Validation of an Inguinal Pain Questionnaire for assessment of chronic pain after groin hernia repair.

BACKGROUND: Long-term pain is an important outcome after inguinal hernia repair. The aim of this study was to test the validity and reliability of a specific Inguinal Pain Questionnaire (IPQ). METHODS: The study recruited patients aged between 15 and 85 years who had undergone primary inguinal or femoral hernia repair. To test the validity of the questionnaire, 100 patients received the IPQ and the Brief Pain Inventory (BPI) 1 and 4 weeks after surgery (group 1). To test reliability and internal consistency, 100 patients received the IPQ on two occasions 1 month apart, 3 years after surgery (group 2). Non-surgery-related pain was analysed in group 3 (2853 patients). RESULTS: A significant decrease in IPQ-rated pain intensity was observed in the first 4 weeks after surgery (P < 0.001). Significant correlations with corresponding BPI pain intensity items corroborated the criterion validity (P < 0.050). Logical incoherence did not exceed 5.5 per cent for any item. Values for kappa in the test-retest in group 2 were higher than 0.5 for all but three items. Cronbach's alpha was 0.83 for questions on pain intensity and 0.74 for interference with daily activities. CONCLUSION: This study found good validity and reliability for the IPQ, making it a useful instrument for assessing pain following groin hernia repair.

A routine method for determination of glycine and taurine distribution in bile acids.

A procedure is described in which the content of glycine and taurine in bile acids is determined. Following an alkaline hydrolysis, the amino acids are separated on a column of Dowex 50-X8 and quantitatively estimated by a ninhydrin colorimetric method. The taurine/taurine + glycine ratios in a series of samples were determined by this method and by an enzymatic bile acid analysis and a good accordance between the two methods was obtained.

Effects of postmenopausal ethinylestradiol treatment on gallbladder bile.

Bile composition was studied in three postmenopausal women without evidence of gallstone disease during administration of 50 micrograms of ethinylestradiol daily. The treatment resulted in an increased fraction of cholesterol in gallbladder bile and a shift in the bile acid composition with decreased relative concentration of chenodeoxycholate and increased fraction of cholate. These changes in bile lipid composition might explain the higher incidence of gallstones in women treated with estrogens.

PIP: Because of previously reported associations between raised incidence of bile composition changes associated with oral contraceptive intake, this study, which the editors note is very small and perhaps is merely indicative, determined the bile composition of 3 women volunteers, all of postmenopausal status, who had been given 50 mcg of ethinylestradiol (EE) daily for 3 weeks followed by 1 therapy-free week. The women had no indications of gallbladder problems and all were suffering from postmenopausal vasomotor symptoms. Gallbladder bile was collected with a duodenal tube after administration of 80 U of cholecystokinin intravenously before treatment and at the end of the third or fourth cycle of treatment. Results showed that the molar fraction of cholesterol in the gallbladder bile increased in all subjects during treatment with EE. A change in the distribution of bile acids also occurred. In addition, the relative concentration of cholate increased whereas the relative concentration of chenodeoxycholate decreased. Deoxycholate decreased in 2 and increased in 1 subjects. It is suggested that these bile composition changes may explain the higher incidence of gallstones encountered in women treated with estrogens.

Subcellular fractionation of human intestinal mucosa by large-scale zonal centrifugation. Characteristics of lysosomes and brush border membranes in the distal ileum of a patient with Crohn's disease.

Lysosomes and brush border membranes from diseased ileal mucosa of a patient with Crohn's disease were separated by rate zonal density gradient centrifugation. The organelles were located and characterized in the density gradient of assay of marker enzymes, and their enzyme content compared to that of similar organelles from normal tissue. The activity and latency of lysosomal enzymes (N-acetyl-beta-glucosaminidase and acid phosphatase) was significantly increased, whereas the activity of brush border alkaline phosphatase was rather decreased. The possible relevance of these findings to the pathophysiology of Crohn's disease is discussed.

Intraperitoneal rupture of the urinary bladder: the value of diagnostic laparoscopy and repair.

A 50-year-old woman was admitted for acute onset of lower abdominal pain. Diagnostic laparoscopy revealed a rupture of the urinary bladder. Laparoscopic biopsy and cystorrhaphy were performed. Our patient was discharged 2 days after surgery, and after 2 more weeks of treatment with an indwelling catheter, she was back to her normal lifestyle. The rupture was considered idiopathic, and the present case underlines the value of diagnostic laparoscopy in acute abdominal pain.

Passage of molecules through the wall of the gastrointestinal tract. Intestinal permeability to polyethyleneglycol 1 000 in patients with Crohn's disease.

We have investigated the intestinal permeability to polyethyleneglycol (PEG) 1 000 in 25 healthy individuals and 28 patients with Crohn's disease who had undergone ileocolic resection. The intestinal permeability was determined by measuring the 6-hour urinary recovery after oral intake of 10 g PEG 1 000. The patients with Crohn's disease excreted significantly less (p less than 0.001) PEG 1 000 than the healthy individuals (33.7 +/- 16.0 per thousand of the ingested dose vs. 48.6 +/- 15.5 per thousand). There was a correlation between the urinary output and the length of ileal resection, but no difference in output between patients with and without recurrent disease or episodic arthralgia. These findings indicate that, although the gut is considerably permeable to larger, polar molecules, and permeability to PEG 1 000 in Crohn's disease is not increased over that in healthy individuals and appears unrelated to the presence of recurrence and arthralgia.

Acute cholecystitis. Frequency of stones in the common duct and predictive value of liver function tests.

Two hundred and forty-three patients aged under 75 years with acute calculous cholecystitis treated by early surgery were studied with a view to investigating the frequency of choledocholithiasis and the predictive value of routine liver function tests (bilirubin, alkaline phosphatase, alanine aminotransferase). 7% had stones in the common duct, but 33% had hyperbilirubinaemia. In less than 10% of the latter could be hyperbilirubinaemia be attributed to common bile duct stones. It was concluded that the frequency of common bile duct stones in acute cholecystitis was low, and that patients often had signs of impaired liver function which was of no help in diagnosing the presence of stones in the common duct.

Effect of operative choledochoscopy after choledocholithotomy on the incidence of retained stones.

OBJECTIVE: To see whether the introduction of operative choledochoscopy would lower the incidence of retained stones in the common bile duct. DESIGN: Retrospective study. SETTING: Mora Hospital, Mora, Sweden. SUBJECTS: 176 patients who underwent exploration of the common bile duct from 1984-1991. INTERVENTIONS: After exploration of the common bile duct, 109 of the 176 patients underwent choledochoscopy; the remaining 67 had the choledochotomy closed over the T-tube, and an operative cholangiogram done. RESULTS: Six of the 109 patients (6%) who have had common bile duct exploration followed by choledochoscopy were found to have residual stones and in 1 of those 6 no stones had been found on the exploration of the duct. Ten of the 67 patients (15%) who had choledocholithotomy followed by an operative cholangiogram had residual stones, and in two of those no stones had been found on exploration. The annual frequency of choledochoscopy after exploration of the common bile duct increased from 50% to 80% over the period. CONCLUSION: We recommend that operative choledochoscopy should always be done after exploration of the common bile duct to reduce the incidence of retained stones.

Anti-brush border antibodies (ABBA) in Crohn's disease.

Seventy-four serum samples from patients with Crohn's disease were analysed for the presence of antibodies against various tissue antigens. With indirect immunofluorescence microscopy 61% of the patient sera were shown to possess antibodies (in a titre of 1:25 or more) reacting with rat brush border membrane antigens in the proximal tubules of the kidneys, in the gastric parietal cells, and in the bile canaliculi of the liver. Serum samples submitted for routine IF autoantibody-screening served as controls; 10% of these sera contained anti-brush border antibodies.

Perforated duodenal ulcer--long-term results following simple closure.

Perforated duodenal ulcer was treated with suture plication in 77 patients. Only one-third of the operations were performed within six hours of the onset of perforation symptoms. The postoperative morbidity and mortality were related to the duration of the perforation and the age of the patient. The postoperative mortality rate was 6.5%. Fifty-three of the patients could be followed up after a mean period of 7.5 years. The long-term results were unsatisfactory in 84% of the patients who had had ulcer symptoms for more than three years prior to perforation, but in only 18% of those with symptoms for less than three years. Simple closure thus seems to be the treatment of choice for perforated duodenal ulcer when the patient's general health is poor or when the history of ulcer symptoms is short. A definitive operation, consisting of selective proximal vagotomy with or without drainage, should be considered for good-risk patients with pre-perforation ulcer symptoms for more than three years.

Duration of T-tube drainage after exploration of the common bile duct.

The optimal duration of T-tube drainage after choledochotomy is not known. In a randomized study, comparison was made between early (postoperative day 4) and late (day 7) removal of the T-tube. The evaluation was made on 62 patients, after exclusion of 20 because of retained stones, technically inadequate postoperative cholangiography, cholangitis or failed T-tube removal. The T-tube was removed on day 4 in 28 cases and on day 7 in 34. There were no clinically significant complications, but two patients with early and two with late removal had transient pyrexia. The mean postoperative stay in hospital was significantly shorter for the patients with early T-tube removal (8.2 vs. 9.8 days). The corresponding figures for the patients younger than 50 years were 7.1 vs. 9.1 days and for those older than 50 they were 8.7 vs. 10.1 days--both differences significant. The results indicated that early removal of choledochal T-tube drain does not increase postoperative morbidity and can significantly shorten the hospital stay.

Choledochoduodenostomy for choledocholithiasis. Indications and functional results.

Choledochoduodenostomy in the prevention and treatment of patients with common bile duct stones has been frequently discussed during several years. The introduction of endoscopic sphincterotomy, with excellent results and low morbidity necessitate further examination of the indications for and the value of this procedure as an adjunct to choledocholithotomy. Twenty patients with a mean age of 73 years have been operated on with choledocholithotomy and subsequent choledochoduodenostomy. In 7 of the patients the anastomosis was performed at a primary operation, in 11 at a secondary and in 2 at a third operation. Seven of the patients had primary bile duct stones, while thirteen had multiple stones, either unextractable or with a doubtful clearance. There was no postoperative mortality and only one early complication, a pneumonia. Eighteen of the 20 patients are free of symptoms postoperatively and have normal liver function tests and verified open anastomoses. Two patients had recurrent postoperative cholangitis, one due to a stricture in the anastomosis, which was reoperated, and one due to multiple retained stones intrahepatically despite an open anastomosis. In conclusion choledochoduodenostomy is easy to perform with low morbidity even in old-aged, high-risk patients. It is a safe and effective method in the prevention of retained or recurrent stones.

Decreased lysophospholipase and increased phospholipase A2 activity in ileal mucosa from patients with Crohn's disease.

Lysophospholipase (EC 3.1.1.5) and phospholipase A2 (EC 3.1.1.4) were determined in ileal mucosa from patients with Crohn's disease (CD) and non-inflammatory bowel diseases ( NIBD ). In addition, the activities of alkaline phosphatase, sucrase, maltase, and lactase were determined. The lysophospholipase activity, like that of alkaline phosphatase, sucrase and maltase, was decreased in affected areas of CD, whereas the phospholipase A2 activity was rather increased. Lysophospholipase and phospholipase A2 activities in apparently unaffected mucosa from CD patients were in between those in healthy mucosa from NIBD patients and those in affected mucosa from CD patients. These findings point to the possibility that the mucosal activity of lysophospholipase, like that of other brush border enzymes, is decreased in CD. This may render the mucosa less capable to handle lysolecithin, a potentially harmful agent formed in the intestine and known to induce inflammation in a number of experimental systems.

The influence of disease at the margin of resection on the outcome of Crohn's disease.

Sixty-seven patients with Crohn's disease undergoing 81 resections followed by a restorative procedure were reviewed to evaluate the influence of microscopic disease at the margin of resection on the recurrence rate. The average follow-up after resection was 5.6 +/- 2.8 years. The resectional margins were classified into three groups depending on the microscopic appearance of the most involved margin. Recurrent disease developed in 36 per cent of the resections without microscopic evidence of Crohn's disease, while 38 per cent of the resections with signs of Crohn's disease developed a clinical recurrence. The recurrence rate increased with the follow-up time, but was independent of microscopical disease at the resectional margins. Therefore we recommend restricted resection of macroscopically diseased bowel. Microscopical involvement does not seem to increase the recurrence rate.

The incidence and course of perianal complications and arthralgia after intestinal resection with restoration of continuity for Crohn's disease.

The influence of bowel resection for Crohn's disease on the frequency of arthralgia and perianal manifestations was evaluated in a follow-up study of 82 patients. Arthralgia and perianal manifestations were analysed according to two separate periods: the preoperative duration of disease (4.2 +/- 3.2 years) and the postoperative duration (4.3 +/- 2.6 years). In patients operated on more than once, the time before the first and after the latest operation was included in the study. At the time of the follow-up, 19 patients suffered from recurrent disease. The frequency of arthralgia did not change after resection irrespective of whether or not there was recurrence. In patients without recurrence, however, perianal manifestations diminished after resection (P less than 0.05). In the postoperative period only 10 per cent of those without recurrence suffered from perianal lesions compared with 47 per cent of those with recurrence (P less than 0.001). If perianal lesions were in existence preoperatively, they healed spontaneously in 80 per cent of the patients without recurrence, but were still active among those with recurrence (P less than 0.001). Our results indicate that the perianal manifestations are closely connected to the inflammatory process in the intestine. On the other hand, the arthralgia seems to be independent of the inflammatory process of the bowel and may be related to a general defect of the gastrointestinal mucosa in Crohn's disease.

Postprandial serum bile acids in resected and non-resected patients with Crohn's disease.

Fasting and postprandial serum conjugates of cholic acid (CCA) and chenodeoxycholic acid (CCDA) were determined by radioimmunoassay in 46 healthy individuals and 15 patients with Crohn's disease (CD), 7 bowel-resected and 8 non-resected. All patients had normal conventional liver test results, and fasting values of CCA and CCDA were within the reference ranges. Two findings appeared: the mean postprandial increases in CCA and CCDA were both lower in CD patients than than in healthy individuals, and the postprandial increase in CCA was lower in the resected patients than in the non-resected, whereas the postprandial increase in CCDA was the same in the resected and the non-resected patients. These findings show that in CD patients, whether resected or not, the postprandial levels of bile acids are low. This could reflect a decreased absorptive capacity of bile acids in the small intestine. The finding that postprandial CCA, but not CCDA, was lower in resected than in non-resected patients may reflect different sites of CCA and CCDA absorption.

Is elective hernia repair worthwhile in old patients?

OBJECTIVE: To find out if elective herniorraphy in patients aged 75 and over is worthwhile. DESIGN: Retrospective study. SETTING: District hospital, Sweden. SUBJECTS: 146 consecutive patients aged 75 years or more, who had their hernias repaired during the period 1992-95. MAIN OUTCOME MEASURES: Patient satisfaction measured by a five-point analogue scale. Clinical and personal details, morbidity, mortality, and surgical variables were obtained from case records. RESULTS: Community social service was not required by 114 (78%) of the patients and 15 (22%) had no preoperative complaints. Our patients rated their satisfaction with their choice to have an operation, as well as its effect on their preoperative symptoms as 4.9. Emergency operations (p = 0.02), femoral hernias (p = 0.01) and direct inguinal hernias (direct:indirect ratio 0.81) were more common in this age group. Femoral and direct inguinal hernias tended to recur more often than usual. Emergency operation, dementia, and diabetes were associated with a reduced short-term survival. CONCLUSION: Elective hernia repair in an elderly population is highly appreciated by the patients, and worthwhile. If coexisting disease and domestic arrangements are controlled, the patients' need for hospital care can be minimised. Mesh is recommended in femoral and direct inguinal hernias, which were associated with an increased reoperation frequency. A more vigilant protocol of indications for hernia surgery in the aged may minimise the need for both emergency and unnecessary operations.

Decreased absorption of ingested unconjugated chenodeoxycholic acid in patients with Crohn's disease.

The intestinal absorption of unconjugated chenodeoxycholic acid (CDA) was studied in 27 healthy individuals and 28 patients with Crohn's disease who had undergone ileal resection. After they had taken 1 g CDA orally serum levels of bile acids were significantly lower in the patients than in the healthy individuals; the difference was apparent already 30 min after ingestion. There was no correlation between CDA absorption and recurrent disease, length of ileal resection, or number of defecations. These findings indicate that the intestinal absorption of ingested CDA in patients with Crohn's disease is decreased. Since CDA is absorbed mainly in proximal areas of the gut, these observations may indicate that proximal areas are involved in ileocolic Crohn's disease.

Subcellular fractionation of human intestinal mucosa by large-scale zonal centrifugation. Separation of the organelles in diseased ileum of a patient with Crohn's disease.

The subcellular organelles in diseased ileal mucosa of a patient with Crohn's disease have been separated by rate zonal density gradient centrifugation. Mucosal scrapings were obtained from a surgical specimen of diseased intestine and the cells disrupted by extrusion under controlled pressure. The homogenized cells were then centrifuged to prepare a cell extract and the extract fractionated in a single-step procedure by zonal centrifugation on a continuous sucrose gradient. The subcellular organelles (brush borders, basal-lateral membranes, lysosomes, mitochondria and endoplasmic reticulum) were located in the density gradient by assay of marker enzymes and their overall distribution compared with the distribution of organelles from a normal tissue. The centrifugal properties of individual organelles in the diseased tissue were largely unaffected but the lysosomes were more fragile than in the normal tissue. Since the fractionation technique used is on a large scale, each fraction of interest can be further analyzed for a variety of compounds. Therefore, the subcellular pathology and pathophysiology in this and other cases of Crohn's disease may eventually be studied and discussed in other than morphological and descriptive terms.