[Saccharomyces boulardii in the treatment and prevention of antibiotic-associated diarrhea]. / Saccharomyces boulardii bei Antibiotika-assoziierter Diarrhöe.

BACKGROUND: Antibiotic-associated diarrhea (AAD) is the most frequent side effect of antibiotic therapy. Clinical signs and symptoms comprise mild and self-limiting courses of diarrhea as well as life threatening courses like pseudomembranous colitis or toxic megacolon. Therapy is symptomatic, antidiarrheal drugs like Saccharomyces boulardii are the therapy of choice. METHOD: Available studies on S. boulardii in the prevention of AAD are presented as a review. RESULTS: In 14 out of 17 studies including 4,627 patients the administration of S. boulardii achieved a protective effect between 43.7% and 87.3%. A meta-analysis (5 studies, 1,076 patients) showed a significant reduction of the risk to develop an AAD from 17.2% to 6.7%,in a furthermeta-analysis (4 studies on eradication of H. pylori, 1,215 patients) the significant reductionwasfrom 12.2% to 5.6%. CONCLUSIONS: There is very good evidence for the yeast S. boulardii to be effective in the prevention of AAD especially in hospitalized adults. The simultaneous administration of S. boulardii to antibiotics resulted in a significant reduction to develop AAD by more than half.

Sleep disordered breathing in the elderly: comparison of women and men.

The prevalence of obstructive sleep apnea syndrome in patients up to the age of 60 is known to be two times higher in men then in women. Hormonal changes during menopause might underlie changes in this relationship in the elderly. This study was designed to detect differences in the type and frequency of sleep-disordered breathing between women and men over the age of 65 years, having the same body mass index. The study was conducted using a matched-pair approach consisting of a sample population of 40 pairs of patients over the age of 65. All patients met the following exclusion criteria: age below 65, heart failure, chronic obstructive lung disease. Polygraphy was conducted by means of a portable recorder. All measured indices were higher in men than in women. The apnea index was 2.8 +/-4.1 in men and 0.6 +/-1.4 in women. The apnea/hypopnea index was 10.2 +/-11.4 and 4.8 +/-3.9, respectively. These differences were significant (P<0.05). Significant differences also were observed when central (men 8.1 +/-13.1, women 3.1 +/-8.2), mixed (men 5.1 +/-11.4, women 0.4 +/-1.3), and obstructive (women men 8.6 +/-20.1, 1.0 +/-4.3) apnea indices were compared. In conclusion, the study demonstrates that elderly patients showed gender-dependent differences in the type and frequency of sleep-related breathing disorders. Men suffered from all kinds of apnea more frequently than women.

[Diarrhea after vascular reconstruction of an abdominal aortic aneurysm]. / Durchfälle nach Gefässrekonstruktion einer aneurysmatischen Bauchaorta.

HISTORY AND CLINICAL FINDINGS: A 60-year-old man had a dacron aortofemoral bypass graft inserted to replace a ruptured infrarenal aortic aneurysm rupture. He subsequently had tachyarrhythmic atrial fibrillation with heart failure, NYHA class IV, and diffuse abdominal pain associated with watery diarrhea. INVESTIGATIONS: Stool tests merely demonstrated Candida albicans. Abdominal ultrasound revealed intestinal loops with thickened walls and decreased peristalsis. Coloscopy demonstrated a retroperitoneal intestinal perforation with abscess formation resulting from ulcerative necrotizing rectosigmoid colitis which had also uncovered the vascular prosthesis near the abscess cavity. DIAGNOSIS: Ischemic transmural necrotizing rectosigmoiditis with retroperitoneal intestinal perforation. TREATMENT AND COURSE: The rectosigmoid colon was resected and an end-colostomy made with closure of the rectal stump (Hartmann's operation). The uncovered right limb of the vascular graft was covered completely and was discharged, being now mobile using a walking frame. There was no evidence of infection in the dacron prosthesis. CONCLUSION: A transmural progression of an ischemic colitis should be considered as a late sequela after emergency vascular reconstruction of the abdominal aorta. Even if symptoms are mild, early postoperative sigmoidoscopy is indicated.

Orthograde whole gut irrigation with mannite versus paromomycine + lactulose as prophylaxis of hepatic encephalopathy in patients with cirrhosis and upper gastrointestinal bleeding: results of a controlled randomized trial.

BACKGROUND/AIMS: In patients with liver cirrhosis and upper gastrointestinal bleeding development of hepatic encephalopathy is a major problem. The aim of the present study was to evaluate the efficacy of the mannite lavage in a controlled randomized trial with respect to the Child-Pugh classification. METHODOLOGY: After initial gastroscopy (+/- sclerotherapy) 39 patients with cirrhosis (18 F, 21 M; age: 57.5 +/- 11.9 yr; Child A: 6, Child B: 16, Child C: 17) and upper gastrointestinal-bleeding were classified according to the Child-Pugh-criteria (A,B,C) and randomized in 2 groups (A,B) for each Child-Pugh level. Patients in group A (n = 18) were initially treated with 2000 mL mannite solution (10%) during the first 2 hours using a naso-gastric tube. Treatment was continued using 2000 mL mannite solution (10%) per day until no rectal blood could be observed. Patients in group B (n = 21) were treated with paromomycine ter in die (1 g tid) and lactulose (10 mL tid). There were no statistical differences between both groups concerning age, sex, Child-Pugh-scores, severity or source of bleeding, initial hemoglobin-levels, number of given blood-transfusions or number of patients with sclerotherapy. RESULTS: Patients in group A were treated with a total of 3325 +/- 1897 mL mannite solution. The application was well tolerated. In addition, kinetics of serum creatinine, potassium and sodium levels did not show any significant changes. No significant differences between both groups could be shown with respect to clinical criteria of encephalopathy according to O'Grady and the length of intensive care unit treatment. Moreover, kinetic of ammonia-levels showed a pronounced decrease (P = 0.05) on day 2 versus day 1 in group A (110.0 +/- 24.2 vs. 156.4 +/- 98 mg/dL) as compared to group B (210.0 +/- 52.7 vs. 162.0 +/- 45 mg/dL). In group A, 6 patients (33.3%) died during the study as compared to 3 patients (14.3%) in group B (P > 0.05). The lethality rate was strongly associated with the larger proportion of Child-C-patients in group A. CONCLUSIONS: The data indicate that whole gut irrigation with mannite is equally efficacious as compared to standard treatment for prophylaxis of hepatic encephalopathy after upper gastrointestinal bleeding in liver cirrhosis. In contrast to previously published controlled studies, no impact of the lavage on the mortality rate or duration of intensive care unit treatment could be shown. With respect to the lower costs for the mannite solution as compared to paromomycine and lactulose (ROTE LISTE, Germany), the mannite lavage should be recommended for the prophylaxis of hepatic encephalopathy after upper gastrointestinal bleeding in patients with liver cirrhosis.

[Diarrhea in a patient with Down syndrome and endemic sprue]. / Diarrhöen bei einer Patientin mit Down-Syndrom und einheimischer Sprue.

BACKGROUND: Down syndrome is associated with disorders such as celiac disease, hypothyroidism, and insulin-dependent diabetes mellitus. In patients with mono- or oligosymptomatic celiac disease the time interval between the onset of symptoms and diagnosis often is unacceptably long. CASE REPORT: A female patient with Down syndrome is presented who had acute watery diarrhea, which spontaneously ceased but recurred after a few days. After endoscopic and histologic evaluation and measurement of gliadin, endomysium, and reticulin antibodies celiac sprue was diagnosed. Further investigation showed findings of autoimmune hypothyroidism and secondary hyperparathyreoidism. After the patient was put on a gluten-free diet her state quickly improved. CONCLUSION: Associations between Down syndrome and autoimmune diseases exist. Patients with acute gastrointestinal symptoms should be evaluated as to celiac disease. The time interval between the onset of symptoms and diagnosis of celiac disease can be shortened, if all diagnostic tools are used at the appropriate time.

Effects of peppermint oil and caraway oil on gastroduodenal motility.

The effect of enteric-coated (Enteroplant) and non-enteric-coated preparations containing a peppermint-caraway oil combination with 90 mg peppermint oil and 50 mg caraway oil was studied on gastroduodenal motility with stationary manometry in six healthy volunteers. The results showed that: (1) both enteric-coated and non-enteric-coated preparations have effects on the migrating motor complex (MMC); (2) mainly a decrease in the number of contractions and contraction amplitudes is seen during the various phases of the MMC; (3) non-enteric-coated preparations have their effects mainly during the first MMC after administration; (4) enteric-coated preparations have their effects temporally delayed during the second MMC after administration. In conclusion, enteric-coated and non-enteric-coated peppermint-caraway oil combinations are safe preparations, acting locally to cause smooth muscle relaxation.

Effects of ginger on gastroduodenal motility.

The effect of a ginger rhizome extract (2 x 100 mg) was studied on fasting and postprandial gastroduodenal motility with stationary manometry in 12 healthy volunteers. The results showed that: the interdigestive antral motility was significantly increased by ginger during phase III of the migrating motor complex; the volunteers also had a significantly increased motor response to a test meal in the corpus; a trend to an increased motor response during ginger treatment was seen in all other regions of interest. Oral ginger improves gastroduodenal motility in the fasting state and after a standard test meal.

[Motility disorders of the esophagus in patients with apoplectic infarct during the acute illness phase]. / Motilitätsstörungen der Speiseröhre bei Patienten mit apoplektischem Insult während der akuten Krankheitsphase.

BACKGROUND: Prolonged oropharyngeal dysphagia occurs in up to 45% of patients presenting with a unilateral hemiplegic stroke. The aim of this study was to investigate esophageal motility in patients with hemiplegic stroke and to evaluate, whether detected motility disorders improve within 10 days after the beginning of symptoms. PATIENTS AND METHODS: Fifteen patients with hemiplegic stroke and dysphagia underwent esophageal manometry within the first 2 days after admission to the hospital and 10 days later. Eighteen healthy volunteers served as controls. RESULTS: The following parameters showed no significant differences between the 2 study days (day 2: day 10: controls, p-value [comparison with controls]): resting pressure of the lower esophageal sphincter: 21 +/- 3 mm Hg: 20 +/- 3 mm Hg: 18 +/- 2 mm Hg, NS, contraction amplitude: 67 +/- 8 mm Hg: 72 +/- 11 mm Hg: 78 +/- 9 mm Hg, NS, duration of contraction: 4.2 +/- 1.0 s: 4.2 +/- 0.9 s: 2.2 +/- 0.7 s, p < 0.001, and contraction velocity: 6.3 +/- 1.1 cm/s: 5.2 +/- 0.9 cm/s: 3.2 +/- 0.8 cm/s, p < 0.001. As far as the contraction pattern was concerned, on both study days significant pathologic contraction patterns were seen compared with normal controls. Normal propulsive contractions were seen in 54 +/- 5%: 60 +/- 6%: 96 +/- 5%, p < 0.001. Patients with no dysphagia after 10 days still had demonstrable abnormal motility patterns. CONCLUSION: The findings indicate that manometrically demonstrable pathologic motility patterns of the tubular esophagus in patients without oropharyngeal dysphagia after 10 days do not induce the symptom dysphagia. The function of the esophagus seems not to be impaired by these measurable pathologic contractions.

[Esophageal manometric studies in patients with an apoplectic stroke with/without oropharyngeal dysphagia]. / Manometrische Untersuchungen der Speiseröhre bei Patienten mit apoplektischem Insult ohne und mit oropharyngealer Dysphagie.

BACKGROUND AND OBJECTIVE: As many as 45% of all strokes can lead to permanent dysphagia, usually considered to be due to abnormal oropharyngeal coordination of contraction. It was the aim of the study to compare oesophageal motility in stroke patients with and without dysphagia. PATIENTS AND METHODS: The study group consisted of 36 patients (13 men, 23 women, mean age 74.1 +/- 11.3 years) who had sustained a stroke (19 [mean age 70.6 +/- 10.5 years] with and 17 [mean age 77.6 +/- 10.5 years] without dysphagia). All these patients underwent oesophageal manometry within 2 days after hospital admission. RESULTS: There were significant differences in the mean proportion of regular peristaltic waves in the distal oesophagus, 93.5 +/- 1.1% in patients without but in only 53.5 +/- 4.4% of those with dysphagia (P < 0.0001). Measurement of the proximal oesophagus showed 93.2 +/- 3.4% and 62.1 +/- 7.3% respectively. There was no significant difference between these two patient cohorts with regard to the resting pressure in the upper and lower oesophageal sphincters as well as in the amplitude and duration or speed of contraction in the region of the smooth and striated oesophageal muscles. CONCLUSIONS: In patients after a stroke who have dysphagia abnormalities of oesophageal motility are also of importance for their symptoms, being due less to pressure relations than to abnormal contraction patterns.

[Acid esophago-pharyngeal reflux as etiology of hoarseness]. / Saurer ösophago-pharyngealer Reflux als Ursache von Heiserkeit.

BACKGROUND: Gastroesophageal reflux has been implicated in otolaryngologic problems, particularly chronic hoarseness that cannot be attributed to other causes. PATIENTS AND METHODS: To study this relationship between gastroesophageal reflux and chronic hoarseness we used 24-h dual-site ambulatory pH-recordings in 68 patients with chronic hoarseness and laryngeal lesions suggestive of acid irritation. RESULTS: Thirty-eight patients (56%) had evidence of at least one esophago-pharyngeal reflux episode. The mean number of esophago-pharyngeal episodes was 6.7 +/- 12 within 24 hours (range: 1-34 episodes). The mean duration of these episodes was 201 +/- 28 seconds (range: 6 seconds-19.6 minutes). Most patients with esophago-pharyngeal reflux had no evidence of pathologic gastroesophageal reflux. Only 28.9% of the patients with esophago-pharyngeal reflux episodes also had pathologic gastroesophageal phageal reflux, whereas 23.3% of the patients without esophago-pharyngeal reflux had no gastroesophageal reflux disease. The esophago-pharyngeal reflux occurred mainly in the upright position. CONCLUSIONS: Occult esophago-pharyngeal reflux, predominantly in the upright position, appears to be common and severe in patients with chronic hoarseness. Gastroesophageal reflux may be an important factor in the pathogenesis of chronic hoarseness. The causative mechanisms are not clear.

[Clinical, diagnostic and pathogenetic aspects of reflux-associated cough]. / Klinische, Diagnostische und pathogenetische Aspekte des reflux-assoziierten Hustens.

Gastroesophageal reflux may be responsible for atypical extra-esophageal symptoms, such as chest pain, dyspnea, chronic cough, or hoarseness. Prospective studies of gastroesophageal reflux have indicated reflux as the cause for chronic cough in 10 to 20% of patients. The precise mechanism by which reflux causes cough remains uncertain, although the possibility that the cough is caused by stimulation of the esophageal mucosa receptors rather than aspiration is suggestive from some studies. Prolonged esophageal pH monitoring affords an opportunity to document objective gastroesophageal reflux. Furthermore, pH monitoring gives the opportunity to correlate temporally acid reflux events with the onset of certain symptoms.

Anorectal functions in patients with spinal cord injury.

We wished to establish anorectal functions in patients with spinal cord lesions, related to the level of lesion and its completeness. We also wished to determine the value of neurophysiological tests for completeness of transsections in comparison with manometry and visceral sensory testing. In 32 patients (31.5 +/- 14.1 years, 25 males) with spinal trauma, completeness of transsection was assessed clinically. In 16 of these patients (30 +/- 15.6 years, nine males), a neurological work-up included recording of somatosensory evoked potentials (SEP) and motor evoked potentials (MEP) from the pudendal nerve within the first week after trauma. Also, anal sphincter EMG and pudendal nerve terminal motor latency (PNTML) were assessed. All patients also underwent conventional anorectal manometry and visceral sensory testing. Of all 32 patients, 15 were judged as 'complete' based on their clinical signs. Of those 16 tested neurologically, seven were labelled 'complete' since no MEP or SEP were detectable; one had pudendal SEP and MEP present, while SEP were present but delayed (47.0 +/- 8.8 msec) in the remaining patients. In four of these patients, also MEP were recorded (27.9 +/- 5.2 msec) and normal. PNTML was present in 12/16 patients independent of the completeness of lesion, and was rated normal in nine and delayed in three patients. EMG was normal in five, and pathological in 11 cases. In 5/15 cases of those judged as 'complete' (in 3/7 evaluated neurologically), visceral sensory testing revealed a minimal threshold for rectal perception of distension of 44 mL (range: 10-130), which sometimes was also perceived as urge to defecate. In a further case, manometry showed major voluntary action of the anal sphincter. These patients had lesions at all levels of the spinal column, ranging from cervical (C4,C6,C7) via thoratical (2 x T7,T8,T12) to lumbar segments. Anorectal function testing, and specifically visceral sensory testing may be superior to neurological assessment of 'completeness' of spinal cord lesions. It may be that visceral afferent pathways others than spinothalamic tract are involved in rectal perception that are less accessible to conventional neurophysiological diagnostic work-up.

[Bronchopulmonary manifestations of gastroenterologic and hepatic diseases]. / Bronchopulmonale Manifestationen gastroenterologischer und hepatologischer Erkrankungen.

Topics of this review are the bronchopulmonary manifestations of gastroesophageal reflux disease, cirrhosis of the liver and chronic inflammatory bowel diseases. About 20% of patients with chronic obstructive airway disease show evidence of gastroesophageal reflux disease. Reflux bronchoconstriction seems to be of greater importance than microaspiration. First studies show the positive effects of acid inhibition by proton pump inhibitors on pulmonary symptoms. Hepatorenal syndrome is characterized by arterial hypoxemia with PaO2-values < 70 mm Hg. Different mediators (endotoxins, amines, polypeptides or allergens) are discussed. Furthermore, elevated levels of prostacycline, atrial natriuretic factor and platelet activating factor have been described. Recently published studies focused on the role of nitric oxide (NO). Patients with cirrhosis of the liver show a higher rate of a pathologically elevated airway resistance which might be induced by a reduced histamine clearance. Ascites leads to reversible restrictive airway disease. Bronchopulmonary manifestations in chronic inflammatory bowel diseases include obstructive and restrictive airway diseases, vascular or serosal changes and show low clinical evidence. In contrast, pathological changes of the common function tests were found in 30 to 50%. These findings may be induced by circulating immune complexes, vasculitis, increased permeability or a combined immune reaction of both, the bronchial and intestinal mucosa. Undesired effects of salicylates should be taken into account. This review shows that bronchopulmonary manifestations in diseases of the Gl-tract or the liver are more common than usually known and should be taken into clinical consideration.

[Manometric studies of the esophagus in healthy subjects of different age groups]. / Manometrische Untersuchungen der Speiseröhre bei gesunden Probanden unterschiedlicher Altersgruppen.

Oesophageal manometry was performed under standardized conditions in 100 healthy persons of different ages (54 males, 46 females; mean age 43.1 [18-84] years). They were grouped by age in decades (< or = 29 years: n = 23; 30-39 years: n = 18; 40-49 years: n = 19; 50-59 years; n = 20; and > or = 60 years: n = 20). The mean resting pressures at the lower oesophageal sphincter ranged among the different age groups from 18-22 mm Hg (total group 19 +/- 7 mm Hg), the mean contraction force at the distal tubular oesophagus ranged from 77-100 mm Hg (84 +/- 35 mm Hg), in the proximal tubular oesophagus from 53-58 mm Hg (56 +/- 22 mm Hg), and the resting pressures at the upper oesophageal sphincter from 34-45 mm Hg (37 +/- 17 mm Hg). There was no statistically significant difference between the various age groups for any of the motility parameters. It is concluded that age does not influence the findings in comparative studies of healthy persons and patients of differing ages.

Acute pancreatitis complicating Crohn's disease: mere coincidence or causality?

An example of acute pancreatitis developing five weeks after initial treatment with 5-aminosalicylic acid (5-ASA) and methylprednisolone for severe Crohn's disease is reported in a 37 year old female patient. She had undergone cholecystectomy for gall stones some years earlier. There was no evidence of acute or chronic pancreatitis. No morphological changes of the upper gastrointestinal tract were found except for some irregularity of the main pancreatic duct and the secondary ducts on endoscopic retrograde pancreatography. Rechallenge with 5-ASA did not induce recurrent pancreatitis or changes in pancreatic enzymes. This case report supports the concept of an association between acute pancreatitis and Crohn's disease.

Esophageal dysfunction in diabetes mellitus: is there a relation to clinical manifestation of neuropathy?

In a prospective study, we evaluated 33 diabetic patients [type I (n = 8) and type II (n = 25)]. Esophageal motor functions were examined by registering clinical symptoms and by performing esophageal manometry. We also investigated peripheral and autonomic neuropathy. In diabetics, the lower and upper esophageal sphincter pressure and amplitudes of peristaltic waves were reduced. Compared with controls (n = 30), in diabetics the esophageal peristaltic velocity was reduced significantly, and the duration of contractions were decreased as well. Multipeaked waves were uncommon in diabetics, while non-propulsive contractions were seen more often. No correlation was found between esophageal dysfunction and peripheral or autonomic neuropathy. Some 60% of diabetics reported esophageal symptoms; however, no relationship between these symptoms and the extent of dysfunction in esophageal motility was found.