Serial levels of CA 19-9 and CEA in colonic cancer.

The use of serial carbohydrate antigen (CA) 19-9 assays was assessed by comparison with serial carcino-embryonic antigen (CEA) levels on the plasmas of 53 patients with colorectal carcinoma. The patients had all undergone resection for their primary tumors and in six instances subsequent resections for hepatic metastases. Initial CA 19-9 levels were greater than or equal to 37 U/mL in 22 of the 53 patients (41%) and in 68% of the patients with metastatic disease. Similar trends of serial CA 19-9 and CEA levels were found in 79% of the 53 patients. One patient with initially normal CEA levels had elevated CA 19-9 levels from the start. In ten of the 53 patients (19%), serial CA 19-9 levels remained low despite tumor recurrence or progression, and despite increasing CEA levels above 5 ng/mL. The increasing serial CEA trends predicted recurrence in 88% and increasing CA 19-9 trends in 50% of cases, which was increased to 70% by including trends of CA 19-9 levels below 37 U/mL. Following hepatic lobectomy, both serial CEA and CA 19-9 levels decreased rapidly. Used alone, serial CA 19-9 levels did not appear to be as sensitive as standard CEA in this retrospective study of selected patients.

Immunoproliferative small-intestinal disease: clinical features and outcome in 30 cases.

Experience with 30 patients with immunoproliferative small intestinal disease followed prospectively between 1971 and 1986 is described. All presented with malabsorption or growth retardation and had similar clinical, biochemical, and radiological features, irrespective of the presence of lymphoma or immunological abnormality. Alpha-chain disease protein was detected in 4 of the 11 patients who had a non-lymphomatous, predominantly plasmacytic infiltration of the small bowel; and in 5 of the 19 cases with diffuse intestinal lymphoma. The importance of exploratory laparotomy to include full-thickness intestinal biopsy in patients who have a benign infiltrate on peroral biopsy is demonstrated by the finding of lymphoma in operative specimens in 9 of 15 patients with mature, lymphoplasmacytic cells, and 5 of 8 patients with atypical, lymphoplasmacytic cells. The majority of patients with fully established benign disease, even those elaborating alpha-chain disease protein, appeared to have a good prognosis. No patient with immunoproliferative small intestinal disease developed immunologically demonstrated alpha-chain disease or frank lymphoma, when this was not found initially at explorative laparotomy.

Betazole-induced GIP secretion is not mediated by gastric HCl.

Betazole, a pyrazole analogue of histamine, as well as pentagastrin and HCl stimulate GIP secretion. We have asked the question as to whether betazole acts directly or via the production of HCl. Eight normal subjects and 4 patients with achlorhydria secondary to pernicious anemia were given betazole (0.5 mg/kg) by IM injection. Another six normal subjects were also given betazole but this was preceded by 200 mgs. of the H2 receptor blocker cimetidine given IV 60 mins. previously and a slow infusion of 200 mg. cimetidine given over the next 4 hr. Our results have shown that the GIP response to betazole is maintained in achlorhydric subjects as well as during H2 blockade. The results suggest that betazole and therefore histamine may stimulate GIP directly and not necessarily via the mediation of HCl.

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.

Pattern-reversal visual evoked potentials in hepatic cirrhosis.

Whole-field pattern-reversal VEPs (VEP) were examined in fifteen patients screened for hepatic cirrhosis. Twelve age- and sex-matched normal individuals and twenty-four psychotic patients on maintenance neuroleptic medication served as controls. There were no differences in latency or amplitude of the major positive component VEP (P100) to binocularly or monocularly presented reversing patterns between hepatic and control groups. Pre-exposure to flicker (the "photostress test") caused no abnormalities of VEP. Only in one patient with hepatic cirrhosis did monocular stimulation in the photostress condition cause a marked delay of P100. It is possible that this was an idiosyncratic response and that visual abnormalities detectable with the VEP technique can be attributed to other factors such as poor attention or accompanying disorders of the visual system.

[Instrumental dilatation of esophageal and gastric stenoses using Gruntzig's catheter and Celestin's dilator. Preliminary results]. / Dilatation instrumentale des sténoses oesophagiennes et gastriques à l'aide du cathéter de Grüntzig et du dilatateur de Celestin. Résultats préliminaires.

The aim of this study was to present the technique of endoscopic dilatation and the preliminary results obtained with 2 new instruments, the Grüntzig balloon catheter, and the Celestin dilator, in patients with esophageal or gastric strictures. The Grüntzig balloon catheter was used 11 times in 7 patients (6 adults and one child aged 1 1/2 year), for the dilatation of severe or irregular strictures of the esophagus (5 cases), the stomach (1 case) and the pylorus (1 case). Partial (4 cases) or complete relief (2) were observed and allowed subsequent use of the Celestin bougies (2 cases), or the introduction of an esophageal prosthesis (1 case). In the child with caustic stricture of the esophagus, dilatation with the Grüntzig balloon-catheter was complicated twice by perforation. In the second case, the perforation was related to the technique used in dilatation and was treated by conservation measures. Endoscopic dilatations with the Celestin bougies were performed in 27 patients with benign (including 9 peptic strictures) or malignant strictures (14 cases, 7 related to esophageal cancer, and 7 to cancer of the cardia). A total of 74 dilatations were performed, attaining a maximum diameter of 16 or 18 mm in one session, in 21 patients (78 p. 100 of the cases). In the case of peptic stricture, the anatomical result was excellent in 8 patients and the functional result good in 7 of 9 cases. In case of malignant stricture, the result was conditioned by the evolution of the tumor; recurrence of dysphagia called for either repeated dilatations (8 cases) or the introduction of an esophageal prosthesis (5 cases).(ABSTRACT TRUNCATED AT 250 WORDS)

Primary intestinal lymphoma in South Africa.

All adult cases of primary intestinal lymphoma seen during the years 1953--77 at Groote Schuur Hospital, South Africa, were reviewed. Seventy percent of patients with solitary lymphoma and 80% with immunoproliferative small intestinal disease were mulatto. Patients in the latter group presented with malabsorption and those with a solitary lymphoma presented with intestinal obstruction. Four of 15 patients tested for the presence of alpha-heavy-chains were found to have alpha-heavy-chain disease. Family studies of potential genetic and immunologic factors showed some significant differences in IgA and IgG levels in the families of two patients with alpha-heavy-chain disease. Elevated alkaline phosphatase of intestinal origin was found in four of six patients with immunoproliferative small intestinal disease and in a high proportion of relatives. Fifty percent of the six patients were of blood group B. Minor blood groups, ABH secretor state and Pi phenotype distribution were similar to those of the control subjects. HLA gene frequency was particularly increased in the HLA-A9 antigen. These studies suggest that genetic factors may be relevant to the pathogenesis of immunoproliferative small intestinal disease.

Heterotopic and metaplastic gastric mucosa in the duodenum.

The presence of gastric epithelium or mucosa at any level of the gastrointestinal tract is a well-known phenomenon. In duodenal mucosa, congenital heterotopic gastric mucosa or acquired metaplastic gastric surface epithelium (MGE) may be found. In the present study 325 duodenal biopsies (260 upper gastrointestinal endoscopy and 65 abdominal surgery biopsies) from 297 patients were retrospectively reviewed. Normal duodenal mucosa was present in 119 specimens, duodenitis in 155 and duodenal ulcer in 51. Heterotopic gastric mucosa was present in only one patient with duodenal ulcer, and MGE in 31% of the biopsies with a normal mucosa, in 21.7% with duodenitis and in 82% with duodenal ulcer (P less than 0.01). MGE was present in 120 biopsies of 109 patients--68 men and 41 women, 91% Jews, and 9% Arabs. The hospitalized population of our region comprised 82% Jews and 18% Arabs. Duodenal ulcer was more frequently found in Arab (69%) than in Jewish patients (41%). We conclude that MGE is a common finding, even in the presence of normal duodenal mucosa (30%) and occurs in most (80%) duodenal ulcer cases. The fact that MGE is more frequent in the Jewish population suggests that a genetic factor may be involved.

Alpha-chain disease. A case report with autopsy findings.

A 19-year-old Coloured man with alpha-chain disease died after perforation of a lymphoma in the duodenojejunal region. At autopsy he was found to have a dense plasma cell infiltration of the lamina propria of the entire small bowel, causing thickening of that organ, and a malignant lymphoma in the duodenojejunal region which had spread to regional mesenteric nodes and to the liver only.

Gastro-intestinal fibre-endoscopic polypectomy.

Gastroscopic and colonoscopic polypectomy by means of a diathermy snare has been carried out on 23 patients, without any significant morbidity. The techniques and potential complications are discussed, and it is concluded that endoscopic polypectomy is a safe and rapid procedure in experienced hands, if close attention is given to detail and if the necessary precautions are taken.

Endoscopic sphincterotomy in biliary tract disease.

In many centers endoscopic sphincterotomy is replacing surgery, which has never been an ideal treatment for retained common duct calculi. We attempted endoscopic sphincterotomy in 70 patients, succeeding in 60 (85%). Sixty-one patients had choledocholithiasis (58 postcholecystectomy), 7 had papillary stenosis, 1 carcinoma of the papilla of Vater, and 1 hydatid disease. Repeat cholangiography in 56 patients with gallstones showed spontaneous passage in 44. In three patients the sphincterotomy required extension, and in three the stones were extracted using a Dormia basket. In four patients the stones did not pass, and surgical removal was necessary. Satisfactory biliary drainage was obtained in all the other patients, and the only complications noted were cholangitis and severe pancreatitis. Endoscopic sphincterotomy is reasonably safe and an acceptable, if not preferable, alternative to surgical removal of retained gallstones, and it is also effective in relieving papillary stenosis.

Pure pancreatic juice cytology obtained at endoscopic retrograde cholangiopancreatography.

Aspiration cytology was performed in 38 patients, in whom endoscopic retrograde cholangiopancreatography (ERCP) was performed because of jaundice or abdominal pain suspected of being pancreatic in origin. The fluid for the cytologic examination was obtained through a catheter in the pancreatic duct after administration of secretin i.v. Neoplastic cells were found in the aspirate of 12 of the 20 patients who were eventually proven to have an adenocarcinoma of the pancreas. Aspiration cytology of fluid obtained during ERCP has been shown to be useful in preoperative confirmation of pancreatic malignancy.

Recurrent acute pancreatitis associated with pancreas divisum.

Described is the case of a 24-yr-old patient in whom recurrent attacks of acute pancreatitis following a cholecystectomy were found to be associated with anomaly of the pancreas--the so-called pancreas divisum. An examination by endoscopic retrograde cholangiopancreatography showed typical findings of a short duct of Wirsung. Cannulation of the secondary duct of Santorini revealed a grossly dilated and strictured duct full of stones. After drainage of the duct by a pancreaticojejunostomy (Puestow procedure), the patient has not had any further episodes of acute pancreatitis during a follow-up period of 4 yr.

Endoscopic retrograde cholangiopancreatography in the evaluation of pancreatic disease.

Endoscopic retrograde cholangiopancreatography (ERCP) was carried out in 98 patients with unexplained abdominal pain or known pancreatitis with recurrent pain. Patients with jaundice were excluded from the study. In 38 patients with a clinical diagnosis of pancreatitis, the radiological findings on ERCP were graded according to the criteria of Kasugai et al. Advanced pancreatitis was found in 20 patients (52,5%), moderate changes in 7 (18,4%) and minimal-change pancreatitis in 6 (15,8%). ERCP had normal pancreatic function tests. In 35 patients investigated for unexplained abdominal pain, changes consistent with pancreatitis were found in 7, pancreatic carcinoma in 5, a duodenal ulcer in 2, gallstones in 1 and a duodenal tumour in 1. ERCP was normal in 19 patients. A comparison of the findings on ERCP and the standard secretin-cholecystokinin pancreatic function test was available in 52 patients. There was a good agreement between the two tests in the patients with advanced or moderate pancreatitis as revealed by ERCP, but less agreement in the patients with minimal-change pancreatitis. A few patients with clinical pancreatitis and abnormal ERCP had normal pancreatic function tests. ERCP increases the diagnostic yield in patients suspected of having pancreatitis and is at present the only reliable method of diagnosing pancreatic carcinoma which is not evident by other non-operative techniques. ERCP is also of value in the assessment of the severity of pancreatitis and is a necessary investigation before pancreatic surgery to confirm or exclude cyst formation or the site of duct obstruction. The finding of an unsuspected cyst at ERCP necessitates early operation because of the danger of introducing infection during the procedure.

A review of colonoscopy in 200 patients.

During the examination of the colon by fibre-optic colonoscopy in 200 consecutive patients it was possible to reach the caecum or suspected lesion in 80% of cases. Careful bowel preparation, sedation and detailed attention to techniques described are necessary for safe and successful performance of this procedure. In 85% of examinations, colonoscopy produced positive results including the definition of uncertain radiological lesions in 45 patients, finding of a cause for rectal bleeding not shown on barium studies in 15 patients, the assessment of inflammatory bowel disease in 28 patients, and the removal of polyps in 40 patients. Important was the finding of a normal colon in 49 cases, which obviated unnecessary surgery. Colonic perforation occurred in 2 patients. The limitations and complications of the procedure must be realised, but it is concluded that the colonoscope provides a valuable and effective means of diagnosis and therapy of lesions in the large bowel.

Primary intestinal lymphoma of "Western" and "Mediterranean" type, alpha chain disease and massive plasma cell infiltration: a comparative study of 37 cases.

The clinical and pathological features of 17 "Western" type primary abdominal lymphomas (WTL) are compared with 14 of "Mediterranean" type (MTL). The MTL involved only young adult Mulatto and African patients in whom malabsorption and abdominal pain were the major clinical features. The WTL also predominantly affected Mulatto patients but four cases occurred in Caucasians, and the mean age at presentation was two decades later. An obstructive presentation was the most common; only one patient in this group had evidence of malabsorption. The WTLs were located mainly in the distal small bowel and were nearly all of monomorphic lymphocytic or histiocytic type. The MTLs were sited mainly in the duodenum and jejunum and were of an unusual pleomorphic histologic type. A spectrum of cells from those resembling atypical lymphocytes to large histiocytic types were seen, some of the latter resembling Reed-Sternberg cells. The pattern of mesenteric node infiltration in the MTLs was also unusual in that preservation of the medullary sinuses was a common finding. A notable feature of the MTLs was the presence of a heavy infiltration of mature-looking plasma cells associated with a fairly severe villous atrophy in the lamina propria of the small bowel. In the WTLs the adjacent small bowel did not show this feature. In addition to the above cases three patients with a similar heavy plasma cell infiltrate and villous atrophy but without evidence of a lymphoma are described. These cases may represent examples of MTL in a pre-malignant phase. Also included in this study are three patients with alpha-chain disease (alpha-CD), all with a heavy plasma cell infiltration and villous atrophy of the lamina propria and a pleomorphic type lymphoma involving the mesenteric nodes in all, and the small bowel in two. The lymphomas in alpha-CD have been interpreted as immunoblastic sarcoma by Lukes and Collins. Both genetic and environmental factors may be operative in the MTLs including the cases of alpha-CD.

Urgent fibre-optic panendoscopy in upper gastro-intestinal haemorrhage.

Urgent fibre-optic panendoscopy was performed in 400 patients within 24 hours of their admission to hospital for upper gastro-intestinal haemorrhage. The cause of bleeding was established by endoscopy in 87%. No cause was found in 10% and endoscopy failed in 3%. Twenty-five per cent of the patients had an additional lesion which was not the cause of bleeding. Complications owing to endoscopy occurred in 2% of the patients. Only 27% of the patients still had blood present in the stomach at the time of endoscopy. Chronic gastric ulcer was causative in 22%, and duodenal ulcer in 20% of the patients. Haemorrhagic gastritis accounted for 13%, Mallory-Weiss tear for 8%, acute ulceration for 5% and varices for 4% of the patients. Only 60% of the patients with dyspepsia were bleeding from peptic ulcers and only 64% of the patients bleeding from ulcers had a history of dyspepsia. Follow-up studies revealed that endoscopy, in experienced hands, is an accurate investigation which allows for an improved approach to management, and which probably also reduces the mortality rate.