Contrast-enhanced ultrasound (CEUS) in hepatic lymphoma: retrospective evaluation in 38 cases.

PURPOSE: Description of contrast-enhanced ultrasound (CEUS) patterns of hepatic lymphoma. MATERIALS AND METHODS: Over a period of 6 years and 1 month from January 2006 to January 2012, n = 38 patients with histological or clinically apparent hepatic lymphoma were studied by means of CEUS prior to B-mode imaging. RESULTS: Using B-mode imaging, lesions were hypoechoic in n = 37 (97.4 %) cases, while a focal lymphoma lesion was echo-rich in 1 case (2.6 %). For comparison, with CEUS, a hyperenhanced signal during the arterial phase was observed in n = 9 (23.7 %), an isoenhanced signal in n = 17 (44.7 %) and a hypoenhanced signal in n = 12 (31.6 %) cases. During the portal phase n = 2 (5.3 %) lesions were isoenhanced and n = 36 (94.7 %) were hypoenhanced followed by a hypoenhancement in n = 38 (100 %) cases in the late phase. CONCLUSION: Lymphomas of the liver can cause different contrast accumulation in the arterial phase of CEUS. Furthermore, a clear differentiation from other malignant liver lesions such as metastases is crucial as different contrast accumulation in the arterial phase of CEUS is observed. In the late phase, hepatic lymphomas lead to a hypoenhancement in CEUS, also known as a "wash-out" phenomenon. In conclusion, CEUS is helpful to differentiate hepatic lesions by means of evaluating the malignancy or benignancy. In this regard, the application of CEUS can help to find the right diagnosis. A final discrimination between malignant liver lesions, such as liver lymphomas, metastasis or HCC, remains impossible.

Effect of peppermint oil and caraway oil on gastrointestinal motility in healthy volunteers: a pharmacodynamic study using simultaneous determination of gastric and gall-bladder emptying and orocaecal transit time.

BACKGROUND: Although peppermint oil and caraway oil are frequently used in herbal drugs for abdominal discomfort and pain, the pharmacological insights into their effects on the gastrointestinal tract are poor. METHODS: The pharmacodynamic effects of 90 mg peppermint oil (WS 1340) and 50 mg caraway oil (WS 1520) on the motility of the stomach and gall-bladder, and on the orocaecal transit time, in comparison with placebo, 10 mg cisapride and 10 mg n-butylscopolamine, were studied in 12 healthy volunteers. The study involved simultaneous ultrasonic determination of gastric and gall-bladder emptying, together with assessment of the orocaecal transit time using the lactulose H2 breath test. The combination of these methods allows three gastrointestinal organs to be studied in one subject simultaneously. RESULTS: The antral filling time was comparable with placebo, peppermint oil, caraway oil and cisapride, whereas it was significantly shortened (P = 0.04, two-sided paired t-test) with n-butylscopolamine. The gastric emptying time did not differ significantly between placebo, peppermint oil, caraway oil and cisapride, but was significantly prolonged by n-butylscopolamine (P = 0.04, two-sided paired t-test). Complete inhibition of gall-bladder emptying was caused by both oils and n-butylscopolamine. Cisapride significantly shortened gall-bladder emptying compared with placebo (P = 0.02, two-sided signed rank test). The orocaecal transit time was significantly prolonged by peppermint oil (P = 0.004) and n-butylscopolamine (P = 0.002), but not significantly prolonged by caraway oil (P = 0.06); it was significantly shortened by cisapride (P = 0.04, all two-sided paired t-test). CONCLUSIONS: Peppermint oil and caraway oil show a relaxing effect on the gall-bladder and the former slows small intestinal transit. Further studies should investigate the effects of both oils on a maximal contraction stimulus on the gall-bladder, and in patients suffering from motility disorders.

Differential therapy of constipation--a review.

Constipation is a common condition occurring with increasing frequency in advanced age. As a symptom, it is not always dealt with directly by the physician, but is often left to the care of nurses. Many patients rely on self-medication. Constipation not only interferes with the quality of life, but often has the rank of a syndrome requiring competent medical intervention. This is of clinical importance, because a thorough understanding of the pathophysiology of constipation enables the clinician to identify the potential causes and, if necessary, initiate a differentiated therapy with the aid of only simple additional investigations. This review outlines a clinical approach including medical history, spectrum of causes, radiopaque pellets method to differentiate between slow transit constipation and defecation disturbances for the differential diagnosis of constipation. The mechanisms of action of laxatives (anti-absorptive, secretagogue, osmotic, filling and swelling agents) are further components and important for the individual therapy. Based on this fundamental information, a differentiated therapy is possible in each specific case such as coprostasis. Chronic symptomatic constipation reduces the quality of life and should be evaluated by physicians. If situations such as drug-induced constipation or hypothyroidism which have to be treated causally can be ruled out, laxative treatment according to the clinical picture, mode of action of drug used and side effects of the laxative can be initiated. Laxative abuse due to chronic constipation is rare and almost always associated with psychosomatic-psychiatric disorders.

[Probiotic therapy of pseudomembranous colitis. Combination of intestinal lavage and oral administration of Escherichia coli]. / Probiotische Therapie einer pseudomembranösen Kolitis. Kombination aus intestinaler Lavage und oraler Gabe von Escherichia coli.

HISTORY AND FINDINGS: An 82-year-old woman was admitted because of acute left heart failure with pulmonary oedema. There was a right basal pneumonia with congestion which was treated with amoxycillin and clavulanic acid. Severe watery diarrhoea with more than 10 stools daily occurred. Clostridium difficile was not isolated. INVESTIGATIONS: Coloscopy as far as the right flexure revealed proximally increasing whitish coatings, like those in severe pseudomembranous colitis (PMC), revealed as acute erosive colitis histologically. The plate-like incomplete erosions contained fibrin and granulocyte deposits so typical of PMC. Clostridium difficile could again not be demonstrated. TREATMENT AND COURSE: As intestinal lavage, already undertaken in preparation of the coloscopy, markedly improved the symptoms it was repeated for therapeutic purposes. This brought about further improvement and a fall in granulocyte count from 29,500 G/l to 10,700 G/l. Subsequently live E. coli bacteria (nissle 1917 strain) were administered. After 5 days stool frequency had fallen to one or two daily, each soft or partly formed. Stools were normal after a further week. Coloscopy 3 weeks after onset of treatment showed almost complete healing of the PMC. CONCLUSION: The successful treatment of PMC with intestinal lavage and physiological E. coli administration agrees with the results of animal experiments and clinical experience. Whether it is an effective alternative to primary standard treatment with vancomycin or metronidazole remains to be tested by further experience, preferably properly controlled therapeutic trials.

[Snow white small intestinal villi in hypobetalipoproteinemia]. / Schneeweisse Dünndarmzotten bei Hypobetalipoproteinämie.

In contrast to the severe clinical picture of abetalipoproteinemia patients with hypobetalipoproteinemia are often asymptomatic. We demonstrate a 52-years-old female patient with a white mucosa of the small intestine casually observed by endoscopy. The white appearance of the mucosa was limited to the villi. As demonstrated by light and transmission electron microscopy this was caused by fat loaded enterocytes similar to the picture of abetalipoproteinemia. Fasting serum lipids and apolipoproteins were only if the lower norm level for some parameters, but no increase of the serum lipids was observed after an oral fat load. Because of the missing symptoms, the typical histomorphology and laboratory findings the snow white mucosa of the small intestine is due by the hetocygote form of the autosomal dominant hypobetalipoproteinemia with fat loaded enterocytes.

[Retroperitoneal, mediastinal and subcutaneous emphysema with pneumothorax after colonoscopy]. / Retroperitoneales, mediastinales und subkutanes Emphysem mit Pneumothorax nach Koloskopie.

HISTORY: Severe ulcerative colitis had been diagnosed in a 25-year-old man six years ago. That same year he underwent laparoscopy for mechanical ileus. Since then he has been on a maintenance dose of sulphasalazine without any further symptoms. Because of a known pseudopolyposis coli, repeat coloscopy was performed. EXAMINATIONS AND FINDINGS: The endoscope was smoothly introduced and the examination was without pain. No premedication had been given. A biopsy was obtained during withdrawal of the endoscope. Suddenly the patient noticed marked scrotal swelling. The examination was terminated abruptly. No lesions of the wall of the distal colon were seen when the endoscope was pulled out immediately. Quickly, cutaneous emphysema developed over the right side of the abdomen and thorax up to the neck. The patient could no more properly hear his own voice. Radiology demonstrated bilateral pneumoretroperitoneum, mediastinal emphysema and pneumothorax. TREATMENT AND COURSE: The patient was put on parenteral nutrition for 4 days and prophylactically received amoxycillin, calvulanic acid and metronidazole. The air was gradually absorbed and the patient discharged symptom-free after 7 days. CONCLUSION: In contrast to intraperitoneal perforation, which usually causes acute symptoms of peritonitis and requires urgent surgical treatment, the course of the much rarer retroperitoneal perforation is more benign with few symptoms and can be managed conservatively.

[Malignant lymphomatous polyposis--a rare disease entity of malignant centrocytic lymphoma with characteristic endoscopic appearance]. / Die maligne lymphomatöse Polypose--eine seltene Krankheitsentität des malignen zentrozytischen Lymphoms mit charakteristischem endoskopischen Aspekt.

It is considered as special gastrointestinal manifestation on the nodal centrocytic lymphoma of intermediate malignancy. We demonstrate a 77 years old male patient, who underwent colonoscopy because of rectal bleeding. We found the colonic mucosa dotted with small, flat, lentiform polyps. In the terminal ileum these polyps were much larger. No changes were seen in the esophagus. In the antrum we found flat elevations and in the duodenum again lentiform nodules. Presenting in stage IV of non-Hodgkin's lymphoma the patient was treated with five cycles of combined chemotherapy with prednimustin and mitroxanthrone without side effects. Restaging showed distinct remission of the disease with significant reduction of the mucosal alterations.

Inhibition of neuronally mediated secretion in rat colonic mucosa by prostaglandin D2.

The effect of prostaglandin D2 (PGD2) on ion transport across the mucosa of the descending colon was studied in rats. PGD2 dose-dependently decreased baseline short-circuit current of mucosa-submucosal preparations mounted either in the Ussing chamber or mounted as an everted sac. However, with the everted sac technique, the tissue was about 1000 times more sensitive to PGD2. Concomitant with the decrease in short-circuit current, PGD2 increased the mucosal-to-serosal fluxes of sodium and chloride and decreased the serosal-to-mucosal flux of chloride. PGD2 inhibited the secretory action of the PGI2 analogue iloprost, PGD2 alpha, and neurotensin. The action of these secretagogues was dependent on the presence of the submucosal plexus. In contrast, PGD2 had no effect on the increase in short-circuit current caused by PGD2, substance P, or serotonin, the actions of which were not dependent on the presence of the submucosal plexus. The results indicate that the action site of the antisecretory mechanism of PGD2 is localized in the secretomotor neurons.

Carboplatin and simultaneous radiation in the treatment of stage IIIA/B non-small cell lung cancer.

The radiosensitizing properties of carboplatin were investigated in preclinical and clinical studies. In human non-small cell lung cancer (NSCLC) cell lines (EPLC 65 H and LCLC 97 TM1) combined carboplatin and radiation therapy was superior to chemotherapy or radiotherapy alone, indicating the existence of additive effects for both treatment modalities. In a subsequent clinical phase II trial, escalating doses of carboplatin were given concurrently with radiation to patients with stage IIIA/B NSCLC. Radiotherapy was given in daily doses of 2 Gy, 5 days a week, during weeks 1-3 and 6 and 7. Carboplatin was given on day 1 in weeks 1-3 and 6 and 7. The starting dose level was 100 mg/m2, followed by dose escalations to 120, 130, 140, 150, 160, 180, and 200 mg/m2. Five patients were to be treated at each dose level until intolerable toxicity (World Health Organization grade 3 or 4 leukopenia) occurred in 3 of the 5. To date, 34 patients have been entered into the study. Toxicity was mild and, even at the 180-mg/m2 dose level, no severe myelosuppression was observed. Thus, the maximum tolerated dose of carboplatin has not yet been reached. Preliminary analysis of response and survival shows an overall response rate of 53% and a median survival of 10 months. Patients receiving higher carboplatin doses (140-160 mg/m2) survived longer than patients who received lower doses (100-130 mg/m2). These preliminary results indicate that combination carboplatin and radiation therapy is a well-tolerated, active regimen in patients with locally advanced NSCLC. Splitting carboplatin administration may reduce its hematologic toxicity.

Splenic lesions: sonographic patterns, follow-up, differential diagnosis.

This report concerns 172 patients with sonographically diagnosed benign and malignant splenic lesions. A variety of echopatterns was observed, but a differential diagnosis was often impossible without contributory clinical data. Thirteen patients underwent ultrasound-guided fine-needle biopsy for histological confirmation or therapy. In 14 cases splenectomy was performed for treatment or final diagnosis. Twenty-three patients had malignant space-occupying lesions of the spleen. 26 cases presented with normal splenic size, 47 showed splenomegaly of different extent. Lymphoma was the main basic illness in 60 patients. Thirteen cases presented with splenic metastases from other neoplasms. 71 malignant splenic lesions were hypoechoic when compared with normal splenic echotexture. Only two patients exhibited hyperechoic metastases. In three cases a 'halo' sign was seen. In 99 patients benign focal lesions of the spleen were diagnosed. These included splenic infarction (n = 36), dysontogenetic cysts (n = 23), splenic abscesses (n = 7), splenic calcification (n = 13), and hyperechoic lesions (n = 17) most probably representing splenic hemangioma.

Antisecretory effect of prostaglandin D2 in rat colon in vitro: action sites.

The effect of prostaglandin D2 (PGD2) on colonic ion transport was studied in the Ussing chamber. PGD2 (10(-6) M) decreased baseline short-circuit current (Isc) in two preparations of rat colon descendens, a mucosa-submucosa preparation with and a mucosa preparation without the submucosal plexus. In both preparations, PGD2 inhibited the neuronally mediated secretory responses to electric field stimulation, the sea anemone toxin ATX II, and different cholinergic agents. Unidirectional flux measurements revealed that PGD2 diminished the secretagogue-induced increase in the serosal-to-mucosal flux of Cl- and thereby inhibited net Cl- secretion. PGD2, however, had no effect on the adenosine 3',5'-cyclic monophosphate-mediated response to forskolin or vasoactive intestinal peptide or on guanosine 3',5'-cyclic monophosphate-mediated secretion induced by the heat-stable enterotoxin of Escherichia coli. The PGD2 also blocked the increase in Isc evoked by two neuronally acting inflammatory mediators, i.e., bradykinin and PGI2 in the mucosa-submucosa preparation, but had no effect on the response to PGE2. Consequently, PGD2 exerts an indirect antisecretory effect caused by an inhibition of enteric secretomotor neurons of both the submucosal and the mucosal plexus.

Sonography of focal lesions of the spleen.

The sonographic appearances of benign and malignant splenic lesions in 154 patients are illustrated. Sixty-six of the 154 patients had malignant splenic lesions; 55 of these had malignant lymphoma and 11 had splenic metastatic lesions. The lesions were hypoechoic in 64 cases (97%), including all cases of malignant lymphoma, and were hyperechoic in two. Eighty-eight patients had benign splenic lesions; findings included cysts, infarcts, abscesses, hemangiomas, and calcifications.

Pleural effusion: an "acoustic window" for sonography of pleural metastases.

We report the sonographic findings in 32 patients with malignant disease associated with pleural effusions diagnosed by chest roentgenograms. No tumor lesions were seen in any case on X-ray films. Thoracic sonography, however, detected previously undocumented metastatic disease with diaphragmatic (N = 19), parietal (N = 8), visceral (N = 2) or combined (N = 3) pleural involvement. Additionally, a distinction could be made between nodular lesions (N = 19), sheet-like tumor masses (N = 10), and combined (N = 3) tumor spread. In all cases thoracentesis was performed. Cytology showed malignant cells in 28 patients. Pleural metastasis was histologically confirmed by ultrasound-guided fine needle biopsy in 2 cases. The present study demonstrates the value of scrutinized thoracic sonography in patients with pleural effusion for the detection of pleural metastases.

Gastrointestinal lymphoma: sonographic findings in 54 patients.

Between 1980 and 1990, 580 patients with known malignant lymphoma were referred for sonography for evaluation of abdominal masses as a part of the initial staging of the disease. In 54 patients, sonography showed different degrees of hypoechoic bowel wall thickening; gastrointestinal lymphoma was confirmed by histologic examination in all of these patients (non-Hodgkin lymphoma in 50, Hodgkin disease in four). Nineteen of the 54 patients had primary gastrointestinal lymphoma; the other 35 had widespread tumor with secondary gastrointestinal involvement. The portions of gastrointestinal tract involved included the stomach (38), small intestine (five), colon (seven), and multiple sites (four). Several sonographic patterns were found: 39 patients had circumferential involvement of the bowel wall, four had bulky tumors, and two had nodular extraluminal spread. Eight patients had segmental infiltration, and one had mucosal involvement. The results of this study indicate that sonography is of value for examining patients with gastrointestinal lymphoma and that several patterns of involvement can be detected.

Sonographic patterns of the affected spleen in malignant lymphoma.

Sonographic examination showed spleen involvement in 43 patients with histological evidence of malignant lymphoma. In 23% of these cases the spleen was of normal size and 77% exhibited variable splenomegaly. Focal lesions could be seen in 27 patients, 16 exhibiting diffuse, small-nodule transformation of the sonographic parenchymal texture. Hodgkin lymphomas caused both focal (7 of 16) and diffuse (9 of 16), splenic lesions. All non-Hodgkin lymphomas of high-grade malignancy exhibited focal lesions, which are larger than 3 cm in diameter in 11 out of 13 patients. In non-Hodgkin lymphomas of low-grade malignancy, focal sites and diffuse destruction of splenic tissue texture were found, lesions of under 3 cm in diameter (11 of 13) being characteristic of this subtype.

Prediction of diuretic mobilization of cirrhotic ascites by pretreatment fractional sodium excretion.

In a randomized prospective study the efficacy and side effects of xipamide versus the combination spironolactone/furosemide in the treatment of cirrhotic ascites were studied. Out of 27 patients four responded to a basic treatment consisting of salt and water restriction and one had to be excluded because of deterioration of kidney function. The remaining 22 patients were randomized to additional treatment with either 20 mg xipamide/day (group I) or 200 mg spironolactone/day combined with 40 mg of furosemide every other day (group II). A response to treatment during the first 4 days was seen in 7 of 11 patients of group I versus only 3 of 11 patients in group II. In the latter group 7 of 11 patients finally responded after 8 days of treatment. Responsiveness to either diuretic treatment strongly depended on pretreatment fractional Na excretion, FENa. The resistance to diuretic treatment can be predicted by a FENa less than 0.2%, and could be overcome by additional strategies known to reduce avid proximal Na reabsorption. Xipamide frequently induced hypokalemia, whereas hyperkalemia was seen following treatment with spironolactone/furosemide. Kidney function remained stable during either diuretic treatment.

Neurofibromatosis and acute monocytic leukemia in adults.

A patient with nonfamilial peripheral neurofibromatosis (NF) (von Recklinghausen's disease) is reported who contracted acute monocytic leukemia at 60 years of age. In the course of the illness, myelonecrosis developed and the patient died 4 months later due to a therapy-resistant bone marrow relapse. This association of the two illnesses would appear to confirm reports on an increased incidence of nonlymphatic leukemia and NF. Such an association is seen during childhood as juvenile chronic leukemia, but it is uncommon in adulthood.

Effect of the stable prostacyclin analogue iloprost on water and electrolyte transfer of the rat ileum and colon in vivo.

The effect of iloprost on water and ion transfer was measured simultaneously in tied-off loops of the rat ileum and colon in vivo. (1) In the ileal loops iloprost had no effect on water and ion transfer neither by intraluminal, nor intraaortal or intravenous application. (2) In the colonic loops only intraaortal bolus application of the high dose of 500 micrograms iloprost significantly decreased net water, sodium and chloride absorption, but did not induce net secretion. (3) Inhibition of endogenous prostaglandin synthesis by indomethacin did not change net water and electrolyte transfer in the ileum and colon. (4) Under this pretreatment i.v.-application of 100 micrograms iloprost, ineffective without indomethacin, induced a net secretion of water and sodium and inhibited absorption of chloride in the colon. (5) At the same time iloprost had no effect in the ileal loops of the same animals. (6) Potassium secretion was activated already by 100 micrograms iloprost administered intraluminally. We conclude from this study, that prostacyclin and iloprost have a specific secretory action in the colon. However this effect is masked under in-vivo conditions, either by interactions of ineffective prostaglandin metabolites with the concerned receptors or by counteracting prostaglandins, and becomes evident only after inhibition of the prostaglandin biosynthesis.