Urinary Excretion of Polyethylene Glycol 3350 during Colonoscopy Preparation

BACKGROUND

Whole gut lavage with a polyethylene glycol electrolyte solution (PEG) is a common bowel cleansing method for diagnostic and therapeutic colon interventions. Absorption of orally administered PEG from the gastrointestinal tract in healthy human beings is generally considered to be poor. In patients with inflammatory bowel disease (IBD), intestinal permeability and PEG absorption were previously reported to be higher than in normal subjects. In the current study, we investigated the absorption of PEG 3350 in patients undergoing routine gut lavage.

METHODS AND RESULTS

Urine specimens were collected for 8 hours in 24 patients undergoing bowel cleansing with PEG 3350 for colonoscopy. The urinary excretion of PEG 3350, measured by size exclusion chromatography, ranged between 0.01 and 0.51 % of the ingested amount, corresponding to 5.8 and 896 mg in absolute amounts, respectively. Mean PEG excretion in patients with impaired mucosa such as inflammation or ulceration of the intestine (0.24 % +/- 0.19, n = 11) was not significantly higher (p = 0.173) compared to that in subjects with macroscopically normal intestinal mucosa (0.13 % +/- 0.13, n = 13).

CONCLUSION

The results indicate that intestinal absorption of PEG 3350 is higher than previously assumed and underlies a strong inter-individual variation. Inflammatory changes of the intestine do not necessarily lead to a significantly higher permeability of PEG.

Effect of oral administration of freshly pressed juice of Echinacea purpurea on the number of various subpopulations of B- and T-lymphocytes in healthy volunteers: results of a double-blind, placebo-controlled cross-over study

BACKGROUND

In a recent double-blind placebo-controlled crossover-study the "immune stimulatory" effects (activation of macrophages leading to enhanced phagocytosis and production of several cytokines) of Echinacea purpurea preparations (EPP) which were observed in vitro experiments and following parenteral administration could not be confirmed following oral application of the drug in healthy volunteers. The aim of the present study was to investigate whether or not oral EPP has any effect on important lymphocyte-subpopulations.

SUBJECTS AND METHODS

Forty healthy male volunteers (age range 20-40 years) participated in the study. They received either a commercially available pressed juice of E. purpurea herbs or placebo juice using a double-blind placebo-controlled cross-over design with two treatment periods of 14 days. The total number of lymphocytes and 12 subgroups of lymphocytes were determined by using Flow-cytometry.

RESULTS

After 1 week of treatment with verum the mean value of the total number of lymphocytes decreased slightly (-6%, p = 0.033) compared to the initial value. Treatment for 1 and 2 weeks with EPP had only minor effects on two of the 12 subtypes of lymphocytes. No significant changes were observed in the verum period for the following types of cells: T- and B-lymphocytes, CD4 + - and CD8 + -T-lymphocytes including the subgroups of "naive" and "memory" CD4 + - and CD8 + -T-lymphocytes as well as the natural killer cells. Using a modified version of the Wilcoxon-Mann-Whitney-U-test, which is claimed to be optimal for the evaluation of the results of studies with a cross-over design, a significant difference was found for the number of CD8 + -T-lymphocytes and natural killer cells corresponding to either a decrease during treatment with verum or an increase in the number of these cells in the placebo period.

CONCLUSION

Oral administration of EPP for 1 and 2 weeks has only minor effects on two out of 12 lymphocyte subpopulations determined in the study. The small differences observed in the number of CD8 + -T lymphocytes and natural killer cells are only of questionable physiological relevance.

Reversibility of increased formation of catecholamines in patients with alcoholic liver disease

BACKGROUND

While chronic alcohol abuse has been shown to be associated with increased production of catecholamines, little is known about the reversibility of this increased sympathetic activity and the influence of severity of alcoholic liver disease (ALD). The aim of the present study was to investigate whether the increase in urinary excretion rates and plasma levels of catecholamines in alcohol-abusing patients are reversible during prolonged abstinence, especially with respect to the severity of ALD.

METHODS

Urinary excretion rates and plasma levels of noradrenaline (NA), adrenaline (A) and dopamine (DA) were determined in 15 subjects with mild to moderate ALD (ALD1) and in 7 alcoholic cirrhotics (ALD2) on admission and after 2 and 12 weeks of abstinence. Eight healthy males, age-matched to ALD1, served as controls (HC).

RESULTS

Urinary excretion rates (24 h) and resting plasma concentrations of NA and A were increased in ALD1 and ALD2 about 2-fold, while those of DA were elevated only moderately compared to HC. During exercise under a load of 100 watts, the increases in plasma levels of NA and A with reference to the resting values were nearly identical in all three groups. Already after 2 weeks of abstinence, the urinary excretion rate of NA had nearly normalized in ALD1 but remained unchanged in ALD2.

CONCLUSION

The marked enhancement of catecholamine production, especially that of NA, observed in actively drinking alcoholics is reversible under abstinence within a few weeks in subjects with mild to moderate ALD but only partially reversible in alcoholic cirrhosis.

Nutritional deficiencies in German middle-class male alcohol consumers: relation to dietary intake and severity of liver disease

OBJECTIVE

The purpose of the present study was to compare the nutrient intake and the nutritional status between German middle-class alcohol consumers and non-drinkers.

DESIGN

Cross-sectional study using patients with different stages of alcoholic liver disease (ALD) and healthy volunteers.

SETTING

Southern Germany.

SUBJECTS

Seventy-six hospitalized German middle-class alcohol consumers with different stages of alcoholic liver disease (ALD) and 22 healthy control subjects.

METHODS

Subjects and controls were nutritionally assessed and mineral and vitamin content was measured in blood and urine.

RESULTS

When compared with controls, alcohol consumers had significantly higher intakes of total calories, but intake of non-alcoholic calories did not differ between groups (P<0.05). Among drinkers, there was a decrease in percentage of energy derived from protein and fat and a significant increase in carbohydrates (P<0.05). With the exception of vitamin E, micronutrient intake of alcoholics was equal to that of controls; however, blood vitamin (vitamin C, retinol, lycopene, alpha- and gamma-carotene) and trace element (selenium, zinc) concentrations of alcohol-drinking patients were lower than those of non-drinkers.

CONCLUSION

From the results of this study it is concluded that in German middle-class male alcohol consumers the status of several micronutrients is disturbed, although dietary intake hardly differs from that in non-alcoholic controls.

Interstitial pneumonitis during combination therapy with interferon-alpha and ribavirin in a patient with chronic Hepatitis C

After nine weeks of combination therapy with recombinant interferon-alpha and ribavirin for chronic hepatitis C a 62-year old woman complained of a dry cough and exertional dyspnea. An elevated erythrocyte sedimentation rate was noticed. Prior to treatment chest X-rays and physical examination revealed no pulmonary abnormalities. Inhalative steroids did not improve the symptoms and afer 12 weeks treatment chest X-ray and computed tomography showed bilateral reticonodular lung infiltration suggesting a diagnosis of interstitial pneumonitis. Cough and dyspnea resolved and abnormal lung shadows were reversible within two months following discontinuation of interferon-/ribavirin treatment. In the Japanese literature there are similar reports on pneumonitis occurring during high-dose IFN-alpha and concomitantly Chinese herbal medicine treatment. To our knowledge this is one of the first cases of interstitial pneumonitis due to combination therapy with IFN-alpha and ribavirin in chronic hepatitis C reported in the western world.

Models of alcoholic liver disease in rodents: a critical evaluation

This article represents the proceedings of a workshop at the 2000 ISBRA Meeting in Yokohama, Japan. The chairs were J. Christian Bode and Hiroshi Fukui. The presentations were (1) Essentials and the course of the pathological spectrum of alcoholic liver disease in humans, by P. de la M. Hall; (2) Lieber-DeCarli liquid diet for alcohol-induced liver injury in rats, by C. S. Lieber and L. M. DeCarli; (3) Tsukamoto-French model of alcoholic liver injury, by S. W. French; (4) Animal models to study endotoxin-ethanol interactions, by K. O. Lindros and H. Järveläinen; and (5) Jejunoileal bypass operation in rats-A model for alcohol-induced liver injury? by Christiane Bode, Alexandr Parlesak, and J. Christian Bode.

Models of alcoholic liver disease in rodents: a critical evaluation

This article represents the proceedings of a workshop at the 2000 ISBRA Meeting in Yokohama, Japan. The chairs were J. Christian Bode and Hiroshi Fukui. The presentations were (1) Essentials and the course of the pathological spectrum of alcoholic liver disease in humans, by P. de la M. Hall; (2) Lieber-DeCarli liquid diet for alcohol-induced liver injury in rats, by C. S. Lieber and L. M. DeCarli; (3) Tsukamoto-French model of alcoholic liver injury, by S. W. French; (4) Animal models to study endotoxin-ethanol interactions, by K. O. Lindros and H. Järveläinen; and (5) Jejunoileal bypass operation in rats-A model for alcohol-induced liver injury? by Christiane Bode, Alexandr Parlesak, and J. Christian Bode.

Inhibition of retinol oxidation by ethanol in the rat liver and colon

BACKGROUND

Epidemiological evidence has been presented for an increased risk of development of colon cancer after chronic alcohol abuse. Alcohol is degraded by cytosolic alcohol dehydrogenases that also are capable of retinol oxidation. Inhibition of retinol oxidation to retinoic acid has been shown to occur in parallel with profound impairment of intracellular retinoid signal transduction and loss of cell differentiation control.

AIMS

In the present study, the change in cytosolic retinol oxidation and retinoic acid formation by ethanol concentrations that occur in body tissues in humans after social drinking was measured in cells from the liver, and small and large intestine of the rat.

RESULTS

The specific catalytic efficiency V(max)/K(m) (ml/min/g) of cytosolic retinol oxidation in the large intestine (28.9) was found to be distinctly higher than that in the liver (3.4), while the efficiency in the small intestine was negligible (0.20). In the presence of increasing ethanol concentrations (9, 17, and 34 mM), V(max)/K(m) for retinol oxidation decreased in a dose dependent manner to 7.8% of the initial value in the large intestine and to 12% in the liver. The V(max)/K(m) of retinoic acid formation in the liver cytosol decreased to 15%.

CONCLUSIONS

Our data demonstrate impairment of hepatic and intestinal cytosolic retinol oxidation and retinoic acid formation by ethanol at concentrations in body tissues after social drinking in humans. The results suggest that the increased risk of developing colorectal neoplasias after alcohol abuse may, at least in part, be caused by impaired retinoid signal transduction.

Thrombolytic therapy in patients with portal vein thrombosis: case report and review of the literature

A 29-year-old male patient with Crohn's disease of the terminal ileum and previous abdominal surgery was admitted because of severe abdominal pain and signs of bacterial sepsis. The diagnosis of portal vein thrombosis and multiple liver abscesses due to Streptococcus intermedius septicaemia was made and antibiotic therapy was instituted immediately. As high-dose heparin therapy was ineffective, urokinase was administered intravenously over a total of 7 days. Within 2 days, the patient's symptoms completely subsided. Colour duplex ultrasonography revealed complete recanalization of the main stem of the portal vein; the right branch of the portal vein, however, remained occluded. Other case reports on thrombolytic therapy in patients with portal vein thrombosis are reviewed.

Increased intestinal permeability to macromolecules and endotoxemia in patients with chronic alcohol abuse in different stages of alcohol-induced liver disease

BACKGROUND/AIMS

No information is yet available about the influence of alcohol abuse on the translocation of larger molecules (Mr>1200) through the intestinal mucosa in man. The present study aimed to determine the intestinal permeability to macromolecules in patients with chronic alcohol abuse and mild to more advanced stages of liver disease, and to measure the concentration of endotoxins in the plasma, as these compounds derive from the intestinal flora and are suspected to contribute to the development of alcoholic liver disease (ALD).

METHODS

The permeability to polyethylene glycol Mr 400, Mr 1500, Mr 4000, and Mr 10,000 and endotoxin plasma concentrations were measured in 54 patients with alcoholic liver disease, 19 of them with cirrhosis, and in 30 non-alcoholic healthy controls.

RESULTS

Permeability to polyethylene glycol Mr 400 was found to be unchanged in patients with ALD in comparison to healthy controls, whereas polyethylene glycol Mr 1500 and Mr 4000 were recovered in about twice as high concentrations in the urine of ALD patients (p<0.01). Polyethylene glycol Mr 10,000 was detected significantly less frequently in urine from healthy controls (0/30) than in urine of patients with alcoholic liver disease (20/54, p<0.01). Endotoxin concentrations in the plasma of alcoholics were increased more than 5-fold compared to healthy controls (p<0.01).

CONCLUSIONS

The results of this study indicate that alcohol abuse impairs the function of the intestinal barrier, which might enhance the translocation of bacterial toxins, thereby contributing to inflammatory processes in alcoholic liver disease.

Influence of the menstrual cycle on the LPS-induced cytokine response of monocytes

We previously observed a gender difference in the cytokine response of peripheral blood monocytes (PBM). The study was performed to find out whether the gender-related difference might be due to hormonal changes during the menstrual cycle in healthy premenopausal females. The release of tumour necrosis factor a (TNF-alpha) was reduced in the premenopausal females during the luteal phase compared to the follicular phase. Compared to the male controls the release of TNF-alpha and of interleukin 6 (IL-6) during the luteal phase was also diminished. In premenopausal females the concentration of estradiol in plasma correlated with the release of TNF-alpha and IL-6 during the luteal phase.

[Alcohol, the gastrointestinal tract and pancreas]

The intake of larger quantities of alcoholic beverages leads to manifold functional disturbances and organ injury in the upper gastrointestinal tract. These damaging effects of alcohol are frequently the cause of complaints, such as heart burn, symptoms of dyspepsia and diarrhoea. Examples of more pronounced organ injury which can occur even following a single episode of heavy drinking are tears in the mucosa at the junction of the esophagus and the stomach (Mallory-Weiss-lesion) and hemorrhagic erosions in the stomach and/or the duodenum which may lead to massive bleeding. In the small intestine alcohol abuse interferes with the absorption of glucose, amino acids, lipids, water, sodium and vitamins (especially thiamine and folic acid). This inhibition of absorption of nutrients may contribute to nutritional deficiencies frequently observed in alcoholics. Acute alcohol ingestion can also damage the mucosa in the upper region of the small intestine and may lead to the disruption of the tips of the villi. Chronic alcohol abuse increases markedly the prevalence of bacterial overgrowth in the small intestine. The findings of human and animal studies suggest that the mucosal injury together with bacterial overgrowth favour the following sequence of events: Alcohol induced mucosal injury in the small intestine increases the permeability of the mucosa to macromolecules, such as endotoxin and/or other bacterial toxins, into the blood or lymph. This results in the release of potentially toxic cytokines and other mediators like Kupfer cells and other phagocytes. These cytokines and other mediators, in turn, exert multiple injurious effects on the microcirculation and membranes. The result is cell damage and even cell death (apoptosis, necrosis) in the liver and other organs. Chronic alcohol abuse is one of the most important risk factors for the development of cancers of the tongue, larynx, pharynx and esophagus. In many countries alcohol abuse is the most important cause for the development of chronic pancreatitis. In the initial phase the disease is frequently characterised by episodes of 'acute' pancreatitis. These episodes develop only on the basis of prolonged alcohol abuse leading to subclinical damage of the gland. The latter is found in about 20-50% of patients with chronic alcohol abuse while the clinically overt pancreatitis is observed in only 1%-3% of alcoholics. Despite numerous studies performed in animal experiments and man the pathogenesis of alcoholic pancreatitis until now has not been clarified.

[Does combination therapy of chronic viral hepatitis C with interferon-alpha and ribavirin approach financial limits?]

Until April 1999, interferon alpha was the only licensed medication in Germany for chronic hepatitis C virus infection with proven effectiveness. In two large placebo-controlled studies the combination therapy with interferon alpha and ribavirin confirmed a major improvement of the sustained response compared to the treatment with interferon alone. These results led to the approval in Germany of the combination therapy for patients with chronic hepatitis C without prior interferon therapy and for patients who relapse after an initial response to therapy with interferon alone. The expenses for the two drugs of the combination therapy are, however, very high (about 40,000 DM for one year of treatment). Considering the large number of patients with chronic hepatitis C in Germany (about half a million), it is suggested that more detailed recommendations for the indication of the combination therapy should be elaborated by a group of experts. Using data from the published literature it is shown for two subgroups of patients with chronic hepatitis C that a more differentiated indication for the use of the combination therapy is possible and justified and might help to avoid a more dramatic increase of drug expenses without shortcomings for the patients.

Effects of chronic alcohol abuse on duodenal mononuclear cells in man

The aim of this study was to investigate whether chronic alcohol abuse alters the number and distribution of mononuclear cells of the duodenal mucosa. The number of common leukocyte antigen (CLA)-positive interepithelial lymphocytes (IEL), B lymphocytes (BL), IgA-producing plasma cells (IgA-PC), and macrophages (MP) was quantitatively evaluated in biopsies of the duodenal mucosa of patients with alcohol abuse compared to subjects without alcohol abuse. Biopsies from the descending part of the duodenum were obtained by endoscopy from two groups of patients with chronic alcohol abuse (group A1, abstinence <5 days, N = 21) and group A2 abstaining 5-10 days (N = 6). Twenty-five subjects without alcohol abuse served as controls (C). Immunohistochemical staining was done by avidin-biotin-complex method. In addition, the content of IgA in the plasma cells was determined by using a TV-densitometric method. The number of B-lymphocytes in the lamina propria was increased by 37% in group A1 (P < 0.005). A distinct decrease was observed in group A1 compared to C in the number of IEL that were CLA positive (-50%, P < 0.025) and in the number of macrophages (-54%, P < 0.025). In group A2 the differences in the number of B lymphocytes and macrophages were no longer seen. In A1, there was no significant change in the number of IgA-producing plasma cells or in the number of interepithelial lymphocytes counted after H&E staining compared to the controls. There was no difference in content of IgA in the IgA-producing plasma cells. From these results it is concluded that chronic alcohol abuse significantly influences the gut-associated immune system, possibly by increasing the permeability of the gut mucosa to macromolecules that act as antigens.

Effect of the type of beverage and meat consumed by alcoholics with alcoholic liver disease

We analyzed meat products and alcoholic beverage preference in patients with the three stages of alcoholic liver disease (ALD) compared with controls using diet history data. Daily consumption of total alcohol, types of alcoholic beverages, and types of meat and meat products in grams was obtained by dietary history taken from patients with biopsy proven stage of ALD. A strong association was found between the ALD subjects and total alcohol and beer consumption. There was a significant increase in the consumption of total pig products, pork, and offal in the ALD groups compared with controls. There was a significant positive correlation between beer consumption and pork in alcoholic hepatitis, total pork products in alcoholic hepatitis, and cirrhosis and offal in alcoholic hepatitis and cirrhosis. There was no correlation with the fatty liver stage of ALD. The strongest correlation was between beer and total pig products in the alcoholic hepatitis group. Wine consumption was negatively correlated with the consumption of pig products and beer in the alcoholic cirrhosis group. In conclusion, the association of total pig product consumption with cirrhosis mortality in various countries was validated by personal diet history data obtained from ALD patients in a tested clinical microcosm. The results suggest that this association may be modified by the type of alcoholic beverage that is preferentially consumed.

[Spontaneous bacterial peritonitis]

BACKGROUND

Since the beginning of the eighties systematic investigations broadened our knowledge about the clinical picture of spontaneous bacterial peritonitis very much. Important insights into epidemiology, pathogenesis, symptomatology, diagnosis and therapy of this disease, which is a frequent complication in patients with cirrhosis of the liver and ascites, could be gained. Actual research work primarily deals with questions of therapy and prophylaxis.

AIM

Aim of this review is a comprehensive presentation of the different aspects of this disease on the basis of the present literature.

CONCLUSIONS

As on the one side the clinical symptoms may be very little and on the other side the prognosis is very bad, it is extremely important to take this entity into the differential considerations to make an early diagnosis and to start an adequate therapy early.

Validation and comparison of two computerized methods of obtaining a diet history

The aim of this study was to validate two computerized methods of obtaining a diet history (DH and EBIS). The food consumption of 12 men and eight women was calculated by weighing each food item over a period of 8 days. Thereafter the diet history was taken over this period by using both programs alternatively. The intake of energy, protein, fat and carbohydrates, and 10 further nutrients was evaluated and the percentage difference calculated. In general, the intake of nutrients calculated from the diet history tended to be underestimated by most of the people interviewed. The mean daily intake of the nutrients calculated from the DH program deviates from -34% to +20% (mean SD = 48.1) and -35% to +15% for EBIS (mean SD = 28.1). In conclusion, both computerized methods proved useful for epidemiological studies, but not for the determination of deficiencies in individuals.

Free methionine supplementation limits alcohol-induced liver damage in rats

Alcohol feeding to rats that were submitted to a jejunoileal bypass operation has been shown to result in liver damage being comparable with alcohol-induced liver disease in man. In the present study, a striking effect of free methionine consumption on histological liver injury, triglyceride accumulation, and energy-rich nucleoside content in the liver of rats with a jejunoileal bypass is demonstrated. The animals obtained 0, 30, and 120 mg of methionine in the control group and 0, 30, 120, and 240 mg in the alcohol-fed group per day and per kilogram of body weight for 12 weeks. Methionine was found to strongly improve the alcohol-induced histological changes in the liver. Triglyceride content of the liver was found to decrease in a dose-dependent manner with increasing methionine ingestion (from 255 +/- 20.7 to 49.7 +/- 6.1 micromol/g of protein in the control group and from 233 +/- 17.3 to 42.1 +/- 7.2 micromol/g of protein in the alcohol group). Hepatic adenosine triphosphate content increased significantly with higher methionine consumption (13.5 +/- 0.8 vs. 26.9 +/- 2.8 micromol/g of protein in the control group and 11.9 +/- 1.4 vs. 20.5 +/- 2.5 micromol/g of protein in the alcohol group), whereas no differences were found in the protein and DNA content of the liver. These results underscore the impairment of the transmethylation/transsulfuration pathway in the development of alcohol-induced liver diseases.

CYP2E1 activity in patients with alcoholic liver disease

BACKGROUND/AIMS

In addition to the possible toxicological impact of cytochrome P4502E1 (CYP2E1) in alcohol-induced liver damage, its activity can be regarded as a variable for drug action in patients with alcoholic liver disease as CYP2E1 is involved in the metabolism of several drugs, for example, paracetamol and halogenated anesthetics. The purpose of our study was to acquire detailed knowledge of CYP2E1 activity in patients with progressingly severe manifestations of alcoholic liver disease.

METHODS

The concentration ratio of 6-hydroxy-chlorzoxazone/chlorzoxazone in plasma 2 h after ingestion of 500 mg chlorzoxazone (so-called metabolic ratio) has been shown to reflect CYP2E1 activity in vivo. We examined CYP2E1 activity in 56 Caucasian inpatients with minor (n=20), more pronounced (n=14) and severe alcoholic liver disease (n=22). Alcohol abusers were compared to healthy teetotallers (n=14).

RESULTS

Metabolic ratios were increased 3-fold in actively drinking (ethanol-induced) compared to abstaining (non-induced) patients with alcoholic liver disease (1.19+/-0.84 vs. 0.44+/-0.45, mean+/-SD, (p<0.0001). CYP2E1 activity was significantly lower in non-induced patients with severe alcoholic liver disease (0.19+/-0.10) than in healthy controls (0.50+/-0.28, p<0.01), abstaining alcohol abusers with minor (0.67+/-0.60, p<0.01) and more pronounced alcoholic liver disease (0.53+/-0.31, p<0.01). When non-induced patients with alcoholic liver disease were arranged in progressing order of liver damage (minor, more pronounced, severe alcoholic liver disease), there was a significant decline in CYP2E1 activity (p=0.0008).

CONCLUSIONS

In non-induced patients, CYP2E1 activity decreases in line with severity of alcoholic liver disease. CYP2E1-mediated drug metabolism is significantly impaired in severe alcoholic liver disease.

Effect of treatment with paromomycin on endotoxemia in patients with alcoholic liver disease--a double-blind, placebo-controlled trial

The results of experimental and clinical studies support the hypothesis that gut-derived endotoxins might be of relevance for the development and course of alcoholic liver disease. The aim of this study was to test the effect of a nonabsorbable, broad-spectrum antibiotic on endotoxemia in patients with alcoholic liver disease. Fifty patients with alcoholic liver disease (27 with cirrhosis, 23 without cirrhosis) were randomly assigned to receive either paromomycin sulfate (3 x 1 g/day) or placebo in a double-blind fashion for at least 3 weeks, and if possible 4 weeks. Endotoxin concentration, liver function tests, and other laboratory parameters were determined in weekly intervals. Endotoxin concentration was also determined in 15 healthy controls. Groups receiving paromomycin or placebo were similar for clinical and biological items collected initially. Mean initial endotoxin concentrations were significantly elevated in both groups (mean +/- SEM; paromomycin, 16.7 +/- 5.3 pg/ml; placebo, 17.5 +/- 6.9 pg/ml; healthy controls, 2.3 +/- 0.4 pg/ml). Although the mean endotoxin concentration was lower in the verum group after 1 week (paromomycin, 8.0 +/- 1.9 pg/ml; placebo, 14.6 +/- 3.5 pg/ml; p > 0.05), paromomycin treatment had no significant effect on endotoxin concentration or liver function tests during the 4-week period. The beneficial effect of paromomycin treatment on endotoxemia in cirrhotics reported in earlier studies could not be reproduced under the conditions of this trial in patients with alcoholic liver disease.

[Risk of hepatitis C virus infection in medical occupations]

Following the introduction of sensitive and specific tests for the detection of hepatitis C virus (HCV) infection studies could be performed to determine the risk to acquire a HCV infection in medical professions. The aim of this report is to summarize the knowledge in this field, especially regarding the risk of transmission of HC virus by injuries with infected material, such as needles. The risk to acquire a HCV infection following needlestick injuries was found to be markedly lower than the risk for transmission of hepatitis B virus infection. In 7 studies from different countries this risk has been found to be between zero to a maximum of 10% (average 2%). When the frequency of HCV infection was studied in occupational groups in hospital (nurses, technical assistants, doctors), it did not differ significantly compared to the prevalence in general population. These and other findings concerning the risk of transmission of HCV infections (between spouses, mother/newborns) clearly show that the risk of transmission of HCV infection is markedly lower than that of HBV infection. These facts should be considered in judging of applications for the recognition of HCV infection as occupational disease.

A diet rich in fat and poor in dietary fiber increases the in vitro formation of reactive oxygen species in human feces

Production of reactive oxygen species in the lumen of the colon, a process that is influenced by nutritional factors, may be important in the etiology of colorectal cancer. Because research on humans in support of this hypothesis is lacking, the objective of this study was to measure the effect of different dietary compositions on the in vitro oxygen radical production in human feces. Over a period of 12 d, seven healthy subjects received a diet rich in fat (50%) and meat and poor in dietary fiber. After a period of 1 wk, they received a vegetarian diet poor in fat (20%) and rich in dietary fiber. At the end of each study period, feces were collected and analyzed for in vitro oxygen radical production with dimethylsulfoxide as the free radical scavenger. The mean hydroxyl radical production was 13 times greater in feces of subjects when they consumed the diet rich in fat and poor in dietary fiber [52.7 +/- 29.5 micromol/(g feces x h)] than when they consumed the diet poor in fat and rich in dietary fiber [3.9 +/- 3.9 micromol/(g feces x h); P < 0.05]. This difference was associated with a 42% higher fecal iron concentration when they consumed the first diet (7.0 +/- 19.2 micromol/g feces) than when they consumed the second (4.9 +/- 1.9 micromol/g feces; P < 0.05). The results of this study confirm that diets high in fat and meat and low in fiber markedly increase the potential for hydroxyl radical formation in the feces, which in turn may contribute to an enhanced risk of colorectal cancer.

[Therapy of hepatitis C]

The purpose of this review is an update of the therapy of hepatitis C especially with Interferon-alpha. From the large number of publications on this topic the established facts were worked out. Taking these facts as a base guidelines for the therapy in practical use were defined. In addition the aspects of therapeutic strategies of chronic hepatitis C which until now can not definitely be judged are discussed. In the relatively few patients in whom hepatitis C is diagnosed already in the acute phase, Interferon-alpha-treatment (3 x 3 million units 3 times a week) for 3 to 4 months increases the percentage of patients in whom HCV-RNA in the serum is eliminated. In patients with chronic hepatitis C, after decision finding for treatment, a standard scheme is recommended which consists of a monotherapy with recombinant Interferon-alpha. The dosage of Interferon-alpha is in the first 12 to 16 weeks 5 up to 6 million units given 3 times a week. For the further therapy 3 million units 3 times a week seems to be appropriate. The recommended duration of Interferon-alpha-therapy is 12 months. A long-term benefit of about 20% can be achieved in unselected groups of patients when judged on the permanent normalisation of serum transaminases and elimination of HCV-RNA in the serum. Important factors which may influence the probability of a sustained response, like HCV genotype, virus titer in serum, duration of the disease, high hepatic iron content and the presence of cirrhosis, are discussed. Up to now there exist no reliable guidelines in the case of a "no change" situation and for patients with a flare-up of inflammatory activity during or after therapy. Combination therapy of Interferon-alpha with other drugs like analogous of nucleotides (for example ribavarin), non steroidal antirheumatic drugs and ursodesoxycholic acid (UDCA) have still to be evaluated in controlled clinical trials.

Decreased endotoxin-binding capacity of whole blood in patients with alcoholic liver disease

BACKGROUND/AIMS

The proinflammatory effects of endotoxemia, which is often observed in alcohol-abusing patients with various degrees of liver disease, may be modulated by changes in the concentration of endotoxin binding factors. Therefore, the plasma endotoxin concentration and the overall endotoxin binding capacity of whole blood were measured in these patients.

METHODS

Patients with minor (A1; n=27), more pronounced (A2; n=13), cirrhotic alcoholic liver disease (A3; n=18), and non-alcoholic cirrhosis (NC; n=6), and 15 healthy control persons (HC) were included in the study. Endotoxin plasma levels were determined using a standardized limulus assay. A modified assay was applied to additionally detect tightly bound endotoxin. To measure the endotoxin-binding capacity, aliquots of whole blood were incubated with serial dilutions of endotoxin, supernatants were obtained, and endotoxin retrieval was estimated by addition of limulus lysate, followed by photometric measurement of the maximal reaction velocity (dODmax). Endotoxin binding capacity equals the endotoxin concentration at which dODmax reaches a predefined threshold.

RESULTS

All groups of alcohol abusers had significantly elevated endotoxin plasma levels with a considerable portion of 'bound' endotoxin. Conversely, the endotoxin binding capacity was markedly diminished, mainly in patients with more advanced liver disease (A1: 85.8% of the control value [non-significant vs. controls]; A2: 25.4% [p<0.05]; A3: 43.6% [p<0.02], NC: 43.2%).

CONCLUSIONS

The endotoxin-binding capacity is diminished in patients with alcoholic and non-alcoholic cirrhosis, as well as in less advanced alcoholic liver disease. Reduced endotoxin binding may contribute to the adverse effects of endotoxemia.

Alcohol's role in gastrointestinal tract disorders

When alcohol is consumed, the alcoholic beverages first pass through the various segments of the gastrointestinal (GI) tract. Accordingly, alcohol may interfere with the structure as well as the function of GI-tract segments. For example, alcohol can impair the function of the muscles separating the esophagus from the stomach, thereby favoring the occurrence of heartburn. Alcohol-induced damage to the mucosal lining of the esophagus also increases the risk of esophageal cancer. In the stomach, alcohol interferes with gastric acid secretion and with the activity of the muscles surrounding the stomach. Similarly, alcohol may impair the muscle movement in the small and large intestines, contributing to the diarrhea frequently observed in alcoholics. Moreover, alcohol inhibits the absorption of nutrients in the small intestine and increases the transport of toxins across the intestinal walls, effects that may contribute to the development of alcohol-related damage to the liver and other organs.

Terlipressin (glypressin) versus somatostatin in the treatment of bleeding esophageal varices--final report of a placebo-controlled, double-blind study

One hundred and six episodes of bleeding from esophageal or gastric varices in 72 patients with cirrhosis of the liver were randomized to treatment either with intravenous terlipressin 2 mg initially and 1 mg every four hours for 24 hours together with bolus injection and continuous infusion of placebo, or with somatostatin 250 micrograms as a bolus and continuous infusion of 250 micrograms/h somatostatin for 24 hours and placebo injections. Standard treatment with transfusions, fluid and electrolyte correction, and lactulose was administered in both groups. In the terlipressin group, 48 out of 53 bleeding episodes (91%) and in the somatostatin group 43 out of 53 bleeds (81%) were initially stopped by the vasoactive drugs. Four of the five bleeds not arrested by terlipressin, and nine of the ten bleeds not arrested by somatostatin, were stopped by balloon tamponade. In one patient in each group variceal bleeding could not be stopped initially, and both patients died. The failure rate of the vasoactive treatment alone, including rebleeds within the study period, was 17% in the terlipressin, and 28% in the somatostatin, group. The initial hemostasis, including balloon tamponade, were 98%, and the definitive bleeding control rates were 89% in both groups. The hospital mortality rate was 21% (11/53) in the terlipressin, and 21% (11/53) in the somatostatin, group. Blood transfusions and duration of bleeding did not differ significantly. The study indicates that a large proportion of bleeds from esophageal and fundic varices can be stopped initially (86%) and definitively controlled (77%) by vasoactive drugs alone.

Effect of methionine on the fatty acid composition of cellular membranes in rats with chronic ethanol consumption and jejunoileal bypass

The objective of this study was to investigate the effect of alcohol administration on jejunoileal bypass (JIB)-induced liver dysfunction in rats resulting in abnormalities of fatty acid composition of cell membranes, and whether methionine is able to reverse these changes. Male Wistar rats were subjected to a jejunoileal bypass operation. For 12 weeks, all groups were pair-fed either an alcohol-containing (36% of total calories) liquid diet or a liquid diet in which alcohol was replaced isocalorically by starch. Methionine supplementation in three control groups was 0, 32, 160 and 224 mg/kg body weight/day and the rats in the four alcohol feeding groups received 0, 32, 160 and 224 mg/kg body weight/day. In the alcohol group without any methionine supplementation, higher proportions of oleic and linoleic acid and lower proportions of docosahexaenoic and arachidonic acid became evident in tissue samples of liver and jejunum, in comparison with the other alcohol group. A possible explanation for this reduction in tissue polyunsaturated fatty acid (PUFA) may be a decrease in the activities of delta 6-and delta 5-desaturases, and subsequently a displacement of PUFA from lipid fractions by other fatty acids. Interestingly, in the alcohol group with the highest methionine supplementation, compared to all other alcohol groups, lower proportions of oleic acid and higher proportions of docosahexaenoic acid, appeared. A possible explanation for this increase of PUFA in tissue may be increased activities of delta 6- and delta 5-desaturases.

Prostaglandin E2 and prostaglandin F2 alpha biosynthesis in human gastric mucosa: effect of chronic alcohol misuse

BACKGROUND AND AIMS

The results of experimental studies support the hypothesis that decreased prostaglandin production might play a part in the gastric mucosal injury induced by alcohol. In this study, it was investigated whether alcohol misuse impairs the synthesis of prostaglandin E2 (PGE2) and prostaglandin F2 alpha (PGF2 alpha) in gastric mucosa.

PATIENTS

Fifty six alcoholic patients and 66 subjects without alcohol misuse were included in the study.

METHODS

Mucosal biopsy specimens were obtained from the antrum and body of the stomach. Maximal synthesis rates of PGE2 and PGF2 alpha were determined in the microsomal fraction of the biopsy specimens.

RESULTS

The rates of synthesis of both prostaglandins in biopsy specimens from the antrum were not significantly different from those obtained in the body. Synthesis of both prostaglandins was significantly reduced in alcoholic patients who abstained less than five days compared with the non-alcoholic group with normal mucosa (PGE2-40%, PGF2 alpha-42% respectively). In non-alcoholic patients with severe gastritis PGE2 synthesis was increased (+30%, p < 0.05) and PGF2 alpha synthesis was decreased (-42.5%, p < 0.025). In alcoholic patients with severe gastritis PGE2 synthesis was depressed by almost 60% (p < 0.001) compared with the non-alcoholic group with severe gastritis. Neither colonisation of Helicobacter pylori nor smoking had a significant influence on the prostaglandin synthesis.

CONCLUSIONS

Chronic alcohol misuse is associated with significantly reduced capacity for prostaglandin synthesis in gastric mucosa and this alcohol induced decrease in prostaglandin synthesis is modulated by the presence and degree of gastritis.

Tumor-necrosis-factor and interleukin-6 response of peripheral blood monocytes to low concentrations of lipopolysaccharide in patients with alcoholic liver disease

Plasma levels of endotoxin and tumor necrosis factor alpha (TNF alpha) and the cytokine response of isolated monocytes were examined in chronic alcohol abusers with various degrees of liver disease. In 35 patients - 19 with alcoholic fatty liver (AF), 7 with alcoholic hepatitis (AH), 9 with cirrhosis (AC) - and in 15 healthy controls (HC), plasma levels of endotoxin were measured in the limulus assay, and plasma TNF alpha in an immunoassay. The cytokine response of monocytes stimulated in vitro with low doses of endotoxin (range: 25 pg/ml to 2.5 ng/ml) was determined in a cytolytic TNF bioassay and in TNF alpha and interleukin-6 (IL-6) immunoassays. All patient groups had elevated plasma endotoxin levels, whereas plasma TNF alpha was elevated only in AC (43.1 +/- 15.2 vs. HC: 5.0 +/- 1.1 pg/ml). Monocytes from all patient groups released increased amounts of bioactive TNF: AF 5.39 +/- 1.70, AH 7.10 +/- 3.28, AC 2.44 +/- 0.54 vs. HC 1.21 +/- 0.30 ng/ml (stimulation with 2.5 ng/ml endotoxin over 3 hrs.). Similar results were obtained in the TNF alpha immunoassay. Increased release of IL-6 from monocytes was shown only for AF, while values in AC were comparable to those in HC. These data confirm that endotoxemia is frequent in chronic alcoholics. In concert with an increased cytokine response of the monocyte/macrophage system, endotoxemia might contribute to the pathogenesis of alcoholic liver disease.

Detection of hepatitis C virus antibodies and hepatitis C virus RNA in patients with alcoholic liver disease

The prevalence of hepatitis C virus (HCV) antibody was determined in 130 patients with alcoholic liver disease using a second-generation anti-HCV enzyme immunoassay (ELISA 2) and confirmed by a sensitive polymerase chain reaction procedure measuring HCV RNA. Hepatic disease was evaluated by clinical and biochemical studies and, whenever possible, by liver biopsy. Seventy-one patients were diagnosed as having cirrhosis, and 59 alcoholic hepatitis (n = 33) or fatty liver (n = 26). The prevalence of anti-HCV in the total group was 9.2% and did not differ significantly in the cirrhotics (11.3%) as compared with the non-cirrhotics (6.8%). HCV RNA was detected in six out of eight cirrhotics and three out of four non-cirrhotics who were ELISA 2 positive. A positive test for antibodies to hepatitis core antigen (anti-HBc) was more frequent in anti-HCV-positive patients (75%) than in the anti-HCV-negative group (14%, P < 0.001). Anti-HBc was also found more frequently in the cirrhotics (25.4%) than in the alcoholics without cirrhosis (11.9%). However, the prevalence of hepatitis B surface antigen was equally low in both groups (cirrhotics 1.4%, non-cirrhotics 1.7%). No correlation was observed between the prevalence of anti-HCV antibodies and the severity of liver dysfunction. These results indicate that HCV, and especially HCV-viraemia, is less frequent in alcoholics in southern Germany than suspected in previous studies, and that the prevalence of HCV markers in alcoholics has been overestimated by ELISA 1 used alone.

Parallel determination of gut permeability in man with M(r) 400, M(r) 1500, M(r) 4000 and M(r) 10,000 polyethylene glycol

Polyethylene glycol has been in use for a number of years for the assessment of gut permeability. The methods so far employed are usually limited to polyethylene glycols in the low relative molecular mass range (up to M(r) 1300). We developed a method for the simultaneous determination of gut permeability to M(r) 400, M(r) 1500, M(r) 4000 and M(r) 10,000 polyethylene glycol, by applying a single oral dose of an appropriate mixture of these polyethylene glycols. After extraction from 24 h-urine, M(r) 1500, M(r) 4000 and M(r) 10,000 polyethylene glycol were quantified by size exclusion chromatography, while M(r) 400 polyethylene glycol was determined by reversed phase chromatography. The detection limit of polyethylene glycol in the relative molecular mass range between M(r) 1500 and M(r) 10,000 was found to be 0.2 mg/l urine, and the detection limit of M(r) 400 polyethylene glycol 5 mg/l urine. Recovery of the polyethylene glycols (N = 6) were 86.6% (CV: 4.8%) for M(r) 400, 94.1% (CV: 7.2%) for M(r) 1500, 97.1% (CV: 5.5%) for M(r) 4000 and 97.4% (CV: 5.6%) for M(r) 10,000. No significant difference was found between the excretion rates in 24 h-urine of M(r) 400 and M(r) 1500 polyethylene glycols in patients with Crohn's disease (M(r) 400: 34.4 +/- 5.5%; M(r) 1500: 5.22 +/- 2.27%; mean +/- SEM, N = 10) and healthy controls (M(r) 400: 33.6 +/- 3.2%, M(r) 1500: 1.09 +/- 0.26%; N = 21). The excretion rate of M(r) 4000 polyethylene glycol was markedly higher in patients with Crohn's disease (0.462 +/- 0.177%) than in healthy controls (0.049 +/- 0.012%, p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[Alcohol abuse as a cause of illness in an internal medicine department with emphasis on gastroenterology and hepatology]

The percentage and spectrum of alcohol-induced diseases were determined in 200 male and female patients. In 28 percent of the men and 8 percent of the women, inpatient treatment had been necessitated in the first instance by alcohol-induced diseases. In both men and women abusing alcohol, the percentage of younger patients was appreciably higher than in patients who did not abuse alcohol. Among male drinkers, the most common pathologies diagnosed were diseases of the liver (78.6%), the upper gastrointestinal tract, the pancreas (51.7%) and the central nervous system (42%), as well as cardiovascular diseases (23.2%). The majority of male patients abusing alcohol had two or more organic diseases (80%). In 35.4%, three or more different diseases were diagnosed. Among female patients abusing alcohol, the pattern of the various diseases was largely identical with that seen among the male patients. The duration of hospitalisation was appreciably longer in male drinkers (mean +/- SD = 14.1 +/- 10.1 days). Among male drinkers 51.8%, and among female drinkers 68.7%, were also heavy smokers. Of the 144 men in whom alcohol abuse was not certain, 30 were heavy smokers and, in the main, were being treated for cardiac and/or bronchopulmonary diseases. It is highly probable that, owing to the nature of the evaluation employed, the percentages of patients abusing alcohol or nicotine were underestimated. The fact that a high 43% of mainly younger male patients presented with diseases that could be traced back mainly or solely to alcohol or tobacco consumption, together with the multimorbidity and chronicity of the diseases of these patients underscores the urgent need to attach more importance to promoting preventive measures.

Endotoxaemia in patients with liver cirrhosis and upper gastrointestinal bleeding: detection by the chromogenic assay with plasma Tween 80 pretreatment

A recently developed chromogenic endotoxin assay with plasma Tween 80 pretreatment was compared with the conventional dilution and heating method. Plasma endotoxin was measured in patients with liver cirrhosis and upper gastrointestinal (GI) bleeding by these methods. Plasma endotoxin concentration was calculated from an individual internal standard curve by adding three different standard endotoxin solutions to each sample. By the conventional heating method, added standard endotoxin gave different OD values in each sample and the slope of the standard curve showed interindividual variations. When sample plasma from chronic alcoholics was pretreated with 1% Tween 80 and ultrasonification after heating, the slope of standard curves was somewhat increased and interindividual variation was minimized. Significantly higher plasma endotoxin levels in cirrhotics with upper GI bleeding compared with those without upper GI bleeding was detected by this Tween 80 method. There was a strongly positive correlation between the endotoxin levels determined by this method and those determined by the perchloric acid method and endotoxin-specific substrate in patients with upper GI bleeding. Endotoxin levels, which were elevated 1-2 days after the bleeding, tended to decrease as patients recovered. In summary, the recovery of endogenous and exogenous endotoxin from plasma sample was increased by adding Tween 80 before the chromogenic substrate assay. Transient elevation of plasma endotoxin was demonstrated by this Tween 80 method in patients with liver cirrhosis and upper GI bleeding.

Breath hydrogen excretion in patients with alcoholic liver disease--evidence of small intestinal bacterial overgrowth

The hydrogen breath test has been used to investigate the incidence of small-bowel bacterial overgrowth in 45 chronic alcoholics and in 60 controls with no history of alcohol abuse. In the group of patients with alcoholic liver disease, the percentage of cases with bacterial overgrowth was almost three times (37.8%) that of controls not abusing alcohol (13.3%; p < 0.001). A separate evaluation of alcoholics with cirrhosis in comparison with those without cirrhosis, revealed no significant difference in the incidence of bacterial overgrowth (42.9% and 33.3%; p > 0.05). Some 16.7% of the controls and 8.9% of the patients with alcoholic liver disease were classified as "non-excreters". Among patients with alcoholic liver disease, the mouth-to-caecum transit time was prolonged by 21.5% in comparison with the controls not abusing alcohol (p < 0.025). The results suggest that bacterial overgrowth might contribute to the functional and/or morphological abnormalities of the small intestine commonly found in patients with chronic alcohol abuse.

Terlipressin vs. somatostatin in bleeding esophageal varices: a controlled, double-blind study

Fifty episodes of bleeding from esophageal or gastric varices in 33 patients with cirrhosis were randomized to treatment with either intravenous terlipressin (2 mg initially and 1 mg every 4 hr for 24 hr together with bolus injection and continuous infusion of placebo) or with somatostatin (250 micrograms as a bolus and continuous infusion of 250 micrograms/hr somatostatin for 24 hr and placebo injections). Standard therapy with transfusions, fluid and electrolyte correction and lactulose was administered in both groups. In the terlipressin group, 22 of 25 bleeding episodes (88%) were initially stopped by the vasoactive drugs, and in the somatostatin group 19 of 25 bleeding episodes (76%) were initially stopped by the vasoactive drugs. Two of the three bleeding episodes not arrested by terlipressin and five of the six bleeding episodes not arrested by somatostatin were controlled by balloon tamponade. In one patient in each group variceal bleeding initially could not be stopped, and the patients died. The failure rate of the vasoactive treatment alone, including rebleeding episodes within the study period, was 20% in the terlipressin group and 32% in the somatostatin group. The control rate, including balloon tamponade, was 96% in both groups. The hospital mortality rate was 16% (4 of 25) in the terlipressin group and 24% (6 of 25) in the somatostatin group. Blood transfusions, use of balloon tamponade and duration of bleeding did not differ significantly.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of alcohol-feeding on IgA-producing immunocytes in the small intestine of rats with and without jejunoileal bypass

Alcohol-feeding to rats subjected to jejunoileal bypass operation has been shown to lead to marked liver injury (fatty liver, necrosis and inflammation). This study investigated the influence of alcohol-feeding over a period of 3 months on the number of IgA-producing immunocytes and the villus surface area in various sections of the small intestine of rats subjected to a jejunoileal bypass or a sham operation. A jejunoileal bypass in animals receiving the control diet led to a decrease in the number of IgA-producing immunocytes in the duodenum and ileum, but not in the bypassed (blind) loop of the jejunum. In animals subjected to a jejunoileal bypass, alcohol-feeding led to an increase in the number of IgA-producing immunocytes in the duodenum and the bypassed jejunal loop as compared with animals with a jejunoileal bypass receiving the control diet. Among the animals with a jejunoileal bypass fed the control diet, the villus surface area within the duodenum and ileum increased as compared with the groups of sham-operated rats. The feeding of alcohol prevented this increase in the villus surface area in animals with a jejunoileal bypass. The increase in the number of IgA-producing immunocytes induced by alcohol in the animals with a jejunoileal bypass, in the duodenum and bypassed jejunum, supports the assumption of a change in antigen uptake in these parts of the small intestine, brought about by alcohol.

[The localization of colorectal polyps and carcinomas in relation to their size and the histological findings]

Location, size and histological appearance of colorectal neoplasms were examined retrospectively. A total of 1,357 polyps (including small ones, diameter below 0.5 cm) were found in 1,022 of 3,057 coloscopies. The coloscopies were indicated by findings on preceding radiological or endoscopic examinations (48%), occult blood in stool (18%), during follow-up after polypectomy (21%), and after colorectal carcinoma (13%). A single polyp was found in 718 cases (70%), two to four in 221 (26%), more than five in 33 (4%), 1,106 polyps (61%) were found on high coloscopy; 380 of these (38%) were located proximal to the left flexure. Among the 1,230 polyps examined histologically 907 (74%) were adenomas (494 tubular [54%], 379 tubulovillous [42%], 34 villous [4%]). 251 (28%) of the adenomatous polyps and 49 (32%) of the 151 carcinomas were located proximal to the left flexure. The incidence of moderately severe to severe dysplasias increased with increasing diameter of the polyps: 55% of those smaller than 0.5 cm were adenomas. 70% of polyps with a diameter over 1.0 cm were tubulovillous or villous adenomas. The findings confirm that there is a high incidence of polyps proximal to the left flexure. A complete coloscopy should therefore be done as a matter of course.

[Granular-cell tumor of the stomach and esophagus]

A 45-year-old man had for the past four years complained of postprandial feeling of fullness and of left-thoracic pressure sensation. Endoscopy revealed a spherical subcardial tumour, about 3.5 cm diameter, a yellow raised flat 7 x 4 mm tumour in the oesophagus about 44 cm from the upper teeth, and 29 cm from the upper teeth a 4 mm bulge. Forceps biopsy of the subcardial tumour and fine-needle biopsy of the rather larger oesophageal tumour indicated a granular cell tumour. Because of the risk of malignancy the gastric tumour was resected (local excision and fundal plication). The patient has remained without symptoms for 28 months. Follow-up endoscopies have demonstrated that the oesophageal tumours had not grown any further.

Plasma endotoxin concentrations in patients with alcoholic and non-alcoholic liver disease: reevaluation with an improved chromogenic assay

Plasma endotoxin concentration was measured in 85 patients with alcoholic liver disease (alcoholic cirrhosis (n = 64), alcoholic hepatitis without cirrhosis (n = 11), fatty liver (n = 10), and in patients with non-alcoholic cirrhosis (n = 15]. Endotoxin concentration was determined with an improved chromogenic substrate assay, using individual standard curves for each plasma sample. In patients with alcoholic cirrhosis the mean endotoxin concentration was significantly higher than in patients with non-alcoholic cirrhosis (p less than 0.05). In addition, distinctly higher endotoxin concentrations (greater than 20 pg/ml) were more frequently observed in patients with alcoholic cirrhosis than in non-alcoholic cirrhosis (34.4 vs. 14.3%, p less than 0.05). Mean endotoxin concentration was not significantly higher in cirrhotics with ascites or esophageal varices as compared with the subgroup without ascites or esophageal varices. The endotoxin concentration did not correlate with serum bilirubin, prothrombin concentration or serum enzyme activities. In patients with alcoholic liver disease, however, endotoxin concentration revealed a negative correlation (p less than 0.05) with the concentration of high density lipoprotein cholesterol. On admission endotoxin concentrations in alcoholics with fatty liver were similarly elevated as observed in alcoholic cirrhosis. In six out of 12 patients with fatty liver or alcoholic hepatitis, in whom a second sample of plasma was investigated after 6 to 8 days, endotoxemia was no longer detectable; in the remaining patients, the endotoxin concentration decreased markedly. The results indicate that, irrespective of the stage of liver disease, alcohol abuse favours the development of endotoxemia. They support the hypothesis that gut-derived endotoxins might play a role in the initiation and aggravation of alcohol-induced liver disease.