M. Staritz

CHARACTERISATION OF A NEW SUBGROUP OF AUTOIMMUNE CHRONIC ACTIVE HEPATITIS BY AUTOANTIBODIES AGAINST A SOLUBLE LIVER ANTIGEN

Autoantibodies against a soluble liver antigen (SLA) were detected in 23 patients with HBsAg-negative chronic active hepatitis (CAH) but not in 502 patients with various other hepatic and non-hepatic disorders or 165 healthy blood donors. Anti-SLA-positive serum samples were negative for antinuclear and liver-kidney-microsomal antibodies, markers of two subgroups of autoimmune-type CAH, 6 anti-SLA-positive patients were negative for all autoantibodies sought. Most of the anti-SLA-positive patients were young women (2 men, 21 women; mean age 37 years) with hypergammaglobulinaemia (mean 3.2 g/l, range 1.8-5.3 g/l); 18 of the 23 patients had received immunosuppressive treatment and all responded well. Anti-SLA titres declined during therapy, corresponding to disease activity. Anti-SLA cannot be detected by immunofluorescence. SLA is not organ-specific or species-specific, but the highest concentrations were found in liver and kidney. Anti-SLA autoantibodies characterise a third subgroup of autoimmune-type CAH and will allow a better differentiation of HBsAg-negative CAH which has therapeutic consequences.

Intravascular oesophageal variceal pressure (IOVP) assessed by endoscopic fine needle puncture under basal conditions, Valsalva's manoeuvre and after glyceryltrinitrate application.

A simple and safe procedure providing sensitive and reproducible direct measurement of intravascular oesophageal variceal pressure (IOVP) during routine oesophagoscopy is described. The method requires only commercially available equipment. First results were obtained in 16 patients with oesophageal varices caused by liver cirrhosis (Childs A) can be summarised as follows: intravascular oesophageal variceal pressure was nearly identical in different varices of the single patient. Varices grade III exhibited a significantly higher intravascular oesophageal variceal pressure than varices grade II (22.7 +/- 2.5 vs 15.7 +/- 0.6 mmHg, p less than 0.05). After Valsalvas manoeuvre there was a remarkable increase in intravascular oesophageal variceal pressure by 13.6 +/- 1.0 mmHg irrespective of the variceal size. The high intravascular oesophageal variceal pressure values observed in grade III varices during the rise of the intraabdominal pressure may indicate an important risk factor for variceal haemorrhage. Glyceryltrinitrate (1.2 mg sprayed onto the tongues of 14 patients) very effectively lowered the intravascular oesophageal variceal pressure from 22.8 +/- 2.0 to 12.0 +/- 0.4 mmHg in grade III varices, and from 16.3 +/- 0.4 to 10.0 +/- 0.4 mmHg in grade II varices (p less than 0.005 in both groups). We conclude that this method provides a suitable tool to study the effect of drugs with presumed influence on the oesophageal variceal pressure and that the impressive effect of glyceryltrinitrate in lowering intravascular oesophageal variceal pressure warrants further study on the effect of longer acting nitrates on intravascular oesophageal variceal pressure, and the rebleeding rate after oesophageal variceal haemorrhage.

Effect of glyceryl trinitrate on the sphincter of Oddi motility and baseline pressure.

It is widely accepted that glyceryl trinitrate (GTN) effectively dilates the smooth muscles of blood vessels. A similar effect has been postulated on the smooth muscles in the gastrointestinal tract. In this study the motility of the sphincter of Oddi and the common bile duct pressure as determined by endoscopic manometry was investigated in nine patients before and after sublingual application of 1.2 mg GTN (nitro group). Eight untreated patients served as controls. Three minutes after application of GTN the papillary contraction amplitude decreased from 69.3 +/- 4.3 mmHg to 36.8 +/- 5.1 mmHg (p less than 0.005) and the papillary baseline pressure fell from 8.9 +/- 0.6 mmHg to 2.9 +/- 0.2 mmHg (p less than 0.005) respectively. The contraction frequency in the nitro group and all motility parameters in the control group remained unchanged. These results indicate that GTN does not influence the sphincter of Oddi motility, but it relaxes very effectively the sphincter of Oddi muscle. Thus, GTN should be taken into account for the treatment of biliary colic. In our endoscopic unit GTN proved to be useful as premedication for endoscopic examinations, particularly for the removal of small and medium size common bile duct stones through the intact papilla.

Effect of modern analgesic drugs (tramadol, pentazocine, and buprenorphine) on the bile duct sphincter in man.

Modern narcotic analgesic drugs, such as tramadol, pentazocine, and buprenorphine share similarities of molecular structure with morphine which is widely believed to cause spasm of the bile duct sphincter and so impede bile flow. This study assessed the effects of intravenously administered analgesics on bile duct sphincter motor activity measured by ERCP manometry. Ten minutes after pentazocine injection the duration of contractions and baseline pressure of the bile duct sphincter rose from 6.2 +/- 0.2 to 8.2 +/- 0.27 s and from 5.1 +/- 0.6 to 8.8 +/- 0.4 mmHg respectively. Tramadol, buprenorphine and saline showed no such effect. These data indicated that the effects of such drugs on bile duct sphincter function can be safely assessed by ERCP manometry and that pentazocine adversely affects the bile duct sphincter, whilst tramadol and buprenorphine do not. We consider therefore that pentazocine is not the premedication of first choice for endoscopic procedures involving the sphincter of Oddi and should also be avoided in patients with pancreatic and biliary disorders.

Elevated Pressure in the Dorsal Part of Pancreas Divisum: The Cause of Chronic Pancreatitis?

In 6 patients with upper abdominal pain of unknown origin presenting with pancreas divisum, the pressure in the pancreatic duct was measured via the minor papilla into which in these patients the main part of the pancreatic duct system drains. For comparison intraductal manometry via the major papilla (papilla of Vater) was performed in 8 patients with normal pancreatic duct system. The pressure in the pancreatic duct of the control group was 10.5 +/- 0.9 mm Hg, whereas in the patients with pancreas divisum it was 23.7 +/- 1.3 mm Hg. The results demonstrate that in patients with pancreas divisum, intraductal pressure may be largely increased even in the fasting state.

Electromagnetically generated extracorporeal shockwaves for fragmentation of extra-and intrahepatic bile duct stones: indications, success and problems during a 15 months clinical experience.

Electromagnetically generated extracorporeal shock waves (without waterbath) were applied after intravenous premedication with 10-15 mg diazepam and 100 mg tramadol in the treatment of 33 patients (aged 32 to 91 years) with multiple intrahepatic stones (n = 4) or huge common bile duct stones (n = 29, 18-30 mm in diameter), which could not be removed by conventional endoscopy. Stone disintegration was achieved in 70% of common bile duct stones and in all intrahepatic concrements after 800-7500 discharges, which were applied during one (n = 21), two (n = 6) or three sessions (n = 6). Apart from mild fleabite-like petechiae at the side of shock wave transmission no other side effects were observed for a total of 51 procedures. We believe electromagnetically generated shock waves are safe, easy to apply, and relatively effective in the therapy of common bile duct and intrahepatic stones.

Electromagnetically Generated Extracorporeal Shock Wave Lithotripsy and Adjuvant Combined Oral Litholysis for Therapy of Symptomatic Gallbladder Stones

A prospective study was conducted to evaluate effectivity, problems and adverse effects of extracorporeal shock wave lithotripsy (ESWL) using a newly developed electromagnetic biliary lithotriptor (Lithostar Plus, Siemens, Erlangen, FRG) for the treatment of selected patients presenting with symptomatic cholecystolithiasis. In addition to generally accepted criteria for the selection of patients, gallbladder contractility was established and pigment stones were excluded by computed tomography (CT). 80 out of 486 patients (63 females, 17 males, mean age 36, range 17-76 years) were selected for ESWL using a standardized diagnostic program. 62 out of 80 patients participating in the study had solitary concrements (diameter 23.3 +/- 6.4 mm) while in 18 patients 2 or 3 stones (diameter below 10 mm) were observed. Stone fragmentation was achieved after an average of 1.35 treatment sessions (range 1-3) in 78 (97.5%) patients. No clinically relevant adverse effects were observed. Immediately after ESWL, ultrasound revealed misleading results with regard to stone fragmentation. 98.7% of patients (n = 77) were seen for follow-up investigations 3, 6 and 9 months after ESWL, and 82% at 12 months. A total of 40 (53%) patients became free of stones. Subgroup analysis showed that 68% of the patients were free of stones (stone diameter 10-20 mm), 54% (20-30 mm) and 33% (multiple stones), respectively. We therefore conclude that ESWL should be restricted to highly selected patients presenting with small (10-20 mm) solitary concrements.

Effect of the artificially elevated common bile duct pressure on the motor activity and function of the papilla of vater: a study by endoscopic manometry

In 10 patients without disease of the pancreatico-biliary system, the common bile duct pressure was artificially elevated by endoscopic retrograde feeding with saline under manometric control. The motor activity of the papilla of Vater was recorded by endoscopic manometry using the hydraulic capillary perfusion system according to Arndorfer. Compared to the baseline motility, a mild pressure elevation (from 9.75 +/- 1.8 to 13.5 +/- 0.26 mm Hg) had no effect. After the following strong pressure elevation (to 32 +/- 0.9 mm Hg), however, the papillary residual pressure and the wave duration of the papillary contractions increased significantly (p less than 0.001) from 5.5 +/- 0.5 s and 6.3 +/- 0.16 mm Hg to 10.7 +/- 0.75 s and 8.6 +/- 0.64 mm Hg, whereas the papillary contraction frequency and amplitude were not affected. These data indicate several clinically important speculations.

Pneumatoceles and pneumothoraces complicating staphylococcal pneumonia: treatment by synchronous independent lung ventilation.

A 54 year old man with a staphylococcal sepsis developed staphylococcal pneumonia complicated by multiple pneumatoceles and bilateral tension pneumothoraces caused by bronchopleural fistulae. Excessive enlargement of the right sided pneumatoceles and a tension pneumothorax not improved by drainage led to mediastinal shift and compression of the right lung. Reversal of the mediastinal shift and closure of the bronchopleural fistulae was achieved by assisted independent lung ventilation.

Is the Bile Duct Diameter a Reliable Parameter to Diagnose Extrahepatic Cholestasis

The common bile duct (CBD) pressure was determined in 57 patients before endoscopic retrograde cholangiography (ERC) and related to the diameter of the CBD and the common hepatic duct (CHD). We found that despite a weak overall positive correlation in the individual patient, CBD or CHD diameters do not correlate with CBD pressure. In patients without extrahepatic cholestasis and normal CBD pressure, both CBD and CHD diameters were measured in a wide range between 5 and 32 mm. Extrahepatic cholestasis due to distal CBD obstruction is reflected by a high CBD pressure, but cannot be identified reliably by measuring the CBD diameter which is found within the range of patients not obstructed. In cholecystectomized patients, CBD and CHD are significantly (p less than 0.005) wider than in non-cholecystectomized patients (8.8 +/- 1.0 vs. 13.3 +/- 1.2 and 9.2 +/- 0.9 vs. 14.2 +/- 1.2 mm, respectively). The CBD pressure, however, is nearly identical in both groups. It is concluded that the assessment of CBD and CHD diameter is not a reliable parameter for the diagnosis of extrahepatic cholestasis which--in certain cases--could be proved by endoscopic retrograde manometry.