[Phenprocoumon-associated necrotizing hepatitis].
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Anticoagulants↗
Biomedical subjects
P Knoflach
Publications and source records attributed to P Knoflach.
[Risk of osteoporosis in steroid therapy. When and how to counter the risk].
Many chronic inflammatory diseases require treatment with steroids, however, a remarkable proportion of steroid-treated patients suffer from osteoporosis as a major complication following longterm treatment. Steroid-induced osteoporosis with its complex pathogenesis represents one of the most important secondary causes of osteoporosis. If we care for patients with steroid therapy we have both to consider this problem and to focus on strategies to evaluate patients at risk. The dosage of the steroid, life style factors, menopausal status, low bone mineral density at baseline and previous osteoporotic fractures predispose for the manifestation of steroid-induced osteoporosis. Decisions in regard of prevention and therapy depend on risk factors of the individual patient. Supplementation of calcium and vitamin D is usually appropriate, and postmenopausal women should be offered hormone replacement therapy. The prescription of bisphosphonates is strongly recommended to patients at elevated risk or to patients with already documented osteoporosis.
Anti-Inflammatory Agents↗
Concomitant manifestation of achalasia and sphincter of Oddi dysfunction.
We report the case of a 44-year-old woman who suffered from biliary-type pain after cholecystectomy, dysphagia, and weight loss. Examinations revealed sphincter of Oddi dysfunction (SOD) and achalasia. Complete relief of symptoms was achieved by endoscopic sphincterotomy and pneumatic dilation of the distal esophagus. This case report demonstrates for the first time the concomitant manifestation of two motility disorders of the upper gastrointestinal tract, i.e. achalasia and SOD. At present, any causal relationship seems speculative; however, both diseases were successfully treated using endoscopic procedures.
Adult↗
Rectal carcinoma unmasked by mud packs.
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Adenocarcinoma↗
[Current concepts in therapy of reflux disease].
Proton pump inhibitors have replaced H2-blockers as first line agents for the therapy of gastroesophageal reflux disease due to their effective acid suppression and faster healing rate. The endoscopic severity of esophagitis and the clinical response are the most important determinants of dosing and duration of therapy. In patients with severe esophagitis continuous maintenance treatment with proton pump inhibitors is recommended. In recent years antireflux surgery has been established as an important alternative therapy.
Anti-Ulcer Agents↗
[A 24-year-old patient with decreased libido and erectile dysfunction as initial manifestations of hemochromatosis].
HISTORY AND CLINICAL FINDINGS: A 24 year old yugoslavian father of two children, complained of decreased libido and impotence since seven months. He also described recurrent joint pains in the knees and wrist joints. The urological and internal examination was unremarkable. INVESTIGATIONS: Except for slightly elevated liver enzymes and a mild thrombocytopenia the laboratory tests were normal. Testosteron, follicle stimulating hormone and luteinizing hormone concentrations were markedly decreased. Hepatosplenomegaly was demonstrated by ultrasound. TREATMENT AND COURSE: During testosteron administration for hypogonadotrophic hypogonadism erectile dysfunction improved. 9 months later the patient became diabetic and was referred to our department. Hemochromatosis was confirmed by serum ferritin concentration of 4010 micrograms/l, transferrin saturation of 85% and hepatic iron concentration of 27,900 micrograms/g dry weight. Molecular genetics showed no mutation of the hemochromatosis gene HFE. After venesection the ferritin concentration decreased, the loss of libido and subfertility improved with testosterone administration. CONCLUSION: In subfertility from an endocrine disorder primary hemochromatosis should be considered in the differential diagnosis. Only early diagnosis and prompt iron depletion may improve the prognosis of these patients.
Adult↗
[Helicobacter pylori and non-steroidal anti-inflammatory agents].
Observations on the interactions between the two main causes of gastroduodenal lesions--treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori(H.p.)-infection--remain controversial. However, H.p.-infection does not need to be harmful additively or synergistically, but could also be protective against the toxic effects of NSAIDs on the mucosa. Therefore, specific therapeutic strategies are needed for different clinical situations.
Anti-Inflammatory Agents, Non-Steroidal↗
Severe pancytopenia after leflunomide in rheumatoid arthritis.
Leflunomide is a novel drug recently introduced for treatment of rheumatoid arthritis as a DMARD (disease-modifying antirheumatic drug). So far, leflunomide has not been associated with severe bone marrow toxicity and pancytopenia. We report of a 62-year-old woman with a 14-year history of rheumatoid arthritis with bone marrow toxicity and reversible pancytopenia developing after treatment with leflunomide.
Anti-Inflammatory Agents, Non-Steroidal↗
[Steroid-induced osteoporosis: pathogenesis and therapeutic consequences].
Many chronic inflammatory diseases require treatment with steroids, however, a remarkable proportion of steroid-treated patients suffer from osteoporosis as major complication after longterm treatment. Steroid-induced osteoporosis represents one of the most important secondary causes of osteoporosis. The pathogenesis is complex, there exists evidence that steroids cause a reduction of circulating testosterone and estrogen concentration and adversely affect calcium balance. The most important mechanism is a decrease in osteoblastic activity. As a consequence loss of bone mineral density and increased risk of fracture develop. In spite of better understanding of the causal relationships preventive strategies were infrequently applied. If we care for patients with steroid therapy we have both to consider the problem of steroid-induced osteoporosis and to focus on strategies to evaluate patients at risk. The dosage of the steroid, life style factors (such as lack of exercise, alcohol consumption and smoking), menopausal status, low bone mineral density at baseline and previous osteoporotic fractures predispose for the manifestation of steroid-induced osteoporosis. Therapeutic decisions depend on risk factors of the individual patient. Supplementation of calcium and vitamin D is usually appropriate, and postmenopausal women should be offered hormone replacement therapy. The prescription of bisphosphonates is strongly recommended to patients at elevated risk.
Estrogen Replacement Therapy↗
Recurrent septicemia with lethal outcome during and after cyclosporine therapy in severe ulcerative colitis.
High dose corticosteroids have been the mainstay in the treatment of fulminant ulcerative colitis (UC) for a long time. In the last years intravenous cyclosporine (CyA) has been reported to be rapidly effective and relatively safe in patients with severe corticosteroid-resistant UC. We report on a 64 year old patient with a severe flare-up of UC who responded well to intravenous CyA after a standard therapy with high dose corticosteroids alone had been ineffective. However, recurrent staphylococcus aureus sepsis developed during CyA therapy. Despite a long-time antibiotic therapy two further episodes of staphylococcus aureus sepsis occurred after discontinuation of CyA treatment. Being in remission with his UC the patient died 14 months later of staphylococcus aureus sepsis despite intense antibiotic treatment. Infectious complications of this therapeutic regime in severe UC are known but to our knowledge a recurrent sepsis complicating this therapy even after cessation of CyA has not been reported in the literature so far.
Colitis, Ulcerative↗
Primary gastric B-cell lymphoma: results of a prospective multicenter study. The German-Austrian Gastrointestinal Lymphoma Study Group.
BACKGROUND & AIMS: Appropriate management of primary gastric lymphoma is controversial. This prospective, multicenter study aimed to evaluate the accuracy of endoscopic biopsy diagnosis and clinical staging procedures and assess a treatment strategy based on Helicobacter pylori status and tumor stage and grade. METHODS: Of 266 patients with primary gastric B-cell lymphoma, 236 with stages EI (n = 151) or EII (n = 85) were included in an intention-to-treat analysis. Patients with H. pylori-positive stage EI low-grade lymphoma underwent eradication therapy. Nonresponders and patients with stage EII low-grade lymphoma underwent gastric surgery. Depending on the residual tumor status and predefined risk factors, patients received either radiotherapy or no further treatment. Patients with high-grade lymphoma underwent surgery and chemotherapy at stages EI/EII, complemented by radiation in case of incomplete resection. RESULTS: Endoscopic-bioptic typing and grading and clinical staging were accurate to 73% and 70%, respectively, based on the histopathology of resected specimens. The overall 2-year survival rates for low-grade lymphoma did not differ in the risk-adjusted treatment groups, ranging from 89% to 96%. In high-grade lymphoma, patients with complete resection or microscopic tumor residuals had significantly better survival rates (88% for EI and 83% for EII) than those with macroscopic tumor residues (53%; P < 0.001). CONCLUSIONS: There is a considerable need for improvement in clinical diagnostic and staging procedures, especially with a view toward nonsurgical treatment. With the exception of eradication therapy in H. pylori-positive low-grade lymphoma of stage EI and the subgroup of locally advanced high-grade lymphoma, resection remains the treatment of choice. However, because there is an increasing trend toward stomach-conserving therapy, a randomized trial comparing cure of disease and quality of life with surgical and conservative treatment is needed.
Adult↗
[Cholestatic hepatitis as a rare side effect of therapy with ticlopidine].
A 71-year-old man with chronic atrial fibrillation was treated with aspirin because of a right cerebral infarction. Oral anticoagulation was not initiated because of a secondary hemorrhagic transformation. Six years later after a left cerebral transient ischemic attack aspirin was replaced by ticlopidine. Two weeks after starting ticlopidine he experienced abdominal cramps and diarrhea. Also dark urine and gray-colored stools were noticed, so that the patient stopped taking ticlopidine. 40 days after starting ticlopidine he was admitted to our hospital because of cholestatic jaundice. Serum alkaline phosphatase (305 U/l) and gamma GT (143 U/l) were elevated, the total bilirubin was 18.6 mg/dl at peak. GOT and GPT were 2.7 fold increased. After exclusion of a viral infection and autoimmune disease liver biopsy was performed, which showed a centroacinar cholestasis compatible with a drug-induced liver damage. 79 days after discontinuation of the drug laboratory signs of cholestasis had disappeared. In patients in whom long-term therapy with ticlopidine is indicated regularly laboratory tests and clinical examinations should be done to recognize infrequent side effects such as the cholestatic hepatitis in time.
Aged↗
[Gastrointestinal hemorrhage needing blood transfusion as the first manifestation of small bowel carcinoid tumor].
Carcinoid tumors arise from enterochromaffin or enterochromaffin-like cells that are present in the gastrointestinal tract, ovaries, and lungs. Over 90% of carcinoids originate in the gastrointestinal tract with the most common sites in order of frequency being the appendix, terminal ileum, rectum, and the remainder of the colon. Gastroduodenal and pancreatic carcinoids are infrequent. Carcinoid syndrome is associated with small intestine carcinoids in about 40%. Common symptoms include intermittent intestinal obstruction with crampy abdominal pain and vomiting, and weight loss. Upper gastrointestinal bleeding with melaena or hematochezia is a relatively rare early symptom of patients with small intestine carcinoid tumors. We report on a 69-year-old man, treated with acenocoumarol for previous thromboembolic complications of hereditary protein S deficiency. He was admitted to hospital because of an acute episode of hematochezia followed by melaena. Endoscopic evaluation of esophagus, stomach, duodenum and colonoscopy revealed no apparent source of bleeding. Selective angiographic evaluation of mesenterial arteries showed pathologic vasculature approximately in mid jejunum. Laparotomy revealed bleeding from a small submucosal malignant carcinoid tumor in small intestine and multiple large metastases within mesenteric tissue. Segmental resection of small intestine and exstirpation of the metastatic masses was performed. Postoperative period was uneventful. Cytotoxic chemotherapy in this adjuvant setting has not been recommended. Small intestinal carcinoid tumor has to be considered as a rare cause of gastrointestinal bleeding with melaena or hematochezia. Nevertheless, bleeding is a relatively rare early symptom of patients with small intestine carcinoid tumor.
Acenocoumarol↗
[Consensus of the Chronic Inflammatory Bowl Disease Study Group of the Austrian Society of Gastroenterology and Hepatology on the topic of "diagnosis and therapy of chronic inflammatory bowel diseases in adolescence"].
Although up to 20% of patients with Crohn's disease have their first flare during childhood or adolescence, there are no or only a few randomized, controlled studies. However, big differences and uncertainty may be observed between the diagnosis and therapy of pediatricians and gastroenterologists specialized for adults. In addition, special problems result from the enormous somatic and psychological evolution during adolescence. The diagnosis is done as in adult patients by enteroclysm and ileocolonoscopy (including multiple biopsies) whereas a deep sedoanalgesia or anesthesia should be performed routinely. Corticosteroids are the gold standard for therapy of Crohn's disease in the adolescence (especially in cases with high inflammatory activity), but also enteral nutrition over 4-12 weeks--or a combination of both. A recent randomized controlled study demonstrates the positive effect of 6-mercaptopurine in newly diagnosed patients with Crohn's disease in the adolescence. 5-aminosalicylates or the probably more effective azathioprine/6-mercaptopurine could be used for prevention of recurrence in Crohn's disease. The therapy of ulcerative colitis is performed as in adults including the very effective local rectal applications. An accompanying psychosomatic therapy is recommended especially in young patients with disturbed separation from the parents and inadequate coping. The indication for surgery is similar to adults. However, a specific indication for earlier surgery is given, if severe malabsorption and delay of growth takes place in spite of adequate therapy, because this delay of growth could be only caught up before puberty. A conservative therapeutic regimen is recommended in young patients with perianal Crohn's disease.
Adolescent↗
[Retroperitoneal fibrosis as the etiology for recent onset of abdominal pain, nausea and vomiting--a rare and easily missed differential diagnosis].
Retroperitoneal fibrosis is a rare disease with unspecific symptomatic signs. Mortality rates are high with a 10-year mortality rate of 10 to 20%. We describe a case of a 55 year old woman with retroperitoneal fibrosis and discuss clinical findings, symptomatic signs, diagnosis, and treatment of this rare disease.
Abdominal Pain↗
[Gastrointestinal hemorrhage after operation for dissecting aneurysm of the thoracic aorta].
We present the case of a 45-year-old man who underwent surgical repair of a dissecting aneurysm of the descending thoracic aorta. 25 days postoperatively, the patient unexpectedly developed hematemesis and hypovolemic shock. Emergency gastroscopy was performed and a suspected aortoesophageal fistula was diagnosed. Unfortunately, the patient died prior to emergency surgery. Aneurysms of the aorta or of aortic grafts occasionally lead to the development of fistulae to the upper gastrointestinal tract. Once this rare, but life-threatening complication is suspected, endoscopy must be performed immediately. Emergency surgery is associated with a high risk, but represents the only possibly chance of survival for the patient.
Aortic Dissection↗
[Diagnosis in chronic inflammatory bowel diseases--report of the Austrian Chronic Inflammatory Bowel Disease Study Group].
Diagnostic procedures in inflammatory bowel diseases (IBD) serve to secure the diagnosis and to optimize treatment. Upon initial diagnosis endoscopy up to the terminal ileum is mandatory including multiple step biopsies. When diagnostic guidelines are followed and adequate clinical information is available, IBD will be correctly classified in about 80 to 90% of cases upon first examination. In contrast endoscopic studies are only of limited value in monitoring treatment. The decision if and when to perform endoscopy during exacerbation of disease must be an individual one. When disease activity is evaluated, a distinction must be made between degree of activity as reflected by laboratory parameters and severity of illness as reflected by the clinical presentation with abdominal complaints, fistulas, abscesses, etc. Distinct activity indices are useful in clinical studies to obtain an objective evaluation of activity and severity of disease. At clinical routine visits questions should not only concern the basic illness but also ask for quality of life and psychosocial status. Only a small number of laboratory tests are needed for basic diagnosis and follow-up. A small bowel enteroclysis should always be performed upon primary diagnosis of Crohn's disease and during the course of disease when there is suspicion of small-bowel involvement. Double contrast barium enema should be limited to special indications as incomplete colonoscopy e.g. due to stenosis or suspected fistula. Sonography is the primary investigation when complications are suspected. CT is useful as an adjunct or when the afore mentioned methods do not show clear findings. NMR is the procedure of choice for detection of pararectal fistulas and abscesses. Transrectal endosonography is comparably good but limited to the experience of the investigators and by patient's tolerability.
Biopsy↗
[Tropical sprue as the cause of chronic diarrhea after travel to Southeast Asia].
A 43-year-old woman developed abdominal pain and diarrhea following a travel to Malaysia. Examinations in another hospital proved no evidence of infection, an empirical antibiotic therapy with ciprofloxacin yielded no benefit. One and a half year later, the patient was admitted to our department because of persistent diarrhea and wasting. Laboratory tests showed megaloblastic anemia, folate deficiency and steatorrhea. Stool specimens for bacterial pathogens and parasites were negative. Endoscopy and biopsy from the distal portion of the duodenum revealed broadening and shortening of the villi and an increased infiltration of the lamina propria by chronic inflammatory cells (plasma cells and lymphocytes). In conclusion, diagnosis of tropical sprue was established. The therapy comprised of tetracycline for six weeks and folic acid for six months. Subsequently, the diarrhea disappeared, the patient continuously gained weight and was free of any complaints. The complete remission following this regimen proved the suspected diagnosis. Differential diagnosis in any patient who recently returned from the tropics may be a challenge. Tropical sprue predominantly occurs during or after a longer stay in endemic areas. However, if chronic diarrhea and signs of malabsorption develop after a short journey to India, South-East Asia and parts of the Caribbean, tropical sprue has to be considered, too.
Adult↗