Role of Brain Biomarkers S-100-Beta and Neuron-Specific Enolase for Detection and Follow-Up of Hepatic Encephalopathy in Cirrhosis before, during and after Treatment with L-Ornithine-L-Aspartate.

INTRODUCTION: Hepatic encephalopathy (HE), in the context of liver cirrhosis, seems to result from low-grade cerebral edema of the astrocytes. Serum brain biomarkers S-100-beta und neuron-specific enolase (NSE) are often elevated in brain injury. We hypothesized that neuromarkers S-100-beta and NSE can be used in the diagnosis of HE, compared with standardized diagnostic tools. MATERIAL AND METHODS: A prospective non-randomized intervention study was performed using L-ornithine-L-aspartate (LOLA) for HE treatment. Primary endpoint was the evaluation of neuromarkers S-100-beta and NSE for detection and diagnosis of follow-up of HE. As secondary endpoints, the efficacy of LOLA on the course of HE and the diagnostic role of Portosystemic-Encephalopathy-Syndrome score (PHES) and critical flicker frequency (CFF) were analyzed. For diagnosis of covert (CHE) and overt (OHE) HE, West-Haven criteria (WHC), PHES and CFF were assessed at study entry. LOLA was applied (20 g i.v.) for 6 days. At the end of the study, HE evaluation was repeated. S-100-beta, NSE and ammonia were assessed in each patient before, during and after therapy with LOLA. RESULTS: 30 patients were included. At study entry, CHE was diagnosed in 50% and OHE in 50% of all subjects. A total of 25 participants completed the study. After LOLA therapy, deterioration of HE occurred in <11%, while most patients showed improvement (e.g. improved CFF in 79%). No significant correlation with HE severity (as diagnosed by WHC, PHES and CFF) could be demonstrated for any biochemical parameter. In addition, there were no significant changes in brain biomarkers during the treatment period. DISCUSSION: While CFF as well as PHES showed good correlation with treatment response, S-100-beta and NSE did not significantly correlate with HE severity compared to proven diagnostic methods, and do not seem reliable biochemical markers for the follow-up under therapy.

INTRODUÇÃO: A encefalopatia hepática (EH) na cirrose é vista como o resultado de edema cerebral de baixo grau dos astrócitos. Biomarcadores cerebrais serológicos S-100-beta e enolase neurónio-específica (NSE) estão frequentemente elevados na lesão cerebral. A nossa hipótese é que os neuromarcadores S-100-beta e NSE podem ser usados no diagnóstico de EH, quando comparados com os meios diagnósticos standard. MATERIAL E MÉTODOS: Estudo prospectivo não randomizado foi realizado usando L-ornitina-L-aspartato (LOLA) no tratamento da EH. O endpoint primário foi a avaliação dos neuromarcadores S-100-beta e NSE para a deteção e vigilância da EH. Foram endpoints secundários a eficácia da LOLA no curso da EH e o papel diagnóstico do Portosystemic-Encephalopathy-Syndrome score (PHES) e do critical flicker frequency (CFF). Para o diagnóstico de EH oculta (EHO) ou declarada (EHD) foram avaliados os West-Haven criteria (WHC), PHES e CFF à entrada do estudo. LOLA foi administrada (20 g ev) por 6 dias. No fim do estudo os testes de EH foram repetidos. Os níveis de S-100-beta, NSE e amónia foram avaliados em todos os doentes antes, durante e após a terapêutica com LOLA. RESULTADOS: Foram incluídos 30 doentes no estudo. À entrada EHO foi diagnosticada em 50% e EHD nos restantes 50% dos participantes. Um total de 25 doentes completaram o estudo. Após a terapêutica com LOLA, verificou-se deterioração da EH em < 11%, enquanto a maioria dos doentes melhorou (melhoria CFF em 79%). Não se demonstrou nenhuma correlação significativa com a gravidade da EH (tendo em conta os WHC, PHES e CFF) para nenhum dos parâmetros bioquímicos. Para além disso, não se demonstraram variaões significativa nos biomarcadores cerebrais durante o período de tratamento. DISCUSSÃO: Apesar do CFF e do PHES apresentarem boa correlação com a resposta terapêutica, a S-100-beta e a NSE não se correlacionaram significativamente com a gravidade da EH quando comparado com os outros métodos diagnósticos standard, não parecendo ser marcadores bioquímicos úteos para a vigilância da resposta terapêutica.

Endoscopic treatment of an oesophageal rupture using an over-the-scope clip (OTSC): A case report.

Oesophageal rupture (Boerhaave syndrome) is a rare but serious complication after vomiting. Early intervention is mandatory in order to avoid a deleterious outcome for the patient. This case report describes the endoscopic approach using an over-the-scope clip.

Buried bumper--the endoscopic approach.

Buried bumper syndrome--ingrowth of the internal bumper of a percutaneous endoscopic gastrostomy (PEG) into the gastric wall--is one of the serious long-term complications of enteral nutrition using PEG systems. There are various endoscopic methods of managing the problem. We report here on a case successfully and rapidly treated with the method described by Müller-Gerbes et al., using a papillotome introduced over a guide wire.

[Nutrition in liver cirrhosis]. / Ernährung bei Leberzirrhose.

BACKGROUND: Malnutrition is highly prevalent among patients with liver cirrhosis. This includes the supply with macronutrients and micronutrients. The pathogenesis is variable and often depends on metabolic characteristics and complications of the chronic liver disease. A reduced nutritional status, i.e., protein and energy malnutrition, has prognostic significance resulting in an increased morbidity and mortality rate. The assessment of malnutrition is frequently a major problem in daily practice. CONCLUSION: A sufficient daily energy supply should be guaranteed in patients with liver cirrhosis, which is higher compared to the normal population. Furthermore, the increased turnover of amino acids requires a sufficient protein supplementation. Ascites may benefit from a restriction of daily low-salt fluid intake. Additional substitution of vitamins and trace elements is indicated when symptoms of deficiency are apparent. Associated hepatic osteopathy is a frequent complication of liver cirrhosis. Nutritional advice in patients with cirrhosis requires an individual management regarding the dominating complications of the disease.