Computed virtual chromoendoscopy versus standard colonoscopy with targeted indigocarmine chromoscopy: a randomised multicentre trial.

OBJECTIVE: Colonoscopy is the accepted gold standard for screening of neoplastic colorectal lesions, but the substantial miss rate remains a challenge. Computed virtual chromoendoscopy with the Fujinon intelligent colour enhancement (FICE) system is a new dyeless imaging technique that might allow higher rates of adenoma detection. METHODS: This is a prospective randomised five tertiary care centre trial of colonoscopy in the FICE mode versus standard colonoscopy with targeted indigocarmine chromoscopy (control group) in consecutive patients attending for routine colonoscopy. Histopathology of detected lesions was confirmed by evaluation of endoscopic resection or biopsy specimens. RESULTS: 871 patients were enrolled, and 764 patients (344 female, mean age 64 years) were subjected to final analysis (368 in the FICE group, 396 in the control group). In total, 236 adenomas (mean of 0.64 per case) were detected in the FICE group and 271 adenomas (mean of 0.68 per case) in the control group (p = 0.92). There was no statistically significant difference in the percentage of patients with >or=1 adenoma between the control group (35.4%) and the FICE group (35.6%) (p = 1.0). For the differential diagnosis of adenomas and non-neoplastic polyps, the sensitivity of FICE (92.7%) was comparable with that of indigocarmine (90.4%) (p = 0.44). CONCLUSIONS: At colonoscopy, adenoma detection rates are not improved by virtual chromoendoscopy with the FICE system compared with white light endoscopy with targeted indigocarmine spraying. However, FICE can effectively substitute for chromoscopy concerning the differentiation of neoplastic and non-neoplastic lesions.

Association of primary biliary cirrhosis and blue rubber bleb naevus syndrome.

A 66-year old woman presented all the features of primary biliary cirrhosis and the blue rubber bleb naevus syndrome. This case represents a new association of primary biliary cirrhosis with an inherited disease.

[Hepatopulmonary syndrome]. / Das hepatopulmonale Syndrom.

The hepatopulmonary syndrome (HPS) is a functional process which is characterized by the triad of liver cirrhosis, intrapulmonary vascular dilatations, and arterial hypoxemia in absence of detectable intrinsic disease of the lung and the heart. The pathophysiological foundation is the presence of a ventilation-perfusion (VA/Q) inequality based on marked vasodilatation of the pulmonary vessels at the precapillary level. Only in critically ill patients limitations of the diffusion of oxygen from the alveolar gas to the capillary blood and intrapulmonary arterio-venous communications will contribute increasingly to the hypoxemia. For diagnosis of HPS arterial blood gases (under condition of room air and 100% oxygen), contrast echocardiography, pulmonary angiography, and multiple inert gas elimination techniques will provide important informations. Regarding recent studies, liver transplantation is the treatment of choice in patients with severe HPS.

[Pneumoretroperitoneum and bilateral pneumothorax after endoscopic biliary sphincterotomy]. / Pneumoretroperitoneum und beidseitiger Pneumothorax nach endoskopischer Sphinkterotomie.

HISTORY AND ADMISSION FINDINGS: A 39-year-old obese woman underwent endoscopic retrograde cholangiopancreatography with elective endoscopic biliary sphincterotomy (papillotomy) for symptomatic retained stones in the common bile duct which were extracted completely after added lithotripsy. Three hours later the patient developed profound subcutaneous emphysema of the face, neck and chest wall and shortness of breath, but had no abdominal pain. Physical examination revealed bilaterally diminished breath sounds and a distended and hyper-resonant abdomen, but no evidence of peritonitis. The patient was afebrile and hemodynamically stable. INVESTIGATIONS: An emergency contrast-enhanced computed tomography (CT) of the chest and abdomen was performed. It demonstrated a bilateral pneumothorax, pneumomediastinum, pneumoperitoneum and pneumoretroperitoneum, in addition to extensive subcutaneous emphysema. There was no evidence of extraluminal leakage of contrast medium or intraperitoneal fluid on the CT. THERAPY AND CLINICAL COURSE: Because of the increasing respiratory distress an intercostal drain was placed in the left pneumothorax and broad-spectrum antibiotics were administered. No drain was placed in the right lung. A follow-up CT after three days showed decreasing pneumomediastinum, pneumoperitoneum and pneumoretroperitoneum as well as resolution of the bilateral pneumothorax. The patient made an uneventful recovery and was discharged home seven days after the intervention. CONCLUSION: Pneumothorax after endoscopic biliary sphincterotomy is a rare but serious complication that should be kept in mind after postinterventional development of shortness of breath.

Diagnosis of small bowel Crohn's disease: a prospective comparison of capsule endoscopy with magnetic resonance imaging and fluoroscopic enteroclysis.

BACKGROUND AND AIMS: The diagnostic yield of capsule endoscopy (CE) compared with magnetic resonance imaging (MRI) in small bowel Crohn's disease is not well established. We prospectively investigated CE, MRI, and double contrast fluoroscopy in patients with suspected small bowel Crohn's disease. METHODS: Fifty two consecutive patients (39 females, 13 males) were investigated by MRI, fluoroscopy and--if bowel obstruction could be excluded--by CE. In 25, Crohn's disease was newly suspected while the diagnosis of Crohn's disease (non-small bowel) had been previously established in 27. RESULTS: Small bowel Crohn's disease was diagnosed in 41 of 52 patients (79%). CE was not accomplished in 14 patients due to bowel strictures. Of the remaining 27 patients, CE, MRI, and fluoroscopy detected small bowel Crohn's disease in 25 (93%), 21 (78%), and 7 (of 21; 33%) cases, respectively. CE was the only diagnostic tool in four patients. CE was slightly more sensitive than MRI (12 v 10 of 13 in suspected Crohn's disease and 13 v 11 of 14 in established Crohn's disease). MRI detected inflammatory conglomerates and enteric fistulae in three and two cases, respectively. CONCLUSION: CE and MRI are complementary methods for diagnosing small bowel Crohn's disease. CE is capable of detecting limited mucosal lesions that may be missed by MRI, but awareness of bowel obstruction is mandatory. In contrast, MRI is helpful in identifying transmural Crohn's disease and extraluminal lesions, and may exclude strictures.

Concentrations of albendazole in serum, cerebrospinal fluid and hydatidous brain cyst.

A young girl with cerebral echinococcosis was treated with albendazole (13 mg/kg/d, p.o.). The concentrations of albendazole sulphoxide were determined in serum, cerebrospinal fluid and hydatidous cyst over a month. The mean ratios of concentration were: CSF/serum = 50%, cyst/serum = 40%, cyst/CSF = 80%.

[Hepatopulmonary syndrome]. / Das hepatopulmonale Syndrom.

The hepatopulmonary syndrome (HPS) is a functional process and is characterized by the triad of liver cirrhosis, intrapulmonary vascular dilatations, and arterial hypoxemia in absence of detectable intrinsic disease of the lung and the heart. The pathophysiological fundament is the presence of a ventilation-perfusion (VA/Q) inequality based on marked vasodilatation of the pulmonary vessels at the precapillary level. Only in critically ill patients limitations of the diffusion of oxygen from the alveolar gas to the capillary blood and intrapulmonary arteriovenous communications will increasingly contribute to the hypoxemia. For diagnosis of the HPS the arterial blood gases (under condition of room air and 100% oxygen), the contrast echocardiography, the pulmonary angiography, and the multiple inert gas elimination technique will give important informations. Regarding recent studies liver transplantation is the treatment of choice in patients with severe HPS.

[Therapeutic results after papilloduodenal injuries following ERCP]. / Behandlungsergebnisse nach papilloduodenalen ERCP-Verletzungen.

INTRODUCTION: Our goal was to compare operative vs. conservative therapeutic strategies after injuries following ERCP. METHODS: Eight patients with ERCP-induced injuries were surveyed retrospectively. Four of them were treated operatively, four conservatively. Criteria for an operative therapy were clinical and radiological findings and laboratory data. RESULTS: The four patients that were treated conservatively had an uncomplicated course whereas three of four patients treated operatively had long and complicated stays. In these patients the operation was performed more than 24 hours after injury. All of them showed advanced biliary peritonitis. One patient was operated on within 24 hours. He was discharged after a short stay without complications. All injuries were located in the retroperitoneum. Five patients showed anatomical abnormality of either duodenum, papilla or common bile duct. In five cases the duodenum was involved in the injury. CONCLUSIONS: The course of disease of the operated patients was longer and more complicated compared to those treated conservatively. According to our data the timing of the operation seems to be an important criterion with respect to the prognosis. Due to the small number of patients, whether conservative therapy should be preferred cannot be determined. The role of the location of injury is also not clarified.

[Acute upper gastrointestinal hemorrhage. Diagnosis and management]. / Akute obere Gastrointestinalblutung. Diagnostik und Management.

Upper gastrointestinal hemorrhage calls for a team approach. Early endotracheal intubation of unconscious patients helps to prevent aspiration. Erythromycin i.v. 20 min. before emergency endoscopy improves the diagnostic yield. Patients without increased risk of rebleeding may be treated on an outpatient basis. Band ligation is the gold standard for acute variceal bleeding. Terlipressin, somatostatin and octreotide are equally effective but require additional measures for prevention of late recurrence. Somatostatin and analogues used as adjunct to ligation slightly reduce the risk of rebleeding but not of death. Three to seven days of prophylactic antibiotics decrease the risk of uncontrolled or recurrent bleeding. Therapeutic failures are rescued by transjugular intrahepatic portosystemic shunting (TIPS). Patients with nonvaricose bleeding should only be treated when active hemorrhage or a "visible vessel" is found. First line treatment is endoscopic injection of diluted adrenalin or isotonic saline. Thermal coagulation is an alternative. Tissue-destructing sclerosants should be avoided. Clipping and injection of fibrin glue are second and third line measures. Proton pump inhibitors improve endoscopic hemostasis, however, it is unclear whether high i.v. doses are required. H. pylori must be eradicated to prevent late recurrence. Rebleeding is treated endoscopically with angiographic intervention or surgery as rescue measures.

[Spontaneous bacterial peritonitis (SBP). Retrospective and prospective data from a multicenter study on prevalence, diagnosis and therapy in Germany]. / Spontane bakterielle Peritonitis (SBP). Retrospektive und prospektive Daten einer multizentrischen Studie zu Prävalenz, Diagnostik und Therapie in Deutschland.

BACKGROUND: Data regarding the prevalence of SBP in patients with ascites or the diagnostic and therapeutic management of SBP in Germany are lacking. PATIENTS AND METHODS: In a multicenter study (40 hospitals), retrospective, then prospective data were collected investigating the prevalence of SBP in patients with ascites and the pertinent diagnostic and therapeutic management. In 272 prospectively entered patients with ascites (cirrhosis/malignant ascites/other: n = 227/42/3) a diagnostic paracentesis was performed and SBP diagnosed using the ascitic neutrophil count. History, clinical symptoms and laboratory findings were recorded and potential risk factors analysed by univariate analysis and stepwise logistic regression. SBP was treated with a standard dose of a third-generation cephalosporin. RESULTS: In the retrospective study, SBP was diagnosed in 648 of 4,697 patients with ascites (14 %). Employed diagnostic and therapeutic pathways were not effective in several hospital departments. In the prospective trial, SBP was found in 134 of 272 patients with ascites (49,3 %). Frequency of symptoms was significantly different in patients either with or without SBP, as were macroscopic aspect of ascites, urine excretion and several biochemical parameters. However, their diagnostic precision was unsatisfactory. Predictive factors for SBP were previous paracentesis, endoscopic procedures and a history of abdominal pain. Treatment was effective in 83,5 % of cases. Inhospital mortality was 10 %. CONCLUSION: The prevalence of SBP in hospitalised patients with ascites in Germany is similar to that in southern Europe and USA. Symptoms alone lack sufficient diagnostic accuracy. Third-generation cephalosporin is an effective antibiotic in SBP. Pertinent diagnostic and therapeutic management calls for improvement.

[Portal vein thrombosis in a patient with lowered protein S level]. / Pfortaderthrombose bei einem Patienten mit erniedrigtem Protein-S-Spiegel.

HISTORY AND CLINICAL FINDINGS: In a 39-year-old man with increasing spasmodic epigastric pain, nausea and vomiting, varices of the esophagus and the gastric fundus were found endoscopically. INVESTIGATIONS: A portal vein thrombosis and a consecutive thrombosis of the splenic vein were diagnosed by colour Doppler sonography and angio CT. A protein S deficiency (59 %) was found to be the underlying illness. TREATMENT AND COURSE: The thrombosis and the resulting clinical symptoms completely resolved shortly after starting therapeutic heparinization. For six months, the patient has been without complaints or clinical symptoms. CONCLUSION: Hence, an isolated protein S deficiency can be the cause for a portal vein thrombosis.

Transjugular intrahepatic portosystemic shunt: short-term and long-term effects on hepatic and systemic hemodynamics in patients with cirrhosis.

The aim of this prospective, nonrandomized study was to assess the short- and long-term effects of transjugular intrahepatic portosystemic shunt (TIPS) on hepatic and systemic hemodynamics and on gastroesophageal collateral flow in patients with cirrhosis and failure of chronic sclerotherapy. Cardiac output (CO), free and wedged pulmonary artery pressure (FPAP and WPAP), systemic vascular resistance (SVR), azygos venous blood flow (AzVBF), and the relative (portal minus vena cava) pressure in the portal vein (rel.PP) were determined immediately before, 30 minutes, 1 week, 3 months, and 1 year after TIPS implantation in 21 patients with alcoholic and biliary cirrhosis with repeated bleeding from esophageal varices despite chronic sclerotherapy. TIPS was inserted when patients were in a stable hemodynamic condition. Palmaz stents were dilated to a 10-mm to 14-mm diameter until gastroesophageal collaterals were no longer visible on direct splenoportography. Relative portal pressure decreased from 21 +/- 5 mm Hg to 11 +/- 5 mm Hg 30 minutes after the procedure (P <.001). CO increased from 7.1 +/- 1.5 L/min at baseline to 8.9 +/- 2.0 L/min (P <.005) at 30 minutes, 8.2 +/- 2.0 L/min (P <. 01) at 1 week, and 8.0 +/- 2.0 L/min (P <.01) at 3 months after TIPS, and returned to 7.2 +/- 1.3 L/min (ns) after 1 year. Before TIPS, SVR was 990 +/- 285 dyne. sec. cm-5 and decreased to 856 +/- 252 dyne. sec. cm-5 (P <.05) and 866 +/- 267 dyne. sec. cm-5 (P <.05) at 30 minutes and 1 week after the procedure, and increased again to 903 +/- 208 dyne. sec. cm-5 (ns) and 1,016 +/- 260 dyne. sec. cm-5 (ns) at 3 months and 1 year, respectively. AzVBF continuously decreased from 474 +/- 138 mL/min before TIPS to 335 +/- 116 mL/min, 289 +/- 147 mL/min, 318 +/- 157 mL/min, and 250 +/- 104 mL/min (all P <.005) at 30 minutes, 1 week, 3 months, and 1 year after TIPS. Portal decompression after TIPS is associated with a significant increase of CO for at least 3 months, which is only partly explained by a transient decrease of SVR. After 1 year, CO had returned to baseline levels. Despite an immediate decrease in portal pressure, the reduction of blood flow through gastroesophageal collaterals is delayed and not complete before 1 year after TIPS. In contrast to previous short-term observations, TIPS does not seem to cause long-term aggravation of the hyperkinetic circulation in patients with cirrhosis.

Transjugular intrahepatic portosystemic shunt for bleeding angiodysplasia-like lesions in portal-hypertensive colopathy.

Portal-hypertensive colopathy has attracted interest in recent years because such lesions can cause life-threatening hemorrhage. In contrast to upper gastrointestinal bleeding from varices, there is no established therapy for bleeding from angiodysplasia-like lesions. This case report describes the first successful use of transjugular intrahepatic portosystemic shunt (TIPS) for long-term control of bleeding from angiodysplasia-like colonic lesions in a patient with cirrhosis caused by chronic hepatitis B infection. During an 18-month course after TIPS, angiodysplasia-like lesions disappeared without any further evidence of recurrent hematochezia. TIPS may be helpful as second-line treatment in patients with recurrent portal-hypertensive bleeding from colonic angiodysplasia-like lesions who do not tolerate or are unresponsive to treatment with beta-adrenergic blockers.

[Endoscopic therapy of cholangiolithiasis by percutaneous approach. Percutaneous gallstone therapy]. / Endoskopische Therapie der Cholangiolithiasis über perkutanen Zugang. Perkutane Gallensteintherapie.

PATIENTS AND METHODS: In a retrospective study, the results of percutaneous transhepatic therapy of bile duct stones under cholangioscopic control (PTCS) were evaluated in 32 patients in which a endoscopic retrograde stone removal was impossible or failed. RESULTS: Previous gastric surgery was the most common reason for choosing the percutaneous route (22 cases). Five patients had biliodigestive anastomosis, two pyloric obstructions, and in three patients the retrograde stone removal failed. Complete stone removal was obtained after 3 to 11 (median 5) percutaneous procedures in all cases, in 28 patients by electrohydraulic lithotripsy, and in the remaining 5 cases by mechanical extraction alone. There was no complication due to cholangioscopy and lithotripsy themselves. Two cases had major complications which needed laparotomy (4%, one case had capsular bleeding from the liver, another one had catheter perforation of the duodenum). In addition, three cases (7%) had minor complications which required no therapy during the percutaneous fistula procedure. Two elderly multimorbid patients (4%) died during hospitalisation after successful stone removal not related to the performed procedure. CONCLUSION: The percutaneous transhepatic cholangioscopy (PTCS) and lithotripsy are highly effective techniques for endoscopic treatment of bile duct stones. Because of an increased rate of complications during the fistula procedures, both methods should be restricted to cases with difficult anatomic situation and high risk of surgery.

Hepatic arterial blood flow velocities: assessment by transcutaneous and intravascular Doppler sonography.

BACKGROUND/AIMS: Doppler sonography has been used to assess hepatic arterial perfusion in a number of published reports. However, adequate validation studies are available for neither the transcutaneous nor the intravascular Doppler approach. The aim of this comparative study was to assess hepatic arterial perfusion with both methods. METHODS: In 15 patients the right hepatic artery was examined with intravascular and transcutaneous Doppler sonography after calibration of Doppler devices in vitro with a thread model. The measurements were performed simultaneously in five and separately within 24 h in 10 patients. RESULTS: In vitro, the correlations between the velocities of the thread and the velocities as determined by intravascular (r=1.0, p<0.001) and transcutaneous Doppler sonography (r=1.0, p<0.001) were excellent. In vivo, the best correlation was found for systolic peak velocities (intravascular: 58.5+/-18.1 cm/s, mean+/-standard deviation, transcutaneous: 58.2+/-25.2 cm/s, r=0.63, p=0.01). Although lower mean (intravascular: 26.5+/-7.7 cm/s, transcutaneous: 32.5+/-14.4 cm/s) and end-diastolic velocities (intravascular: 11.5+/-4.0 cm/s, transcutaneous: 18.4+/-8.6 cm/s) were found with intravascular compared to transcutaneous Doppler sonography, significant correlations were demonstrable between results obtained by both methods (r=0.63, p=0.01 for mean and r=0.57, p=0.025 for diastolic velocities). Similarly, the calculated resistive (intravascular: 0.79+/-0.07, transcutaneous: 0.68+/-0.06, r=0.65, p=0.009) and pulsatility indices (intravascular: 1.78+/-0.47, transcutaneous: 1.26+/-0.25, r=0.55, p=0.034) were somewhat higher using the intravascular device, but correlated well with the numbers obtained by the transcutaneous approach. CONCLUSIONS: The data suggest that with use of different Doppler devices, systolic velocities are the most suitable parameter for Doppler assessment of hepatic arterial perfusion.

The 13C-urea breath test--detection of Helicobacter pylori infection in patients with partial gastrectomy.

The 13C-urea breath test (13C-UBT) for diagnosis of Helicobacter pylori (Hp) infection was evaluated in 41 patients after partial gastrectomy and was used for determination of the Hp-prevalence after two different procedures of reconstruction of the gastrointestinal tract, i.e. Billroth's II operation and Roux-en-Y anastomosis. Breath samples were taken at various time points within 30 minutes after a motility inhibiting liquid test meal with citric acid followed by 75 mg of 13C-urea. The 13CO2/12CO2-ratio (delta-value) was measured using isotope ratio mass spectrometry and the recovery of tracer in the exhaled breath was calculated (UBT-value). In all patients and in the corresponding control groups comparison of established reference methods (culture, CLO test, and Fuchsin staining) with the 4 point breath analysis for detection of Hp was investigated. In patients with partial gastrectomy, the sensitivity of the 13C-UBT to detect the presence of Hp and the negative predictive values were 100%, whereas the specificity and the positive predictive values were about 80%. In patients without gastric surgery quality control parameters were not significantly different. Hp-prevalence in postoperative patients was about 45%. All results were independent of their expression either as delta-value or as UBT-value and were not significantly different between the patients with Billroth's II operation and the patients with Roux-en-Y anastomosis. In conclusion, the 13C-UBT is a suitable method for diagnosis and therapeutic monitoring of Hp-status in patients after partial gastrectomy.

Decreased and variable systemic availability of zidovudine in patients with AIDS if administered with a meal.

The systemic availability of oral zidovudine has been studied in 13 patients with the acquired immunodeficiency syndrome (AIDS) dosed either fasting or with breakfast. The mean peak plasma concentration and AUC of zidovudine were significantly 2.8- and 1.4-times higher in fasting patients than in those treated during meal. In both conditions the mean half-life was about 1.5 h and the period of plasma zidovudine concentrations greater than 1 mumol.l-1 was 2 h (NS). It is concluded that if zidovudine is taken on an empty stomach, high peak plasma concentrations and decreased variation in pharmacological parameters may be expected. Whether or not this will influence toxicity and efficacy remains to be shown.

Individualized dosage of gentamicin: a programmed pocket calculator is useful only when applied properly.

Various methods of gentamicin dosing were compared in order to evaluate factors that prevent achievement of therapeutic peak and trough plasma concentrations in every patient. When standard doses of 3 x 80 mg of gentamicin/day (i.e., 3 x 170 mumol/day) were administered, only 26% of peak and 51% of trough plasma concentrations were within the desired range. This percentage increased for peak levels to 54% (p less than 0.001) when physicians were instructed in the use of a programmed pocket calculator (PPC) and to 70% (p less than 0.001) when in addition the nursing staff was trained. The best results were achieved when dosing and blood sampling were supervised by a single trained person, 76% of initial peak and 71% of initial trough levels being within the therapeutic range. In this group of patients, further dosage adjustments by the PPC achieved 92% of peak levels in the desired range, while no patient had elevated trough levels. Analysis of the factors that led to these results revealed that neither the laboratory nor the PPC are limiting factors for optimal results. The goal of therapeutic plasma concentrations can be achieved, but requires appropriate attention to the accuracy of blood sampling and dosing. For this purpose, a special program, i.e., more than ordinary attention to drug therapy, is needed.

Higher levels of serum aminoterminal type III procollagen peptide, and laminin in alcoholic than in nonalcoholic cirrhosis of equal severity.

In vitro models have shown that metabolites of ethanol (acetaldehyde and lactate) stimulate collagen synthesis, thereby, suggesting that they may be important as fibrogenic mediators. The relevance of these findings for fibrogenesis in the human liver in vivo, however, has not as yet been demonstrated. Serum markers for collagen (PIIINP, using radioimmunoassays employing polyclonal antibodies and Fab-fragments (PIIINP-Fab), respectively) and basement membrane (laminin) metabolism were therefore investigated in 25 alcoholic cirrhotics (Pugh-Score: 6.7 +/- 1.9 S.D.) and in 19 comparable nonalcoholic cirrhotics (Pugh-Score: 6.3 +/- 1.5, n.s.) with only slight evidence for inflammation: GOT 28 +/- 22 vs. 24 +/- 21 U/l; GPT 24 +/- 23 vs. 31 +/- 28 U/l; gamma-globulins 24 +/- 8 vs. 22 +/- 5%, respectively (all n.s.). Severity of the disease was assessed by quantitative liver function tests. Levels of PIIINP, PIIINP-Fab and laminin measured by RIA were 21 +/- 19 micrograms/l, 90 +/- 42 micrograms/l and 2.5 +/- 0.8 U/ml in alcoholic cirrhosis and 10 +/- 6 micrograms/l, 61 +/- 10 micrograms/l and 1.9 +/- 0.4 U/ml in nonalcoholic cirrhosis, respectively (all p less than 0.01). Differences on PIIINP and PIIINP-Fab remained significant even after accurate matching for galactose elimination capacity, aminopyrine breath test and hepatic sorbitol clearance. Laminin levels were higher in alcoholic cirrhosis only after matching for the hepatic sorbitol clearance (p less than 0.01). The higher levels of serum markers for collagen and basement membrane metabolism in alcoholic vs. nonalcoholic patients with cirrhosis at equal severity of the disease and with only minimal signs of inflammation may be the clinical reflection of a specific fibrogenic effect of ethanol metabolites.