Intestinal secretion: stimulation by peptides.

Two peptides isolated from intestinal mucosa, vasoactive intestinal peptide, and gastric inhibitory peptide, stimulate small intestinal secretion in conscious dogs. Glucagon and pentagastrin also stimulate, but secretin and the octapetide of cholecystokinin do not. The stimulants may participate in regulation of intestinal secretion in health and in diseases with excessive secretion.

Omeprazole therapy decreases the need for dilatation of peptic oesophageal strictures.

BACKGROUND: Better control of gastric acid secretion with omeprazole appeared to decrease the need for dilatation of oesophageal strictures complicating gastro-oesophageal reflux disease in our hospital-based endoscopy service. AIM: To investigate whether the perceived decrease in the need for oesophageal dilatation could be documented from endoscopy records, and, if confirmed, whether this could be related to the treatment used. PATIENTS AND METHODS: Retrospective study of the records of 69 patients who had peptic oesophageal strictures dilated, followed by treatment with acid inhibition for at least 6 months. Mean duration of follow-up was 3.9 years during treatment with H2-receptor antagonists and 2.1 years while on omeprazole (258 and 78 patient-years, respectively). Re-dilatation rates were compared between those treated with H2-receptor antagonists or omeprazole. RESULTS: There has been a significant decrease in dilatations performed for gastro-oesophageal reflux induced strictures (P<0.001), while dilatation rates for other indications remained constant. Treatment with omeprazole not only decreased the need for further dilatations, but also prolonged the mean time between any further dilatations to 26.3 months compared to 9.3 months for those on an H2-receptor antagonist (P<0.0001). CONCLUSIONS: Following dilatation of peptic oesophageal strictures, treatment with omeprazole in place of an H2-blocker significantly decreases the need for repeat dilatation.

A prospective evaluation of injection sclerotherapy in the treatment of acute bleeding from esophageal varices.

In a 25 month study of massive upper-gastrointestinal hemorrhage, 64 patients were shown to have esophageal varices on emergency endoscopy. Twenty-four patients were actively bleeding from varices and were treated with a Sengstaken tube, and in 22 this was followed by emergency injection sclerotherapy using a rigid esophagoscope and general anesthesia. These 22 patients were followed prospectively and had 51 episodes of endoscopically proven active bleeding from esophageal varices which required Sengstaken tube control of hemorrhage during 36 separate admissions. This group included our total experience of injection sclerotherapy in acute variceal bleeding. The majority (14 of 22 patients) had alcoholic cirrhosis. Definitive control of variceal bleeding during the period of hospitalization was achieved in 33 hospital admissions (92%), usually with a single injection (27 hospital admissions: 75%). The results were satisfactory in 26 hospital admissions (72%). There were nine deaths (41% overall patient mortality rate), but no patient died primarily of variceal bleeding, and exsanguinating variceal bleeding was no longer a problem. The mortality rate per injection was 18%, and the mortality rate per hospital admission was 25%. Injection sclerotherapy is proposed as the emergency treatment of choice for patients with proven bleeding esophageal varices who do not stop bleeding on initial conservative treatment.

Diagnosis of helicobacter pylori infection by polymerase chain reaction: is it worth it?

The aim of this study was to determine to what degree polymerase chain reaction (PCR) was superior to histology and culture, and whether a noncommercial urease test was of value, in detecting Helicobacter pylori in gastric biopsy specimens. Gastric biopsy specimens from the antrum and corpus of 134 consenting patients were subjected to PCR, targeting the glmM (ureC) gene, histology, culture, and a rapid urease test. PCR detected H. pylori in the biopsy specimens from 59 patients. All methods showed a high degree of sensitivity and specificity, but histology gave 2 false-negatives, and culture and the urease test gave 1 false-negative compared with PCR. PCR of a glmM gene segment was superior to the other methods for the detection of H. pylori infection and was comparable to histology in terms of cost. Nevertheless, in this study, histology and culture were found to be relatively reliable methods for examining gastric biopsy specimens.

Kinetics of somatostatin inhibition of pentagastrin-stimualted gastric acid secretion.

Dogs with gastric fistulae and denervated gastric pouches received graded doses of pentagastrin with and without a background infusion of somatostatin (1 microgram kg-1 h-1). Similarly, graded doses of somatostatin (0.25, 0.5, 1, 2 and 4 microgram kg-1 h-1) were infused after a steady state gastric secretion had been achieved with pentagastrin (1.5 microgram kg-1 h-1), about twice the dose required to produce half maximal (D50) response. Somatostatin inhibited pentagastrin-stimulated gastric acid secretion with competitive inhibition kinetics, but its precise site of action remains uncertain. The minimum effective dose of somatostatin on a twice D50 dose of pentagastrin was 0.25 microgram kg-1 h-1.

A single-blind crossover trial of the anti-inflammatory drug sodium meclofenamate and placebo, including an evaluation of hand grip and of lymphocyte responsiveness.

A single-blind crossover trial was carried out in 21 patients with active rheumatoid arthritis to assess the effectiveness and tolerance of sodium meclofenamate (300 mg per day) compared with placebo. After a 1-week washout period patients had two periods of active medication, each of 2 weeks, separated by 1 week on placebo. Morning stiffness, walking speed, pain score, patient impression of response, joint tenderness and power, work and maximum grip strength achieved by hand grip were all improved by sodium meclofenamate and an anti-inflammatory effect of the drug was demonstrated, with some reduction in the swelling of PIP joints. There was no advantage in assessing pain on full movement of the small joints of the hands in addition to direct tenderness. Power, work and rate of grip release achieved during hand grip provided more information about hand function than maximum grip strength alone. Lymphocyte transformation to non-specific mitogens was enhanced by the drug. Twelve patients had some form of gastro intestinal complaint during the study and it is suggested that diarrhoea is likely to prove to be the major limiting factor of acceptance by some patients.

Seroprevalence of Helicobacter pylori in a birth cohort of 21-year-old New Zealanders.

OBJECTIVE: To determine the seroprevalence of Helicobacter pylori (H. pylori) in a subset of a birth cohort of New Zealanders at age 21 and examine the association with risk factors and digestion-related symptoms. DESIGN: Assay of serum collected from members of a longitudinal study during 1993-94 and a survey of risk factors and digestion-related symptoms by interview and questionnaire. METHODS: Serum from 785 sample members (413 males, 372 females) of the 950 participating in the Dunedin Multidisciplinary Health and Development Study (DMHDS) at age 21 was analysed for H. pylori antibodies. Serum samples (n = 579) from the cohort at age 11 collected in 1983 were analysed for those who were seropositive at age 21. RESULTS: The seroprevalence of H. pylori at age 21 was 4.1% (32/785), with proportionally more males in the seropositive group (chi 2 = 6.7, P < 0.01). Serum samples taken at age 11 were available for 19 of the seropositive group and 74% of these (11 males, three females) were seropositive. The seropositive group at age 21 was no different in the size of their families, but at age 5 contained proportionally more individuals from families of low socioeconomic status (SES) (chi 2 = 6.1, P < 0.05). There was no difference between the two groups in terms of upper gastrointestinal tract symptoms, recent use of medications, smoking or alcohol consumption. CONCLUSION: The seroprevalence of H. pylori among a birth cohort of 21-year-old New Zealanders is significantly lower than among most populations of about the same age in other countries. Seropositivity is higher in males and among families of lower SES, and is not associated with digestion-related symptoms. The seroconversion rate after age 11 appears to be low.

New treatment for Barrett's oesophagus.

Barrett's esophagus is characterised by the presence of specialised intestinal metaplasia in the lower esophagus. Its importance is related primarily to its link with adenocarcinoma of the lower esophagus, often preceded by dysplastic changes. The incidence of this carcinoma has increased dramatically over the last few decades. Although modern treatments, particularly acid suppression with proton pump inhibitors, have been most useful in controlling the reflux symptoms associated with Barrett's esophagus, they have not reduced the incidence of adenocarcinoma of the esophagus. The same can be said about anti-reflux surgery. Surgical excision of Barrett's esophagus has been advocated when high-grade dysplasia is detected; this carries considerable morbidity and mortality, so alternative treatments are being developed. This update summarises recent information concerning newer treatments aimed at eradicating Barrett's esophagus. These vary from thermal coagulation (using electrocoagulation and heater probes) to lasers, photodynamic therapy and mechanical methods. Of these, photodynamic therapy using a porphyrin precursor (5-amino-laevulinic acid) seems to give the most consistent satisfactory results with a minimum of complications. However, persistence of some metaplastic cells beneath the neo-squamous layer remains a problem. Ongoing effective acid control (by medical or surgical therapy) is also essential to prevent recurrence of Barrett's esophagus. Future research is aimed at perfecting these methods. Ultimately, it may be possible to understand the molecular biology which could help to predict which patients are at greatest risk of developing dysplastic and carcinomatous changes.

Benign lymphoid hyperplasia of the gastric antrum - another cause of "etat mammelonne".

The radiological and endoscopic appearance of "etat mammelonne" has been attributed to hypertrophic gastritis or prominence of the areae gastricae. An additional cause for this appearance is described in two patients with benign lymphoid hyperplasia of the gastric antrum. The significance of these lesions is discussed.

Comparative in vitro enzyme activities of five commercially available pancreatic supplements.

A comparative in vitro analysis was performed of the enzyme activities contained in five commercial pancreatic supplements available in New Zealand. there was considerable individual variation between each product. Lipase was regarded as the most important enzyme, as lipase deficiency is the most significant clinical factor in patients with exocrine pancreatic insufficiency. Viokase not only contained the most lipase per tablet, but was also the cheapest product.

Prospective evaluation of patients with upper gastrointestinal haemorrhage.

A prospective study was conducted to collect data on clinical and endoscopic diagnosis, associated factors and outcome of 112 consecutive patients with acute upper gastrointestinal haemorrhage admitted to the Dunedin public hospitals over an 18 month period. The mean interval between admission and endoscopy was 20.2 hours. There was a poor correlation between the provisional clinical diagnosis and the endoscopic diagnosis. The causes of bleeding were demonstrated at endoscopy in 87.5% of patients. A history of salicylate, non-steroidal anti-inflammatory drug or significant alcohol ingestion was present in about two-thirds of patients with mucosal abnormalities. The incidence of continued or repeated bleeding was 16%; peptic ulcers accounted for half of these patients. The presence of active bleeding or a visible vessel or blood clot on the ulcer surface indicated a 33% chance of rebleeding; none of the peptic ulcer patients without these signs rebled. Surgery was performed in 11.6% of patients, predominantly for peptic ulcer. The overall mortality was 8% (reducing to 5.4% if patients dying in hepatic failure are excluded), most of the deaths occurring in older patients with complicating medical conditions, and not from uncontrolled haemorrhage.

Evaluation of a new fine needle technique in routine percutaneous liver biopsy.

A new fine needle aspiration biopsy technique (Vacu-Cut, 19.5 G) was compared to the 17 G Menghini needle in 20 consecutive patients scheduled for routine percutaneous liver biopsy (10 at random with each needle). The Menghini system was superior in producing sufficient material for histological assessment with 90% success on first pass biopsy (100% with 12 passes in 11 patients) as compared to 60% with the Vacu-Cut needle (90% with 16 passes in 10 patients). The latter was easier to use. Ability to reach a histological diagnosis was 100% with both needles. No major complications occurred: only one Vacu-Cut patient (10%) developed pain at the puncture site as compared to seven patients (65%) in the Menghini group, irrespective of number of passes. The ease of use and lower incidence of pain may favour the Vacu-Cut needle in selected ill patients.

Lactose malabsorption and calcium intake as risk factors for osteoporosis in elderly New Zealand women.

OBJECTS: to evaluate the prevalence of lactose malabsorption and to assess dietary calcium intake, in elderly New Zealand women with hip fractures, in age matched case controls without hip fractures drawn from general practice, and in healthy young women. METHODS: lactose malabsorption was assessed by measuring breath hydrogen after a 50 g oral lactose tolerance test. Dietary calcium was estimated from a food frequency questionnaire. RESULTS: the elderly fracture cases (n = 15), and their elderly controls (n = 16), showed a similar (60% and 63% respectively), but significantly higher prevalence (p less than 0.001), of lactose malabsorption than young women (12%, n = 50). Dietary calcium intake was similar in lactose absorbers and malabsorbers. CONCLUSIONS: malabsorption of lactose occurs commonly in elderly New Zealand women but is scarce in young adults. A high prevalence of lactose malabsorption may be a risk factor for exacerbation of type II osteoporosis in the elderly.

A comparison of oxmetidine and cimetidine in the treatment of duodenal ulcer.

Oxmetidine (1 g/day), a new histamine H2-receptor antagonist, or cimetidine (1 g/day) was given to 30 patients with endoscopically proven duodenal ulcers in a randomised, double-blind trial. Ulcer healing was assessed endoscopically after four weeks' treatment, and again at eight weeks in those who had not healed in the first four weeks. Of the 15 patients receiving oxmetidine, 11 (73 percent) had healed their ulcers in four weeks, while 14 (93 percent) had healed their ulcers in eight weeks. Comparable healing rates were found with cimetidine, namely 13 of 15 (87 percent) after four weeks and all 15 patients (100 percent) after eight weeks. The patients were relieved of their symptoms to a comparable degree with both drugs. Weekly clinical, haematological and biochemical monitoring failed to reveal any relevant adverse effects except for a mild asymptomatic rise in serum creatinine levels with both oxmetidine and cimetidine.

Clostridium difficile toxin in chronic idiopathic colitis.

Clostridium difficile toxin was isolated from the stools of three patients with chronic idiopathic colitis. Two patients were known to have chronic idiopathic colitis before Cl difficile toxin was isolated. The third patient was subsequently found to have ulcerative colitis after presentation with Cl difficile toxin in the stool. Two patients were on sulphasalazine at the time of diagnosis of Cl difficile infection and one had taken sulphasalazine two months previously. Only one patients had antibiotic exposure and that was at least three months before presentation. In each patient, treatment with vancomycin was accompanied by symptomatic improvement and disappearance of the toxin. The underlying colitis remained unaffected. In patients with inflammatory bowel disease in relapse, the presence of Cl difficile toxin should be sought as this may be a factor in the relapse. In any patient presenting with diarrhoea, the presence of Cl difficile toxin may obscure the presence of underlying inflammatory bowel disease.

The prevalence of coeliac disease in Otago.

This retrospective study of coeliac disease in Otago showed that the cumulative prevalence in childhood was low at 35 per 100,000. The overall prevalence of the condition in Otago was also low at nine per 100,000. This low prevalence is probably the result of underdiagnosis. Only 35% of patients diagnosed during the 10 year period of the study were members of the Coeliac Society.

Crohn's disease: a ten year retrospective review at Dunedin hospitals.

Based on strictly defined criteria, 48 patients were judged to have Crohn's disease in a retrospective 10 year survey of Dunedin Hospital case notes. An apparent increase in the frequency of this disease in the Otago area is documented. Age (mean 39.5 years) and sex distribution (female/male:1.6/1) of cases and the patterns of clinical presentation are in accordance with similar studies in other countries. Mean follow up was for 28 months (range 3-108 months). The dominant localisation of the disease was to the large bowel only (60%), or large bowel plus terminal ileum (17%) with only 23% having disease confined to the small bowel. This is the reverse of experience in a similar survey recently reported from Auckland. No cases were detected in Polynesians in either survey. The difficulty of early and accurate diagnosis of Crohn's disease is emphasised. Although 21 (44%) of the patients required some surgery, no deaths were recorded in these patients.