Reproducibility of gallbladder emptying scintigraphic studies.

UNLABELLED: This study was designed to investigate the reproducibility of the results obtained from 99mTc-dimethyliminodiacetic acid (99mTc-EHIDA) cholescintigraphy, when used as a method of estimating gallbladder emptying. METHODS: In a random controlled fashion, the reproducibility of scintigraphic gallbladder emptying studies was assessed in 30 subjects, of whom six were normal, four had duodenal ulcers and the remaining 20 had undergone antiulcer gastric surgery. In fasting subjects, who 30 min later drank 250 ml of fresh milk, 2 mCi of 99mTc-EHIDA was intravenously injected. Liver and gallbladder areas were scanned for 60 sec and then every 5 min for 1 hr. The study was repeated in all subjects within 2-5 wk. From the gallbladder emptying curves, the duration of the lag phase (time from milk ingestion to actual start of emptying), the ejection fraction of emptying (peak to least activity in the gallbladder), the time by which maximal emptying was achieved and the pattern of gallbladder emptying were calculated. RESULTS: Two subjects were excluded from the study because their gallbladders did not fill. Lag phase duration was well reproduced in duplicate studies (r = 0.87), as was ejection fraction (r = 0.84). The time by which maximal emptying was achieved was not sufficiently reproduced. The normal pattern of emptying (exponential function) was reproduced in all controls, subjects with duodenal ulcers and patients after antiulcer surgery that did not involve duodenal exclusion. The abnormal pattern of emptying, characterized by refilling, was reproduced in five of the seven patients with gastric surgery that mainly involved duodenal exclusion. CONCLUSION: Scintigraphy with 99mTc-EHIDA to assess gallbladder motility is a method with satisfactory reproducibility of both parametric variables and patterns of emptying.

Octreotide enhances the accelerating effect of erythromycin on gastric emptying in healthy subjects.

BACKGROUND: Erythromycin exhibits gastrokinetic properties through cholinergic pathways. Reports regarding the action of octreotide on gastric emptying are conflicting. AIM: : To assess: (i) the hypothesis that serotonin receptors are involved in the accelerating effect of erythromycin on gastric emptying; and (ii) any modification of the gastrokinetic action of erythromycin induced by octreotide. SUBJECTS AND METHODS: Gastric emptying of a standard meal was estimated in 20 healthy subjects by scintigraphy on three different occasions in a double-blind, placebo-controlled manner and in random order: (i) after placebo; (ii) after 200 mg of intravenous erythromycin; and (iii) after 200 mg of intravenous erythromycin following pre-treatment with either 4 mg of intravenous ondansetron (10 subjects) or 50 micro g octreotide. RESULTS: Erythromycin significantly accelerated gastric emptying in all subjects by abolishing the lag phase. Pre-treatment with ondansetron abolished the accelerating effect of erythromycin by restoring the emptying times to placebo levels. Octreotide significantly enhanced the accelerating effect of erythromycin by reducing both the lag and post-lag phases of gastric emptying. CONCLUSIONS: Serotonin receptors are involved in the accelerating effect of erythromycin on gastric emptying. This effect seems to be enhanced by pre-treatment with octreotide, possibly as a result of the modification of the gastrointestinal hormonal environment.

Roux-en-Y gastroenterostomy severely disturbs emptying of the gallbladder.

BACKGROUND: It is documented that truncal vagotomy and Billroth II gastroenterostomy disturbs the emptying of the gallbladder. The aim of the present prospective study was to assess the emptying of the gallbladder after Roux-en-Y gastroenterostomy. STUDY DESIGN: There were 34 patients, who had undergone either truncal vagotomy with pyloroplasty (TVP, 14 instances) or Billroth II gastrectomy (20 instances), and were subsequently subjected to Roux-en-Y gastroenterostomy. The emptying of the gallbladder was assessed before and after the Roux-en-Y procedure, by milk-technetium-99m labeled hepatoiminodiacetic acid (milk-99mTc-HIDA) scintigraphy. Milk-99mTc-HIDA scintigraphy was also performed on twenty-eight healthy subjects, who served as the control group. RESULTS: After excluding the subjects having spontaneous gallbladder evacuation before milk ingestion, there remained 26 subjects in the control group, 12 patients with TVP, and 19 with Billroth II gastrectomy. Truncal vagotomy with pyloroplasty was associated with delayed onset (p < 0.001) and decreased rate (p < 0.01) of emptying of the gallbladder compared with the control group. Truncal vagotomy with pyloroplasty also changed the normal pattern of emptying in two patients (sequential emptying and refilling events). Billroth II gastrectomy was associated with decreased extent and abnormal pattern of emptying compared with subjects in the control group (p < 0.0001) and patients having TVP. Roux-en-Y gastroenterostomy, performed upon patients with TVP, significantly increased lag phase duration (p < 0.001), decreased ejection fraction (p < 0.01), and changed the pattern of emptying of the gallbladder (p < 0.01). Roux-en-Y procedure performed upon patients with Billroth II gastrectomy significantly increased lag phase duration (p < 0.0001). CONCLUSIONS: Roux-en-Y gastroenterostomy severely disturbs all parameters of the emptying of the gallbladder.

Surgical treatment of the enterogastric reflux syndrome: preoperative and postoperative estimation by 99mTc-HIDA scintigraphy.

Twenty-nine patients with enterogastric reflux syndrome after anti-ulcer gastric surgery underwent a revisional Roux-en-Y gastrectomy. The diagnosis of enterogastric reflux syndrome was based on symptomatology and endoscopy in the first eight patients. The latter 21 patients had, in addition, a 99mTc-HIDA scintigraphy for the documentation and measurement of reflux. An enterogastric reflux index > 20 per cent is considered to justify symptoms due to reflux. Three of the first eight patients continued postoperatively to experience the same symptoms as before. These symptoms were eventually attributed to other than enterogastric reflux syndromes. The latter 21 patients were relieved from their preoperative symptoms and classified as Visick I and II (18 patients) and Visick III (3 patients). The authors conclude that enterogastric reflux syndrome must be documented on scintigraphy before the patient is subjected to revisional anti-reflux surgery in order for failures due to misdiagnosis to be avoided.

Alterations in pancreatic B-, A- and D-cell populations following administration of corticosteroids. Immunocytochemical study in rats.

Prednisolone was administered to two groups of rats for 2 or 4 weeks, respectively. A third group served for control. Serum glucose and insulin levels were measured, and changes in population size along with alterations in staining density of the intracellular granules in pancreatic B-, A- and D-cells were assessed. Two weeks of prednisolone treatment induced significant increases in the staining density of the intracellular granules of B- and D-cells as well as the population size of A-cells, while significant hyperglucosaemia and hyperinsulinaemia were observed. Four weeks of prednisolone administration induced significant increases in population size of B- and D-cells and significant decrease in the population size of A-cells, while hyperglucosaemia and hyperinsulinaemia were even greater. It is concluded that corticosteroids cause an increase in pancreatic B-cell activity and, eventually A-cell numerical atrophy by altering the glucose metabolism. The changes in activity of D-cells possibly reflect functional adaptation to increased B-cell activity.

Distribution of G-cells in the antrum and duodenum and D-cells in the fundus, antrum, duodenum and pancreas of the guinea pig.

Antral and duodenal G-cells and fundic, antral, duodenal and pancreatic D-cells were demonstrated immunocytochemically and their population size was estimated in guinea pigs of both sexes. The population of antral (210 + 18.03 SD cells/cm) and duodenal (13.20 + 3.12 SD cells/cm) G-cells is lower in guinea pigs than in dogs. Antral and duodenal G/D-cell ratios (1.6/1 and 1.2/1) are also lower in the guinea pig than in man. Antral G- and D-cell populations are greater in male (210 + 18.03 SD cells/cm and 128.2 + 17.63 SD cells/cm) than in female (176 + 13.8 SD cells/cm and 108.4 + 6.9 SD cells/cm) guinea pigs. The percentage of pancreatic D-cells is greater in the guinea pig (20-25%) than in man and rat. It is concluded that the differences in gastric and duodenal G- and D-cells between guinea pigs and other species possibly reflect different gastric secretory functions. Sex related differences in the endogenous sex hormones can explain differences in gastric secretion between the two sexes. Pancreatic D-cells possibly exert their action on neighbouring endocrine cells through different pathways from those seen in man and rat.

Vagotomy for duodenal ulcer resistant to H2-receptor antagonists.

One hundred and twenty-seven male patients were subjected to antiulcer surgery for duodenal ulcer resistant to H2-receptor antagonist treatment. Fifty-four (group A) had been on conservative treatment for up to 6 months, while the remaining 73 (group B) had been on conservative treatment for more than 6 and up to 20 months. Of the group A, 43 underwent truncal vagotomy with pyloroplasty (group A1) and 11 highly selective vagotomy (group A2). Of group B, 52 underwent truncal vagotomy with pyloroplasty (group B1) and 21 highly selective vagotomy (group B2). Follow-up ranged between 18 and 72 months (mean 37 months). There were one ulcer recurrence in group A1, none in group A2, nine in group B1 and five in group B2, the difference between group A and group B being statistically significant (p less than 0.05). There was significantly higher nonulcer-associated morbidity after truncal than after highly selective vagotomy (p less than 0.05). No significant difference in the degree of peak acid output reduction was observed between the patients with and those without ulcer recurrence. These findings show that the administration of H2-receptor antagonists for more than 6 months in duodenal ulcer patients who, however, fail to have their ulcer healed is associated with high recurrence rate after vagotomy. It is suggested that such patients should undergo vagotomy as soon as they fulfill the criteria of resistance to H2-receptor antagonists. If conservative treatment has lasted for more than 6 months, vagotomy plus antrectomy has to be considered as the surgical treatment for these patients, with the possible cost of higher nonulcer-associated morbidity.

Effect of nifedipine on rectoanal motility.

PURPOSE: Based on the rationale that the calcium channel blocker, nifedipine, decreases lower esophageal sphincter pressure in achalasia, a prospective controlled trial was performed to evaluate the effect of sublingual nifedipine on the anal sphincter of controls and patients with high anal resting pressures. METHODS: Ten age-matched and sex-matched controls without evidence of anal disorder and ten patients with hemorrhoids and/or fissure-in-ano were included in the study. Anorectal manometry, with an eight-channel, water-perfused catheter was performed on all patients before and 30 minutes after administration of 20 mg of sublingual nifedipine. RESULTS: Nifedipine significantly reduced anal resting pressure in both controls and patients by approximately 30 percent (P < 0.001 and P < 0.0001, respectively). A significant reduction was also noted in the length of high-pressure zone of the anal sphincter (P < 0.02 for both groups) and in the frequency (controls, P < 0.05; patients, P < 0.03) and amplitude (controls, P < 0.03; patients, P < 0.009) of slow waves in both groups, whereas the presence, frequency, and amplitude of ultraslow waves were significantly reduced only in the patient group (P < 0.05; P < 0.01; P < 0.0005, respectively). CONCLUSION: Nifedipine reduces the activity of the internal anal sphincter both in controls and patients with high anal resting pressure. The drug might be of some use in relieving symptoms in patients with hemorrhoids or anal fissure.

Anorectal function after low anterior resection of the rectum.

Impaired neorectal function or sphincter incompetence have been respectively implicated as causative factors of increased frequency of defaecation or incontinence after low anterior resection of the rectum (LARR) for rectal carcinoma, although individual mechanisms of anorectal function have not been fully studied. Functional and laboratory results were evaluated in 19 subjects, who had a LARR for rectal carcinoma before and after the procedure, and were compared to those of normal subjects. LARR worsened anorectal function, mostly by significantly increasing the daily number of defaecations (p < 0.001), while major incontinence was reported in three cases. Patients with rectal carcinoma have a decreased resting anal pressure on manometry, as compared to controls (p < 0.001). LARR further reduces anal resting pressure (p < 0.001) as well as all parameters that express internal sphincter activity, such as presence and amplitude of either slow (p < 0.05 and p < 0.01) or ultraslow waves. LARR also impaired external anal sphincter activity, as expressed by the reduction in anal squeeze pressure (p < 0.001). Anorectal sampling was found reduced in incidence and frequency in LARR patients as compared to controls (p < 0.01 and p < 0.001), and was impaired even further postoperatively (p < 0.001). Rectoanal inhibitory reflex was present in all but three patients postoperative, but significantly impaired as compared to controls. Rectal volumes to elicit transient or permanent desire to defecate, maximal tolerable rectal volume and rectal compliance were also significantly reduced after LARR (p < 0.001, p < 0.001, p < 0.01 and p < 0.001 respectively). Large bowel transit was significantly enhanced after LARR (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)