[Infectious diarrhea in routine pediatric practice]
Klinik fur Kinder und Jugendliche, Universitat Erlangen, Deutschland.
Diarrhea, caused by infectious agents in childhood leads to dangerous loss of fluid and electrolytes. So the main issues in diagnosis and therapy are the evaluation of dehydration and the rapid compensation of deficits. The oral rehydration is superior to the parenteral as long as the clinical course allows. A infectious agent specific diagnosis and therapy is necessary only in well defined instances.
[Therapy of viral hepatitis]
Rambusch EG. Manns MP.
Abteilung Gastroenterologie und Hepatologie, Medizinische Hochschule Hannover.
The therapy of viral hepatitis has great medical and socioeconomic impact. Today chronic viral hepatitis is the most important cause for chronic liver disease, liver cirrhosis, and hepatocellular carcinoma. Hepatitis A and E cause acute courses exclusively whereas infection with the hepatitis B, C, and D virus might result in chronic hepatitis as well. The goal of therapy of chronic viral hepatitis has to be a reduction/normalisation of elevated transaminases, decrease of the serologic parameters of active viral replication, improvement of histology and prevention of complications of chronic hepatitis. The only drug with proven benefit in the treatment of chronic viral hepatitis is interferon alpha. This therapy results in a sustained response in 25 to 40% for hepatitis B and 10 to 25% for hepatitis C infection. New developments under clinical evaluation are Lamivudine and Famciclovir in the treatment of HBV-infection and Ribavirin in combination with INFa for chronic HCV-infection.
[Treatment of alcoholic liver diseases and psychiatric and psychosocial problems]
Fisch HU. Lauterburg BH.
Psychiatrische Poliklinik, Universitat Bern.
Only about 15% of the subjects abusing ethanol will eventually develop cirrhosis of the liver, suggesting that other factors in addition to the consumption of large quantities of ethanol play a role in the pathogenesis of alcoholic cirrhosis. Important contributors may be infection with hepatitis viruses, in particular HCV, protein-calorie malnutrition and immunologic factors. Abstinence improves the prognosis of patients with alcoholic cirrhosis, provided that the liver disease is not too far advanced. No pharmacotherapeutic intervention has shown a convincing improvement of the prognosis of alcoholic liver disease, so that the therapeutic efforts should be mainly directed towards abstinence. The patient with alcoholic liver disease needs support and guidance by the treating physicians. Supportive treatment with Disulfiram, Acamprosate or Naltrexon can help with achieving durable abstinence.
[Non-surgical treatment of portal hypertension]
Klinik und Poliklinik fur Innere Medizin, Universitat Halle-Wittenberg.
The choice of methods for the treatment of acute variceal hemorrhage critically depends on the locally available expertise. Vasoactive drugs or balloon tamponade may bridge the time to more definitive measures such as sclerotherapy or band ligation. Drugs (nonselective beta-adrenergic blockers and long-acting nitrates) are almost equivalent to endoscopic sclerotherapy for the prevention of recurrent bleeding, while band ligation offers both increased efficacy (reduced rate of rebleeding and death) and decreased complication rates when compared to sclerotherapy. Thus, ligation will predominantly be used for the prevention of recurrent bleeding. Alternatively, drugs may be applied when acute bleeding was effectively stopped without the use of endoscopic means. Endoscopic sclerotherapy and surgery have no place in the primary prophylaxis of variceal hemorrhage in patients who have not bled before. Prevention of the first bleed is clearly the field for beta-blockers or nitrates. The role of banding ligation in this situation remains to be defined.
[Treatment of portal hypertension by portosystemic shunts]
Rossle M. Siegerstetter V. Huber M.
Medizinische Klinik, Universitatsklinik Freiburg.
The use of shunts for the treatment of portal hypertension has been revived after the introduction of the transjugular intrahepatic portosystemic shunt (TIPS) into clinical practice. This interventional procedure has mainly been used as rescue treatment for variceal bleeding resistant to endoscopic therapy and for ascites refractory to diuretic treatment and paracentesis. With respect to variceal bleeding TIPS has a low rate of "operative" mortality of < 1% and variceal rebleeding of 6 to 18%. In patients with refractory ascites the response to treatment is 50 to 92%. The major problems of the TIPS procedure are the increased incidence of hepatic encephalopathy and the high rate of shunt insufficiency of about 50%. Therefore, control of shunt function by duplex-sonography is essential to detect malfunction of the shunt. Radiological revision is then indicated if the clinical symptoms of portal hypertension (varices, ascites) reappear. The TIPS treatment has partially replaced the surgical shunting procedures. This decision is based on the potentially higher mortality of the surgical procedure. However, this has not been proven by randomized studies and, therefore, surgical shunts may also be indicated in selected patients with low operative mortality.
[Cholestasis: therapeutic options]
Beuers U. Oswald M.
Medizinische Klinik II, Klinikum Grosshadern der LMU Munchen.
Ursodeoxycholic acid (UDCA) has been shown to be both an effective and well-tolerated treatment of primary biliary cirrhosis, a model chronic cholestatic liver disease. Beneficial effects of UDCA have also been observed in other cholestatic disorders such as primary sclerosing cholangitis, cystic fibrosis, or intrahepatic cholestasis of pregnancy. Liver transplantation is the treatment of choice in end stage chronic cholestatic liver disease. Symptomatic therapeutic concepts include the treatment of cholestasis-associated problems such as pruritus, osteopathy and vitamin deficiency.
[Diagnosis and therapy of obstructive jaundice]
Herfarth H. Scholmerich J.
Klinik und Poliklinik fur Innere Medizin I, Universitat Regensburg.
Obstructive jaundice is a sign of intra- or posthepatic blockage of bile flow. This diagnosis has to be differentiated from various other diagnoses such as disorders of bilirubin metabolism or hepatocellular causes of jaundice. An accurate evaluation of the past medical history and clinical examination of the patient can already establish obstruction as the cause of jaundice in most cases. For prevention of a cholangitis further imaging procedures should focus on rapidly establishing the cause and the location of obstruction. Further therapeutic procedures are dependent on the type of obstruction and the condition of the patient. Most importantly there should be a decompression of the biliary tree with ES or PTBD.
[Cholelithiasis--laparoscopy or laparotomy?]
Schafer M. Krahenbuhl L. Farhadi J. Buchler MW.
Klinik fur Viszerale und Transplantationschirurgie, Inselspital Bern.
Between 10% and 15% of the adult population have gallstones and therefore symptomatic cholelithiasis is the second most common indication for surgery in general practice. It's diagnosis depends on the patients history, clinical findings, laboratory tests and ultrasound. In case of symptomatic gallstones surgery offers the only permanent cure and specific complications due to gallstones such as ileus or fistula are becoming rare. With the introduction of minimal invasive surgery at the end of this century laparoscopic cholecystectomy is now considered to be the standard treatment for symptomatic gallstones. This approach can be offered to > 90% of patients in elective cases and in between 60%-80% of patients having acute cholecystitis with a low morbidity and mortality rate. The main advantages of the laparoscopic approach are the overall increased patients comfort with less postoperative pain, shorter hospital stay, recovery and off work time. Although the rate of common bile duct injury appears to be increased using this minimal invasive approach, this rate is still sufficiently small to justify the use of laparoscopic cholecystectomy for symptomatic disease. Open cholecystecomy remains the treatment of choice for complicated gallstone disease (i.e. cancer, Mirizzi syndrome, severe inflammation) and high risk patients. In case of acute cholecystitis the laparoscopic treatment with all it's advantages may also be offered to many patients. However, in those cases the conversion rate to the open approach may be markedly increased which has not to be considered as a complication of the laparoscopic approach but as a maximization of safety and effectiveness of the treatment.
[Treatment of choledocholithiasis]
Abteilung fur Gastroenterologie, Kantonsspital Basel.
Passage of gallstones into the common bile duct occurs in 10-15% of patients with cholecystolithiasis. The incidence of common bile duct stones increases with age of the patient and can reach up to 50% in certain series. The diagnosis of choledocholithiasis is usually made by endoscopic retrograde cholangiography (ERC), either preoperatively or intraoperatively at the time of laparoscopic cholecystectomy. Endoscopic sphincterotomy followed by balloon or basket extraction is the method of choice for the management of patients with common duct stones.
[Differential diagnosis and therapy of benign liver tumors]
Jonas S. Vogl TJ. Schwarz W. Neuhaus P.
Chirurgische Klinik, Virchow-Klinikum der Humboldt-Universitat zu Berlin.
Hemangioma, focal nodular hyperplasia (FNH) and hepatocellular adenoma represent the most common and clinically relevant benign liver tumors. Improved diagnostic imaging procedures as well as the broad use of oral contraceptives resulted in an increased detection rate during the past 25 years. Focal liver diseases are primarily diagnosed by ultrasonography, while a specific diagnosis can be established by contrast enhanced magnetic resonance imaging. Hepatocellular adenomas should be resected, since they bear the potential of a malignant transformation as well as the risk of rupture and intraperitoneal hemorrhage. Conversely, a conservative approach is advocated for hemangioma and FNH. However, surgical procedures may be justified when a mass becomes symptomatic, and should be applied liberally when the diagnosis remains uncertain.
[Diagnosis and treatment of hepatocellular carcinoma]
Baer HU. Holzinger F. Feodorovici M. Buchler MW.
Klinik fur Viszerale und Transplantationschirurgie, Inselspital, Universitat Bern.
Worldwide, hepatocellular carcinoma is one of the most common intra-abdominal malignancy. It occurs mostly in patients who are carriers of the hepatitis B or C virus and/or have liver cirrhosis. There is no screening-test for early recognition of the development of liver cancer and this delays often an accurate diagnosis and early treatment. Resection is the best form of treatment offering a chance of cure. In the last decades, considerable progress has been made in the field of liver diagnostic and operative techniques for liver resection. This has been followed by an increase in the resection rate of patients with malignant liver tumours and by a decrease in postoperative morbidity and mortality. Nowadays, after curative resection, 5-year survival rates up to 30% can be achieved. Promising results are also obtained by new adjuvant therapeutic modalities demonstrating improvement in survival. Therefore, in the field of malignant liver tumours there is no more space for therapeutic nihilismus.
[Indications and results of liver transplantation]
Klinische Abteilung fur Transplantationschirurgie, Chirurgische Universitatsklinik, Innsbruck.
Liver transplantation offers cure and high a quality of life to patients with otherwise incurable diseases. For patients suffering from chronic liver diseases or metabolic disorders, a life expectancy of less than one year or an unacceptable quality of life are considered to be indications for transplantation. For unresectable primary liver tumors without vascular invasion or tumor manifestations outside the liver long-term survival can be achieved with transplantation. Because of the enormous regenerative capacity of the liver, indication for transplantation can be difficult in case of fulminant hepatic failure, for which own criteria have been defined. In relation to the under-lying liver disease one-year patient survival varies from 60%-80%. Recurrence of tumors or viral hepatitis may have a negative impact of long-term outcome. Various indications and results are discussed in detail.