[Rapid development of liver cirrhosis following acute non-A, non-B hepatitis]. / Rasche Entwicklung einer Leberzirrhose nach akuter Hepatitis Non-A-Non-B.

Four cases of shortly developed liver cirrhosis as consequence of non-A-non-B-hepatitis are described. Liver cirrhosis was diagnosed by liver histology at days 254, 298, 651 and 891 after acute infection, respectively. For the first time a normal liver histology was documented in one case immediately before infection together with follow up biopsies of chronic hepatitis up to liver cirrhosis (day 891) after acute posttransfusion non-A-non-B-hepatitis. Further 20 cases with liver cirrhosis are described in the literature having developed between 90 and 2190 days after acute non-A-non-B-hepatitis. It is concluded that non-A-non-B-hepatitis has to be concerned as a serious etiological factor of liver cirrhosis developing shortly after acute infection.

[Prophylactic sclerosing of esophageal varices. Results of a prospective randomized 7-year longitudinal study]. / Prophylaktische Osophagusvarizensklerosierung. Ergebnisse einer prospektiven, randomisierten Langzeitstudie über 7 Jahre.

Over a period of six years, esophageal varices (stage III or IV) were endoscopically diagnosed in 49 patients with confirmed liver cirrhosis and no previous bleeding. Prophylactic sclerotherapy of the esophageal varices was performed in 25 patients, while 24 were treated conservatively (control group). The groups were comparable as to duration, cause and severity of the cirrhosis, but differed in sex distribution. The patients had been followed for at least two, maximally seven, years (median 44 months). Only five bleedings occurred in the prophylactic sclerotherapy group, 15 in the control group during the entire observation period. Among the control group eight patients died due to bleeding, compared to only one in the sclerotherapy group; but there were eight deaths in the control group, 13 in the sclerotherapy group from other complications of liver cirrhosis. Survival rate was higher in the sclerotherapy group, especially in the first year and with alcoholic cirrhosis. There were no serious complications from the sclerotherapy. It is concluded that prophylactic sclerotherapy clearly reduces the number of bleedings from varices, but improvement in prognosis is relatively short.

[Nonalcoholic fatty liver hepatitis and fatty cirrhosis mimicking alcoholic liver diseases]. / Nicht alkoholbedingte Fettleberhepatitiden und Fettzirrhosen unter dem täuschenden Bild alkoholtoxischer Lebererkrankungen.

Non-alcoholic steatosis hepatitis and fatty cirrhosis represents an unfamiliar liver disease of yet unknown etiology, which is usually indistinguishable from alcoholic lesions by histological criteria. For the affected patients this means automatically the inappropriate assumption of hidden alcohol abuse. Out of 1467 liver biopsies during 1979 to 1982 we selected 25 patients (group I), who either denied alcohol intake or reported negligible consumption. None of them had taken steatogenous drugs or had been treated by jejuno-ileal bypass operation for morbid obesity. Nevertheless, in all cases liver biopsy demonstrated changes that were thought to be characteristic of alcoholic liver disease. This group was compared with an additional series of 25 patients (group II, selected out of 342 alcoholics), who admitted to a mean daily alcohol ingestion of 145 +/- 37 g. According to body weight, sex ratio, estimated degree of hepatocellular fat deposition and relation of steatosis hepatitis (n = 15) to fatty cirrhosis (n = 12) there were no differences between both groups. In contrast to the alcoholics (group II) significantly lower (p less than 0.001) values of serum gamma-glutamyltransferase (127 +/- 138 vs 669 +/- 588 U/l) and mean corpuscular erythrocyte volume (89 +/- 4,7 vs 102 +/- 7,8 fl) occurred among the abstinent patients (group I). However, the considerable overlap of measured values argued against a sufficiently discriminative function of both parameters. On the other hand, the serum SGOT/SGPT ratio (I: 1,0 +/- 0,4 vs II: 3,5 +/- 1,4) as well as the serum immunoglobulin-index IgG/IgA (I: 5,6 +/- 2,1 vs II: 2,7 +/- 0,7) allowed a more than 90% separation between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

The renin-angiotensin-aldosterone system in fulminant hepatic failure.

The relationship of the renin-angiotensin-aldosterone system to blood pressure and sodium homeostasis and to renal function was investigated serially in 12 patients with fulminant hepatic failure. The plasma concentrations of renin, angiotensin II, and aldosterone were, in most instances, markedly increased. Systolic blood pressure, which was often very low, showed a significant inverse relationship to the plasma renin concentration, suggesting that the marked stimulation of the system is a homeostatic response to hypotension. However, the plasma renin substrate concentration was markedly decreased, and the conversion of angiotensin II to inactive peptides increased, both of which may have severely limited the full 'expression' of the stimulated system. Renin and angiotensin II levels were both related to creatinine clearance, which was often reduced, but it is not clear as to which was cause and which effect. No relationship between the plasma aldosterone concentration and renal sodium excretion could be detected.

[Peliosis hepatis. A clinical status inventory]. / Peliosis hepatis. Eine klinische Bestandsaufnahme.

Peliosis hepatis is a rare condition, recognizable by macroscopical view. It is characterized by multiple blood-filled cystic spaces in the liver parenchyma. According to 49 out of 152 more recent case reports (1951-1981/82) its spontaneous occurrence is frequently associated with malignant and toxic processes. However, in about 70% peliosis may be induced by the action of certain drugs, especially by 17 alpha-alkylated steroids. Usually peliosis is found by chance at autopsy or peritoneoscopy, as the clinical picture does not provide sufficient conclusive criteria to allow a definite diagnosis. The striking macroscopical appearance contrasts to the dispute on the as yet unestablished natural history. As most important complication spontaneous intraabdominal bleeding can occur in occasional cases. On the other hand, the patients predominantly die of their underlying diseases and not of a peliosis hepatis.

PIP: Peliosis hepatis is a rare condition, recognizable macroscopically. It is characterized by multiple blood-filled cystic spaces in the liver parenchyma. According to 49 out of 152 recent case reports (1951-1981/82), its spontaneous occurrence is frequently associated with malignant and toxic processes. However, in about 70%, peliosis may be induced by the action of certain drugs, especially by 17alpha-alkylated steriods. Usually, peliosis is found by chance at autopsy or peritoneoscopy, as the clinical picture does not provide sufficient conclusive criteria to allow for a definitive diagnosis. The striking macroscopic appearance contrasts to the dispute on the as yet unestablished natural history. Spontaneous intraabdominal bleeding is the most important complication occurring in occasional cases. However, patients predominantly die of their underlying diseases and not of this condition. (author's modified)

[Alpha 1-antitrypsin deficiency and the liver (author's transl)]. / Alpha 1-Antitrypsinmangel und Leber.

Alpha 1-antitrypsin (alpha 1 AT) is a glycoprotein of hepatic origin which functions as a systemic protease inhibitor (Pi). Its production is controlled by two autosomal-codominantly transmitted alleles. Among the numerous genetic variants some alleles (predominantly PiZ) may induce alpha 1 AT-deficiency, facultatively associated with childhood liver disease. However, the pathogenesis of this congenital disorder, which may progress to complete cirrhosis remains obscure at present. In addition, no clear cut relationship has been proven between alpha 1 AT-deficiency and deranged liver architecture, observed in advanced aged adults. Possibly this may reflect a more accidental coincidence with the consequences of chronic viral hepatitis (Non A-Non B-type). Nevertheless, this hypothesis is hitherto unestablished as it holds for the supposed association between alpha 1 AT-deficiency and the occurrence of malignant hepatoma.

[Classification of esophageal varices - endoscopic and clinical aspects (author's transl)]. / Klassifizierung von Osophagusvarizen - endoskopische und klinische Aspekte.

Endoscopic demonstration of esophageal varices in a diagnostic procedure with high precision, with almost no complications, and which does not impose too much inconveniences to the patient. The extent of the varices may be classified according to different criteria; thus in practice different systems of classification have evolved. Though there is no clearcut correlation between the extent of varicosis and hemodynamic parameters of portal hypertension it nevertheless can be stated, that esophageal bleeding is associated quite regularly with advanced esophageal varicosis. Of 136 patients with cirrhosis of the liver 71 had esophageal varicosis stage III and IV, as judged by endoscopy; these 71 cases constituted approximately 90% of the cases, which had had previous esophageal bleeding; 65 patients had varices stage I and II, constituting 80% of the patients, which had had no previous esophageal bleeding. thus classification of varicosis seems to allow identification of patients prone to bleeding, and might allow prophylaxis as for instance injection sclerotherapy.

[Renin-angiotensin system in acute hepatitis (author's transl)]. / Renin-Angiotensin-System bei akuter Virushepatitis.

Plasma renin activity (PRA) and plasma concentrations of angiotensin II (A.II) were measured radioimmunologically in 31 patients suffering from acute virus hepatitis during the course of the disease. Average PRA and A II values did not differ from values of normal persons, neither during the acute phase of the disease nor during the recovery phase though there were deviations from the normal in single cases. PRA and A II were correlated significantly (r = 0,86, p < 0,001), but there was no correlation to the levels of transaminases. There was no indication, that A II plasma levels were lowered because of increased activity of angiotensinases. In some cases PRA and A II were elevated; this however was probably due to increased renin secretion following changes in water and electrolyte balance rather than to decreased hepatic metabolism of renin.

[Secondary hyperaldosteronism in patients with liver cirrhosis, frequently caused by therapy]. / Seikundärer Hyperaldosteronismus bei Patienten mit Leberzirrhose häufig therapeutisch induziert.

Plasma angiotensin II and plasma aldosterone was measured by radioimmunoassay in 78 patients with cirrhosis of the liver (group I: untreated, without ascites, n = 21; group II:untreated, with ascites, n = 25; group III: with ascites, during saluretic therapy, n = 32). From the obtained results it was concluded: (1) Excluding any pretreatment on the outpatient basis in most cirrhotics with or without ascites unaltered plasma levels of angiotensin II and aldosterone were found. (2) In contrast to previous suggestion secondary aldosteronism seems to be a minor determinant of hepatic ascites formation. (3) In untreated patients the 24-h-urinary excretion of electrolytes (Na+/K+ less than 1) represents an insufficient index of hyperaldosteronism. Obviously the kidney retains considerable amounts of sodium independent of circulating aldosterone levels. (4) Far above other mechanism hyperaldosteronism is most often induced by saluretic treatment of ascites and edema. The increased aldosterone secretion might indicate an adaptation phenomenon to restore total body sodium content. Certainly, the established concept of ascites therapy remains unimpaired by this physiological reaction.

Total immunoreactive angiotensin ii, its hepta-octapeptide fraction, and its hexapeptide in patients with liver disease.

Arterial and venous plasma concentrations of total immunoreactive angiotensin II (AT II), its bioactive hepta-octapeptide fraction and its inactive hexapeptide were measured in normal subjects (n=16), in patients with acute viral hepatitis (n=12), and in treated (n=16) and untreated (n=17) patients with cirrhosis of the liver and ascites. Independent of normal or increased values of total immunoreactive AT II, the ratio between the hepta-octapeptides and the hexapeptide remained unchanged. This might indicate continuous octapeptide generation and balanced metabolite turnover throughout the systemic circulation. Moreover, a significant arterio-venous peptide gradient was lacking. It has to be concluded that total venous plasma AT II sufficiently reflects both the arterial hormone concentration and its major fraction of hepta-octapeptides in arterial (79%) and venous (76%) blood.

Studies on the activity of the renin-angiotensin-aldosterone system (RAAS) in patients with cirrhosis of the liver.

Plasma renin activity (PRA), plasma renin concentration (PRC), angiotensinogen, angiotensin II (AT II) and plasma aldosterone were determined by radioimmunoassay in 77 patients with cirrhosis of the liver [group I: with ascites, untreated (n=23); group II: patients with ascites during treatment (n=32); group III: after removal of fluids, but under further spironolactone therapy (n=10); group IV: untreated subjects without ascites (n=12)]. With the exception of decreased angiotensinogen values in all groups ranging between 39% (group IV) and 73% (group III) no significant changes of the other parameters of the RAAS were found in untreated patients. A highly significant increase of PRA, PRC, AT II and plasma aldosterone was observed in treated cirrhotics with (group II) or without (group III) ascites. In the total series of patients AT II was closely related to PRA, PRC and aldosterone emphasizing aldosterone secretion. Plasma sodium was inversely correlated to PRA, PRC, AT II and aldosterone, but no relationship was detected between these parameters of the RAAS and plasma potassium. Our results indicate that hyperaldosteronism in cirrhosis appears unlikely to be the major determinant of avid renal sodium retention and ascites formation. An increased activity of the RAAS is most often initiated by therapeutic factors and/or markedly altered electrolyte metabolism. Therefore, basal conditions of the patients to be studied must be well defined to exclude any artificially induced stimulation of the RAAS.

[Septate gallbladder (author's transl)]. / Septierte Gallenblasen

In 3,8% of 2,437 in-side patients, examined by x-rays, septs of the gallbladder, supposed to be congenital form variations, were found. There were no differences in sex distribution of the segmented organs and no recognizable correlation to increasing age. Usually, septations were found by accident without clinical relevance. In the proximal parts of the gallbladder located septs occasionally cause symptoms not to be differentiated from those of cholelithiasis. In these cases ectomize is indicated. Calculi are found to be more frequent in septate gallbladders than in unsegmented ones. Sex differences between concrement-bearing, septate gallbladders and unsegmented organs containing stones, were not observed. Likewise, there was no correlation of gallbladder-septs to other diseases, particularly to hepatitis.

[The role of laparoscopy in pulmonary disease (author's transl)]. / Laparoskopie bei Lungenerkrankungen?

Laparoscopy demonstrated sarcoidosis in 79 of 94 proven cases. In addition, it made it possible to assess the involvement of intraabdominal organs which cannot be judged clinically or biochemically and may not be parallel to changes in the thoracic X-ray. Extensive liver sarcoidosis was revealed in 12 and required treatment independent of other organ manifestations. Miliary exudative or cavernous pulmonary tuberculosis in 15 cases revealed gross non-specific changes in one, miliary foci of the liver surface in 13 and coarse nodular infiltration in one. In each case the visual findings were confirmed histologically in the liver biopsy, in 11 before the bacteriological results were known, which retrospectively were positive in only 9 instances. Laparoscopy is, therefore, an important and relatively sparing test, also in confirmation of pulmonary disease (sarcoidosis, certain forms of tuberculosis).