[Periportal hyperechogenicity of the liver. Clinical aspects and pathology of the so-called fixed star heaven phenomenon of the liver]. / Periportale Hyperechogenität der Leber. Klinik und Pathologie des sogenannten Fixsternhimmelphänomens der Leber.

INTRODUCTION: The clinical significance of the sonographic finding "periportal hyperechogenicity", which is characterized by hard periportal echoes, is largely undetermined. This phenomenon has been reported in a large number of disorders, as well as in healthy persons. METHODS: A prospective study of 1853 patients revealed this finding in 12 cases. These 12 patients were followed up after two to four months. RESULTS: Only four cases were seen to still have diffuse periportal accentuation in the follow-up, while five patients showed a partially and three a completely normal liver. The laboratory values of these 12 patients were largely normal at the time of diagnosis and follow-up. Periportal accentuation was not correlated with any hepatological disorders. Examination using two different ultrasound devices revealed no major differences. DISCUSSION: Overall, these findings confirm the earlier assumption that this sonographic picture designated as periportal hyperechogenicity or accentuation is not diagnostic of any hepatological disorder, nor is it even a sign of disease, because most patients with this phenomenon can be termed hepatologically "healthy".

LDL-unbound apolipoprotein(a) and carotid atherosclerosis in hemodialysis patients.

High lipoprotein(a) [Lp(a)] plasma concentrations, which are genetically determined by apo(a) size polymorphism, are directly associated with an increased risk for atherosclerosis. Patients with end-stage renal disease (ESRD), who show an enormous prevalence of cardiovascular disease, have elevated plasma concentrations of Lp(a). In recent studies we were able to show that apo(a) size polymorphism is a better predictor for carotid atherosclerosis and coronary artery disease in hemodialysis patients than concentrations of Lp(a) and other lipoproteins. Less than 5% of apo(a) in plasma exists in a low-density lipoprotein (LDL)-unbound form. This "free" apo(a) consists mainly of disintegrated apo(a) molecules of different molecular weight, ranging from about 125 to 360 kDa. LDL-unbound apo(a) molecules are elevated in patients with ESRD. The aim of this study was therefore to investigate whether the LDL-unbound form of apo(a) contributes to the prediction of carotid atherosclerosis in a group of 153 hemodialysis patients. The absolute amount of LDL-unbound apo(a) showed a trend to increasing values with the degree of carotid atherosclerosis, but the correlation of Lp(a) plasma concentrations with atherosclerosis was more pronounced. In multivariate analysis the two variables were related to neither the presence nor the degree of atherosclerosis. Instead, the apo(a) phenotype took the place of Lp(a) and LDL-unbound apo(a). After adjustment for other variables, the odds ratio for carotid atherosclerosis in patients with a low molecular weight apo(a) phenotype was about 5 (p<0.01). This indicates a strong association between the apo(a) phenotype and the prevalence of carotid atherosclerosis. Finally, multivariate regression analysis revealed age, angina pectoris and the apo(a) phenotype as the only significant predictors of the degree of atherosclerosis in these patients. In summary, it seems that LDL-unbound apo(a) levels do not contribute to the prediction of carotid atherosclerosis in hemodialysis patients. However, this does not mean that "free", mainly disintegrated, apo(a) has no atherogenic potential.

[Visualization of the inferior mesenteric artery in the ultrasound B image]. / Die Darstellbarkeit der Arteria mesenterica inferior im Ultraschall B-Bild.

AIM: Reports in the literautre differ widely with regard to visualisation of the inferior mesenteric artery (IMA) by B-mode ultrasonography. Hence, our study aimed at obtaining exact data on the feasibility of visualising the inferior mesenteric artery via B-mode ultrasonography in a relatively large patient population. METHOD: At the outpatient department of gastroenterology and hepatology 51 males (aged 14 to 75 years) and 53 females (aged 16 to 79 years) were examined consecutively by two experienced investigators via B-mode scan within the overall framework of a routine screening programme, in each case after overnight fasting. Knowledge of normal anatomic conditions and of the possible variations of the IMA is mandatory for correct IMA visualisation. RESULTS: We succeeded in visualising the IMA via B-mode scan in 41 of the 51 males (80.39%) and in 40 of the 53 females (75.47%), i.e. in a total of 81 of 104 patients (77.88%) in 2-3 cm length. CONCLUSION: The results show that IMA can be visualised by B-mode ultrasonography in a manner comparable to visualisation of the superior mesenteric artery (82). This is an essential finding, since duplex sonography of the IMA yields important information on disease activity in inflammatory bowel disease, and B-mode scanning of the IMA is the prerequisite for duplex scanning.

Apolipoprotein(a) phenotypes predict the risk for carotid atherosclerosis in patients with end-stage renal disease.

Several studies have demonstrated that atherosclerotic complications are the major cause of morbidity and mortality in hemodialysis patients. High lipoprotein(a) [Lp(a)] plasma concentrations are an independent risk factor for atherosclerosis. Patients with end-stage renal disease (ESRD) have elevated plasma concentrations of Lp(a), which are not explained by size variation at the apolipoprotein(a) [apo(a)] gene locus. The aim of our study was to investigate whether Lp(a) concentrations and/or apo(a) phenotypes are predictive of the degree of atherosclerosis in the extracranial carotid arteries in ESRD patients. Of 167 patients, 108 showed atherosclerotic plaques (65%). Univariate analysis showed that the plaque-affected group was significantly older and had a higher frequency of angina pectoris, previous myocardial infarction, or cerebrovascular accident. Furthermore, this group included significantly more patients with low-molecular-weight apo(a) isoforms (26.9% versus 8.5%, P < .005) and had significantly higher mean Lp(a) plasma concentrations (29.3 +/- 31.0 versus 19.7 +/- 25.7 mg/dL, P < .05). Lp(a) plasma concentration increased significantly with the number of affected arterial sites, from 19.7 mg/dL in patients without plaques to 40.1 mg/dL in patients with seven or eight affected sites. In patients with low-molecular-weight phenotypes, significantly more arterial sites were affected (3.62 versus 2.08, P < .001). Multivariate regression analysis showed that age, angina pectoris, and the apo(a) phenotype were the only significant predictors of the degree of atherosclerosis. We conclude that, besides age, the apo(a) phenotype is the best predictor of carotid atherosclerosis in ESRD patients and may be used for assessment of general atherosclerosis risk in this patient group.

Decreased beta-endorphin content in peripheral blood mononuclear leukocytes from patients with Crohn's disease.

Increased activation of lymphocytes in inflammatory bowel disease is reflected by alterations of various immunological functions including enhanced spontaneous secretion of rheumatoid factor by mononuclear cells. since in rheumatic diseases increased secretion of rheumatoid factor is associated with decreased levels of beta-endorphin in circulating blood mononuclear leukocytes, we investigated levels of leukocyte beta-endorphin in inflammatory bowel disease and compared them with those in hepatobiliary disorders and in healthy subjects. Levels of beta-endorphin were measured in extracts from peripheral blood mononuclear leukocytes by radioimmunoassay. beta-Endorphin levels ranged from 0 to 67 pg/10(6) cells. Mononuclear leukocytes from ulcerative colitis patients contained as much beta-endorphin as those from healthy control subjects. In patients with Crohn's disease, levels of beta-endorphin were reduced by as much as roughly 50%. An inverse relationship was found between leukocyte beta-endorphin on the one hand and erythrocyte sedimentation rate, blood granulocyte or thrombocyte counts, and C-reactive protein levels in plasma on the other. In patients with various hepatobiliary disorders including fatty liver disease, viral hepatitis, primary biliary cirrhosis, and cryptogenic or alcoholic cirrhosis, beta-endorphin levels were not significantly different from the normal range values. Data indicate that leukocyte beta-endorphin may be involved in regulation of the systemic inflammatory activity of Crohn's disease.

[Duplex sonography of dialysis shunts. Noninvasive evaluation of the arteriovenous fistula in dialysis patients]. / Duplexsonographie von Dialyseshunts. Nichtinvasive Beurteilung der arteriovenösen Fistel bei Dialysepatienten.

Duplex sonography permits non-invasive evaluation of both the anatomy and function (flow volume) of the AV-fistula in patients on hemodialysis in a single session. It should be the first imaging procedure to be applied when access to the circulation presents a problem. Comparisons with angiography and surgical reports confirm the adequate sensitivity and specificity of the procedure. Diagnostic problems may occur with ambiguous vascular anatomy, stenoses affecting the anastomosis or central veins. Duplex sonography makes the establishment of the indication for angiography or therapy much more accurate.

[Differential diagnostic importance of sonographically detected lymph node enlargement of the liver hilum in non-malignant liver diseases]. / Differentialdiagnostische Bedeutung sonographisch nachweisbarer Lymphknotenvergrösserung im Leberhilus bei nicht-malignen Lebererkrankungen.

A total of 234 patients, 112 of whom were suffering from inflammatory liver disease and 122 from non-inflammatory liver disease were examined for enlarged lymph nodes in the hepatoduodenal ligament. Patients with malignancy were excluded from the study. In the 112 patients with inflammatory liver disease, enlarged lymph nodes in the hepatoduodenal ligament were demonstrated in 29 cases (25.9%). In cases with acute hepatitis (n = 25), lymphomas were seen in 18 examinations (72%). These enlarged lymph nodes disappeared when the liver enzymes fell to normal values. In patients with chronic inflammatory liver disease (n = 54), enlarged lymph nodes were found in only nine cases (16.7%). Of 27 "healthy" HBsAG-carriers, 26 were without lymph node enlargement. None of the patients without inflammatory, non-malignant liver disease showed lymph nodes in the hepatoduodenal ligament. Once malignancy is ruled out, lymphomas in the hepatoduodenal ligament should be considered an indication of inflammatory liver disease.

[Non-invasive morphologic and functional assessment of arteriovenous fistula in dialysis patients with duplex sonography]. / Nicht-invasive morphologische und funktionelle Beurteilung arteriovenöser Fisteln von Dialysepatienten mit der Duplexsonographie.

In 61 patients with end-stage renal disease the results of 89 consecutive Duplex examinations of the arteriovenous fistulas used for haemodialysis were evaluated. The examinations were performed because of various problems concerning the vascular access or before the first puncture. Using 7.5 and 10.0 MHz probes (pulsed Doppler 3.0 and 4.5 MHz) the morphology and the function of the fistulas were evaluated. In 35 cases the results were normal, in a further 27 cases minor anomalies were seen without influencing the function. Complete thrombosis was observed in 7, partial thrombosis and severe stenosis in 4 cases each. Large aneurysms were documented in 6 examinations and in the remaining 6 the fistulas had not matured sufficiently within 4 weeks. The ultrasound results correlated well with consecutive angiography or surgery. The mean flow in normal fistulas was 514 +/- 223 ml/min. It was higher in PTFE shunts (614 +/- 242 ml/min) than in Cimino-Brescia fistulas (464 +/- 199 ml/min). Complications were observed more often in the PTFE group (63.9% vs. 58.5%). We think that Duplex sonography offers an accurate, non-invasive way to evaluate the morphology and the function of arteriovenous fistulas of patients on haemodialysis. This should therefore be performed as the first imaging method whenever problems concerning the fistula occur.

[Sonography of the liver in Wilson's disease. Sonographic studies of the liver in Wilson's disease--significance for assessing prognosis?]. / Zur Sonographie der Leber bei Morbus Wilson. Sonographische Beobachtungen an der Leber bei Morbus Wilson--Bedeutung für die Beurteilung der Prognose?

Five patients with Wilson's disease with prognostically different hepatic manifestation were studied via ultrasound. Three of them presented histologically with fatty changes, fibrosis and interspersed areas of normal parenchyma. In these three patients, a peculiar ultrasound picture of the liver was observed which was quite different from the findings in the two others and which has not yet been recognized in the context of Wilson's disease. The parenchymal echo pattern was of increased echogenicity with numerous roundish foci of decreased echogenicity resembling metastatic liver disease. In contrast, the echo texture of the two patients with chronic active hepatitis leading to hepatic failure, was coarse, diffusely enhanced and without focal lesions. These findings indicate that ultrasound may help to define Wilson patients with good prognosis for the predominance of fatty changes and fibrosis in the liver.

Differential diagnosis of malignant intrahepatic tumors by ultrasonically guided fine needle aspiration biopsy and by laparoscopic/intraoperative biopsy. A comparative study.

Thirty-six cases of ultrasonographically detected liver tumors (28 malignant and 8 benign lesions) were investigated by both fine needle aspiration (FNA) biopsy and laparoscopic or intraoperative tissue biopsy. The sensitivity of FNA biopsy in detecting a neoplasm was 85.7% while that of tissue biopsy was 82.1%. Specificity was 100% in both methods. A correct histologic diagnosis of the neoplasm could be made on the cytologic smear in only 14 cases (50.0%) due to technical and methodologic difficulties. Endoscopic and intraoperative tissue biopsy yielded sufficient material to make a definite histologic tumor diagnosis in 23 of 28 cases. Additional information on tumor spread and sequelae of liver infiltration was obtained by macroscopic tissue observations in nine cases. These results indicate that FNA biopsy is less sensitive in the classification of primary or secondary liver tumors and that tissue biopsies obtained during laparoscopy or laparotomy are required if a suspected hepatic neoplasm needs to be classified exactly to plan therapy and to establish a prognosis.

Beta 2-microglobulin: a prognostic parameter for graft survival after renal transplantation.

The determination of beta 2-microglobulin has recently been proposed as a promising diagnostic method to monitor the state of renal allografts. Elevated levels of beta 2MG in the serum and/or urine allow the substantiation of the diagnosis of an acute graft rejection and are helpful in distinguishing acute tubular necrosis from a rejection reaction. In this paper, the usefulness of beta 2MG serum levels is evaluated, not only during the immediate post-operation phase but also for the long-term prognosis of renal allografts. The immunosuppression treatment included methylprednisolone and azathioprine in all the presented patients. The data indicate that a rapid normalization of beta 2MGSL within 6 days, even if the decrease is interrupted by re-elevation due to acute rejection episodes or inflammatory diseases, represents a good long-term prognosis for kidney allografts.