High prevalence of chronic gastrointestinal symptoms in a National Guard Unit of Persian Gulf veterans.

OBJECTIVES: To determine the prevalence and spectrum of GI complaints in a group of Persian Gulf veterans (PGV) and to compare these data to a group of veterans (controls) from the same unit who were not deployed to the Persian Gulf region. METHODS: A 68-item survey was distributed to 136 members of a single National Guard Unit. The survey asked the veterans to rate the frequency of GI symptoms before, during, and after the Persian Gulf war had concluded. The participants were also asked to rate frequency of 10 non-GI symptoms at the time of this survey. RESULTS: Fifty-seven PGV and 44 nondeployed veterans participated in the survey. Before the Persian Gulf war, both PGV and control groups reported low frequencies of GI symptoms. A majority of the PGV experienced GI symptoms during their deployment to the Gulf region, which persisted after their return to the United States. There were many significant differences observed between the two groups in frequency of both GI and non-GI symptoms. The greatest differences seen were for excessive gas, loose or greater than three stools per day, incomplete rectal evacuation, and abdominal pain. CONCLUSIONS: A high prevalence of chronic GI symptoms exists in this group of PGV and is significantly greater than a group of controls. The most prevalent chronic GI symptoms are those that have been associated with functional GI disorders. However, the abrupt onset and clustering in this group suggests that nonfunctional etiologies may be contributing factors.

Diversion colitis: a nutritional deficiency syndrome?

The dependence of cells of the colonic epithelium upon lumenal short-chain fatty acids (SCFA) for some of their energy supply is well known. SCFA (mainly acetic, propionic, and n-butyric acids) comprise the predominant solutes in the aqueous phase of colonic contents and are produced by anaerobic bacterial fermentation of polysaccharides. Acetic acid is the principal fatty acid, but n-butyric acid is the preferred energy source for colonocytes, both in normal human colon and in colons of patients with ulcerative colitis. Four patients with diversion colitis, an inflammatory process in surgically excluded colon and rectum, were successfully treated by colonic instillation of a solution of mixed SCFA. This review examines the evidence that diversion colitis may be a new type of nutritional-deficiency syndrome based upon a local mucosal requirement for SCFA.

The reticular pattern as a radiographic sign of the Barrett esophagus: an assessment.

A two-part retrospective study was conducted to assess the value of a reticular pattern as a sign of columnar-lined esophagus. Radiographic, endoscopic, and histologic findings were reviewed in 124 patients with known Barrett esophagus; then all barium esophagrams done at our institution during a 3 1/2 month period were reviewed and presence of a reticular pattern was correlated with available endoscopic and histologic data. In patients with known Barrett esophagus, the reticular pattern was found in 26% of double-contrast examinations. Twelve of these patients underwent careful esophageal mapping biopsies: the pattern was in squamous mucosa with ulceration in two, in columnar epithelium with ulceration in six, and in columnar epithelium without ulceration in four. In the group of 314 unselected patients who had double-contrast examinations, the reticular pattern was found in 26 (8%). Thirteen of the 26 had had endoscopy and biopsy: the site of the pattern was located in a squamous carcinoma in one, in squamous epithelium adjacent to squamous carcinoma in three, in squamous epithelium with esophagitis in five (two of whom had columnar mucosa distally), in normal squamous mucosa in one, and in columnar epithelium with esophagitis in three. The reticular pattern is a strong indicator of important esophageal disease, but is not specific for Barrett esophagus.

Adenocarcinoma and Barrett's esophagus. An overrated risk?

The risk of developing esophageal cancer in Barrett's esophagus has been estimated at about 10%. This estimate is based primarily on data concerning the prevalence of that association in series of hospitalized patients and autopsies--a practice that tends to exaggerate the risk. We have reviewed retrospectively our experience with 115 patients whom we treated for Barrett's esophagus between September 1962 and March 1983, and have distinguished our data on the prevalence of esophageal cancer from that on incidence. For 8 patients, we found both Barrett's esophagus and esophageal adenocarcinoma during the initial evaluations for a prevalence ratio of 7%. We followed 105 patients not found to have esophageal cancer initially for a total of 350 person-years. Only 2 patients developed adenocarcinoma during that follow-up period for an incidence of 1 case per 175 person-years. This incidence, although some 40-fold greater than that of the general population, is substantially lower than previously estimated. Routine endoscopic and histologic surveillance has been recommended for patients with Barrett's esophagus because of the alleged high incidence of esophageal cancer. Inasmuch as that incidence now appears to be low, we question the value of such surveillance for these patients.

Prevalence of normal serum amylase levels in patients with acute alcoholic pancreatitis.

Acute alcoholic pancreatitis is uncommonly diagnosed when the serum amylase level is normal. We defined acute alcoholic pancreatitis as a clinical syndrome in which hyperamylasemia was not a necessary component and sought support for the diagnosis by ultrasonography and computed tomography of the pancreas. In 68 episodes of acute alcoholic pancreatitis identified in a one-year period, the serum amylase level was normal at the time of hospital admission in 32%. In 40 episodes, we performed ultrasonography and computed tomography within 48 hr of admission. The diagnosis was supported by ultrasonography in 43%, by computed tomography in 68%. Ultrasonography and computed tomography supported the diagnosis as frequently in patients with normal serum amylase levels as in patients with hyperamylasemia. We conclude that patients with acute alcoholic pancreatitis frequently have normal serum amylase levels. The widespread clinical practice of relying solely on hyperamylasemia to establish the diagnosis of acute alcoholic pancreatitis is unjustified and should be abandoned.

The prevalence of Barrett's esophagus in patients with chronic peptic esophageal strictures.

Both Barrett's esophagus and peptic stricture of the esophagus are consequences of chronic reflux esophagitis. Barrett's esophagus appears to be a premalignant condition, and continued histologic surveillance for dysplasia and carcinoma has been recommended for affected patients. While patients with peptic esophageal strictures and persistent reflux are at risk for the development of Barrett's epithelium, such patients often do not receive continued histologic surveillance if Barrett's epithelium is not identified on the initial endoscopic evaluation. Using endoscopic and peroral aspiration biopsy techniques, we studied the prevalence of Barrett's esophagus in 25 patients with chronic peptic esophageal strictures in whom Barrett's epithelium had not been identified previously. We found Barrett's esophagus in 11 (44%) of our 25 patients. One patient who did not have Barrett's esophagus was found to have an undifferentiated esophageal carcinoma. We conclude that patients with chronic peptic esophageal strictures frequently have Barrett's esophagus. A program of continued histologic surveillance seems advisable for such patients.

Gastrointestinal tract bleeding of unknown origin.

Gastrointestinal (GI) tract bleeding of unknown origin is a vexing clinical problem. In this review, we discuss those causes of GI tract hemorrhage most likely to escape detection by conventional diagnostic modalities and explain how newer techniques of flexible fiberoptic endoscopy, radionuclide scanning, and angiography may be used to establish a diagnosis. We reviewed the literature on the role of exploratory surgery in the diagnosis of occult GI tract bleeding and conclude that its diagnostic yield is small and its value limited. Finally, we present a diagnostic approach to the patient with GI tract bleeding of unknown origin.

Barrett's epithelium complicating lye ingestion with sparing of the distal esophagus.

We report a patient with a history of lye ingestion in whom a band of ectopic gastric mucosa is associated with a stricture of the mid-esophagus. Specialized columnar epithelium (a type of Barrett's epithelium) developed along the edges of this band. This specialized columnar epithelium is separated from the mucosa of the stomach by a continuous sheet of normal stratified squamous epithelium. Heretofore, Barrett's epithelium involving the middle esophagus has been reported only as the proximal extension of a sheet of columnar mucosa lining the entire distal esophagus. The development of specialized columnar epithelium in this setting suggests that local factors besides gastroesophageal reflux may be involved in the pathogenesis of Barrett's epithelium.

Occult bronchogenic carcinoma masquerading as esophageal cancer. Case reports with recommendations for a change in reporting esophageal cytology.

We describe two patients with benign esophageal stricture in whom exfoliative esophageal cytologic features positive for squamous cell carcinoma is attributed to roentgenographically occult lung cancer. The discovery of alveolar macrophages within the esophageal washings of these patients prompted a retrospective analysis assessing the prevalence of esophageal washings contaminated by cellular material from the lower respiratory tract. Alveolar macrophages were observed in 11 of 28 patients (39%) and in 12 of 33 specimens (36%). Alveolar macrophages were noted in half of patients with benign esophageal disease, but in only one of eight cases with proved esophageal cancer. Criteria alerting physicians to the coexistence of benign esophageal stricture and occult respiratory neoplasm are given, and recommendations for a change in reporting esophageal cytologic features are proposed.

Revised radiologic concepts of the Barrett esophagus.

The radiologic findings in 39 cases of histologically proven Barrett esophagus are reviewed. Esophageal strictures were not found in 18% of the cases, and when present were more often distally located. Esophageal ulcers were found in only 46% of the patients. In 13% of the cases neither ulcer nor stricture was found. The majority (72%) of these cases did not fit the classic stereotype of high esophageal stricture and/or ulcer.

Barrett's esophagus. Clinical review of 26 cases.

Barrett's esophagus was diagnosed in 26 men in a five-year period by demonstrating esophageal specialized columnar epithelium in target biopsies obtained at endoscopy or in peroral suction biopsies of the esophageal mucosa. The clinical, radiologic and manometric features of these patients were reviewed retrospectively. Esophageal lesions associated with this epithelium included distal and midesophageal strictures and ulcers, alone or in combination, or simply esophagitis. One patient had an associated adenocarcinoma. Twenty of 26 (77%) had heartburn or regurgitation, 16 (62%) had easily elicited reflux of barium while supine and 16 of 17 tested had lower esophageal sphincter pressure in the incompetent range. Ninety-six percent had one or more of these parameters positive. This series demonstrates a wide spectrum of esophageal lesions in Barrett's esophagus, and supports the concept that this lesion occurs as a consequence of gastroesophageal reflux and erosive esophagitis. The case of adenocarcinoma in this series adds to the concern that the columnar lined lower esophagus may be a premalignant lesion.

The columnar-lined esophagus--analysis of 26 cases.

A review of 26 cases of columnar-lined (Barrett's) esophagus suggests that this lesion is more common than generally appreciated, usually arising consequent to reflux esophagitis. The radiologically detectable lesions frequently do not support the idea that Barrett's esophagus presents only with high esophageal ulcer and/or stricture. Hiatal hernia, gastroesophageal reflux, stricture, ulcers, and even minor mucosal abnormalities may be present alone or in combination, and may be variably located.

A randomized, double blind controlled trial of the efficacy of immune serum globulin for the prevention of post-transfusion hepatitis. A Veterans Administration cooperative study.

A double blind, randomized, controlled trial has been conducted in 11 Veterans Administration hospitals during a 49-month period to compare the relative efficacies of immune serum globulin (ISG) and an albumin placebo for the prevention of post-transfusion hepatitis (PTH). A total of 2204 patients, of whom 1094 received ISG, participated in the study. The results indicate that ISG significantly reduced the incidence of icteric type non-B hepatitis only (inferred to be also type non-A hepatitis). Adverse reactions were rare, and the ISG did not significantly alter the incubation period or duration of the disease. The data suggest, however, that a similar reduction in type non-A, non-B hepatitis would have occurred had commercial blood been excluded from use. Analysis of the 241 patients who developed hepatitis indicates that type B hepatitis constituted less than 20% of the cases each year of the study. Furthermore, the efficacy of the ISG, manufactured in 1944, against apparent type non-A, non-B hepatitis suggests that this overlooked disease has existed from at least that time. Host- and transfusion-related factors that might have modified the development of PTH were examined. The use of commercial blood was observed to be the most important risk factor. It is concluded that the PTH incidence can be most effectively reduced by eliminating commercial donor blood, and continuing to screen volunteer donors for hepatitis B surface antigen (HBsAg) by sensitive procedures. Of prime importance is the need to define the agent(s) responsible for type non-A, non-B hepatitis.