Best practice & research. Clinical gastroenterology
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Best Pract Res Clin Gastroenterol · Aug 2005
Endocrine tumours of the gastrointestinal tract. Transplantation in the management of metastatic endocrine tumours.
Patients with neuroendocrine tumours often present with synchronous liver metastases or develop hepatic metastases in the course of their disease. A complete removal of liver metastases with an intention to cure may be accomplished by liver resection or, if hepatic disease is disseminated or hormonal symptoms and pain cannot be controlled medically, by total hepatectomy and transplantation. The indications for orthotopic liver transplantation for metastatic neuroendocrine tumour disease should be anchored in a multimodal and multidisciplinary therapeutic approach. ⋯ However, further indicators of favourable long-term prognosis are needed. Tumour biology characterised by Ki67 and E-cadherin expression may help to identify patients with a favourable outcome so that patient selection can be improved, but this needs further evaluation in larger patient cohorts. Orthotopic liver transplantation for patients with remission of disease or stable disease under medical treatment, and orthotopic liver transplantation for palliative reasons, should be restricted to selected individual cases.
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Best Pract Res Clin Gastroenterol · Oct 2003
ReviewProbiotics, antibiotic-associated diarrhoea and Clostridium difficile diarrhoea in humans.
Probiotics are living organisms which, when ingested, have a beneficial therapeutic effect. Examples are bacteria, especially Lactobacillus rhamnosus GG, and the yeast Saccharomyces boulardii. Controlled trials indicate a benefit of both of these in the prevention of antibiotic-associated diarrhoea. ⋯ In the difficult clinical problem of recurrent Clostridium difficile disease, S. boulardii as an adjunct to antibiotics has shown benefit in controlled trials. There is, however, less convincing evidence for the efficacy of Lactobacillus GG in this disease. Additional controlled trials and safety studies are needed before there can be a widespread endorsement of probiotics for these two conditions.
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Best Pract Res Clin Gastroenterol · Jun 2003
ReviewGastrointestinal disorders of the critically ill. Shock liver.
Shock liver describes a collecting pool of critically ill patients in whom the elevation of liver function tests or overt hepatic dysfunction is apparent. Different grades of shock liver affect about 50% of all intensive-care patients, varying from a mild elevation of serum aminotransferase and bilirubin levels in septic patients to an acute onset of high serum aminotransferases after haemodynamic shock. Abnormalities can subside within days or progressively deteriorate when persistent hepatic microcirculatory failure is present. ⋯ The hepatocyte undergoes dramatic alterations in synthetic activity, biliary transport, bile flow and glucose metabolism. Although standard determinations of aminotransferases, coagulation studies, glucose, lactate and bilirubin can detect hepatic injury they only partially reflect the cellular mechanisms driving shock liver. The management of shock liver is focused on the prevention of precipitating causes by controlling sepsis, circulation parameters and metabolism in addition to the cautious monitoring of therapeutic measures that can increase hepatic injury, which include intravenous nutrition, mechanical ventilation and catecholamine administration.
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Best Pract Res Clin Gastroenterol · Dec 2002
ReviewEvolving concepts in functional gastrointestinal disorders: promising directions for novel pharmaceutical treatments.
In recent years there has been an increasing appreciation of the complexity of functional gastrointestinal disorders. These represent a spectrum of conditions which may affect any part of the gastrointestinal tract in which there appears to be dysregulation of visceral function and afferent sensation and a strong association with emotional factors and stress. There is a clear psychological dimension, with up to 60% of irritable bowel syndrome (IBS) patients reported to have psychological co-morbidities and altered pain perception is also common in comparison with control populations. ⋯ Such targets include serotonin and selected 5-HT receptors, which are involved in gut motility, visceral sensation and other aspects of gut function, CCK receptors which are involved in the mediation of pain in the gut and nociception in the CNS, opioid receptors involved in pain in the brain, spinal cord and periphery, muscarinic M3-receptors, substance P and neurokinin A and B receptors which are involved in motor adaptation and pain transmission in association with inflammation, gabba receptors involved in nociception and cannabinoid receptors which are involved in the control of acetyl choline release in the gut. With a better understanding of the structures and pathways involved in visceral perception and hyperalgesia, in the CNS, spinal cord and the gut and new pharmacological tools we will be better able to elucidate the neuropharmacology of visceral perception and its relationship to gut dysfunction. It is likely that there will be multiple therapeutic options based on the spectrum of abnormalities capable of causing the spectrum of symptoms of functional gastrointestinal disorders in any individual patient.