Intrahepatic cholestatic jaundice related to administration of ranitidine. A case report with histologic and ultramicroscopic study.

Ranitidine may cause liver injuries ranging from transient, subclinical serum transaminases increase every 100-1,000 treated patients to cholestatic hepatitis in less than 1/100,000. Other H2-receptor antagonists are more dangerous: 11 toxic hepatitis cases have been reported as adverse effect after 1 year of marketed ebrotidine. A 75-year-old male with ischemic cardiopathy history was started on an 8 days treatment of oral ranitidine due to pirosis, without any other changes of therapy; 48 h after drug withdrawal, light-coloured stools, dark urine and icteric scleras developed. On hospital admission, 10 days later, physical examination showed slight hepatomegaly and severe jaundice with skin excoriations followed by serum mixed bilirubin further increase and aminotransferases activities mild rise. Total bilirubin peaked at 381.33 mmol/l (5.1-17.1) and progressively returned to normal, after discharge home, in 3 months and now, 1 year later, there is no sign of liver disease. Ultrasonographic biliary anomalies and the most frequent causes of liver damage were excluded. Liver biopsy confirmed ranitidine as the most likely cause of liver toxicity since histological and ultramicroscopical study revealed a drug-induced picture. We report a rare case of intrahepatic cholestasis jaundice related to ranitidine, a widely used drug. Diagnosis would need an ethically unacceptable rechallange test.

Recurrence of acute fatty liver of pregnancy.

We report this rare recurrence of biopsy-proven acute fatty liver of pregnancy. In two successive pregnancies, an emergency cesarean section was performed with delivery of healthy babies and rapid maternal recovery with complete normalization of liver function. This is the third such report.

[Synchronous adenomas of the stomach and rectum with severe protein-losing syndrome]. / Adenomi sincroni dello stomaco e del retto con grave sindrome da proteinodispersione.

The authors report a case of generalized edema with low colloidal osmotic pressure of plasma in an elderly man. After the exclusion of malnutrition and any myocadic, renal or hepatic involvement it has been shown that the physiopathogenetic mechanism is based on protein-losing enteropathy. Upper and lower endoscopy of the gastrointestinal tract reveals double synchronous villous adenomas of the rectum and stomach (the latter rare but often associated with the former). It is likely that these two lesions may play an important role in the development of "anasarca" but only complete reversal of symptoms after surgical excision of tumors would demonstrate the causative relationship. The study confirms two findings already observed in the literature. The first is the increased risk of villous adenoma malignant transformation, especially where rarely located, such as in the gastric site. The other depends upon the variety of villous adenoma symptomatology. The effects of low plasmatic protein levels are prominent in this case, but clinical manifestations range form insidious signs of occult bleeding, to frank diarrhea and/or rectal bleeding, up to unusual cases of secretory diarrhea with profound dehydration and hypokalemia or malabsorption.

[The multiple-organ failure syndrome in acute pancreatitis. Its pathogenesis and treatment]. / La sindrome da insufficienza poliorganica nella pancreatite acuta. Patogenesi e trattamento.

Multiple organ system failure (MOSF) is a severe clinical process that causes progressive renal and liver failure. Acute pancreatitis (AP) can cause MOSF. Several series document high mortality rate from necrotizing forms is associated with MOSF. The authors observed 199 cases of acute necrotizing pancreatitis in 10 years, with a mortality rate of 14.1%. MOSF occurred in 14 cases, resulting in death in 100% of affected patients. In AP, MOSF follows hemodynamic abnormalities suspected to be secondary to activation of kinins system and other vasoactive peptides that are responsible for pathogenetic mechanism of disease. Similar hemodynamic abnormalities can be observed in septic shock. Then many authors suppose causes of MOSF in AP are local (abscess, infection of pancreatic necrosis) and systemic septic complications or translocation of enteric bacteria or their endotoxins from the gut lumen. So it is important to provide prophylactic use of antibiotics that are effective against expected bacteria and also achieve a therapeutic concentration in pancreatic tissue and juice. Fluid replacement, nutritional support and other therapeutic strategies must be employed to prevent MOSF. When the MOSF is clearly developed, medical and surgical measures are unuseful and the mortality rate is very high also in an intensive care unit.

5-Aminosalicylic acid suppositories in the maintenance of remission in idiopathic proctitis or proctosigmoiditis: a double-blind placebo-controlled clinical trial.

Thirty patients with distal ulcerative colitis in remission (17 proctitis, 13 proctosigmoiditis) were randomly given either 5-aminosalicylic acid (5-ASA) or placebo suppositories, 400 mg bid. During the 1-yr follow-up, patients were assessed clinically every month, and flexible sigmoidoscopy with a rectal pinch biopsy specimen and laboratory data were carried out every 3 months. Two patients in the 5-ASA group chose to withdraw from the study, one relapsed, and 12 remained in remission. In the placebo group, one patient chose to withdraw, 11 relapsed, and three remained in remission. The cumulative remission rate at the 12th month was 92% in the 5-ASA group and 21% in the placebo group. Log rank test showed a significant difference in the relapse rate between the two groups (chi 2 = 14.26, p less than 0.001). No side effects were observed. We conclude that 5-ASA in suppository form (800 mg/day), administered for 1 yr, is safe and effective in maintaining remission of distal ulcerative colitis.

[The 75-seleno-homocholic acid-taurine test (SeHCAT). A useful method for detecting the idiopathic malabsorption of bile salts in chronic functional diarrhea]. / Il test al 75-selenio-omotauroglicolato (SeHCAT). Un utile metodo per rilevare il malassorbimento idiopatico di sali biliari nella diarrea cronica funzionale.

The 75-SeHCAT test has been used for identifying, within a group of patients with chronic functional diarrhea, a subgroup of cases with ileal bile acid malabsorption. Thirty-four subjects were studied: 10 healthy subjects and 24 patients with chronic functional diarrhea. Findings are expressed as percentage of basal abdominal radioactivity after 7 days. Normal values in our control subjects were: over 25% on day 4 and over 10% on day 7. Pathological results were found in 9 of 24 patients (37.5%) on day 4 and of 24 patients (41.7%) on day 7. A significant correlation was found between the percentages of retention on days 4 and 7 (p less than 0.001). In SeHCAT-positive patients cholestyramine administration led to clinical improvement. According to our experience, the SeHCAT test is a useful tool for the evaluation of bile acid malabsorption in the differential diagnosis of chronic functional diarrhea.