[Gastrointestinal surgery and gastroenterology. XV. Polycystic liver disease]. / Gastro-intestinale chirurgie en gastro-enterologie. XV. De polycystische leverziekte.

Polycystic liver disease is a congenital disorder with an autosomal dominant pattern of inheritance. There are two variants. In one, liver cysts occur as an extra-renal phenomenon in autosomal dominant polycystic kidney disease. In the other, the disease is not associated with renal pathology. The cysts have to reach a certain diameter before becoming clinically manifest and therefore are generally only detected many years after birth. Polycystic liver disease causes symptoms in 20% of the patients. These symptoms are the consequence of the weight and size of the liver or of complications such as abscess formation, obstructive jaundice or the Budd-Chiari syndrome. Most symptoms can be treated at least temporarily by fenestration of the larger cysts and resection of parts of the liver, which are affected by large groups of small cysts. A permanent cure of the disease is only obtained by liver transplantation.

[Acetaminophen use by chronic alcohol abusers: a therapeutic dose may be too much for the liver]. / Paracetamol bij chronisch alcoholgebruik: weinig is voor de lever snel teveel.

Two patients, both women aged 31 and 73 years, were admitted with chest pain and coma, respectively. They had very high aspartate aminotransferase levels, accompanied by relatively low alanine aminotransferase levels. The second patient had developed acute liver failure and hepatic encephalopathy. Both patients were chronic alcohol abusers and had taken therapeutic doses of acetaminophen for a couple of days. The marked elevation of the aminotransferase levels and the rapid decline of these levels after discontinuing the use of acetaminophen and alcohol led to the diagnosis of acetaminophen hepatotoxicity. In chronic alcohol abusers, cytochrome P450 2E1 is induced and the amount of glutathione is depleted. This combination causes the formation of a relatively large amount of the radical N-acetyl-p-benzoquinone imine and a low potential to detoxify this metabolite, so that even small amounts of acetaminophen may cause liver damage. It is recommended that chronic alcohol abusers (more than four alcoholic beverages per day) use no more than 2 g acetaminophen per day.

[Chronic hepatitis ascribed to the use of sotalol]. / Chronische hepatitis toegeschreven aan het gebruik van sotalol.

In a 68-year-old woman with severe chronic hepatitis an extensive investigation revealed no other cause than the use of sotalol for 10 months due to atrial fibrillation. Once the use of the medication had been discontinued the patient's symptoms quickly disappeared and the liver function disorders normalised within 5 months. Sotalol is a beta-adrenergic receptor blocking and anti-arrhythmic agent. It is widely used in patients with supraventricular and ventricular arrhythmias. An adverse effect in terms of liver damage is not known. The pathogenesis of the observed hepatitis remained an enigma because sotalol is a hydrophilic substance which is not metabolized by the liver and is cleared by the kidneys unchanged.

Plasma glutathione S-transferase alpha 1-1 levels in patients with chronic liver disorders.

Recent data suggest that plasma levels of the phase II detoxification enzyme glutathione S-transferase alpha may be a sensitive indicator of hepatocellular integrity in acute liver disorders but little information is available in chronic hepatic disorders. Using a newly developed enzyme linked immunosorbent assay, glutathione S-transferase A1-1 (GSTA1-1) levels were measured in 279 plasma samples from patients with chronic liver disorders. Results were categorized as normal or elevated plasma GSTA1-1 and normal or elevated plasma aspartate aminotransferase (AST) levels. In 24 patients with alcoholic liver cirrhosis, plasma GSTA1-1 levels were not significantly different from a group of 350 healthy controls and only one patient (4%) had an elevated GSTA1-1 level while 10 (42%) patients had elevated AST activities. In samples from patients with primary biliary cirrhosis (n = 150), primary sclerosing cholangitis (n = 26) or chronic hepatitis (n = 79) significantly (P < 0.0001) elevated plasma GSTA1-1 concentrations were detected in 25 (17%), 7 (27%) and 17 (22%) of the samples, respectively. AST activities were increased in a higher percentage of samples in all three disorders: 89%, 88%, and 57%, respectively. Plasma GSTA1-1 and AST levels were significantly correlated (P < 0.005) in the above mentioned disorders but not in alcoholic liver cirrhosis. It is concluded that plasma GSTA1-1 is not a sensitive parameter for the detection of hepatocellular damage in chronic liver disorders.

[Hypothermia during use of pipamperone]. / Hypothermie bij gebruik van pipamperon.

Two women aged 84 and 86 years developed hypothermia after use of pipamperone. In one of the patients repeated administration of pipamperone again induced a decrease of body temperature. Although other clinical and environmental factors may have contributed to the development of hypothermia, a causal relationship between the use of pipamperone and the fall in body temperature appears likely considering the close temporal relationship. Hypothermia has been documented as a side effect of neuroleptics, especially phenothiazines, but it has not been reported in relation to pipamperone. Hypothermia is a potentially lethal condition; the cases described confirm the necessity of being careful with use of neuroleptics in elderly people.

[Hepatitis attributed to the use of terbinafine]. / Hepatitis toegeschreven aan het gebruik van terbinafine.

A 71-year-old woman was admitted to our hospital with jaundice after she had been using terbinafine for a few weeks. The liver function tests showed a mixed cholestatic-hepatocellular pattern. A liver biopsy revealed large amounts of intracellular bile pigment. Causes of the liver disorder other than the use of the aforementioned antimycotic drug were excluded. Ten months after cessation of the drug the patient had recovered completely. The Netherlands Inspectorate for Health Care received 20 reports of liver enzyme elevations due to terbinafine in 1991-1994.

Effect of oral zinc supplementation on metallothionein and superoxide dismutase concentrations in patients with inflammatory bowel disease.

Oxygen-derived free radicals may contribute to intestinal tissue damage in inflammatory bowel disease. The concentrations of metallothionein and superoxide dismutase, two copper and zinc containing proteins involved in the scavenging of free radicals; were previously found to be decreased in the intestinal mucosa of patients with this disorder. The plasma zinc concentration is often decreased also in these patients. Since zinc is reported to be an efficient inducer of metallothionein synthesis, and probably of superoxide dismutase, we evaluated the effect of oral zinc supplementation on metallothionein and superoxide dismutase levels in patients with inflammatory bowel disease. Fourteen patients with inactive to moderately active inflammatory bowel disease received oral zinc supplementation (300 mg zinc aspartate, equal to 60 mg elemental zinc per day) for 4 weeks in a placebo-controlled double-blind cross-over trial. The plasma zinc concentration of these patients was low at the start of the study (12.2 +/- 1.7 mumol/L, P < 0.05), when compared to that of 22 healthy controls (13.6 +/- 2.3 mumol/L), but increased (P < 0.05) towards the levels of controls during the supplementation period (13.3 +/- 2.5 mumol/L). The concentrations of metallothionein and superoxide dismutase in plasma and in erythrocytes did not change in relation to the supplementation. The metallothionein concentration in both inflamed and non-inflamed intestinal mucosa was slightly higher after zinc supplementation but the superoxide dismutase concentration in the tissue was not altered. The histological inflammation score of intestinal biopsies, plasma albumin levels, and the disease activity index of the patients did not change during the study.(ABSTRACT TRUNCATED AT 250 WORDS)

[Sepsis caused by non-O1-Vibrio cholerae: a patient in The Netherlands]. / Sepsis door non-O1-Vibrio cholerae: een patiënt in Nederland.

In a 84-year-old woman extraintestinal infection by non-OI Vibrio cholerae was diagnosed. She had septicaemia with cholangitis and cholecysto- and choledocholithiasis. Until now 26 patients with non-OI V. cholerae septicaemia have been reported. Most had an underlying disease, usually a chronic liver disease or haematological malignancy. These disorders were not present in our patient. She was treated with co-trimoxazole and afterwards she underwent a cholecystectomy and common bile duct exploration. At the time of operation no non-OI V. cholerae could be isolated from the gallbladder or the bile from the common bile duct. A possible cause of the infection was a herring which the patient had eaten six weeks before hospital admission.

Villous tumours of the duodenum. An analysis of the literature with emphasis on malignant transformation.

Until 1992, 192 patients with a villous tumour of the duodenum have been reported. The symptoms and signs of this tumour are mostly related to obstruction of the duodenal lumen or bile ducts. Radiological examination (e.g., hypotonic duodenography) may be of some help in diagnosing a villous tumour of the duodenum. In histological specimens, superficial parts of the tumour may appear benign while deeper parts may contain adenocarcinoma. Therefore, endoscopy with multiple biopsies or the use of electrocautery for removal of large fragments of the tumour should play a major role in obtaining an accurate preoperative diagnosis. Forty-two per cent of all reported villous tumours showed malignant changes at the time of presentation. Because of this great risk of malignant transformation, these tumours should always be resected. Unlike large bowel mucosa, small bowel mucosa contains lymphatics that course through the villi extending near the luminal surface, suggesting the possibility of early lymphatic spread before invading the muscularis mucosae. In 24 patients with intramucosal carcinoma, however, no metastases were found. For this reason, a mucosal resection of these tumours would appear to be an effective and safe treatment. Invasive carcinomas or recurrent villous tumours require more radical surgery. Depending on histological evaluation, location in the duodenum and intraoperative findings, segmental resection of the villous tumour or pancreaticoduodenectomy would seem to be an appropriate surgical procedure. A pedunculated villous tumour may be removed endoscopically. It is recommended that all patients who had their tumour resected locally, should be surveyed endoscopically.

Metallothionein concentration in the liver of patients with Wilson's disease, primary biliary cirrhosis, and liver metastasis of colorectal cancer.

In patients with primary biliary cirrhosis and Wilson's disease liver copper concentrations become elevated during the evolution of the disorder. The accumulated copper is thought to be detoxified by metallothionein, a protein which binds copper and zinc. In liver metastasis of colorectal cancer, copper and zinc concentrations are usually decreased compared to normal liver tissue, but little is known about the concomitant metallothionein levels. In the present study metallothionein concentrations were determined in archival liver samples from patients with primary biliary cirrhosis and Wilson's disease, and in both normal and malignancy-containing liver samples from patients with metastasis from a colorectal adenocarcinoma. Twenty-seven control liver samples contained 3.98 +/- 1.55 mg metallothionein/g protein. From the 21 liver samples of patients with primary biliary cirrhosis, which had a mean metallothionein concentration of 6.06 +/- 5.03 mg/g protein, 6 were above the highest control level. Liver metallothionein concentrations for the 8 patients with Wilson's disease were significantly elevated (10.98 +/- 6.93 mg/g protein, p < 0.005 vs. controls and p < 0.05 vs. primary biliary cirrhosis). In the 11 liver metastases from colorectal adenocarcinomas metallothionein concentrations (1.17 +/- 0.90 mg/g protein) were significantly (p < 0.005) lower than surrounding normal liver tissue (4.25 +/- 1.75 mg/g protein). We conclude that in primary biliary cirrhosis and Wilson's disease increased liver metallothionein concentrations may detoxify the accumulated copper. Furthermore, liver metastasis of colorectal cancer contains less metallothionein than the surrounding normal liver tissue.

Plasma metallothionein concentration in patients with liver disorders: special emphasis on the relation with primary biliary cirrhosis.

The plasma metallothionein concentration was evaluated in healthy subjects and in patients with several types of liver disorders. Plasma metallothionein concentrations in controls varied between 2.4 and 4.8 ng/ml. Patients with disorders associated with increased liver copper concentrations (i.e., primary biliary cirrhosis and primary sclerosing cholangitis) had significantly (both p less than 0.002) elevated plasma metallothionein concentrations (range = 1.8 to 52.2 ng/ml), and a considerable number of these were above the maximum control level (21 of 41 patients). In contrast, patients with liver disorders not associated with increased liver copper concentrations (alcoholic and cryptogenic cirrhosis, and acute viral and chronic active hepatitis) generally had normal plasma metallothionein concentrations and only a few were above the maximum control level (11 of 64 patients, maximum = 8.8 ng/ml). The metallothionein concentrations in plasma samples from patients in stage I or II primary biliary cirrhosis were within or slightly above the control range, whereas most patients in stage III had elevated levels (p less than 0.002), and almost all patients in stage IV had clearly elevated (p less than 0.0001) concentrations. In primary biliary cirrhosis the plasma metallothionein concentration tended to increase during the evolution of the disorder, and the concentration correlated significantly with the serum total bilirubin concentration. In conclusion, the plasma metallothionein concentration is significantly elevated in patients with primary biliary cirrhosis and in patients with primary sclerosing cholangitis. Although related to the histological stage of primary biliary cirrhosis, the measurement of plasma metallothionein concentrations contributes little to the diagnosis or the evaluation of the severity of these disorders.(ABSTRACT TRUNCATED AT 250 WORDS)

Villous tumors of the duodenum. Presentation of five cases.

Five cases of villous tumors of the duodenum are reported. These tumors have a predilection for the periampullary region and tend to present with jaundice or obstruction of the duodenal lumen. In four of these patients, malignant transformation was seen. Endoscopy and biopsy play a major rôle in attempting to obtain an accurate preoperative diagnosis. Unfortunately, the diagnosis of malignant degeneration is frequently missed, even when multiple biopsies are taken. For this reason villous tumors should always be resected, and the strategy of treatment must depend on pre-, intra- and postoperative histological evaluation, location in the duodenum and intra-operative findings.

Second evaluation of HEPAR, an expert system for the diagnosis of disorders of the liver and biliary tract.

HEPAR is an expert system which can be used as a supportive tool in the diagnosis of disorders of the liver and biliary tract. When consulted for a particular patient, the system assesses the patient's disorder in two stages. In the first stage, data of medical history, physical examination and routine laboratory tests are used to determine whether the disorder is hepatocellular or biliary obstructive, and whether benign or malignant features are present. In the second stage, the system produces a differential diagnosis out of a set of 80 disease categories, using the conclusions of the first stage of the assessment and the results of a restricted number of supplementary investigations, i.e. serological tests and ultrasonography. The conclusions of the two stages are ordered by the amount of evidence computed by HEPAR. The system is not yet suitable for clinical use. The system has been evaluated using data of 181 patients selected from a population of 214 consecutively admitted patients with jaundice. The patients were classified by the system as having a hepatocellular or biliary obstructive, and a benign or malignant disorder in 96% and 100% of the cases, respectively. When comparing the conclusions with strongest evidence with the final clinical diagnoses, the patients were classified correctly in 86% and 83% of the classified cases, respectively. A differential diagnosis was produced in 87% of the patients. A correspondence between the diagnosis with strongest evidence and the final clinical diagnosis was found in 78% of the classified patients.

Decrease in two intestinal copper/zinc containing proteins with antioxidant function in inflammatory bowel disease.

Oxygen derived radicals contribute to tissue injury in inflammatory bowel disease. We measured the content of superoxide dismutase and metallothionein (two endogenous copper and zinc containing proteins involved in radical scavenging) in intestinal resection specimens from 29 patients with Crohn's disease and 12 patients with ulcerative colitis and compared the concentrations with those obtained in the normal mucosa of a control group of 18 patients with colorectal cancer. The superoxide dismutase content was similar in control mucosa and non-inflamed mucosa from patients with inflammatory bowel disease (mean (SEM) 2.13 (0.10) and 2.24 (0.10) mg/g protein, respectively) but was decreased in inflamed mucosa (1.87 (0.08) mg/g protein, p less than 0.005 v non-inflamed mucosa). The metallothionein content was decreased in non-inflamed inflammatory bowel disease mucosa compared with control mucosa (0.23 (0.03) and 0.36 (0.04) mg/g protein, respectively, p less than 0.02) and a further decrease was found in inflamed mucosa (0.17 (0.02) mg/g protein, p less than 0.001 v control mucosa). No differences were found between Crohn's disease and ulcerative colitis and no significant effect of medication or tissue localisation was noted. These findings might indicate a decreased endogenous intestinal protection against oxygen derived radicals in inflammatory bowel disease which could contribute to the pathogenesis of the disease.

Development and validation of HEPAR, an expert system for the diagnosis of disorders of the liver and biliary tract.

HEPAR is an expert system in the field of hepatology which can be used as a supportive tool in the diagnosis of disorders of the liver and biliary tract. The representation language employed in HEPAR consists of production rules with object-attribute-value triples. In the system, medical diagnosis is modelled according to the strategy which is clinically used in this field. The patient's disorder is assessed in two stages. In the first stage, available data from medical interview, physical examination and simple laboratory tests are used to determine whether the disorder is hepatocellular or biliary obstructive in nature, and whether benign or malignant features are present. In the second stage the system produces a subset of possible diagnoses out of a set of more than 80 disease categories, using additional data from supplementary tests. The results of the first stage classification cause considerable pruning of the search space. In this paper the structure, development process and approach followed in the validation of the HEPAR system are described. The results of a recent performance validation study using data from 181 consecutive patient cases are discussed.

Detection of gastric erosions: comparison of biphasic radiography with fiberoptic endoscopy.

Biphasic radiography was compared with fiberoptic endoscopy in detecting gastric erosions in a prospective, blinded study of 385 patients with dyspepsia. Because no absolute standard was available for the comparison, since histologic confirmation of all erosions was not possible, the kappa statistic was used to compare results from both modalities. Flat (incomplete) erosions were detected with endoscopy only and were considered to be present in 42 patients (11.2%). Varioliform (complete) erosions were identified with both radiography and endoscopy in 12 patients (3.2%). For the detection of varioliform erosions, a substantial agreement beyond chance between both modalities was found (kappa = 0.73; standard error, 0.12). Thus, flat erosions were detected with endoscopy only, whereas state-of-the-art radiography and endoscopy were equally sensitive for detecting varioliform erosions. Histologic confirmation of erosions was obtained in only 75% of the patients. It is unknown whether the demonstration of erosions with radiography and/or endoscopy correlates with dyspepsia.

Isolation, characterization, and determination of human liver (copper/zinc) metallothionein.

A copper-containing protein was purified from the liver of a patient with primary biliary cirrhosis by a combination of gel filtration and anion exchange chromatography. This copper-protein had UV absorption and emission spectra, an amino acid composition, and a molecular mass which were characteristic for metallothionein (MT). From 8 livers (3 control, 1 fetal and 4 primary biliary cirrhosis) MT was extracted with non-reducing buffer and centrifuged, and pellets were re-extracted with a 1% 2-mercaptoethanol-containing buffer. The non-reducing buffer extracted a predominantly copper-containing MT from the livers of patients with primary biliary cirrhosis and a predominantly zinc-containing MT from control livers and the fetal liver. Only from the fetal liver was a copper/zinc containing MT solubilized during the re-extraction with 2-mercaptoethanol-containing buffer. These results indicate that human MT is a unique metalloprotein with age and disease-dependent characteristics.

Development of a radioimmunoassay for human metallothionein.

We report the development of a radioimmunoassay (RIA) for human metallothionein (MT). The MT was isolated from the liver of a patient with primary biliary cirrhosis and used to raise high titer antibodies in rabbits. The RIA was developed using Bolton-Hunter labeled MT as label and purified MT as standard. The detection limit of the assay was 0.4 ng/ml and concentrations between 0.8 and 100 ng/ml could be routinely measured. Dilutions of plasma samples containing high endogenous MT concentrations and tissue extracts in assay buffer showed parallelism with the standard curve and MT added to plasma could be fully recovered.

Recurrent Listeria monocytogenes bacteraemia in a liver transplant patient.

We report a case of a recurrent Listeria monocytogenes bacteraemia in a 46 year-old liver transplant patient. Serotyping revealed that the two episodes of bacteraemia were caused by different strains. The possibility of a recrudescence of a persisting infection was rejected. We concluded that the recurrent bacteraemia in this predisposed patient was due to re-infection, and that antibiotic treatment (amoxicillin plus an aminoglycoside) resulted in a complete eradication of the infective microorganism. Therefore long-term suppressive antibiotic treatment was not indicated. The source of these L. monocytogenes infections was not found.

[Comparison of biphasic radiologic stomach and duodenum studies with fiber endoscopy for the diagnosis of peptic ulcer and stomach carcinoma]. / Vergelijking van bifasisch radiologisch maag-en duodenumonderzoek met fiberendoscopie voor de diagnostiek van peptische zweren en maagcarcinomen.

In a prospective, blind study of 385 patients with dyspepsia, the diagnostic value of biphasic radiological examination of stomach and duodenum was compared with endoscopy. The patients were examined for presence of peptic ulcers and gastric carcinomas. No golden standard being available, kappa values were calculated for the comparison. The kappa values were 0.67 and 0.77 for gastric and duodenal ulcers, respectively; for gastric carcinomas the value was 0.91. These values indicate good agreement. The sensitivity and specificity of both methods were high; a lower sensitivity of radiological examination for duodenal ulcers was accounted for by ulcers smaller than 5 mm; for larger ulcers, the sensitivity and specificity of both methods were practically the same. It is concluded that the two methods are of equal value for the diagnosis of peptic ulcers and gastric carcinomas. Endoscopy offers the major advantage that biopsy samples can be taken for histological examination or culturing. The biphasic radiological examination, on the other hand, is cheaper and often better tolerated by the patient.