[Antibiotic prophylaxis in gastrointestinal endoscopy--recommendations of the Austrian Society of Gastroenterology and Hepatology]. / Antibiotikaprophylaxe in der gastrointestinalen Endoskopie--Empfehlungen der Österreichischen Gesellschaft für Gastroenterologie und Hepatologie.

The recommendations of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) for antibiotic prophylaxis in gastrointestinal endoscopy of the year 2002 have been updated in accord with the recently published guidelines of the American Society of Gastrointestinal Endoscopy (ASGE) and the American Heart Association (AHA). Antibiotic prophylaxis for any endoscopic intervention to prevent infectious endocarditis is no longer necessary. Moreover, the prophylactic use of antibiotics for ERCP without biliary obstruction and ERCP with obstruction and a likelihood of complete drainage is no longer recommended. For ERCP with obstruction and anticipated incomplete drainage, a full course of antibiotics should be administered to prevent cholangitis. For the prevention of local infections antibiotics are useful prior to endoscopic puncturing, contrasting or drainage of cystic lesions as well as just before application of a PEG tube. In cirrhotic patients with GI bleeding antibiotic prophylaxis should be started as early as possible and be administered for several days.

[The first case of anisakiasis acquired in Austria]. / Anisakiasis - der erste in Osterreich akquirierte Fall einer seltenen Helminthozoonose.

Anisakiasis is caused by a fish parasite of the Nematode family. This kind of rare helminthozoonosis can mainly be found in countries where consumption of raw fish is traditionally high like Japan, the Netherlands, Pacific Islands, South Europe, Scandinavia, USA, and Canada. Man is the wrong hoste. Clinical manifestation depends on the localisation of penetration in the GI tract. In Japan, predominantly the stomach is affected in 97 % of cases, probably due to hypo- and achlorhydria; whereas mainly intestinal anisakiasis occurs in Europa. We report on a 67-year-old male patient with a gastric infestation of anisakiasis. The patient was on proton pump inhibitor which migh have caused the localisation of the infestation. The anisakis was an accidental endoscopic finding in a patient for control of an H. p.-positive gastric ulcer. Otherwise the patient was free of pain. The helminth (larva III) was endoscopically extracted. Thereafter, the patient remained in good health. Anisakis serology as well as repeated differential blood counts were without finding. The uneventful medical history and the normal blood findings indicate that our patient had a very early stage of infestation of anisakiasis. The patient reported no stay outside of Austria within the last years. However, he consumed on a regular basis "rolled pickled herring" produced by a well-known Viennese company for canned fish. This is the first documented case of this rare helminthozoonosis acquired in Austria.

Case volume and outcome of endoscopic retrograde cholangiopancreatography: results of a nationwide Austrian benchmarking project.

BACKGROUND AND STUDY AIM: In a quality assessment project for endoscopic retrograde cholangiopancreatography (ERCP), initiated in 2006 by the Austrian Society of Gastroenterology and Hepatology, benchmark data were collected on a voluntary basis. Results from the individual participating centers, both academic and community-based, were compared with pooled benchmark data, with the intention that individual problems should be identified and corrected in order to improve patient care in Austria. Success and complication rates in nonselected patients were evaluated, especially with regard to case volume. METHODS: In Austria, with a population of 8 million, 140 sites are registered for ERCP, and it is estimated that up to 15 000 procedures are done annually. Of these sites, 28 participated in the "Benchmarking ERCP" project during the first year, reporting on 3132 procedures, or 22 % of the total number. RESULTS: The overall complication rate in nonselected patients was 12.6 %, consisting of post-ERCP pancreatitis (5.1 %), bleeding (3.7 %), cholangitis (1.9 %), cardiopulmonary complications (0.9 %), and perforation (0.5 %); procedure-related mortality was 0.1 %. The overall therapeutic and diagnostic target was achieved in 84.8 %. High case volume (endoscopists performing > 50 vs. < 50 ERCPs per year; 21 vs. 68 endoscopists) was associated with significantly higher success (86.9 % vs. 80.3 %, P < 0.001) and lower overall complication rates (10.2 % vs. 13.6 %, P = 0.007); significance was not reached for all subgroups of complications. CONCLUSION: Success and complication rates for ERCP in Austria are comparable to those reported elsewhere. In our study, endoscopists with a case volume exceeding 50 ERCPs per year had higher success and lower overall complication rates.

Prospective multicentre clinical study on inter- and intrapatient genetic variability for antimicrobial resistance of Helicobacter pylori.

OBJECTIVES: We report on a large prospective, multicentre clinical investigation on inter- and intrapatient genetic variability for antimicrobial resistance of Helicobacter pylori. METHODS: Therapy-naive patients (n = 2004) who had undergone routine diagnostic gastroscopy were prospectively included from all geographic regions of Austria. Gastric biopsy samples were collected separately from antrum and corpus. Samples were analysed by histopathology and real-time PCR for genotypic resistance to clarithromycin and quinolones. Clinical and demographic information was analysed in relation to resistance patterns. RESULTS: H. pylori infection was detected in 514 (26%) of 2004 patients by histopathology and confirmed in 465 (90%) of 514 patients by real-time PCR. PCR results were discordant for antrum and corpus in 27 (5%) of 514 patients, indicating inhomogeneous infections. Clarithromycin resistance rates were 17% (77/448) and 19% (84/455), and quinolone resistance rates were 12% (37/310) and 10% (32/334) in antrum and corpus samples, respectively. Combination of test results per patient yielded resistance rates of 21% (98/465) and 13% (50/383) for clarithromycin and quinolones, respectively. Overall, infection with both sensitive and resistant H. pylori was detected in 65 (14%) of 465 patients. CONCLUSIONS: Anatomically inhomogeneous infection with different, multiple H. pylori strains is common. Prospective clinical study design, collection of samples from multiple sites and microbiologic methods that allow the detection of coinfections are mandatory for collection of reliable data on antimicrobial resistance patterns in representative patient populations. (ClinicalTrials.gov identifier: NCT02925091).

Plasma amino acids in hepatic encephalopathy.

In 75 cases of histologically verified liver cirrhosis the plasma amino acids were determined by ion exchange chromatography and the results were correlated with different liver function tests as prothrombin time, pseudocholinesterase, serum albumin, GOT, bilirubin and venous ammonia. Out of these parameters prothrombin time, pseudocholinesterase and serum albumin significantly correlated with the sum of branched-chain amino acids and with the Fischer's quotient (molar ratio of branched-chain and aromatic amino acids). Methionin and aromatic amino acids inversely correlated with these parameters, additionally methionin positively correlated with bilirubin and GOT. By comparing plasma amino acid levels in cirrhotics without and with hepatic encephalopathy (grade 3 or 4) no significant differences were found. "Fischer's quotient" showed an overlap in patients with and without encephalopathy. Therefore the precipitation of hepatic encephalopathy is not fully explained by the changes in plasma amino acids. Therapeutic administrations of specially mixtures of amino acids with a high content in branched-chain and a low content in aromatic amino acids correct the plasma amino inbalance for a short time and improves hepatic encephalopathy.

Hormone serum levels during oral cimetidine treatment of patients with peptic ulcers.

Radioimmunoassayable basal serum levels of luteinizing hormone (LH), follicle stimulating hormone (FSH), prolactin (hPRL), 17 beta-estradiol (E2) and testosterone (T) were estimated in a total of 68 patients, who were treated because of peptic ulcer with 1 g cimetidine per day. 37 patients were male and 31 were female subjects, respectively. Hormone serum levels were assayed before and 4 to 6 weeks after start of therapy. A significant increase of LH serum levels (p less than 0.025) and a significant decrease of hPRL (p less than 0.025) was noted in the male subjects during therapy. Similarly, a decrease of hPRL serum levels (p less than 0.001) was registered in the female subjects during treatment with 1 g cimetidine per day. All other hormone serum levels in both female and male subjects remained unchanged. The present data combine to suggest that 1 g cimetidine per day does not provoke hyperprolactinemia. In addition, cimetidine at the dose used does not interfere with other hormones of the hypothalamus-pituitary-gonadal axis and therefore, cannot be considered, responsible for endocrine disorders during treatment with cimetidine.

[The influence of therapy with silymarin on the survival rate of patients with liver cirrhosis (author's transl)]. / Zur Wirksamkeit von Silymarin auf die Uberlebensrate von Patienten mit Leberzirrhose.

A randomized double-blind study about the therapy of the cirrhosis of the liver shows a significant higher surviving rate of the alcoholic cirrhosis in the group treated with Silymarin. This result can be well explained by the protective influence of this substance against toxic injuries. The etiology of many chronic liver diseases is uncertain and therefore it is advisable to try the therapy also in other cases. The conditions of the study are exactly reported. The influence on the clinic of the disease and on the laboratory data obtained in many controls will be published later, because the statistical analysis needs some more time.

[Hepatitis b infection in renal transplant recipients (author's transl)]. / Nierentransplantation und Hepatitis-B-Infektion.

During a period of 4 1/2 years the incidence and clinical course of endemic hepatitis B infection was studied in 43 renal transplant recipients with an observation time of 3 to 47 (average: 26.3) months after surgery. During the investigation period 27 out of 43 patients (62.8 per cent) had hepatitis B infection. In 8 patients HBs antigenaemia persisted after chronic dialysis treatment. After surgery HBs antigenaemia was detected for the first time in 7 patients. Recurrence of HBs antigenaemia was noted in one patient. In 7 further cases with HBs antigenaemia after transplantation regular controls of HBsAg and HBsAb were not available before transplantation. In 2 patients HBs antibodies were detectable at the time of transplantation; 2 further patients developed HBs antibodies postoperatively. Hepatitis B infection showed a mild and persistent clinical course. 6 out of 7 icteric patients simultaneously had other severe mycotic and viral infections. Therefore, the conclusion was drawn that in patients with coexisting multiple infections liver damage is not necessarily attributable to HBs antigenaemia.

OMGE--Study on prevalence of hepatitis B surface antigen in different liver diseases.

The prevalence of hepatitis B viral infection has been evaluated by means of a questionnaire. Contributions were made by 160 institutions from 39 countries and involved more than 400 collaborators. HBsAg was identified by a variety of test kits which were available at the time of the questionnaire. Data are presented for the prevalence of HBsAg in acute viral hepatitis, chronic hepatitis, cirrhosis of the liver and primary liver cancer. Wide variations in antigenaemia were identified in different countries and between the various forms of liver disease. HBsAg is positive more often in chronic hepatitis than cirrhosis. More data using sensitive tests are needed but it appears as if at least one-fifth of the world population has had a previous hepatitis B virus infection.

[An unusual cause of severe abdominal pain]. / Massive diffuse Bauchschmerzen bei einem 33-jährigen bislang gesunden Mann.

A 33-year-old previously healthy man was admitted to the hospital with a 6-day history of diffuse abdominal pain and constipation. He was afebrile, looked unwell with a pale skin and displayed an elevated blood pressure. He had no peritoneal sign, and bowel sounds were normal. Blood tests were remarkable for a hematocrit of 26 % and mean cell volume of 83 fl, bilirubin levels were slightly elevated. Abdominal radiographs, abdominal ultrasound and computed tomography showed stool throughout the colon with a non-specific bowel gas pattern. Moreover, colonoscopy and gastroscopy provided no information on the underlying cause of the patient's severe pain. He was treated with fluids and spasmolytic drugs until the result of the urinary porphyrin level was received, which showed an elevated concentration of 1608 microg/d. Consequently, the plasma lead concentration was determined showing an elevated level of 92.3 microg/d. The examination of blood slides revealed erythrocytes with basophile stippling. On physical examination, a bluish discoloration could be seen along the gums. After starting the detoxication therapy with DMPS - 1800 mg p. o. for the first two days followed by 600 mg DMPS daily - the complaints disappeared. In spite of an extensive anamnestic exploration the source of the lead intoxication could not be found until now.

[Faulty nutrition as viewed by the hepatologist]. / Fehlernährung aus der Sicht des Hepatologen.

Looking back over the past centuries, a survey shows that for the past 2000 years definite dietetic rules have existed for the treatment of liver diseases, which to a great extent have disregarded the distribution of protein and carbohydrates. Deviations from the principles of nutrition followed as a result of intensive physiological-chemical research during the 19th century. This new knowledge, however, lead to misinterpretation and exaggerations in the recommended dietary proportions of fat, protein and carbohydrates. Protein deficiency, which is particularly disadvantageous in cases of hepatitis during pregnancy, and lack of vitamins, along with other types of malnutrition, became apparent. Various attempts providing diets rich in protein and fat, for the treatment of hepatitis, proved rather the tolerance of these nutrients than discovering a new, more efficient therapy. In spite of some resignation, recommendations made on the basis of experience should rather be dispensed with, as regards diet, and the search for further knowledge of the supply of nutrients in liver diseases should be continued. In addition, the study of endotoxins and toxic amines in the metabolism of the brain offers a source of future research.

[Parenteral feeding of patients with liver cirrhosis with hepatic encephalopathy]. / Parenterale Ernährung von Patienten mit Leberzirrhosé mit hepatischer Enzephalopathie.

The amino acid solution, Aminofusin hepar, was evaluated for treatment of hepatic encephalopathy and for parenteral nutrition of patients with liver cirrhosis in correlation to changes in amino acid levels. In contrast to amino acid solutions used for the parenteral nutrition of patients without liver disease, this solution contains an increased proportion of branch chained amino acids and of arginine and ornithine, and a reduced proportion of phenylalanine, methionine, glycine and threonine. The changes in the plasma amino acid levels after infusion of this solution were measured in 4 cirrhotics. The concentration of leucine, isoleucine, valine, ornithine and arginine increased markedly, whereas phenylalanine, methionine, tyrosine, glycine and threonine decreased. The ammonia level in venous blood increased slightly. 4 cirrhotics with encephalopathy were treated for 7 days. In 3 of them the neuropsychiatric symptoms were completely reversed, whereas in the remaining 1 no clinical improvement was achieved in spite of normalization of the plasma aminogramm. In this patient a constant rise of blood ammonia was noted. The indications for special amino acid solutions in liver diseases are discussed.

[Parenteral nutrition in liver diseases]. / Die parenterale Ernährung bei Lebererkrankungen.

A total parenteral nutrition may particularly be used in patients with liver diseases, for comatous patients or postoperatively. By using central venous catheterization the practical application of high osmolar solutions, fat emulsions and amino acid mixtures is easy to be performed. Partial parenteral nutrition is needed mainly for decompensation of metabolic disturbances of amino acids in liver diseases. As carbohydrates particularly glucose is used, but because of the deranged glucose tolerance also fructose and glucose substitutes are given in mixed solutions. The infusion of fat emulsions partly covers the need of energy and on the other side prevents a lack of essential fatty acids. Recent investigations demonstrated that fat emulsions may be tolerated by patients with liver diseases and fat is utilized for energy metabolism. The changes of plasma amino acids in blood in patients with chronic liver diseases, especially in the stage with liver insufficiency, demands for a special amino acid solution. For the accomplishment of a total as well as for partial parenteral nutrition principles are given and relevant clinical problems are discussed.

[Therapy of hepatic encephalopathy. Modification of the plasma aminogram using amino acid infusions]. / Therapie der hepatalen Enzephalopathie Beeinflussung des Plasmaaminogrammes durch Aminosäureinfusionen.

When amino acid solutions with high concentrations of branched chained amino acids and low concentrations of aromatic amino acids were administered to patients with cirrhosis of the liver 1. the serum levels of tyrosine and phenylalanine were significantly reduced, 2. the molar ratio of the branched chained amino acids to the aromatic amino acids substantially increased, and 3. as therapeutic response in all cases treated, a marked improvement of hepatic encephalopathy was achieved.