Cholesterol reduces the effects of dihydroxy bile acids and fatty acids on water and solute transport in the human jejunum.

Jejunal perfusion studies were performed in 16 healthy volunteers to test the hypothesis that intraluminal cholesterol can mitigate the fluid secretion induced by dihydroxy bile acids and fatty acids. Fluid secretion in the presence of 5 mM taurodeoxycholate was somewhat reduced by 4 mM mono-olein which was used for the solubilization of cholesterol. Addition of 0.8 mM cholesterol reduced fluid secretion further (P less than 0.05). Fluid secretion induced by 4 mM oleic acid was changed to net absorption in a linear fashion with increasing cholesterol concentration in the perfusion solutions. 1 mM cholesterol reduced fluid secretion induced by 6 mM oleic acid (P less than 0.005), but had no effect on fluid secretion induced by 6 mM linolenic acid. Glucose absorption was generally affected in a similar manner as water transport. In vitro, 1 mM cholesterol reduced monomer activity of 6 mM oleic acid to 72.3 +/- 0.9% of control and that of linolenic acid to 81.1 +/- 1.7% of control. Although statistically significant (P less than 0.001), the difference in the effects of cholesterol on monomer activities of the two fatty acids was rather small and it is unlikely that changes in monomer concentration of fatty acids and bile acids account for the protective effect of cholesterol. The in vivo observations point to a new physiological role for biliary cholesterol: the modification of the response of the small intestine to the effects of dihydroxy bile acids and fatty acids.

Duodenal angiomyolipoma: a case report.

The authors present a case of duodenal angiomyolipoma. Angiomyolipoma is a benign neoplasm, the most common site being the kidney. Extrarenal angiomyolipomas are rare. Only one case of duodenal angiomyolipoma has been reported. A 66 year old man presented with GI bleeding for two years. Endoscopy revealed a duodenal polyp which on histopathology revealed features of angiomyolipoma. On immunohistochemistry, smooth muscle component was positive for Smooth Muscle Actin. HMB-45 showed mild focal positivity. Patient had no history of tuberous sclerosis. Surgical excision of angiomyolipoma is usually curative with rare cases of local recurrence.

Portal hypertensive gastropathy and gastric antral vascular ectasia.

Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are gastric mucosal lesions that mostly present as chronic anemia and rarely cause the acute gastrointestinal hemorrhage. Despite similar clinical manifestations, their pathophysiology and management are entirely different. PHG is seen exclusively in patients with portal hypertension, but GAVE can also be observed in patients with other conditions. Their diagnosis is endoscopic, and although generally each of them has a characteristic endoscopic appearance and distribution, there are cases in which the differential is difficult and must rely on histology. This review focuses on the management of both entities. The mainstay of management of PHG is based on portal-hypotensive pharmacological treatment while GAVE benefits from hormonal therapy, endoscopic Nd:YAG laser, and argon plasma coagulation. More invasive options should be reserved for refractory cases.

Cimetidine in the treatment of non-ulcer dyspepsia: results of a randomized double-blind, placebo-controlled study.

A randomized double-blind, placebo-controlled study was carried out in 56 patients with essential dyspepsia to investigate the therapeutic efficacy of cimetidine in providing symptomatic relief. Patients received either 1 tablet of cimetidine (400 mg) or identical looking placebo twice daily for a period of 4 weeks. A detailed symptomatic assessment was made at weekly intervals. Abdominal pain, the primary symptom, was relieved in a higher proportion of cimetidine-treated patients compared to placebo group (67% versus 40%, p less than 0.05). Most of the secondary gastro-intestinal symptoms also improved in a higher proportion of patients in the cimetidine group although the difference was statistically not significant. The outcome of treatment was not influenced by factors such as duration of disease, initial severity of pain and smoking habits of the patient.

Nocturnal gastric acid secretion in duodenal ulcer: inhibition by cimetidine.

The inhibitory effect of cimetidine 200 mg, cimetidine 400 mg, cimetidine 200 mg + oxyphenonium bromide 10 mg and placebo was studied on nocturnal gastric acid secretion in 10 patients with duodenal ulcer. Each patient was studied over a period of four nights and trial medication was given in a randomized sequence. Cimetidine in both doses significantly inhibited the nocturnal gastric acid secretion. The drug reduced both the H+ concentration and gastric juice volume but the reduction of H+ concentration was more impressive. Mean percentage inhibition of nocturnal acid output with cimetidine 400 mg (89.6 +/- 2.868) was significantly higher than cimetidine 200 mg (80.3 +/- 4.085; p less than 0.01). Combination of cimetidine 200 mg and oxyphenonium bromide 10 mg was significantly better than cimetidine 200 mg alone (p less than 0.05) and this combination produced inhibition of gastric juice volume, H+ concentration and acid output comparable to cimetidine 400 mg.

Hormone producing pancreatic islet cell carcinoma: changing clinical presentation.

A patient with pancreatic islet cell carcinoma demonstrated spontaneous remission and recurrence of hyperinsulinism and disappearance of elevated plasma motilin levels. Despite evidence for gastrin production by the tumor initially, the Zollinger-Ellison syndrome was not diagnosed until three years after initial presentation. Diarrhea and steatorrhea could be attributed to hyperchlorhydria rather than to direct intestinal effects of elevated cirulating gastrin, gastric inhibitory peptide or motilin. Pancreatic islet cell carcinomas, considered as a type a APUD cell proliferation, frequently produce more than one hormone; the pattern of hormone secretion may differ with time and clinical manifestations may change accordingly.

Corrosive injury to the upper gastrointestinal tract.

Corrosive injury to the UGI tract is a common problem and has a wide spectrum of presentations. Unlike in the West, where lye ingestion is more frequent, corrosive injury in India is more commonly due to acids. Depth of the injury is the most important factor which determines the outcome. Endoscopy done soon after corrosive ingestion is safe and is very helpful in assessing the extent and severity of injury and in planning proper management of these patients. At present no therapy has been proven to be effective for prevention of stricture formation. Endoscopic dilatation seems to be the treatment of choice for management of most esophageal strictures with very good short and long term results. Surgery should be considered only when dilatation fails.

Magnetic resonance imaging in pancreatic diseases: comparison with other imaging techniques.

Magnetic resonance imaging (MR) was performed in 14 healthy subjects and 16 patients with pancreatic disease. All the 16 patients were subjected to ultrasonography (USG), computed tomography (CT) and MR while endoscopic retrograde cholangiopancreatography (ERCP) was performed in 10 cases. In one patients with adenocarcinoma and two with gastrinoma, MR demonstrated abnormalities while USG and CT were normal. MR was, however, inferior to ERCP in demonstrating ductal abnormalities in chronic pancreatitis. Our initial experience suggests that MR is superior to other imaging modalities in the diagnosis and staging of pancreatic tumors; however, it is inferior to ERCP in the diagnosis of pancreatitis.

AIDS cholangiopathy.

A 45-year-old man presented with diarrhea and profound weight loss over one year. His serum alkaline phosphatase was raised and ultrasonography showed dilated intrahepatic biliary ducts and upper part of common bile duct (CBD). ERCP showed papillary stenosis, dilated CBD, stricture at the confluence and saccular dilatation of the left intrahepatic biliary ducts. He was found HIV-positive. Duodenal biopsy, rectal biopsy and stool examination could not identify any opportunistic organism.

Splenoportovenography: safety, success rate and hemodynamic changes, and incidence and natural history of splenic hematoma.

Forty-five non-cirrhotic patients undergoing splenoportovenography (SPV) were studied. SPV was performed successfully in 43 (95.5%) patients. Local pain was encountered in 12 (26.6%) and lasted for a mean (+/- SD) of 7 +/- 3.8 hours. Local tenderness was noted in 17 (37.7%) and lasted for 6.8 +/- 3.7 hours. The mean rise in the pulse rate after the procedure was 6.5 +/- 4.7 beats per minute and the fall in the systolic and diastolic blood pressures was 3.4 +/- 2.5 and 0.8 +/- 1.7 mmHg respectively. Post-SPV splenic hematoma was noted in 3 (6.6%) patients. All were subcapsular, at the site of puncture, and disappeared by the seventh day. There was no difference in the age, change in the pulse rate, and fall in systolic or diastolic blood pressures between those who developed and those who did not develop hematoma. One patient required one unit of blood transfusion. There were no deaths. SPV was noted to be a simple and safe procedure with a high success rate with minimal morbidity and no mortality.

Primary sclerosing cholangitis with chronic pancreatitis.

We report a patient with primary sclerosing cholangitis and associated pancreatitis. She had exocrine and endocrine pancreatic insufficiency.

Combination of anticholinergic agent and H2 receptor antagonist in duodenal ulcer treatment--a randomized, double blind multicenter study.

BACKGROUND: The acid suppressive abilities of H2 receptor antagonists and anticholinergics have been claimed to be additive. METHODS: A multicenter, double-blind, randomized trial comparing ranitidine (150 mg) plus propantheline bromide 15 mg at bedtime to ranitidine 300 mg alone at bedtime was conducted in 161 patients with endoscopically confirmed uncomplicated duodenal ulcer. RESULTS: After six weeks of therapy, ulcer healing rates in the two groups were comparable ie 80% in the combination group (ranitidine + propantheline) and 79.4% in the ranitidine group. Pain relief after one, two and four weeks of treatment was also comparable in the two groups. Side effects to drugs were minor and comparable in both the groups. CONCLUSION: A combination of 150 mg ranitidine and 15 mg propantheline bromide is as efficacious as 300 mg ranitidine in inducing healing of uncomplicated duodenal ulcers, with similar side-effects but at greatly reduced cost.

Traveler's diarrhea-I. Definition, etiology and epidemiology.

With the development of rapid and convenient means of transportation, several million persons travel from industrialized countries to developing countries every year. From USA alone, approximately 4 million persons visit Mexico annually. These travelers are at risk to develop several infections during their stay abroad, but the most commonly experienced illness is diarrhea. The attack rate of diarrhea in travelers may be as high as 25 to 50 percent; 30 percent of those who get diarrhea are ill enough to be confined to bed and another 40% have to change their scheduled travel plans. The disease affects all ranks and it has achieved worldwide fame by its several euphemisms. Various epithets used to describe this illness include GI trots, Aden gut, Barsa belly, Turkey trot, Delhi belly, Hongkong dog, Montezuma's revenge, gyppsy tummy and turista. There have been considerable advances in our understanding about the etiology and epidemiology of this disease in the last two decades and the purpose of this review is to highlight some of this new information.

Intestinal metaplasia--its association with gastric cancer.

Endoscopic gastric biopsies from 230 patients and post gastrectomy specimens of 18 patients were evaluated for the presence of intestinal metaplasia (IM) and its association with the gastric lesions. There were a total of 78 malignant and 170 benign lesions. IM was present in 53% of patients with gastric carcinoma (GC) and in 10.6% with benign lesions of the stomach. The IM in association with GC was of type 1 (Small Intestinal) in 58.8%; type II (mixed gastric and small intestinal) in 11.8% and type III (Colonic) in 29.4%. In patients with benign lesions the IM was predominantly of type I (94.5%) except in 1 patient who had type III metaplasia. Our findings indicate that type III IM was significantly more frequent in patient with GC than with benign lesions (29.4% Vs 5.5%; p < .005). Therefore we conclude that patients with type III IM should be kept on surveillance for GC.

Swallowing performance after radiotherapy for squamous cell carcinoma oesophagus.

OBJECTIVE: To consider assessment of swallowing performance status as an alternative to survival in reporting results of treatment in patients with carcinoma oesophagus. METHODS: Twenty five patients of squamous cell carcinoma of oesophagus treated with radiotherapy were evaluated clinically, radiologically and endoscopically, to assess their response to treatment. RESULTS: Two months after radiotherapy, 10 of 25 patients had swallowing score-1. During radiotherapy, oesophagitis involving normal oesophagus and diseased segment was seen in 64% of cases. Fifty six percent of patients developed stricture (24% malignant, 32% benign). At the end of two years, only five patients were alive, two with swallowing score of 2, two with swallowing score of 3 and one with swallowing score of 4. CONCLUSION: As the overall survival in carcinoma oesophagus is poor, the short term criteria for assessing the response of treatment should be swallowing performance status. Radiotherapy treatment can provide substantial palliation for patients debilitated by dysphagia.

Spectrum of gastrointestinal malignancy over a period of 10 years at a tertiary referal center of India.

We studied the frequency of different gastro intestinal malignancies (GIM) diagnosed in a given year, among patients attending gastroenterology department, and changing pattern of their occurrence over a period of 10 years (1984-1993). The records of all patients with histologically confirmed GIM were screened. Out of 83380 outdoor patients registered in the department over 10 years, there were a total of 1751 (2.1%) patients with GIM. The relative distribution of malignancy according to site was esophagus 36.0%, stomach 19.9%, liver secondaries 13.9%, colon 9.8%, periampullary 5.6%, gall pladder 4.5%, duodenum 3.0%, malignant ascites 2.6%, HCC 2.3% and pancreas 1.1%. Mean age for cancer of esophagus was 53.5 +/- 11.4 year, stomach 51.8 +/- 12.9, colon 49.1 +/- 16.7, duodenum 45.3 +/- 11.4, malignant ascites 51.8 +/- 13.1, pancreas 46.9 +/- 15.3 and HCC 52.5 +/- 12 years with an overall mean age of all GIM being 49.7 +/- 13.4 years. All malignancies were common in males except for cancer of gall bladder. The annual distribution of GIM did not confirm to a rising or declining trend with reference to the frequency of occurrence or age and sex distribution over the last decade.

Percutaneous catheter drainage in pancreatic pseudocysts.

Percutaneous catheter drainage (PCD) was performed in 12 pancreatic pseudocysts in 11 patients. The procedure was performed under realtime ultrasound guidance adopting a direct transperitoneal approach in all cases. Complete cure was achieved in 9 (75%) of the Pseudocysts drained. Success rate was higher in pseudocysts not communicating with the main pancreatic duct (MPD), 7 of 8 (87.5%) as compared to those with ductal communication, 2 of 4 (50%). The mean duration of catheter drainage was 14.2 days in the first group while it was significantly longer, (42.5 days) in the latter group. No death or major complication related to the procedure was encountered in the study. A single pseudocyst got infected after catheter insertion but it was treated successfully with antibiotics. The follow up period was 3-18 months with a mean of 6.8 months. PCD failed in 2 pseudocysts communicating with MPD and associated strictures in the MPD. In one case having no communication with MPD the procedure failed because the cyst had thick debris which could not be drained properly. PCD may be a safe and effective therapy in the management of pseudocysts with best results in those not communicating with the MPD. Communicating pseudocysts, also having strictures in MPD, should not be subjected to PCD.

Clinical and endoscopic features of hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease) in India.

Hereditary hemorrhagic telangiectasis (HHT) is an autosomal dominant disease characterized by recurrent epistaxis and telangiectasia of the skin and mucous membranes. Most reports of HHT are from Europe and N. America. In this report of 7 patients from India we postulate that increased skin pigmentation in Asians and Negroids masks the cutaneous manifestations of the disease but without any discernible effect on mucosal lesions. The median hemoglobin value in these patients was 4 g/dl. Endoscopic lesions in the stomach or duodenum were detected in six patients. Most patients in our report (5/7) presented with a chronic iron deficiency anaemia. The treatment of HHT is mainly supportive although our preliminary data shows that low dose ethinyl estradiol therapy decreases transfusion requirement in these patients.

Small bowel adenocarcinoma mimicking tubercular stricture. Role of enteroscopy in early diagnosis.

We report a patient with high jejunal stricture initially thought to be tubercular in origin. There was, however, no response to antitubercular treatment and enteroscopic biopsy revealed it to be an adenocarcinoma. This case illustrates the role of enteroscopy and biopsy in the definitive diagnosis of high small bowel strictures.

Clinical and etiological profile of acute viral hepatitis.

There is a paucity of data on the incidence of sporadic viral hepatitis in Indian children. Clinical, biochemical and etiological profile of 54 patients with acute viral hepatitis was evaluated. Of these, 32 (59.25%) patients had Hepatitis A, 18 (33.33%) had NANB, 2 (3.7%) had Hepatitis B and 2 (3.7%) concurrent Hepatitis A and B infection. It was not possible to distinguish the etiological agents on the basis of the clinical and biochemical profile. Fulminant hepatitis was documented in 8 (14.8%) cases. Children with NANB infection were at a greater risk (p less than 0.05) of developing fulminant hepatitis as compared to Hepatitis A infection.