 0.7 s, p < 0.001, and contraction velocity: 6.3 +/- 1.1 cm/s: 5.2 +/- 0.9 cm/s: 3.2 +/- 0.8 cm/s, p < 0.001. As far as the contraction pattern was concerned, on both study days significant pathologic contraction patterns were seen compared with normal controls. Normal propulsive contractions were seen in 54 +/- 5%: 60 +/- 6%: 96 +/- 5%, p < 0.001. Patients with no dysphagia after 10 days still had demonstrable abnormal motility patterns.

CONCLUSION

The findings indicate that manometrically demonstrable pathologic motility patterns of the tubular esophagus in patients without oropharyngeal dysphagia after 10 days do not induce the symptom dysphagia. The function of the esophagus seems not to be impaired by these measurable pathologic contractions.

Anorectal functions in patients with spinal cord injury

We wished to establish anorectal functions in patients with spinal cord lesions, related to the level of lesion and its completeness. We also wished to determine the value of neurophysiological tests for completeness of transsections in comparison with manometry and visceral sensory testing. In 32 patients (31.5 +/- 14.1 years, 25 males) with spinal trauma, completeness of transsection was assessed clinically. In 16 of these patients (30 +/- 15.6 years, nine males), a neurological work-up included recording of somatosensory evoked potentials (SEP) and motor evoked potentials (MEP) from the pudendal nerve within the first week after trauma. Also, anal sphincter EMG and pudendal nerve terminal motor latency (PNTML) were assessed. All patients also underwent conventional anorectal manometry and visceral sensory testing. Of all 32 patients, 15 were judged as 'complete' based on their clinical signs. Of those 16 tested neurologically, seven were labelled 'complete' since no MEP or SEP were detectable; one had pudendal SEP and MEP present, while SEP were present but delayed (47.0 +/- 8.8 msec) in the remaining patients. In four of these patients, also MEP were recorded (27.9 +/- 5.2 msec) and normal. PNTML was present in 12/16 patients independent of the completeness of lesion, and was rated normal in nine and delayed in three patients. EMG was normal in five, and pathological in 11 cases. In 5/15 cases of those judged as 'complete' (in 3/7 evaluated neurologically), visceral sensory testing revealed a minimal threshold for rectal perception of distension of 44 mL (range: 10-130), which sometimes was also perceived as urge to defecate. In a further case, manometry showed major voluntary action of the anal sphincter. These patients had lesions at all levels of the spinal column, ranging from cervical (C4,C6,C7) via thoratical (2 x T7,T8,T12) to lumbar segments. Anorectal function testing, and specifically visceral sensory testing may be superior to neurological assessment of 'completeness' of spinal cord lesions. It may be that visceral afferent pathways others than spinothalamic tract are involved in rectal perception that are less accessible to conventional neurophysiological diagnostic work-up.

Esophageal dysfunction in diabetes mellitus: is there a relation to clinical manifestation of neuropathy?

In a prospective study, we evaluated 33 diabetic patients [type I (n = 8) and type II (n = 25)]. Esophageal motor functions were examined by registering clinical symptoms and by performing esophageal manometry. We also investigated peripheral and autonomic neuropathy. In diabetics, the lower and upper esophageal sphincter pressure and amplitudes of peristaltic waves were reduced. Compared with controls (n = 30), in diabetics the esophageal peristaltic velocity was reduced significantly, and the duration of contractions were decreased as well. Multipeaked waves were uncommon in diabetics, while non-propulsive contractions were seen more often. No correlation was found between esophageal dysfunction and peripheral or autonomic neuropathy. Some 60% of diabetics reported esophageal symptoms; however, no relationship between these symptoms and the extent of dysfunction in esophageal motility was found.

Interaction of monoclonal antibodies with the IgE-receptor on rat mast cells and rat basophilic leukemia (RBL) cells

The close relation between rat mast cells and rat basophilic leukemia (RBL) cells with regard to the presence of receptors for IgE and Fc gamma led us to generate monoclonal antibodies directed against cell surface antigens. Hybridomas were obtained by the fusion of NS1 mouse myeloma cells with murine spleen and lymph node cells. The culture supernatants were assayed by two ELISA techniques: a) for the production of mouse immunoglobulin in general and b) for antibodies directed against surface antigens of RBL cells. For this purpose RBL cells were attached to polyvinyl chloride microtitre plates. Eight hybrids produced antibodies directed against surface antigens on RBL cells. Hybrids were cloned and characterized with regard to their isotype and light chains. All eight clones secreted IgM with K light chains. Immunofluorescence studies performed with RBL cells revealed that all eight antibodies were able to show a specific fluorescence. Furthermore, four of these eight antibodies also showed a specific fluorescence with purified rat mast cells. These four antibodies were analyzed as to their ability of interacting with the IgE-receptor on RBL cells and purified rat mast cells. They reduced the binding rate of radiolabelled rat IgE to RBL and rat mast cells. A mutual inhibition of the passive cutaneous anaphylaxis (PCA) reaction in the rat by either mixing mouse reaginic serum directed against 2,4-dinitrophenol bovine serum albumin (DNP-BSA) or by mixing monoclonal mouse anti-DNP IgE with the monoclonal mouse anti-cell surface (rat basophilic leukemia, rat mast cell) IgM was determined.(ABSTRACT TRUNCATED AT 250 WORDS)