Interest of the association clonidine-spironolactone in cirrhotic patients with ascites and activation of sympathetic nervous system.

BACKGROUND: The aim of this study was to examine the effects of spironolactone, clonidine and the association of clonidine-spironolactone on renin-aldosterone and sympathetic systems, renal function, systemic hemodynamics and mobilization of ascites in 32 alcoholic cirrhotic patients with marked increase in sympathetic system. METHODS: Measurements were taken before and after an 8-day treatment with spironolactone (200 mg/day), after an 8-day treatment with clonidine (0.150 mg/day) and 10 days after adjunction of spironolactone (200 mg/day) to clonidine. RESULTS: Three patients abandoned the treatment or were excluded because lack of compliance. Spironolactone alone induced an increase in renin-aldosterone and sympathetic systems without any remarkable increase of natriuresis and body weight loss. Given for 8 days, clonidine alone induced a significant decrease in plasma norepinephrine associated with a significant increase in glomerular filtration rate without effect on natriuresis. In contrast, 10 days after adjunction of spironolactone to clonidine, plasma renin and aldosterone significantly decreased, natriuresis increased (from 7.4 +/- 0.7 to 41.6 +/- 3.2 mEq/24 h) and body weight decreased (from 66.03 +/- 2.3 to 63.5 +/- 2.3 kg) without adverse effects. CONCLUSION: In cirrhotic patients with ascites and marked activation of sympathetic nervous system, spironolactone (200 mg/day) is unable to mobilize ascites. In these patients, after 8 days, clonidine decreases sympathetic activity, increases glomerular filtration rate and after 18 days, decreases plasma renin and aldosterone concentrations allowing a better action of spironolactone. The association clonidine-spironolactone enhances natriuresis and body weight loss.

[Biological factors influencing response to diuretics in patients with cirrhosis and ascites]. / Facteurs biologiques influençant la réponse aux diurétiques des malades atteints de cirrhose en décompensation ascitique.

PURPOSES: To examine the biological factors influencing response to diuretics in patients with cirrhosis and ascites. METHODS: Sixty-nine patients were evaluated. Patients were classified into 3 groups: group 1: "good responders" (responding to spironolactone 200 mg/day), group 2: "bad responders" (responding to spironolactone doses above 200 mg/day or requiring addition of furosemide), and group 3: "non-responders" (not responding to spironolactone 400 mg/day and furosemide 160 mg/day). RESULTS: There were 30 patients in group 1, 24 in group 2 and 15 in group 3. The degree of activation of the renin-aldosterone and sympathetic system in group 2 was significantly higher than in group 1 and lower than in group 3. Natriuresis in group 2 (11 +/- 0.7 mEq/24h) was significantly below group 1 (20 +/- 2 mEq/24h) and above group 3 (5 +/- 0.6 mEq/24h). CONCLUSIONS: In patients with cirrhosis and ascites, the degree of activation of the renin-aldosterone and sympathetic nervous system influences diuretic response of ascites and is estimated by measured baseline natriuresis.

[Diagnosis and treatment of gastroesophageal reflux in the adult: guidelines recommended by French and Belgian consensus]. / Diagnostic et traitement du reflux gastro-oesophagien de l'adulte: les orientations suggérées par les consensus français et belge.

Usual gastroesophageal reflux (GER) presentations are heartburn and acid regurgitation. The prevalence in occidental population ranges from 5 to 45% according to symptoms frequency. Oesophagitis is observed in 30 to 50% of examined patients and only erosive and ulcerative lesions must be considered. Distinction is made between non-severe oesophagitis (isolated loss of substance), severe oesophagitis (circonferential loss of substance) and complicated oesophagitis (stenosis, ulcerations, brachyoesophagus). 24-hour pH-monitoring analyses reflux duration and relations between symptoms and reflux specially in unusual extraoesophageal presentations. Symptoms and quality of life are the main criteria for staging. In few patients, oesophagitis is severe. Complications (stenosis, ulcerations, bleeding, endobrachyoesophagus) are observed in 10 to 15% of cases. Endobrachyoesophagus with intestinal metaplasia is a risk for neoplasia. The consensus conference proposes this initial therapeutic strategy. In cases of time-spaced symptoms: antiacids, alginic acid or low doses of anti-H2 with life style changes. In cases of typical frequent symptoms, in patients younger than 50 years: 4-weeks treatment with half dosed proton pump inhibitors (PPI) or standard doses of anti-H2 or prokinetics. Nowadays, the majority of the experts propose empiric full-dose treatment. This attitude is more logical as total symptoms suppression with full dose PPI brings positive clues for exact GOR diagnostic without endoscopy. In patients older than 50 years or with alarming symptoms (weight loss, dysplagia, bleeding, anemia): endoscopy must be performed. Patients with non severe oesophagitis: PPI without checking endoscopy. In patients with severe or complicated oesophagitis: 8-weeks treatment following by endoscopy; in non relieved patients: doses are increased. In cases of extraoesophageal presentations: standard PPI treatment during 4 to 8 weeks if GER is well established. In long term strategy, if recidives are rare: intermittent treatment. In early and frequent recidives: long term adapted PPI or surgery. Stenosis are treated by PPI, pneumatic dilatation or surgery if unsuccessful. Brachyoesophagus must be checked by endoscopy every 2 years (malignancy risk).

[Factors influencing healing of duodenal ulcer in smokers treated with cimetidine]. / Facteurs influençant la guérison de l'ulcère duodénal chez des fumeurs traités par la cimétidine.

In 118 male patients with duodenal ulcer smoking cigarettes, treatment with cimetidine 1 g/day promoted healing of the ulcers in 67% after four weeks. No differences were observed between healed and not healed patients for age, symptom period before treatment, early onset and multiple ulcers. In not healed patients, more had a greater ulcer diameter (p less than 0.001) and more were heavy smokers (greater than 30 cig./day; p less than 0.001). In not healed patients, pentagastrin-induced maximal acid output, corrected for age, was higher than in healed patients (p less than 0.001). We confirmed the linear relationship between acid output and the number of cigarettes smoked per day (p less than 0.001). By the stepwise logistic regression model, the following factors were selected as predictors for healing of duodenal ulcer with 68% correct classification: ulcer size (p less than 0.01) and daily consumption of cigarettes (p less than 0.01). (Acta gastroenterol. Belg., 1990, 53, 299-306).

[Comparison of 24-hour gastric pH in normal controls and patients with duodenal ulcer or atrophic gastritis]. / Comparaison du pH gastrique de 24 heures chez des témoins, des ulcéreux duodénaux et des malades atteints de gastrite atrophique.

Twenty-four intragastric acidity was measured by continuous recording using intragastric glass electrodes in 16 normal controls, 18 inactive duodenal ulcer patients and 7 patients with atrophic gastritis. Median pH for the 24 h period, for the 8 AM-8 PM period, and for the 8 PM-8 AM period were significantly lower in duodenal ulcer patients than in controls (1.19 vs 1.78; 1.17 vs 2.05; 1.27 vs 1.64). Median pH for these 3 periods were significantly higher in patients with atrophic gastritis than in controls (3.90; 3.72; 3.81). The median pH for the 24 h period was higher than the lower quartile value of the control group in 33 per cent of duodenal ulcer patients. During the night (24 h-3 h), duodenal ulcer patients had significantly lower median pH (1.03) than controls (1.51). Antisecretory treatment should be directed to decrease this period of unbuffered acidity.

[The effect of cigarette smoking on the cicatrization of duodenal ulcers in patients treated with cimetidine. The role of acid hypersecretion]. / Influence de la consommation de cigarettes sur la cicatrisation de l'ulcère duodénal chez des malades traités par la cimétidine. Rôle de l'hypersécretion acide.

In 92 patients with duodenal ulcer, male cigarette smokers treated with cimetidine 1 g/day, 66.3% healed after four weeks. No differences were observed between healed and non-healed patients for age, symptom period before treatment, early onset (less than 30 years), multiple ulcers. In non-healed patients, more had a greater ulcer diameter (p = 0.0026) and more were heavy smokers (p = 0.0002). In non-healed patients, pentagastrin-induced maximal acid output, corrected for age, was higher than in healed patients (p less than 0.05). We confirmed the linear relationship between acid output and the number of cigarettes smoked per day (p less than 0.05). These observations suggest that cigarette smoking over a long period could stimulate the vagus. This would increase the functional parietal cell mass and explain the observed increase in pentagastrin-induced acid output.

[Comparison of 24-hour gastric pH in control subjects, in patients with duodenal ulcer and in patients with atrophic gastritis]. / Comparaison du pH gastrique de 24 heures chez des témoins, des ulcéreux duodénaux et des malades atteints de gastrite atrophique.

Twenty four hour intragastric acidity was measured by continuous recording using intragastric glass electrodes in 16 controls, 18 inactive duodenal ulcer patients and 7 patients suffering from atrophic gastritis. Medians pH for the 24h period, for the 8 AM-8 PM period, for the 8 AM-8 PM period were significantly lower in duodenal ulcer patients than in controls (1.19 vs 1.78; 1.17 vs 2.05; 1.27 vs 1.64). Median pH for these three periods were significantly higher in patients suffering from atrophic gastritis than in controls (3.90; 3.72; 3.81). In duodenal ulcer patients, 33 p 100 had medians for the 24h period higher than the lower quartile value of the control group. During the night (24h-3h) duodenal ulcer patients had median pH (1.03) significantly lower than controls (1.51). Antisecretory treatment should be directed to decrease this period of unbuffered acidity.

[Effect of 300 mg of ranitidine, 800 mg of cimetidine and a placebo administered after the evening meal on 24-hour gastric pH in patients with duodenal ulcer]. / Effet de 300 mg de ranitidine, de 800 mg de cimétidine et d'un placebo administrés après le repas du soir sur le pH gastrique de 24 heures chez l'ulcéreux duodénal.

Twenty-four-hour intragastric pH monitoring was performed in 20 patients with duodenal ulcer in order to compare the results obtained with placebo, ranitidine 300 mg and cimetidine 800 mg administered one hour (7 PM) after evening meal (6 PM). During each 24 h period (8 AM-8 AM), gastric pH was continuously monitored in standardized dietary conditions. Treatment was started the evening (7 PM) before the test. Median acidity was calculated and percent of time of recording at or above any pH unit was graphically represented. Median acidity and areas under the curves were submitted to statistical comparison. The values were computed for the 24-h period, for the 8 AM-8 PM period, for the 8 PM-8 AM period. In these three periods studied gastric acidity decreased more with ranitidine than with cimetidine. No statistical difference was found between cimetidine and placebo for the 8 AM-8 PM period.

[Sensitivity and specificity of blood amylase, amylase and creatinine clearance ratio and urinary amylase/urinary creatinine ratio in the diagnosis of acute pancreatitis]. / Sensibilité et spécificité de l'amylasémie, du rapport des clairances d'amylase et de créatinine et du rapport amylasurie/créatininurie pour le diagnostic des pancréatites aiguës.

The sensitivity and specificity of amylasemia, the ratios of amylase/creatinine clearance and amylasuria/creatininuria were determined in four groups of patients: a control group (n = 43), patients with acute pancreatitis detected on computed tomography (n = 30, 25 cases of alcoholic pancreatitis), patients with an acute surgical abdomen without pancreatitis (n = 25), and patients with renal failure (n = 20). Sensitivity was defined for the acute pancreatitis group and specificity for the other groups. When amylasemia was greater than 20 UI/dl and the amylasuria/creatininuria ratio greater than 100, sensitivity was 98 per cent. The specificity of these two results in patients with an acute surgical abdomen was 98 per cent. When the ratio amylase/creatinine clearance ratio was greater than 4 sensitivity was 73 per cent and specificity in patients with acute surgical abdomen was 75 per cent. These two values were lower than those of the two preceding tests (p less than 0.01). Sensitivity of the association of an amylasemia greater than 13 UI/dl (m + 2SD) with a clearance ratio greater than 4 was 73 per cent. The amylase/creatinine clearance ratio did not seem to be reliable since its change was delayed with respect to the increase of amylasemia and amylasuria. This ratio has a poor specificity as it increased when the clearance of creatinine decreased in the group with an acute surgical abdomen associated with functional or organic renal failure. In these two groups, the correlation between the amylase/creatinine clearance ratio and creatininemia was significant. This suggested that the clearance of creatinine fell more rapidly than the clearance of amylase as renal failure increased.

Infective endocarditis on mitral valve prolapse (IEMVP): report of one case due to H. paraphrophilus and discussion of IEMVP with emphasis on its prophylaxis.

We describe one case of infective endocarditis on mitral valve prolapse (IEMVP) due to H. paraphrophilus and briefly discuss this pathogen and the valvulopathy. We than enhance some notions on IEMVP and especially on its controversial prophylaxis.