Regina Pötzi

Dental and periodontal disease in patients with cirrhosis - role of etiology of liver disease

BACKGROUND/AIMS Bacterial infections are frequent complications in patients with cirrhosis, especially in alcoholics. A potential source of infection may be dental foci. The aim of the study was to assess the role of cirrhosis and chronic alcoholism in the development of dental or periodontal disease. METHODS Dental and periodontal examinations were performed prospectively in 97 patients with cirrhosis (alcoholic: 64, nonalcoholic: 33), in 68 alcoholics without cirrhosis and in 71 healthy subjects (subdivided into age groups: 21-30, 31-40, 41-50, and 51-60 years). RESULTS Measures of oral hygiene (p < 0.01), dental care (p < 0.001), and periodontal parameters were worse and the number of teeth requiring treatment (p < 0.001) was higher in alcoholics with or without cirrhosis than in healthy subjects and nonalcoholic patients with cirrhosis. Alcoholics had a lower total number of teeth than patients without alcohol abuse and healthy controls (p < 0.05). The dental and periodontal status of patients with nonalcoholic cirrhosis did not differ from the control group. The severity and duration of liver disease had no influence on dental and peridontal disease. CONCLUSION The presence of cirrhosis itself, therefore, is not a predisposing factor for dental and periodontal diseases. In alcoholics, these diseases appear to be caused primarily by bad oral hygiene and poor dental care.

The efficacy of antimicrobial treatment in Campylobacter pylori-associated gastritis and duodenal ulcer.

The efficacy of various antimicrobial and anti-ulcer agents on the elimination of Campylobacter pylori in duodenal ulcer patients was investigated. Ranitidine, cimetidine, pirenzepine, aluminium phosphate gel as well as combinations of H2-receptor antagonists or pirenzepine + penicillin V, ciprofloxacin, ofloxacin, phenyl-mercuryborate or rifampicin had no influence on C. pylori in vivo. Short term elimination of C. pylori was achieved in 3/15 patients treated with ranitidine + bacampicillin and in 1/5 treated with cimetidine + metronidazole. This elimination was accompanied by a significant reduction of polymorphonuclear infiltration of the antral mucosa. Development of bacterial resistance was observed in patients with additional quinolones, metronidazole and rifampicin but not in patients treated with betalactam antibiotics.

Prospective evaluation of interferon-α in treatment of chronic active Crohn's disease

Several case reports suggested good effects of interferon-α in patients with Crohns disease. In addition, a decreased production of interferon-α in Crohns disease has been shownin vitro. Treatment with interferon-α may activate intestinal natural killer cells and down-regulate the overproduction of inflammatory cytokines like interleukin-6 in Crohns disease. To evaluate the clinical efficacy of interferon-α, we treated 12 patients with a chronic active course of Crohns disease with recombinant human interferon-α prospectively for 24 weeks. Prednisolone was continuously tapered and discontinued at week 12. The end point of the study was the prevention of worsening of clinical symptoms defined with the Crohns disease activity index and was monitored by acute-phase proteins, interleukin-6 serum concentrations, and endoscopy. The biochemical activity of interferon-α was measured by 2′,5′-oligo adenylate serum levels. The end point of the study was reached in four patients (33%). In these patients the final Crohns disease activity index was above 150, which means that they did not achieve clinical remission. All other patients (66%) did not respond to interferon-α and had to be withdrawn prematurely. Interferon-α did not show any beneficial effect on interleukin-6 or acute-phase protein concentrations and on endoscopic activity. The 2′,5′-oligo adenylate levels continuously increased during interferon therapy. Considerable side effects were noted. These results fail to demonstrate a therapeutic role of interferon-α in chronic active Crohns disease.

Establishment of primary cultures from human colonic tissue during tumor progression: Vitamin‐D responses and vitamin‐D‐receptor expression

Primary cultures derived from pre‐cancerous and cancerous human colon tissue are essential for understanding normal and abnormal growth function in the large intestine. Here presented are (i) the methodology for routine establishment of primary cultures of normal, adenoma‐ and carcinoma‐derived cells, and (ii) data for the apparently protective role of vitamin‐D compounds in colon carcinogenesis. The steroid hormone 1,25‐dihydroxyvitamin D3 and some non‐hypercalcemic analogs reduce the high mitotic rate of adenoma cells to that of normal colonocytes. After vitamin‐D treatment, tumor cells are less proliferative and differentiation is enhanced. Primary‐colon‐cancer cultures display a mosaic pattern of vitamin‐D‐receptor expression, at the mRNA level and at the protein level, with varying intensity of expression in positive cells. This suggests that, in human colorectal tumors in vivo, a large fraction of cells will respond to genomic action of vitamin‐D compounds. Int. J. Cancer 75:467–472, 1998.

The relationship between juxtapapillary duodenal diverticula and biliary stone disease.

Objective: To assess the relationship between juxtapapillary duodenal diverticula (JDD) and common bile duct stones and biliary stone disease in general. Design: A retrospective study. Methods: We analysed 1115 patients who underwent consecutive endoscopic retrograde cholangiopancreatography examinations. The patients were subdivided into three groups: the first group (group I; n = 482) had no biliary stone disease, the second one (group II; n = 329) had common bile duct stones, and the third group (group III; n = 304) had biliary stone disease of the gallbladder but without evidence of common bile duct stones. Additionally, the patients were subdivided into age groups of <50, 50‐59, 60‐69, 70‐79, and ≥ 80 years of age. Logistic regression was applied for statistical analysis. Results: Juxtapapillary duodenal diverticula were diagnosed in 111 (10.0%) patients. The incidence of JDD was 6.9% in group I, 14.3% in group II and 10.2% in group III. Age was the most dominant influence factor for JDD, common bile duct stones, and biliary stone disease (P<0.0001). Sex was also a factor, female patients having a higher risk for common bile duct stones (P=0.01) and biliary stone disease (P< 0.0001). After adjustment for age and sex, JDD was found to have a noticeable, but not statistically significant (P= 0.073), influence on common bile duct stones and no influence on biliary stone disease (P=0.15). Conclusion: Our data support only moderately the existence of a relationship, which had been conjectured in a part of the literature, between JDD and common bile duct stones. No noticeable influence on biliary stone disease was found.

Successful symptomatic management of a patient with Ménétrier's disease with long-term antibiotic treatment.

We present the case of a 79-year-old female patient with criteria typical for Ménétrier’s disease, i.e. enlargement of the gastric folds due to foveolar hyperplasia associated with severe protein-loss along with epigastric pain, nausea, vomiting and weight loss. Gastrin levels were within the normal range, but elevated Helicobacter pylori antibody titers (83 μg/ml) were indicative of a recent infection. Histologic examination of a gastric polyp, which was removed in toto, revealed the presence of early gastric cancer of the mucosal type. After initiation of antibiotic treatment with clarithromycin (3 × 250 mg/day) and metronidazole (2 × 500 mg/day) in combination with lansoprazole (30 mg/day), the patient’s condition improved rapidly along with abrogation of protein loss. Under maintenance treatment as indicated above, the patient has been free of symptoms now for a period of more than 2 years. On repetitive endoscopic follow-up, there was no change in gastric mucosa morphology either endoscopically or histologically, and also no evidence of recurrence of a malignant lesion. We conclude that this therapeutic regimen represented an effective alternative to surgical intervention in this patient and should be considered in similar cases.

Histological findings after routine biopsy at the gastro-oesophageal junction

OBJECTIVE Endoscopy with biopsy is an important diagnostic procedure in patients with gastro-oesophageal reflux disease. However, it is still unclear whether histological findings such as intestinal metaplasia, squamous epithelial hyperplasia, and carditis should have an impact on patient management, and whether routine biopsies at the gastro-oesophageal junction should be taken. DESIGN Patients undergoing routine gastroscopy for various indications were biopsied twice just below, directly at, and right above the gastro-oesophageal junction. METHODS Clinical symptoms, endoscopic oesophagitis, and histopathologies such as carditis, reflux disease, and intestinal metaplasia were determined and graded. RESULTS Epithelial hyperplasia suggestive of reflux disease (63%), chronic carditis (94%), active carditis (40%), foveolar hyperplasia (75%), and intestinal metaplasia (14%) were frequently observed. For patients with a normal appearing Z-line, there was a weak correlation of intestinal metaplasia at the cardia with intestinal metaplasia in the stomach (Spearmans R = 0.2, P = 0.008), but no correlation with either chronic or active carditis, or with epithelial hyperplasia in the oesophagus. There was no correlation between H. pylori status or symptoms of reflux disease with epithelial hyperplasia. The severity of chronic and active carditis was closely correlated with H. pylori status (R = 0.37, P < 0.00001). The median time for gastroscopy in 30 control patients was 4.6 min, while endoscopy with additional biopsies at the gastro-oesophageal junction took a median of 8 min (U-test, P < 0.00001). CONCLUSIONS Intestinal metaplasia at the gastro-oesophageal junction was encountered too frequently to warrant regular follow-up in a surveillance programme. Correlation of epithelial hyperplasia with symptoms of reflux disease is poor. We propose that routine biopsy at the gastro-oesophageal junction is not warranted until an impact on patient management can be demonstrated.

Transient and long-term feeding by means of percutaneous endoscopic gastrostomy in neurological rehabilitation

In 28 patients of a neurological rehabilitation unit of a hospital the use of enteral nutrition via percutaneous endoscopic gastrostomy (PEG) tubes was reviewed. During a total observation period of 5,172 days no life-threatening complications occurred. Minor complications were observed in 12 patients (43%) in the first 2 weeks after the insertion and in 5 patients (18%) afterwards. The nutritional status stabilized in all subjects. Transient PEG feeding was performed in 11 patients (39%) with a mean duration of 150 days. We conclude that hesitation in the application of PEG feeding in neurological rehabilitation should be abandoned. The timing and monitoring of PEG feeding in patients undergoing neurological rehabilitation for acute remitting neurological disorders is discussed.

Occurrence of campylobacter pyloridis in patients from Vienna with gastritis and peptic ulcers

SummaryDuring routine gastroduodenoscopic examination of 120 patients, biopsies of gastric mucosa were taken for the isolation ofCampylobacter pyloridis. The organism was isolated from six of seven patients with ulcus ventriculi, 14 of 15 with ulcus duodeni, 15 of 20 with erosions of the gastric mucosa, 31 of 61 with gastritis and five of five with duodenitis. In contrast, the cultures were negative in all of the 12 patients with histologically normal mucosa.C. pyloridis was isolated significantly more frequently from patients with active chronic gastritis than from those with inactive chronic gastritis (100% vs. 50%). These results support the suggestion ofMarshall andWarren that this bacterium may play an important role in the development of gastritis and peptic ulcer.ZusammenfassungBei insgesamt 120 Patienten wurden im Rahmen routinemäßiger gastroduodenoskopischer Untersuchungen Schleimhautbiopsien zur Kultivierung vonCampylobacter pyloridis entnommen. Bei sechs von sieben Patienten mit Ulcus ventriculi, 14 von 15 mit Ulcus duodeni, 15 von 20 mit Erosionen der Magenschleimhaut, 31 von 61 mit Gastritis und fünf von fünf mit Duodenitis konnteC. pyloridis isoliert werden. Hingegen war der Keimnachweis bei allen 12 Patienten mit histologisch unauffälliger Mukosa nicht möglich. Bei chronisch aktiver Gastritis ließ sichC. pyloridis signifikant häufiger als bei chronisch inaktiver Gastritis nachweisen (100 bzw. 50%). Diese Ergebnisse stützen die Hypothese vonMarshall undWarren, die besagt, daßC. pyloridis möglicherweise eine wichtige Rolle in der Entstehung von Gastritis und Ulcus pepticum zukommt.

Liver penetration by a duodenal ulcer in a young woman

Liver penetration is a rare but serious complication of peptic ulcer disease. We report a case of a 33-year-old woman who took large doses of nonsteroidal antiinflammatory drugs and developed a giant duodenal ulcer that penetrated into her liver. The diagnosis was based on histologic examination of endoscopic biopsies. She was initially treated with a proton pump inhibitor, but, within 5 weeks, she developed a symptomatic postbulbar stricture that required surgical correction. We also review 11 other reported cases of endoscopically and histologically diagnosed peptic ulcer penetration into the liver.