Octreotide in the prevention of pancreatic injury associated with endoscopic cholangiopancreatography.

BACKGROUND: Data on whether long-acting somatostatin analogue octreotide causes or prevents pancreatic injury following endoscopic retrograde cholangiopancreatography (ERCP) are controversial. AIM: This multicentre, prospective trial studied the effect of octreotide on pancreatic injury in a large unselected group of patients after ERCP and endoscopic sphincterotomy. METHODS: The study was carried out in a prospective random manner on 2102 patients in 11 endoscopic centres. Patients in the study received 0.1 mg octreotide acetate and those in the control group received isotonic sodium chloride, subcutaneously before and 45 min after ERCP. Pancreatic injury was assessed by clinical symptoms such as pain, fever and abdominal tenderness. Serum amylase and blood sugar were determined prior to, and 6 and 24 h after the endoscopic procedure. RESULTS: Data from 599 patients in the study group and 600 in the control group were included in the final evaluation. When all the patients were considered, octreotide did not induce pancreatic injury as assessed by clinical symptoms, and diminished the increase of serum amylase levels following ERCP. However, when subgroups of patients were studied, the frequency of increased amylase levels decreased significantly in patients with chronic obstructive pancreatitis and in patients who underwent endoscopic sphincterotomy (P < 0.01). The peak serum glucose level was higher in the treated group when compared to the controls. CONCLUSION: The prophylactic use of long-acting somatostatin does not alter the frequency of post-ERCP pancreatic injury, but it may diminish the rate of increased serum amylase levels in patients with chronic obstructive pancreatitis and also in those with an endoscopic sphincterotomy.

Changes in gastric mucosal blood flow in patients with duodenal ulcer following proximal selective vagotomy (PSV).

Pentagastrin-stimulated mucosal blood flow and acid secretion were studied in duodenal ulcer patients by means of the 99mTc-4-methylaminophenazone clearance method in the active and inactive phases of the disease, and before and after proximal selective vagotomy. The results suggest that the mucosal blood flow--acid secretion ratio in the patients differs from that found in normosecretory subjects. In duodenal ulcer patients in the inactive phase, the secretory capacity of the gastric mucosa was found to be significantly elevated as compared with the mucosal blood flow. In the active phase of the disease the mucosal blood flow increased in parallel with acid secretion. Following proximal selective vagotomy the normal blood flow-secretion ratio was restored. Comparison of the pre- and postoperative gastric mucosal blood flow and secretion values via the 99mTc-methylaminophenazone clearance technique proved useful for the evaluation of the effectiveness of vagotomy.

[Early gastric carcinoma detection by endoscopy and biopsy; clinical experiences (author's transl)]. / Unsere Erfahrungen bei der Diagnostik des Magenfrühkarzinoms.

This report presents the clinical features of 15 cases of early gastric cancer detected amont altogether 144 gastric cancers diagnosed with the aid of gastroscopy and directed biopsy in a series of 2953 patients. Since the clinical and laboratory data of the patients with early gastric cancer do not provide satisfactory diagnostic evidence, careful X-ray examination must be carried out in all cases with long-standing symptoms relating to the upper part of the abdomen, especially in patients over 40 years old. Gastroscopy is essential in the clarification of any suspected pathological signs indicated by the radiologists and, furthermore, in all cases in which no radiological diagnosis was reached to account for the patient's symptoms. During gastroscopy multiple biopsy specimens should be taken from all lesions which may mask any type of the early cancers. The importance of regular endoscopic examination of high-risk persons for gastric cancer is emphasized.

[Palliative treatment of large bile duct stones by endoscopic implantation of endoprosthesis in high risk patients]. / Fokozott mütéti kockázatú betegek nagy epeúti köveinek palliatív kezelése endoscopos endoprothesis implantatióval.

UNLABELLED: Endoscopic insertion of biliary stents is an established method in the palliative treatment of malignant bile duct stenoses. However, there is less experience concerning the long term effect of endoprostheses in patients with large bile duct stones. PATIENTS AND METHOD: Straight polyethylen endoprostheses of 12 Fr diameter were transpapillary placed because of large bile duct stones in 25 patients during a 5-year-period. The stents were inserted for transitoric decompression and for permanent treatment in 2 and 23 cases, respectively. Unsuccessful endoscopic stone removal (inc. mechanical lithotripsy) in high risk patients or extremely limited tolerability of patients during the endoscopic procedure were regarded as indications of stenting. The patients were followed clinically, biochemically and endoscopically for a period of 6 months to 5 years (mean 22.7 months). RESULTS: No early complication was observed. Late cholangitis occurred in three patients due to endoprosthesis dislodging and clogging in two cases and one, resp. All complications were successfully managed by endoscopic route. In further three patients elective stent exchange was performed. 8 patients died during the follow-up period, the cause of death was independent of gallstone disease in all cases. Without any stent exchange, 13 patients are symptom-free for 6-60 months. CONCLUSIONS: Endoscopic endoprothesis placement is a simple, cost-effective, relatively safe and well tolerable method for transitoric biliary decompression and for long term treatment in high risk patients with endoscopically not removable large bile duct stones. In contrast with malignant stenoses, in cases of bile duct stones elective exchange of the stent is not necessary, only clinical and biochemical follow-up suggested.

Gastric blood flow and acid secretion: problems of the methodology and regulatory mechanisms.

Methods for proper measurement of gastric mucosal blood flow (MBF) in animal experiments or in clinical studies are critically reviewed. It can be stated that none of the techniques hitherto published fulfill all the criteria for proper measurement of the mucosal blood flow and concomitant acid production in the stomach. Some give an estimate of local blood flow changes (e.g. H2 gas clearance, laser Doppler flowmetry) in man without the possibility of simultaneous acid measurement. The 99mTc-MAP clearance technique developed by the authors reflects changes in both parameters and may also be used in clinical studies, when limitations of the method are taken into consideration. As a rule we assume that acid production and mucosal blood flow may change independently. The effects of various bioactive substances and drugs on both parameters are analysed. It seems that many contradictory findings have arisen because of differences in technique and experimental animals used.

[Endoscopic treatment of cholestasis caused by Ascaris lumbricoides]. / Ascaris lumbricoides okozta cholestasis endoszkópos megoldása.

The most common infection of the hepatobiliary system and of the pancreas is the infestation with Ascaris lumbricoides. Pancreatobiliary ascariasis may present as recurrent biliary colic, acalculous cholecystitis, cholangitis, pancreatitis, or hepatic abscess. Although ultrasonography is a highly sensitive and specific method for the detection of the disease, endoscopy may have also therapeutical potential. The majority of these infections is registered in developing countries, but the number of reports from Europe and North America is increasing. So far there has not been any publication from Hungary. Both of the two reported patients were admitted the hospital with colic pain in the right hypochondrium. The laboratory parameters revealed cholestasis. The transabdominal ultrasonography was normal in one case, but suspected alien body in the choledochus in the other patient. Ascaris lumbricoides was identified with endoscopic procedure in the ductus choledochus in both cases. Endoscopic extraction of the worm resulted in cessation of the complaints in both patients, their cholestatic laboratory parameters became normal. Although the parasitic tests in the stool were negative in both patients and in their relatives, mebendazole therapy was administered.

[Octreotide in the prevention of hyperamylasemia following ERCP (a controlled multicenter study)]. / Octreotid az endoszkópos retrográd cholangiopancreatographiát követó hyperamylasaemia prevenciójában (Multicentrikus kontrollált tanulmány).

UNLABELLED: The aim of the multicentric trial was to study the effect of octreotide (Sandostatin) on the rise of pancreatic amylase in the serum after ERCP based on a large number of patients. The study was carried out in a prospective random manner in 2102 patients in 11 endoscopic centers. Patients in the treated group received 0.1 mg octreotide acetate, and those of the nontreated (control) group received isotonic sodium-chloride subcutaneously before the ERCP and 45 minutes after. Serum amylase and blood sugar were checked before the endoscopic procedure, 6 and 24 hours later. Out of the total number of patients involved, data of 1199 patients (599 in the treated group, and 600 in the control group) were evaluated. Octreotide diminished the percentual increase of serum amylase levels following ERCP. However, the frequency of hyperamylasaemia was decreased only after in patients with chronic obstructive pancreatitis or in such patients after endoscopic sphincterotomy. The peak serum level of blood sugar was higher in the treated group compared to the controls. There was no difference in the clinical symptoms following ERCP between the two groups. CONCLUSION: the prophylactic use of long-acting somatostatin may diminish the frequency of hyperamylasemia after ERCP in patients with chronic obstructive pancreatitis or in those patients who subsequently underwent EST.

[Management of Oddi sphincter dyskinesis. Results of drug therapy and sphincterotomy]. / Az Oddi-sphincter dyskinesis kezelése. A gyógyszeres terápia és a sphincterotomia eredményei.

UNLABELLED: In a retrospective evaluation, the outcome of the long term treatment of the sphincter of Oddi dyskinesia (OD, type III. dysfunction) has been analysed. PATIENTS AND METHOD: Therapeutic results of 64 cholecystectomised patients with OD were evaluated by means of regular follow-up and questionnaire filled in either by the patients or their practitioners. RESULTS: Conservative treatment (nitroglycerin, calcium channel blocker or both) resulted in symptom-free condition or improvement with 53% of the patients (37/64). Out of 27 patients whose condition did not improve by combined drug therapy, in 20 cases endoscopic sphincterotomy (EST) and in 1 case transduodenal sphincterotomy were performed. Having followed sphincterotomy, out of 21 patients only 9 became symptom-free and 5 improved. CONCLUSIONS: Therapeutic benefit of sphincter relaxants fail in nearly half of the cases with OD, and even sphincterotomy can lead to symptomless condition only in a portion of OD. Regarding the high incidence of complications following EST in OD, it can only be recommended after failure of the conservative therapy in correctly diagnosed cases. The results emphasise a need for a prospective randomised controlled clinical study to seek for the optimal therapeutic regimen.

[Sinoatrial block caused by gastroesophageal reflux. The role of simultaneous 24 hr. esophageal pH-metry and Holter-ECG in the differential diagnosis of angina pectoris]. / Gastrooesophagealis reflux által provokált sinoatrialis block. A szimultán elvégzett 24 órás nyelöcsö pH-mérés és Holter-EKG jelentösége az angina pectoris elkülönítö kórisméjében.

UNLABELLED: The authors report on a 61-year-old female patient, who has suffered from recurrent angina-like chest pain for 30 years. The patient's complaints became intolerable, in spite of therapy with nitroglycerin, H2 receptor blockers and sedative medication. The echocardiography, the ECG exercise testing and Thallium scintigraphy were normal, the upper gastrointestinal endoscopy did not prove oesophagitis either macroscopically or microscopically. The simultaneous 24-hr Holter ECG monitoring and esophageal pH-metry demonstrated pathological acid gastro-oesophageal reflux and frequent sinoatrial blocks (Mobitz I) in painful periods. After monotherapy with proton pump inhibitor (omeprazole) the patient became complaint-free. Repeated combined 24-hr oesophageal pH-metry and Holter ECG monitoring indicated nonpathological acid reflux and insignificant number of sinoatrial blocks. During the course of 19 months the patient was asymptomatic. The acid pump inhibitor was stopped for a 10 day-period, while the chest pain returned. The combined 24-hr Holter ECG and esophageal pH-metry proved pathological acid gastro-oesophageal reflux and frequent sinoatrial blocks during chest pain period. After treatment with acid pump inhibitor the patient became asymptomatic again. CONCLUSIONS: 1. The acid gastro-oesophageal reflux may be a provocative factor of sinoatrial blocks and it can be influenced by proton pump inhibitor successfully. 2. Simultaneous 24-hr oesophageal pH-metry and Holter ECG monitoring can be contribute to the differentiation among causes of atypical chest pain.

[Management of hypertensive dyskinesia of Oddi's sphincter. Correlation between the frequency of complications from endoscopic sphincterotomy and the diameter of the common bile duct]. / A hypertoniás Oddi-sphincter dyskinesis kezelése. Osszefüggés az endoscopos sphincterotomia szövdményeinek gyakorisága és az epevezeték átméröje között.

OBJECTIVES: to evaluate the treatment possibilities in different forms of sphincter of Oddi dysfunction (SOD), in particularly that of the hypertonic sphincter of Oddi dyskinesia (HOD, biliary type group III). In the first part of retrospective evaluation the higher complication rate of endoscopic sphincterotomy (EST) and its probable causes were analysed. MATERIAL AND METHODS: The frequency and reasons of post-EST complications were retrospectively evaluated in a three-year (1990-1992) EST material of two gastroenterological departments using identical treatment principles and methods. Endoscopic sphincterotomies performed for bile duct stone extraction or treatment of HOD in cholecystectomized patients were included only. The data of 308 patients were analysed regarding two areas: 1. EST was performed for HOD treatment in 20 patients, and in 288 patients for stone removal, 2. the diameter of common bile duct was found non-dilated in 40 patients, and dilated in 268 patients, respectively. RESULTS: 1. The frequency of complications in the group of patients with EST for HOD treatment was significantly higher: 8/20 (40%) vs. 17/288 (5.9%) (p < 0.01). 2. There was also a significant difference in the percentage of total complications between the patients of nondilated bile ducts and those patients with dilated bile ducts: 8/268 (3.3%) vs. 17/40 (42.50%) (p < 0.01), detailed: bleeding: 4/268 vs. 6/40, pancreatitis: 4/268 vs. 10/40, and perforation: 0 vs. 1/40. CONCLUSIONS: Therapeutic endoscopic sphincterotomy is more hazardous in patients with non-dilated bile ducts, thus evidently also in patients suffering from the biliary III. type (hypertonic Oddi-sphincter dyskinesia) of sphincter of Oddi dysfunctions.

[Treatment of carcinoid syndrome with a somatostatin analogue]. / Carcinoid szindróma kezelése somatostatin analoggal.

Octreotide, a long-acting somatostatin analogue has recently been introduced in the therapy of gastroenteropancreatic endocrine tumors, but home experience has been lacking. With the aim of drawing attention to this therapeutic possibility, a case of malignant carcinoid syndrome treated with octreotide for 18 months is reported. Despite the therapeutic attempts preceding the octreotide administration a gradual progression in clinical symptoms was observed and cardiac failure due to fibrotic and valvular heart disease developed. Cytotoxic chemotherapy, serotonin antagonists or repeated selective embolisation of the hepatic artery only resulted in a short transitional improvement. Octreotide in a dose of 100 micrograms three times daily by subcutaneous injection provided effective and rapid relief from episodic flushing and serious diarrhoea. Plasma level of serotonin and 24-hour urinary excretion of 5-hydroxyindolacetic acid decreased from 6 micrograms/ml to 2 micrograms/ml and from 800 mumol/day to 70 mumol/day, respectively. No changes in the number and extension of liver metastases could be seen after introducing the octreotide treatment. The patient's compensated cardiac status could be preserved and continuous therapy provided an acceptable quality of life.

[Evaluation of the effectiveness of pantoprazole and ranitidine in the treatment of duodenal ulcer. Result of an international multicenter study]. / A pantoprazol és a ranitidin hatékonyságának vizsgálata nyombélfekély kezelésére. Nemzetközi multicentrikus vizsgálat eredménye.

A double-blind, randomized, multicenter, multicountry study (Poland, Chech Republic, Hungary) was carried out in 1995 on patients (n = 326) with endoscopically confirmed duodenal ulcer treated with ranitidine vs. pantoprazole. In Hungary-in 4 gastroenterology centers-123 patients have been involved (age 18-75 years). The treatment schedule has been 300 mgs of ranitidine or 40 mgs of pantoprazole q. d. for 2 or if necessary for 4 weeks. In the Hungarian study 60 DU patients were treated with pantoprazole vs. 63 ones with ranitidine. Having finished the two-week schedule the healing rates of duodenal ulcer were as follows: pantoprazole 71%/72% (Hungary/International) vs ranitidine 57%/51%, (p < 0.001). After 4 weeks the corresponding values showed the following: pantoprazole 98%/94% vs. ranitidine 88%/86%, respectively, (p < 0.005). Both drugs have shown to be effective and safe to cure duodenal ulcer however in our study pantoprazole was significantly more efficacious and provided quicker healing than ranitidine.

[Diagnostic value of CA 19-9 and CEA in gastrointestinal pathology]. / A CA 19-9 és a CEA tumorantigén diagnosztikus értéke gastrointestinalis kórképkben.

The diagnostic values of CA 19-9 and CEA were evaluated in 187 cases (including 31 gastric, 41 colorectal, 12 pancreatic, 7 hepatobiliar and 5 hepatocellular carcinomas). These tumor markers were compared to the other laboratory parameters [hemoglobin, erythrocyte sedimentation rate, serum bilirubin, ASAT (aspartate amino transferase), ALAT (alanine amino transferase) GGT (gamma glutamil transpeptidase), ALP (alkaline phosphatase)]. The specificity of CA 19-9 was 89.5%, while the sensitivity of this tumor markers was 91.7% in pancreatic carcinoma, 54.8% in gastric carcinoma and 43.9% in colorectal carcinoma. The sensitivity of CEA only in colorectal patients was higher than that of CA 19-9 (specificity 73.9%, sensitivity 64.5%). Although the CA 19-9 and CEA are not known to give any cross-reaction with each other, simultaneous measurement and evaluation of these two tumor antigens did not result in a better diagnostic sensitivity. After undergoing a gastrointestinal carcinoma operation, CA 19-9 indicated the appearance of tumor recidiva with a 62% sensitivity. Calculated together with CEA the sensitivity elevated to 88.9%. In most of the patient with benign cholostasis, the CA 19-9 and CEA values were out of the normal range (53.3% and 36.4% respectively), so these tumor markers are not suitable to differentiate between benign and malign cholostasis. According to the authors, CA 19-9 is the most useful diagnostic tool to differentiate between pancreatic carcinoma and pancreatitis chronica (both group without cholostasis), as well as for monitoring the patients after surgery of a gastrointestinal cancer.

[Early stage gastric cancer in Vas County]. / Korai gyomorrák Vas megyében.

UNLABELLED: Between 1983 and 1992, 44 patients with early gastric cancer underwent operative treatment. This group comprised 13.3 percent of all patients with gastric cancer operated on during this period. Every patient underwent oesophago-gastro-duodenoscopy before operation. The indication for surgery was histologically confirmed carcinoma in 37 patients, gastric haemorrhage in 2 patients and gastric ulcer unresponsive to medical treatment in 5 patients. The gastric carcinoma was limited to the mucosa in 28 cases and involved the submucosa in 16. Five patients, one with mucosal and four with submucosal early gastric cancer had regional metastatic lymph node involvement. Life-table calculated patient survival rate at 5 years, excluding the perioperative mortality, was 79.4 percent. CONCLUSIONS: 1. The prevalence of early gastric cancer proved to be similar to previously published in West-Europe and United States. 2. If early gastric cancer is limited only to the mucosa, regional metastatic lymph node is relatively rare. 3. Gastrointestinal bleeding can be the first clinical sign of early gastric cancer. 4. Therapy resistant gastric ulcer requires surgery irrespective of the histological examination of the biopsy specimen.

[Efficiency of electro-hydrothermal coagulation in the management of non-variceal upper gastrointestinal bleeding]. / Az elektro-hidro-termoszondával végzett coagulatio eredményessége a nem varix eredetü felsö gastrointestinalis vérzés kezelésében.

UNLABELLED: The data of 596 electro-hydrothermal coagulations in nonvariceal acute gastrointestinal bleeding were retrospectively evaluated and the results were compared to a previous period in which the endoscopic hemostasis was not regularly applied. Initial hemostasis was achieved in 96.1%, the rebleeding rate was 20.5%, perforation occurred in 0.5%. Comparing the two period the need of urgent surgery decreased from 9.2% to 3.4% (p < 0.05) and the mortality from 25.4% to 12% (p < 0.01). CONCLUSION: The electro-hydro-thermal coagulation is a safe and effective method in the treatment of nonvariceal gastrointestinal bleeding.

[Epidemiologic study of primary liver cancer in Vas County]. / Az elsödleges májrák epidemiológiai vizsgálata Vas megyében.

The incidence of primary liver carcinoma in the last twelve years was investigated retrospectively in the county Vas. A continuously increasing tumor frequency was found, by the end of the period the value had doubled. The phenomenon attained nearly exclusively the male population while no change could be seen in females. For further clarification comparative investigations into the association between chronic HBV infection and chronic alcohol abuse as well and hepatic carcinoma were performed. Changes in these factors cannot fully explain the gross increase in hepatic tumor incidence, the effect of other risk factors has to be suspected.

[Has Campylobacter pylori infection any clinical relevance? Methodologic, epidemiologic and clinical studies]. / Van-e klinikai relevanciája a Campylobacter pylori infekciónak? Metodikai, epidemiológiai és klinikai vizsgálatok.

The occurrence of Campylobacter pylori (CP) was studied in 180 patients referred for endoscopy. The bacterium was detected by culture, histology (Warthin-Starry staining) and urease test of antral biopsy samples. Patient groups were formed according to endoscopic diagnoses, clinical symptoms and antral mucosal histology. 50 CP positive patients with chronic antral gastritis were treated by bismuth subsalicylate (2,4 g/day) for 3 weeks. Positivity by culture and/or silver-stained histology proved to be the most reliable way for detecting CP. CP was proved in about 30% in patients with normal gastroduodenum (13/42) or with stump gastritis (4/15), in 75% with endoscopic antral gastritis (51/68) and in 89% with duodenal ulcer (49/55). A close relationship between CP and histological chronic antral gastritis could be demonstrated. No causal link between CP positive chronic active antral gastritis and non-ulcer dyspepsia could be verified. The decrease in histological activity of chronic gastritis and in dyspeptic complaints after bismuth salt therapy was found to be independent of CP elimination. The results of control investigations following a therapy-free interval of 7-10 days speak in favour of CP recolonialisation within a relativelly short period. It can be concluded that, despite the undeniable relationship between CP and chronic antral gastritis and duodenal ulcer, further studies are necessary to clarify the clinical relevance of the CP infection.

[Helicobacter pylori allergy]. / Helicobacter pylori allergia.

A case of a 44 year old woman with antrum gastritis and H. pylori infection was reported. After unsuccessful treatment of the disorder with bismuth and tinidazole, an auto-vaccine was prepared from the bacterium in order to eliminate the infection. After the first injection of the vaccine a generalised urticaria was observed. In the development of the skin eruptions a type I, and a type IV allergic reaction could be demonstrated using the H. pylori specific RAST-test and leukocyte migration inhibition respectively. After eradication of the bacterium by amoxycillin treatment, the clinical signs of both the gastrointestinal and allergic diseases disappeared.

[Onset of Philadelphia chromosome negative chronic myeloid leukemia with symptoms of intrahepatic cholestasis]. / Intrahepatikus cholostasis tüneteivel kezdödö Philadelphia chromosoma negatív chronikus myeloid leukaemia.

The case of a chronic myelogenous leukemia (CML) starting in an unusual form in a young woman is reported. Rapidly progressing icterus was the first and leading symptom of the disease. Simultaneously with the exclusion of the possibility of hepatitis and extrahepatic obstruction of the bile duct the qualitative blood picture roused the suspicion of a myeloproliferative disease. Detailed hematological examinations confirmed Philadelphia chromosome (Ph1) negative CML. Besides the histologically diffuse leukemic infiltration intrahepatic cholostasis could be demonstrated in the background of the icterus. In the chronic and accelerated phase clinical symptoms developing as a consequence of hepatic organic manifestation were dominating. In the authors's case the moderate leukocytosis, initial thrombocytopenia, absence of splenomegaly, early blast-phase and short survival were atypical, characteristic of Ph1 negative CML. The diagnosis and the absence of other associated hepatopathies was supported also by the post-mortem examination. CML beginning with icteric symptoms due to intrahepatic cholostasis is considered as rarity in the literature.

[Epidemiology of non-variceal upper gastrointestinal hemorrhage in Vas County in Western Hungary]. / A nem varix eredetü felsö gastrointestinalis vérzés epidemiológiája Vas megyében.

Data of 3014 patients with nonvariceal upper gastrointestinal bleeding were retrospectively evaluated in county Vas between 1984 and 1995. The annual incidence of bleeding increased progressively in this period. In this change the role of nonsteroidal antiinflammatory drugs in questionable, because in the investigated period the sale of these drugs decreased, although the purchase of oxicame, one of this drug-group associating with higher risk for bleeding increased. The risk of bleeding enhanced with ageing that can be explained by higher rate of Helicobacter pylori infection, by the greater consumption of nonsteroidal antiinflammatory drugs and by the more frequent serious concomitant diseases in elderly age. The risk of bleeding in males proved to be higher than in females, the frequency of bleeding in men was twice as much as it could be expected according to the sex rate of the peptic lesions. Their results concerning the reduction of mortality underline the importance of the early endoscopic diagnosis and therapy.