Lege Artis Medicinae

[RIFAXIMIN IN THE TREATMENT OF HEPATIC ENCEPHALOPATHY - A MULTICENTRIC STUDY]

SZALAY Ferenc, TELEGDY László, SZELI Dóra, CSÁK Tímea, FOLHOFFER Anikó, HORVÁTH Andrea, ABONYI Margit, SZABÓ Olga, RÉDEI Csaba, NEMESÁNSZKY Elemér

MAY 20, 2004

Lege Artis Medicinae - 2004;14(05)

[INTRODUCTION - Hepatic encephalopathy is a well-known neuropsychiatric syndrome occurring in patients with either acute or chronic liver diseases. Rifaximin, a non-absorbable antibiotic is accepted for the treatment of hepatic encehalopathy. Our aim was to investigate the efficacy and the safety of rifaximin in cirrhotic patients with hepatic encephalopathy in Hungary. PATIENTS AND METHODS - 49 patients (25 male and 24 female) with hepatic encephalopathy stage I., II. and III. were involved into the study. Patients were treated with rifaximin for seven days. The daily dose was 3x400 mg in tablets. The severity of hepatic encephalopathy was characterised by hepatic encephalopathy index (HEi) calculated as a score of five parameters; mental state, asterixis, ammonia level, number connection test and critical flicker frequency. Pretreatment and postreatment HEi were compared. RESULTS - The study was completed in 46 patients. The treatment was suspended in 2 patients who died in liver failure and in one because of oesophageal variceal bleeding. The plasma ammonia level decreased from 103.7 ± 46.4 μmol/L to 67.7 ± 32.3 μmol/L (p=0,007) during the treatment. The hepatic encephalopathy index improved in 39 (85%) patients, worsened in 4 (9%) and no change was observed in 3 cases (6%). Improvement was observed in patients both with Child B and Child C stages. Loose stool in two patients and nausea in one patient were the only registered side effects. No severe adverse event related to the study medication was observed. CONCLUSIONS - Rifaximin is an effective and safe medicine for the treatment of hepatic encephalopathy.]

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[POSSIBILITES AND DIFFICULTIES OF COLORECTAL CANCER SCREENING IN HUNGARY]

ÚJSZÁSZY László, SIMON László, HORVÁTH Gábor, TAM Beatrix

[The frequency of colorectal cancer is increasing all over the world. It is the second most frequent oncological disease leading to death in both sexes in Hungary. The main part of colorectal cancer develope after the age of 50. In case of patients having higher risk we have to calculate with the earlier appearance of the tumour and detectable molecular genetic disorders. The development of colorectal cancer needs a long time. Before the appearance of the cancer, precancerous processes (adenomas, polyps) can be detected in the large intestine. The development of colorectal cancer can be prevented by the removal of the adenomas (polypectomy). There are many different and efficient methods to detect the precancerous and early disorders. For increasing the compliance to screening programs the common efforts of the society, the National Health Care Services and medical doctors are necessary. The education of the population and the medical services would also be helpful. The colorectal cancer screening programs are costeffective and supported by the different health services independently from the type of the insurance. Screening the patients having higher risk is one of most important task. In these cases the use of colonoscopy is the most frequent method for the screening and follow up as well.]

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[16th National Conference of the Supervisors of General Practitioners]

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[NEUROFIBROMATOSIS, MALIGNANT MELANOMA AND HYPERTHYREOIDISM IN A HCV POSITIVE PATIENT]

FOLHOFFER Anikó, HORVÁTH Andrea, CSÁK Tímea, NÉBENFÜHRER László, TELKES Márta, IVÁNYI András, SZALAY Ferenc

[INTRODUCTION - Similar occirrence of neurofibromatosis and malignant melanoma is rare. We report a patient with neurofibromatosis, cutaneous melanoma, hyperthyreoidism and HCV positivity. CASE REPORT - A 43-year-old woman has been under care for neurofibromatosis for 16 years when she presented with increased serum ?- glutamyltransferase, alkaline phosphatase activity and anti-HCV antibody positivity at regular checkup. A pigmented lesion removed from her back histologically proved to be cutan melanoma. Interferon treatment was applied. She lost 8 kilograms in half a year which was caused not by the tumor progression, but hyperthyreoidism. A rapid clinical and laboratory improvement was observed for thyreostatic treatment and she regained her bodyweight. One year later she presented with a cough caused by pulmonary tumor. The tumor was surgically removed and histologically diagnosed as metastasis of melanoma. Cytostatic treatment was applied and she became asymptomatic. Four years after the diagnosis of melanoma she died of apoplexy. During the autopsy there was no sign of either melanoma or liver disease. CONCLUSIONS - The careful investigation of skin should be emphasised even in case of long established neurofibromatosis. The presented case shows an association of malignant melanoma and neurofibromatosis. In the background of loss of bodyweight even in a patient with history of malignant disease other causes should also be searched such as hyperthyreoidism especially during interferon therapy.]

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[CURRENT STATUS OF THE DIAGNOSTICS AND THERAPY OF UROLOGICAL TUMOURS]

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[Significant amount of urological patients have malignant disease. Prostate cancer is the second most frequent cancer in males associated with high mortality and decreased quality of life. Hence the importance of early diagnosis. Furthermore, diagnostical protocols, operative and conservative therapeutic modalities are summarised. Hematuria is the most frequent sign of bladder cancer. Diagnostical, surgical and adjuvant therapeutical differencies of the superficial and muscle invasive bladder cancers are discussed. The urinary deviation after cystectomy could be associated with complications therefore regular follow up of patients is necessary. The standard therapy of renal cancer is surgical. Unfortunately its mortality has not change during past years. Testicular cancer is the disease of young males. If diagnosed early, most cases are curable. Therapy is complex, involving surgical, chemoand radiation therapy as well. Penis cancer is a rare disease, but highly malignant. In advanced stage patients are incurable.]

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[Sonographic appearance of the cytostatic therapyrelated hepatic injury]

JÓKÚTI László, VARGA Edit, KARÁDI Zoltán, KOVÁCS GÁBOR

[INTRODUCTION - The correlation between biochemical parameters and sonographic appearance of the liver in children and young adults receiving cytostatic therapy was investigated. PATIENTS AND METHODS - 104 (54 male, 50 female) patients at the hemato-oncologic unit of 2nd Department of Pediatrics, Semmelweis University Budapest were enrolled into this prospective, single-blind, uncontrolled study: patients’ ages were between 2.0 and 32.7 years (mean 12.2 yrs, ± SD 5.7). 69 patients received chemotherapy for acute lymphoblastic leukemia (ALL), 35 patiens for osteogenic osteosarcoma (OSC). The time interval between the initiation of the cytostatic therapy and the examination was between 1 month and 16 years (mean 3.9 yrs). Ultrasonography was performed after 5-8 hours of fasting, without sedation. Echogenicity, distal attenuation of liver parenchyma and Doppler waveforms of the hepatic vein branches were evaluated. Alanine-aminotransferase (ALT) and gamma-glutamyltransferase (GGT) activity were measured in peripheric blood samples. Statistical correlation was analysed between sonographic appearance and biochemical parameters of the liver. RESULTS - 35 patients had at least one sonographic abnormality: of these, 9 had elevated enzyme activity. Among the 69 patients with normal ultrasound findings, only 2 had increased enzyme activity (Chi square test, p=0.001). When tested against enzyme activity, echogenicity and attenuation showed significant (p=0.002 and p=0.01, respectively), Doppler waveform in the hepatic vein branches showed marginally significant correlation (p=0.05). All three ultrasound parameters had low sensitivity regarding the elevation of enzyme levels, however attenuation and hepatic vein waveform proved to be specific (both 94%) for enzyme level elevation and all three showed high negative predictive values (96%, 93% and 92%, respectively). When combining all three sonographic parameters in a single variable, correlation was even higher (p=0.001), sensitivity became acceptable (82%) and negative predictive value increased further to 97%. CONCLUSIONS - The authors conclude that a correlation exists between three simple sonographic indicators (echogenecity, distal attenuation, Doppler waveforms of the HVs) and liver injury detected by biochemical parameters. Due to the low sensitivity of the ultrasound parameters to confirm of the presence of diffuse liver injury is not possible. However, the combined use of the ultrasound and biochemical parameters a good negative predictive power can be achieved and therefore this is a useful tool in the follow-up for hepatic status.]

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[Diabetes mellitus and the liver]

BECHER Péter, PATAI Árpád, MÁJER Katalin

[In the past years, the prevention of micro- and macrovascular complications has been the main target of diabetes treatment. Its unfavourable effects on the liver have been forgotten: the accelerated progression of the liver diseaeses and the increased risk of hepatocellular carcinoma. The multimetabolic syndrome leads to non-alcoholic fatty liver diseases (steatosis, steatohepatitis, cirrhosis). On he other hand some types of liver cirrhosis (for example the common alcoholic form) are worsening the insulin resistance, so they may due to a hepatogenous diabetes mellitus, that’s treatment is different and needs more regard, than type 2 diabetes.]

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[Prevention and treatment of hepatic encephalopathy]

HUNYADY Béla

[As acute or chronic liver diseases progress, liver failure and related hepatic encephalopathy may develop. The latter occurs in more than 70% of patients with hepatic cirrhosis. Because of declining cognitive functions, sleep disturbances, memory problems and impaired motion coordination, this condition can - even in mild form - limit the patient's self-sufficiency and activity and can lead to a decreased quality of life and ability to work. Its most advanced stage, hepatic coma is one of the leading causes of liver-related mortality. These conditions generate a substantial healthcare costs. Treatment of hepatic encephalopathy involves dietary restrictions, prevention and treatment of precipitating factors, inhibition of the production and absorption of toxic substances (especially ammonia) and restoration of the amino acid balance. In addition to the traditionally used treatment with disaccharids (lactulose, lactitol), evidence has been accumulating regarding the efficacy and safety of a nonabsorbable antibiotic compound, rifaximin, which targets enteral pathogen bacteria, both in treatment and in prevention of hepatic encephalopathy. Artificial liver support therapies have been also introduced in Hungary. This review summarises the experience regarding treatment of hepatic encephalography for physicians involved in the management of patients with hepatic diseases.]

Lege Artis Medicinae

[MANAGEMENT OF LIFE-THREATENING ENDOSCOPIC THERAPY-RESISTENT OESOPHAGUS VARICEAL BLEEDING]

ERŐSS Bálint Mihály, SZÉKELY György, SIKET Ferenc, LÁZÁR István

[INTRODUCTION - Liver cirrhosis has two serious consequences: hepatic failure and portal hypertension. Portal hypertension has two important clinical appearances: variceal bleeding and therapy resistant ascites. Variceal bleeding can be recurrent and resistant to endoscopic treatment. These complications can be prevented by implantation of Transjugular Intrahepatic Portosystemic Shunt (TIPS). CLINICAL CASE - A 59 year old male with cirrhosis due to hepatitis C, was hospitalized in our department in April 2004 with variceal bleeding. We tried to control the bleeding twice by band ligation, once by sclerotherapy and with the use of Sengstaken-Blakemore tube, but bleeding continued for three weeks despite the endoscopic treatment. The patient needed intensive care therapy and was treated with more than forty units of packed red cells and plasma. At that point we decided to implant a TIPS, which was carried out succesfully. After TIPS implantation no rebleeding occured and the shunt had good patency. Moderate hepatic encephalopathy was observed, which is a well known phenomenon, but it could be treated with pharmacologic therapy. CONCLUSIONS - In case of portal hypertension TIPS implantation can prevent from variceal rebleedings and may caus significant improvement in the quality of life.]