Diflunisal and ibuprofen: effects on gastric and duodenal mucosa in patients with osteoarthritis.

Patients with osteoarthritis make up the largest group of users of nonsteroidal anti-inflammatory drugs (NSAIDs), but the effects of these agents on the gastrointestinal mucosa of such patients have not been well studied. This article describes a short-term comparison of two widely used NSAIDs, diflunisal and ibuprofen, in patients requiring these medications for their osteoarthritis. Efficacy, tolerability, and endoscopically documented effects of these drugs on the gastric and duodenal mucosa were assessed. Consenting, eligible patients were randomly assigned to one of the two study drugs for a two-week course. Clinical assessments were made after each week of treatment. Fiberoptic endoscopy and laboratory tests were performed before and after the treatment period. Thirty patients completed the study: 16 received diflunisal and 14 received ibuprofen. Similar improvements in pain, joint mobility, functional capacity, and joint swelling and tenderness were observed in both treatment groups. Transient, mild abdominal cramping was reported by two patients in each group; one patient receiving ibuprofen complained of transient dizziness. No patient withdrew from the study because of side effects. Follow-up endoscopy revealed slight (grade 1) changes in the gastric mucosa of two patients in each treatment group. An additional patient in the ibuprofen group had gastric erosions (grade 2) at the end of the study. Endoscopic changes were not correlated with symptoms. Diflunisal and ibuprofen were found to be similarly effective and well tolerated in the treatment of osteoarthritis. Their use may be associated with some gastrointestinal side effects even during short-term use.

Crohn's disease complicated by idiopathic central serous chorioretinopathy with bullous retinal detachment.

A case of idiopathic central serous chorioretinopathy with bullous retinal detachment occurring in a patient with Crohn's disease is described. This rare eye condition (36 reported cases in the world's literature) has previously been seen in association with ulcerative colitis, and its occurrence in a patient with Crohn's disease suggests that it may represent another ophthalmologic complication of inflammatory bowel disease.

The significance of gastric bile reflux seen at endoscopy.

We evaluated the significance of bile seen in the stomach at the time of endoscopy. Twenty-three percent of 110 consecutive patients undergoing elective panendoscopy were found to have bile in their stomachs. Gastric biopsies were obtained from these patients. To assess the significance of bile reflux, the patients underwent a quantitative gastric bile analysis on two separate days. On day 1, gastric juice was aspirated by nasogastric suction, and bile acid concentrations were measured. On day 2, bile reflux into the stomach was quantitated by scintiscan measurement of gastric nucleotide after intravenous administration of 99mTc-DISIDA. Approximately half the patients with bile reflux showed histologic evidence of mucosal injury. However, fewer than half with histologic injury had significant bile reflux when measured by quantitative methods. There was no correlation among the gastric bile acid concentration, degree of histologic injury, or severity of endoscopic changes. We conclude that finding bile reflux at endoscopy is probably of no clinical significance.

The effect of topical pharyngeal anesthesia on esophageal motility.

A strong gag reflex may be a limiting factor to perform esophageal motility in some patients. Even though local anesthetics could alleviate such a problem, they are not used for fear of interfering with various manometric parameters. In this study, we evaluated the effect of topical pharyngeal local anesthesia on lower esophageal sphincter pressure, amplitude, duration, and velocity of esophageal contractions. We also studied its effects on the patient's tolerance. Esophageal motility was performed before and after topical anesthesia with 20% benzocaine. The baseline tracing and the tracing obtained after topical anesthesia were number coded and separated. They were evaluated blindly as to the pressure in the lower esophageal sphincter, amplitude, duration, and velocity of esophageal contractions. An average of 10 wet swallows was used to determine the above values. There was no significant change in the lower esophageal sphincter pressure or the amplitude of esophageal contractions after benzocaine. Similarly, there was no change in the duration or velocity of peristaltic activity. The patient's tolerance to the tube was unchanged or improved in 12 of 14 patients. Six patients had some difficulty in swallowing, but were able to compensate by sucking on the syringe. Our results indicate that topical pharyngeal anesthesia does not affect the usually measured manometric parameters; and while it may improve the patient's tolerance to the manometric catheter, it interferes with the ability to swallow.

Comparison of hypertonic glucose to other provocative tests in patients with noncardiac chest pain.

The effect of hypertonic glucose as a provocative test was studied in 51 patients with noncardiac chest pain, 15 patients with esophagitis, and 16 asymptomatic controls. It was compared to esophageal perfusion with 0.1 N HCl and saline and intravenous administration of 10 mg edrophonium. Continuous esophageal manometric recordings were performed at the time of testing. The patients' symptoms were monitored every minute. The effect of these solutions and edrophonium on lower esophageal sphincter (LES) pressure and amplitude of esophageal contractions was also evaluated. Esophageal perfusion with hypertonic glucose, saline, or acid had no significant effect on LES pressure or amplitude of esophageal contractions in most patients. Edrophonium, however, resulted in a significant rise in the amplitude of esophageal contractions and the LES pressure in all groups studied. Hypertonic glucose resulted in chest pain in 13.6% of patients with noncardiac chest pain and 20% of those with esophagitis, whereas edrophonium reproduced the pain in 38.7 and 37%, respectively. Our results indicate that hypertonic glucose is not effective as a provocative test for noncardiac chest pain nor does it contribute to the chest pain in esophagitis. They also had no significant effect on the amplitude of esophageal contractions or LES pressure. Edrophonium continues to be a relatively sensitive test for noncardiac chest pain.

Achalasia associated with squamous cell carcinoma of the esophagus: a case report.

A case of achalasia associated with squamous cell carcinoma of the esophagus is presented. Microscopic examination of the resected esophagus demonstrated abundant nerve fibers but absent ganglion cells throughout the tumor-involved segment. This finding is believed to be the cause of achalasia in this patient.

Primary esophageal motor disorders: clinical response to nifedipine.

The effect of nifedipine on esophageal symptoms was evaluated in 20 patients with primary esophageal motor disorders. The patients were randomized to receive nifedipine (10 mg t.i.d.) or placebo for two weeks, and then crossed over to receive the other medication. Ten patients had hypertensive lower esophageal sphincter, four had diffuse esophageal spasm, three had vigorous achalasia, two had "nutcracker esophagus," and one patient had achalasia. The score of chest pain or dysphagia was recorded on a scale of 0 to 10 during each study. The patients who received nifedipine improved significantly compared to those who received placebo. This improvement was most marked in patients with hypertensive lower esophageal sphincter. No significant side effects or changes in blood pressure were encountered in any of the study groups. Our results indicate that patients with primary esophageal motor disorders have a good clinical response to nifedipine therapy.

Value of serum immunoglobulins in the diagnosis of liver disease.

Serum immunoglobulins were determined in 145 consecutive patients with biopsy-proven steatosis, alcoholic hepatitis, alcoholic hepatitis with fibrosis, alcoholic hepatitis with cirrhosis, inactive cirrhosis, chronic active alcoholic hepatitis, chronic active hepatitis, primary biliary cirrhosis and nonspecific hepatitis. IgM was both a sensitive (90.5%) and specific (86.2%) marker for primary biliary cirrhosis, and mean IgM levels were higher in primary biliary cirrhosis than in other diagnostic categories (p less than 0.05). IgA levels were most commonly elevated in alcoholic liver disease (p less than 0.005). IgA detected 95% of alcoholic disease, but was poorly specific (41.1%). A trend of rising IgA with increasing severity of alcoholic injury was observed, but the differences were not significant. IgG was most commonly elevated in chronic active hepatitis and alcoholic hepatitis with cirrhosis, but the IgG values did not differ significantly from those found in other diagnostic categories. Our results substantiate assertions of a diagnostic sensitivity for elevated IgA in alcoholic liver disease and IgM in primary biliary cirrhosis. With the exception of IgM in primary biliary cirrhosis, however, serum immunoglobulins are not specific markers of liver histology.

Fat absorption after longitudinal pancreaticojejunostomy.

This study was undertaken to determine whether fat absorption is improved following longitudinal pancreaticojejunostomy. Ten consecutive patients with chronic pancreatitis underwent measurement of fat absorption (fecal fat, 14C-labeled phenylacetic dipalmitate oil absorption test) before and after operation. Fecal fat increased in 8 of 10 patients following side-to-side pancreaticojejunostomy. However, the average postoperative fecal fat increase of 4.3 gm was of no clinical significance. The observed mild postoperative decline in fat absorption was confirmed by the 14C-labeled phenylacetic dipalmitate test. An improvement in postoperative fat absorption following side-to-side pancreaticojejunostomy Roux-en-Y should not be expected. The primary indication for this procedure for patients with chronic pancreatitis continues to be intractable pain.

Comparative effects of Criticare HN and Vivonex HN in the treatment of malnutrition due to pancreatic insufficiency.

The effect of high nitrogen Criticare and Vivonex on nutritional repletion was evaluated in 12 patients with malnutrition secondary to pancreatic insufficiency. The patients were randomized to receive either Criticare HN or Vivonex HN for a total period of 9 days. Each patient received 3000 kcal/day of either preparation, in addition to 1000 kcal of solid food. A significant weight gain was encountered in the group of patients receiving Criticare HN. Increased blood urea nitrogen was encountered in both groups of patients. All patients tolerated both diets well without evidence of relapse of their pancreatitis. No significant complications were encountered. Our results indicate that Criticare HN is of superior nutritional value, but both preparations resulted in increased blood urea nitrogen retention.

Serum isoamylase as a test for pancreatic insufficiency.

Total and pancreatic serum isoamylases were performed on 38 control subjects (21 non-smokers and 17 smokers) and 21 consecutive patients with pancreatic insufficiency before and after meal stimulation. There was no difference in the fasting or stimulated levels of total amylase (T), pancreatic isoamylase (P), or % P/T between smokers and non-smokers. The P/T ratio was significantly reduced in patients with pancreatic insufficiency when compared with each of the control groups (p less than 0.0005). Eleven of 21 patients with pancreatic insufficiency had raised total serum amylase, but none had a rise in the pancreatic fraction or P/T ratio. Our findings indicate that the T, P, and P/T ratio of serum amylase are not influenced by smoking or meal stimulation. A reduced P/T ratio in a patient with steatorrhoea suggests pancreatic insufficiency as the cause. Hyperamylasaemia in patients with pancreatic insufficiency does not necessarily imply a relapse.

The value of [14C]phenyl acetic dipalmitate (PADP) as a test for maldigestion.

[14C]phenyl acetic dipalmitate (PADP) was prepared and evaluated in vitro and in vivo. Upon incubation with lipase it was hydrolyzed into phenyl acetic acid and monoglycerides. Phenyl acetic acid is not metabolized by the body and is quantitatively excreted in urine. When tested in rats there was no tissue deposition of the 14C label in any of the organs studied. There was also no evidence of absorption from the colon. The newly prepared compound was evaluated in 15 human volunteers and 24 patients with chronic pancreatitis and compared to fecal fat and D-xylose. Normal volunteers had a urinary excretion of 34.5 +/- 6.4% of the administered 14C label in 5 h. Both fecal fat and PADP were abnormal in 16 of 20 patients with chronic pancreatitis. They were both normal in two, while in two other patients fecal fat was normal and PADP abnormal. Both of the latter patients had clinical evidence of steatorrhea but reduced oral intake due to pain. D-xylose was abnormal in five patients presumably due to bacterial overgrowth. Our findings indicate that PADP is a simple, accurate and rapid test for pancreatic function; is not dependent on fat intake and may be run concomitantly with D-xylose.