[Gastroenterology in the former GDR (1975-1990) and the changes after German reunification]

This short overview sketches the state of Gastroenterology in the GDR (1975 - 1990) from the point of view of an East-German contemporary witness. The "Society for Gastroenterology/GDR" (GfG) has played a decisive role for the development of the Gastroenterology in the GDR. The society promoted medical education and constitutions of gastroenterological centers, fostered gastroenterological research and controlled the standards for the recognition of Gastroenterology as a state-accepted medical sub-discipline. An extensive program of scientific and educative events included two-annual meetings of scientific congresses, the "Berka-Talks", endoscopic workshops" and featured special symposia such as for Hepatology, Pancreatology and gastro-intestinal Microbiology. Temporary working groups developed technical and professional legal advice. Although the GfG was a full member of the respective international organizations (OMGE, ASNEMGE, ESGE), it was almost impossible building up reliable international contacts in a mutual interest. Especially, contacts with colleagues representing the "German Society of Digestion and Metabolic Diseases" (DGVS) were impeded. With the political changes of 1989/1990, an association of the two German Societies for Gastroenterology seemed within reach. At a meeting in Halle (Saale) (March, 22nd, 1990), representatives of DGVS and GfG quickly agreed on modalities to merge the two societies. After the 45th meeting of the DGVS (October 3rd-6th, Essen) more than 600 GDR physicians could join the BRD society under accommodating conditions. The GfG had fulfilled its historical function as a "bridge" during the division of Germany with dignity and was suspended (November, 24nd,1990).

Effects of twelve months ethanol feeding on rat liver metabolic activity

Thirty male Wistar rats were fed with 15% ethanol (V/V) for one year. Thirty other male animals were the control group. To determine the possible metabolic disturbances caused by chronic ethanol feeding in blood we measured in blood metabolic parameters, and in a liver perfusion assay the hepatic insulin clearance and hepatic urea production in these animals. Between the ethanol-fed and the control animals there were significant differences in the following parameters: blood insulin concentration (47 vs. 2 microU/ml) and activities of amino acid transferases in liver homogenates at the end of the perfusion experiments (ASAT, 5950 vs. 70; ALAT, 3632 vs. 93 U/l). The other parameters were still normal in the ethanol-fed animals. Thus in these experiments after 12 months of 15% (V/V) ethanol feeding the rats still showed only a state of beginning metabolic disturbances in the liver. The results are discussed under consideration of the formation of acetaldehyde protein adducts in all rat organs investigated, namely, liver, kidney, heart and skeleton muscle, gut and spleen.

Occurrence of acetaldehyde protein adducts formed in various organs of chronically ethanol fed rats: an immunohistochemical study

We investigated the pathophysiological role of acetaldehyde protein adducts formed in vivo in organs of chronically alcohol fed male Wistar rats. Thirty male Wistar rats were fed on rodent pellets and 15% alcohol (V/V) for 5, 8 and 12 months, respectively before they were sacrificed. Further 30 male rats were chosen as the control group. We tested several organs by histological and immunohistochemical methods. Using immunohistological analysis, in the 12 months groups the basal membranes of glomerula, the membranes of liver, skeleton muscle and heart cells, and the gut were stained positively for acetaldehyde adducts. Using Western blotting of liver cell fractions (mitochondria/ lysosomes; microsomes; cytosol) adducts in charateristic molecular weight regions were detected. Approximately 30% of the sera of experimental rats contained antibodies against the acetaldehyde adducts formed in vivo. Immunologically detectable acetaldehyde adducts could be found in all rat organs tested. The stage of alcohol disease attained in this experiment after 12 months of ethanol feeding is described as the initial phase of manifestations of disturbances that are seen also in the carbohydrate metabolism.

Therapeutic efficacy of L-ornithine-L-aspartate infusions in patients with cirrhosis and hepatic encephalopathy: results of a placebo-controlled, double-blind study

One hundred twenty-six patients with cirrhosis, hyperammonemia (>50 micromol/L), and chronic (persistent) hepatic encephalopathy (HE), which developed spontaneously without the existence of known precipitating factors, were enrolled in a randomized, double-blind, placebo-controlled clinical trial of intravenously administered L-ornithine-L-aspartate (OA). Patients with subclinical (grade 0, West-Haven criteria) hepatic encephalopathy (SHE), characterized by a prolonged number connection test A (NCT-A) time, and manifest HE (grades I and II, West-Haven criteria) were included in the investigation. The trial was planned as a confirmatory clinical trial OA administered in a dose of 20 g/d, as well as placebo, were dissolved in 250 mL of 5% fructose and infused intravenously for a period of 4 hours during 7 consecutive days with a superimposed protein load at the end of the daily treatment period. Primary variables were postprandial venous ammonia and NCT-A performance time measured following OA or placebo infusions to evaluate the net effect of the treatment on the prevention of the protein-induced hyperammonemia, and on parameters such as NCT-A influenced by hyperammonemia. Mental state gradation, portal systemic encephalopathy index (PSEI), and fasting ammonia levels were estimated as additional efficacy parameters. The data presented are based on the total study sample (intent-to-treat analysis), which included 63 patients in the placebo group and 63 patients in the OA group. Of the 126 patients, 114 met all the criteria for inclusion and completed the trial and treatment as outlined in the protocol (treated-per-protocol analysis). During baseline, the placebo and treatment groups were homogeneous with regard to mental states, NCT-A performance time, fasting venous blood ammonia levels, and Child-Pugh criteria. Although a slight improvement occurred in the placebo group, NCT-A performance times (P < .001) and postprandial venous ammonia concentrations in the OA-treated group showed improvements in comparison with placebo. In addition, venous fasting blood ammonia concentration (P < .01), mental state gradation (P < .001), and PSEI (P < .01), which includes the mental state gradation, NCT-A time, and postprandial venous ammonia in this trial, improved to a much higher degree in the OA group than in the placebo group. In subgroups retrospectively classified according to their initial mental state gradation, OA showed differential but uniformly significant efficacies in patients with manifest HE with respect to ammonia-lowering, improvement in NCT times, and mental state gradation. In patients with initial SHE, OA revealed differences between the medications in the psychometric test used. Adverse events consisting of mild gastrointestinal disturbances were observed in 3 of the OA-treated patients (5%). OA infusion appears to be a safe, effective treatment of chronic (persistent) manifest HE in cirrhotic patients. Additional investigations are required to assess the efficacy of OA in patients with SHE, as well as in patients with more severe grades of HE.

A histochemical study of the distribution of dextran 500 in human corneas during organ culture

PURPOSE

The aim of this histochemical study was to demonstrate the absorption of dextran 500 and its distribution in the cornea after storage under standard eye bank conditions. Furthermore, an attempt was made to distinguish between the soluble and insoluble parts of dextran 500 absorbed by the cornea, in order to see how much dextran remains in the cornea after transplantation.

METHODS

Forty-nine fresh and 65 organ-cultured human corneas were investigated. The corneas were cultured for 28 days in a dextran-free medium, followed by a period of 1-14 days in a medium containing 5% dextran 500. Cryosections were stained by aqueous PAS and a modified alcoholic PAS to determine the amount of dextran.

RESULTS

Dextran was not found in the epithelium, stroma or endothelium of fresh human corneas. By contrast, extra- and intracellular positive staining reactions were detected in corneas following storage in a medium containing dextran. Dextran 500 absorption was relatively diffuse in the epithelium after storage in a dextran medium. Initial accumulations were found in the stroma near Bowman's and Descemet's membranes and also in the central part of the cornea, as the period of culture in the medium containing dextran lengthened. We also observed interaction between the stroma and endothelium: decreasing amounts in the endothelium were followed by an increase of same in the stroma. Intracellular deposits of dextran were detected after only one day. A much greater part of the extracellular dextran than previously described was found to be insoluble.

CONCLUSIONS

As the amount of dextran in the cornea increases over a longer storage time, we conclude that the period of storage in a medium containing dextran should be limited to four days. The fact that the cornea is saturated with dextran after seven days has been shown in further studies to interfere with mitochondrial function and may also cause severe post-operative swelling of the transplant, hence leading to a longer recovery period for the patient.

[Endogenous digitalis-like factor in liver cirrhosis and cholestasis]

Endogenous digitalis-like factor (EDLF), an inhibitor of membrane Na+/K(+)-ATPase, is discussed to be involved in the pathogenesis of cirrhogenic portal hypertension, ascites formation and development of functional hepatorenal failure. Therefore, we investigated the serum content of this mediator in patients with liver cirrhosis Child-Pugh stage A, B, and C (n = 27) by means of enzyme immunoassay with a specific digoxin antibody. Furthermore, a correlation analysis was performed in order to find out correlations between signs of cell injury, cholestasis, synthetic cell function, ascites formation, and hepatorenal failure. Our results demonstrate that EDLF is significantly elevated in Child C cirrhosis (0.61 +/- 0.15 ng/ml) in comparison to Child A cirrhosis (0.013 +/- 0.2 ng/ml) and is also higher than in Child B cirrhosis (0.23 +/- 0.25 ng/ml). In patients without ascites EDLF (0.056 +/- 0.19 ng/ml) differs significantly from that of patients with non-complicated ascites (0.156 +/- 0.176 ng/ml) and from that of patients with therapy refractory ascites (0.66 +/- 0.17 ng/ml) or hepatorenal failure (1.56 ng/ml). There are no correlations between EDLF and renal function. Significant correlations were demonstrated for cholestasis (serum bilirubin), synthesis function (serum protein, Quick's value, cholinesterase, fibrinogen, albumin), and the degree of portasystemic encephalopathy (number connection test). We conclude that EDLF may act as a mediator in the process of progressive portal hypertension and its complications due to cirrhosis. This process of progression is caused by the inhibition of Na+/K(+)-ATPase, vasoconstriction, and endothelin secretion.

[Rational laboratory diagnosis of cholestasis syndrome]

Laboratory diagnostics efficiently applied is of decisive importance for a great deal of questions in spite of the technical and endoscopic methods which are available today in the field of examinations. By means of a screening programme consisting of ALAT, gamma-GT, ChE at a sensitivity of > 90% alterations in both the hepatobiliary system and cholestasis can be recognized with sufficient reliability. Clinical data and a defined laboratory routine programme as a second step in diagnostics results in reliable indication for distinction between obstructive and non-obstructive cholestasis which can be promoted by computer-aided techniques. On the basis of such pre-selections special laboratory methods (differential diagnosis of consecutive non-obstructive cholestasis in liver diseases) or invasive methods to clarify their reason and localization diagnostics of biliary obstruction can then be applied in a well-directed manner to obtain a definite nosologic diagnosis. Effective diagnostic procedures in this three-step programme are described.

[The prognostic value of serochemical cholestasis parameters in liver cirrhosis]

In a semiprospective study on the prognosis of liver cirrhosis we investigated whether common, selected cholestasis parameters in liver diagnostics are associated with the survival time and the probability of survival and whether they permit prognostic statements. In 93 patients with liver cirrhosis of different aetiology the serum-bilirubin, gamma-GT, AP and AAP were determined for this purpose and applied in the same way as a clinically proven icterus to the survival time of the patients. The mean time of observation was 13.8 years (+/- 1.9 years). In the simple correlation matrix none of the cholestasis parameters correlated with the survival time. There was no difference in the frequency with which deceased and surviving patients suffered from icterus and, with the exception of AAP, there was no different serum concentration of the cholestasis parameters according to univariate analysis. However, icterus in the early phase of the observation time and increased gamma-GT (over 3000 nmol/l.s) in the late phase of observation were associated with a reduced probability of survival. Correspondingly, the serum-bilirubin of deceased patients (only slightly) correlated in the simple linear regression with their survival time. In multivariate analysis gamma-GT proved to be non-redundant for the estimation of the patients' probability of survival.

[Endoscopic sclerosing of esophageal varices--technique, possibilities and limits of the method]

The paper intends to give a survey of the significance of endoscopic sclerotherapy in gastro-esophageal varices. The control of an acute bleeding can be achieved in a high percentage (70-95%). However, the hospital mortality has persisted in 30% depending on early rebleeding episodes and alterations in hepatic function. Controlled trials have confirmed a lowering of rebleeding risk as well as an improved survival by repeated sclerotherapy. The effectiveness of prophylactic sclerosing before the first bleeding is uncertain because of contrary results published. A prophylactic application seems to be favourable in patients at high risk of bleeding only.

[Portal hypertensive gastropathy--a rare cause of upper gastrointestinal hemorrhage]

There is evidence that the portal-hypertensive gastropathy is a clinical complication of portal hypertension and a distinct clinical entity being different from various types of gastritis. According to endoscopical findings one can differentiate 4 stages: I = superficial reddening on the surface of the gastric rugae, II = white reticular pattern separating areas of prominent pink oedematous mucosa (snake-skin or mosaic pattern), III = cherry red spots, IV = diffuse bleeding. These alterations occurring more prominently in the gastric fundus are caused by venous and capillary ectasia and by arteriovenous shunts. The potential of diffuse mucosal bleeding distinct from variceal haemorrhage is of clinical importance. Additionally, congestive mucosa seems to be more vulnerable to noxious agents in the gastric lumen. For therapy propranolol has been recommended.

Hepatic aldehyde dehydrogenase (E.C. 1.2.1.3.) isoenzymes and malondialdehyde levels in alcoholic liver disease

To clarify the controversially discussed behaviour of hepatic ALDH isozymes in different liver diseases, 98 liver biopsy specimens were investigated as to their total ALDH and their isozyme activity. Simultaneously the malondialdehyde (MDA) content was measured in both biopsy samples and serum. The results show a significant decrease of the "low Km" isozyme E-2 activity depending on the severity of the liver disease. The tendency for the E-2 activity to decrease was greater in alcoholic than in nonalcoholic liver diseases. Although in all our diagnosis groups elevated MDA concentrations could be measured in both serum and liver tissue, a direct specific inhibitory effect on the E-2 activity could not be confirmed. The change from the low Km pathway to the high Km pathway of aldehyde detoxification, however, may contribute to the progress in alcoholic liver disease.

Prophylactic endoscopic sclerotherapy of esophageal varices--a prospective randomized trial

Sixty-three patients with degree III or IV esophageal varices and the so-called red color sign, but without previous bleeding were randomly assigned to either prophylactic sclerotherapy (PST) (n = 30) or to a control group (n = 33). In 58 cases the portal hypertension was caused by liver cirrhosis (40% alcoholics). The two groups were comparable with respect to demographic data and endoscopic appearance, causes and severity of liver damage. Sclerotherapy was performed as combined intra-and paravariceal injections of 2 or 3% polidocanol. All patients, both in the treatment and in the control groups, who bled from varices after randomization, received sclerotherapy until the varices were eradicated, and remained in their groups. After a mean follow-up of 44.5 months, the bleeding rate in the PST group was significantly lower (30% vs 75%, p less than 0.01). The difference became significant from the second year onward. Fourteen patients of the PST group and 19 of the controls died (4 and 14, respectively, p less than 0.05 as a result of the bleeding). Life table analysis (Kaplan-Meier) revealed no differences in survival between the two groups. At the present time PST cannot yet be recommended as a method for clinical routine use.

[Therapy strategy in bleeding esophageal varices]

In the therapeutic regimen in the haemorrhage of the oesophageal varices the sclerotherapy part from measures for the combat against shock and prophylaxis of the liver coma occupies a central position both for control of haemorrhage and for avoiding recidivations of haemorrhages. Advantages of the method are the relatively good efficacy, the small rate of serious complications and a relatively good practicability. Furthermore, liver function, portal circulation and course of the in most cases underlying liver cirrhosis are not negatively influenced. On the basis of the hiherto got experiences the value of the prophylactic sclerosation of oesophageal varices before a bleeding cannot yet be reliably assessed.

[Thromboembolism risk factors in kidney transplant patients with secondary erythrocytosis in relation to hemorheologic aspects]

In patients undergoing dialysis and patients who underwent a transplantation of a kidney cardiovascular risk factors increase the lethality to 50%. A secondary polyglobulia (Pg) after transplantation enhances the risks of thromboembolism. In 180 patients who underwent a transplantation we saw in 11% a polyglobulia with 50% of thromboembolic complications. For the study of the secondary polyglobulia and other risk factors haemorheologic investigations were carried out on 20 patients who underwent a transplantation with Pg, 10 patients who underwent a transplantation without Pg and 19 healthy test persons. In patients with secondary polyglobulia we found a slightly increased plasma viscosity and an increase of the aggregation of the erythrocytes without decrease of their deformability. A decreased deformability of the erythrocytes in patients who underwent a transplantation with Pg and diabetes results in an additional risk, as was casuistically observed on a patient with 2 amputations of the legs and 2 myocardial infarctions. Our findings confirm the correctness of the isovolaemic haemodilution for the avoidance of additional cardiovascular complications in patients who underwent a transplantation of a kidney with polyglobulia.

Immunoglobulin allotypes and immunoreactivity in chronic liver disease

The immunoglobulin allotypes Gm (a; x; f) and Km 1 have been estimated in 194 patients with chronic liver disease, and compared with the frequency distribution of a representative reference group (Gm : n = 2171; Km : n = 2179). In relation to the Gm phenotypes we have investigated the cell-mediated immunoreactivity by the E rosette test, lymphocyte transformation test and migration inhibition test. Virus-induced chronic liver disease showed significantly higher prevalence of the phenotypes Gm a+x-f+ and Gm a+x+f+ as well as of the marker Km + 1 (p less than or equal to 5%; chi 2-test). In auto-immune chronic liver disease we observed a decrease in the phenotype Gm a+x-f+ while the factor Km + 1 was significantly multiplied. Patients with cryptogenic and alcoholic hepatopathy showed no differences in comparison with the reference group. In the progressive forms of the chronic liver disease (chronic active hepatitis, liver cirrhosis) Gm a+x+f+ was significantly more frequent. The investigations concerning cell-mediated immunity in different Gm allotypes generally showed a trend to increased reactivity in Gm a+x+ in comparison with Gm a-x- in non-alcoholic liver disease. It is possible to presume different genetic and immunologic situations in the various liver diseases as endogenous factors promoting the disease.

Haptoglobin type and liver disease

The haptoglobin phenotype has been estimated in patients suffering from chronic liver disease (n = 222) and acute hepatitis (n = 59) in comparison with the haptoglobin pattern of a normal population (n = 1726). The frequency of Hp 1-1 was significantly increased in non-alcoholic chronic liver disease (p = 5%; chi 2-test) in contrast to alcoholic disease. The highest incidence of Hp 1-1 occurred in cryptogenic cases (p = 1%). The follow-up of patients suffering from acute hepatitis failed to indicate any relationship between the haptoglobin phenotype and the course of hepatitis. The results suggest that Hp 1-1 is a genetic marker of special kinds of chronic liver diseases.

[Genetic studies in etiologically different chronic liver diseases]

In 198 patients with chronic liver diseases of different etiology 16 genetic feature systems were investigated (blood groups, erythrocytic enzymes, immunoglobulin allotypes, proteins). In comparison to a representative normal population significant differences of the frequency of the distribution of phenotypes of various systems were found. In these cases is remarkable that association between genetic markers and hepatopathies were above all proved in their classification according to etiopathogenetic criteria. We evaluate our findings as a reference to the importance of genetic factors in the development of chronic liver diseases.

[Rational procedures in the differential diagnosis of jaundice]

In jaundice after exclusions of prehepatic and functional hepatogenic hyperbilirubinaemias the sonography should pre-eminently be used as a riskless, economical and qualified investigation method, taking into consideration clinical and laboratory-chemical data. If sonographically the findings of an intrahepatic cholostatis are shown, in therapeutic relevance the histological clarification must follow. Only in unequivocal focal changes of the liver (perhaps thin needle puncture) further investigations are unnecessary. If there are findings of an extrahepatic cholostasis, in a not unequivocal sonographic result or before a surgical intervention further aimed investigations, such as ERCP, PTC and CT, are necessary for the exact clarification of the cause of the obstruction of the bile ducts.

[Thyrostatic therapy in patients with liver cirrhosis]

The thyreostatic therapy of a hyperthyroidism in coincident chronic hepatopathy is problematic. On the one hand, this therapy may be an additional load, particularly by the development of a cholestasis for the ill liver. On the other hand, due to the hyperthyroidism disturbance of the liver function and liver diseases up to cholestatic hepatitis may develop. At the instance of two patients with liver cirrhosis, whose simultaneous hyperthyroidism was treated thyreostatically, the therapeutic problems are represented. On the basis of the treatment of a not small number of patients with this constellation of findings we recommend the use of Thiamazol as therapy of choice in the at present, usual lower initial dosage. If functional disturbances of the liver and other side effects appear under this therapy, the radio-iodine therapy offers itself as alternative.

[Results of sonographic kidney diagnosis]

In a prospective study of the examination of the accuracy of the ultrasound tomography in the renal diagnostics the kidneys of 361 patients could be demonstrated as at 100% sufficiently to be judged. Tumours, congestion kidneys, cystic kidneys/renal cysts and cirrhoses of the kidney were diagnosed with an efficiency of 0.92-0.96-0.97-1.0. The sensitivity was in the same order 0.90-0.96-0.99-1.0 and the specificity 0.94-1.0-0.95-1.0. Insufficient results were obtained by the sonographic search for renal calculi. As non-invasive and rapid method of diagnostics the sonography in a valuable way contributes to the differentiation of the symptom "quiescent kidney" and oligo-anuria.

Aldehyde dehydrogenase (E.C. 1.2.1.3) in chronic alcoholic liver diseases

Acetaldehyde dehydrogenase (ALDH) activity in liver biopsy specimens was considerably reduced in alcoholic cirrhosis (n = 5), elevated in alcoholic fatty liver (n = 11)--probably due to enzyme induction--only slightly elevated in alcoholic hepatitis (n = 6), but unaffected in non-alcoholic liver diseases (n = 23) in comparison with specimens obtained from patients with minimal liver lesions. We will argue as a working hypothesis that alcoholics with induced ALDH activity will mainly develop fatty liver, whereas reduced hepatic ALDH appears to be a reason for elevated acetaldehyde levels followed by additional liver injury and progression at least for alcoholic cirrhosis.

Levamisole therapy in chronic hepatitis--results of a multicentric double blind trial

The effectiveness of levamisole in the immunmodulatory treatment of chronic hepatitis was assessed in a multicentric double blind trial. Twenty patients received in the first week 50 mg, in the second 100 mg and thereafter 150 mg, levamisole on two days every week for 6 months, 20 others received a placebo. Five patients dropped out (non-compliance 1, pregnancy 1, adverse effects 3). The diagnoses were confirmed by clinical, biochemical immunological and histological data. After 6 months 26 subjects allowed us to take a control liver biopsy. The results showed that the rate of improved, unchanged and impaired cases was not significantly different in the levamisole and placebo groups. No correlation was found between etiology, activity or histological type of chronic hepatitis, skin test reactivity (DNCB, PPD, Streptokinase) and therapeutic effect, respectively. Clinical improvement was not associated with the elimination of HBs antigen. In general levamisole was well tolerated, but we saw one case of severe agranulocytosis.

[Cell-mediated immune reactivity in skin tests in chronic liver diseases]

For the judgment of cell-mediated immune reactivity in patients with chronic liver diseases in comparison to healthy test persons tests of the skin were performed by means of the neoantigen DNCB and the recall antigens tuberculin and streptokinase. Depending on the degree of severity of the hepatopathies the intensity of reaction decreased in the DNCB-test. There were no relations to the etiopathogenetic factors of the liver diseases. The results speak for the fact that the disturbed immune reactivity to DNCB is to be regarded as sequela of the disease. The anamnestic immune response controlled by means of the two recall antigens did not show any quantifiable differences to the reference collective in the chronic hepatopathies. It is concluded that the findings of skin tests are not able to contribute to the indication for immunosuppressive or immune modulating therapeutic methods.

[Acetaldehyde-induced leukocyte migration inhibition in alcoholic liver diseases]

Acetaldehyde in non-toxic doses (15.6 micrograms per start) causes in the inhibition test of the migration of leucocytes an inhibition of the migration in 6/13 of the patients with alcoholic hepatitis, a stimulation of the migration in 6/11 of alcohol cirrhoses. Healthy (n = 16) persons, patients with alcoholic fatty degeneration of the liver (n = 3) as well as non-alcoholic liver diseases (chronic persisting hepatitis, n = 11; chronic active hepatitis, n = 8, cirrhosis, n = 7) did not show this cellular immune reagibility. The inhibition of the migration and the stimulation of the migration, respectively, might develop by hapten autoantigen complexes (altered cytoskeleton?) with release of the factors of inhibition of migration and stimulation of migration, in which case the role of a hapten belongs to acetaldehyde. The results of the tests did not correlate with functional and histological findings of the liver, with the actual consumption of alcohol and also not with haptoglobin phaenotypes. When it is postulated that by acetaldehyde also the release of further lymphokines is mediated, origin and progression of alcoholic hepatitis and alcoholic cirrhosis might be explained immunopathogenetically.

[Alkaline phosphatase isoenzymes and hyperthyroidism]

We determined the serum total alkaline phosphatase as well as the alkaline phosphatase isoenzyme pattern in untreated and treated hyperthyreoses in the condition of euthyreosis and compared them with those of a healthy control group. The isoenzyme patterns, expressed as L/K quotient, ranged between 1.3 and 2.5 in the normal group and between 0.3 and 1.3 in the group with hyperthyreosis. The increase of the total alkaline phosphatase in hyperthyreosis was nearly exclusively conditioned by the increase of the activity of the osseous isoenzyme. The latter was increased already also then, when the total alkaline phosphatase had not transgressed the upper border of the normal. Depending on the functional condition of the thyroid gland the liver isoenzyme did not show any significant changes. In the course up to one year under thyrostatic therapy the increased activity of the osseous alkaline phosphatase decreased into the normal region as an expression of the very slowly repairing hyperthyreosis-conditioned disturbances of the osseous metabolism. An increase of the activity of the total alkaline phosphatase or of the osseous isoenzyme in the initial phase of a thyreostatic therapy of the sequel of an increase of the reactive activity of osteoblasts and must not lead to diagnostic and therapeutic uncertainties. By reason of the high sensitivity of the L/K quotient in hyperthyreoses (L/K at 95.5 % below 1.3) with a simultaneously high specifity of 89.5% the alkaline osseous phosphatase is to be discussed by all means as a helpful parameter of the peripheral function of the thyroid gland.

[Contribution of sonography to the diagnosis of colonic tumors]

Though also in future roentgenological and endoscopic bioptic techniques determined the practice in the diagnostics of tumours of the large intestine the routine use of sonography may shorten the way to diagnosis in numerous cases when the so-called cocard phenomenon (= infiltrated intestinal wall) is proved. On the other hand, the cocard phenomenon may serve as an additional criterion of malignity when a roentgenological and/or endoscopic suspicion of malignoma at first cannot be confirmed bioptico-histologically.

[Use of B-sonography in the diagnosis of liver diseases]

The criteria important for the sonographic judgment of the liver and the value of the sonography in the strategy of the diagnostics of liver diseases are described. Since none of the symptoms mentioned, such as size of the liver, ventral contour, lower margin of the liver, demarcability, sound conduction as well size, density and distribution of the structural reflexes, is typical for a certain disease, an approximate diagnosis or the exclusion of certain diseases is a possible only taking into consideration several symptoms and also extrahepatic, sonographically probable ones. On account of the simplicity and of the undangerousness of the examination it is obvious to use the sonography immediately after the examination and thus to organize the selection of further diagnostic measures more rational.

[Possibilities of ultrasonic diagnosis of thyroid and gastrointestinal diseases]

Issuing from the physical principles of the ultrasound technique and the explanation of the different investigation methods, the possibilities of the ultrasonic diagnosis are demonstrated on own results in 1,166 cases of struma nodosa and 154 palpatorically and radiologically, respectively, localised enlargements of the organs or demands of space in the abdominal region. The establishment of 46 cysts in 357 scintigraphically warm nodes of the thyroid gland allows the conclusion that a relatively high percentage of the warm nodes contains solid cold regions. In several cases the ultrasonic diagnosis makes a clear diagnosis, in other cases it is an important supplementation to the other diagnostic possibilities. The A-picture-apparatuses produced in the GDR are suitable for the differential diagnosis of palpatorically or radiologically localised enlargements of the organs or space demands. In diffuse diseases of the organs and for the search of disturbances in extended regions B-picture-apparatuses with improved resolving power are necessary.

[Pseudo-lupus erythematosus syndrome and interstitial nephritis]

First in 1972 under the preliminary term pseudo-lupus-erythematodes-syndrome a clinical picture was represented which clinically resembles the lupus erythematodes disseminatus and which is characterized by the proof of antimitochondrial antibodies and the lack of antinuclear factors. We report on a female patient with this syndrome and interstitial concomitant nephritis. Possible causal factors, clinical picture, typical laboratory findings, therapy and prognosis are discussed with the help of the casuistics.

[Value of sonography in the differential diagnosis of icterus]

In early use the sonography may facilitate and accelerate the differential diagnosis of the jaundice. In parenchymal hepatic icterus frequently pathologic changes of the liver may be proved sonographically. The typical findings of dilated and thus sonographically demonstrable intra- and extrahepatic biliary ducts speak for obstructive jaundice. Characteristic constellations of dilated segments of the bile duct allow conclusions to the localisation of the occlusion. Changes which cannot be explained by sonography are a cause for further examinations.

[Cellular immunoreaction in alcohol-induced liver damage]

Of 231 patients with alcohol-induced liver diseases of different degrees of severity 170 patients had a pathological result of the migration inhibition test, when autologous homogenate of the liver was used as antigen. Of them in 25 cases a stimulation, in the other patients an inhibition of the migration of leucocytes was present. With increasing degree of severity of the liver lesion the number of cases with migration inhibition increased. These findings refer to a cellular immune reactivity in alcohol induced liver diseases.

[Hepatic coma--causes, recognition, treatment]

The name of the disease coma hepaticum is a collective notion for etiologically, pathologo-anatomically and biochemically different kinds of a failure of the function of the liver. A demarcation of different forms of the liver coma is necessary above all for prognostic and therapeutic reasons: hepatic disintegration coma, coma in hepatic failure, mixed coma, false hepatic coma, ferment block coma. Despite certain progress the therapeutic possibilities in hepatic coma cannot satisfy in recent years. Also the use of different, partly very expensive methods of the so-called liver substitute (exchange function and plasmapheresis, heterologous and homologous extracorporal liver perfusion, parasymbiotic crossed circulation, haemoperfusion with encapsulated activated charcoal, liver transplantation) up to now did not lead to a decisive improvement of the nearly infaust prognosis of the hepatic disintegration coma. Therefore preventing measures and careful control of endangered patients deserve particular attention.