Comparison of 99m technetium hexamethylpropylene-amine oxime labelled leucocyte with 111-indium tropolonate labelled granulocyte scanning and ultrasound in the diagnosis of intra-abdominal abscess.

Fifty patients with suspected intra-abdominal abscess were investigated prospectively with ultrasound and with 99mTc-hexamethylpropylene-amine oxime (HMPAO) isotope labelled mixed leucocytes, using 111-In tropolonate granulocyte scanning as the reference standard. Twenty five patients had inflammatory bowel disease (three were postoperative): 21 of these had Crohn's disease and four had ulcerative colitis. The remainder comprised nine with postoperative fever and 16 with fever and abdominal pain. An abscess was diagnosed when focal activity on serial 111-In tropolonate and 99m-Tc-HMPOA images at one, three, and 24 hours resulted in activity at least equal to liver activity at 24 hours. Thirteen abscesses were diagnosed using each type of white cell scanning, resulting in 100% sensitivity for 99m-Tc-HMPAO compared with 111-In tropolonate. Bowel inflammation was easily distinguished from abscess on serial images. Eight of these 13 abscesses were detected by ultrasound. Altogether 17 abscesses were found. Ultrasound detected 12, including four liver abscesses which were not purulent and had not been detected by white cell scanning. Ultrasound had a sensitivity of 71% (12 of 17) and a specificity of 87% (33 of 38) using all confirmed abscesses as the reference standard. White cell scanning showed a sensitivity of 76% (13 of 17: as a result of the four non-purulent liver abscesses) and a specificity of 100%. 99m-Tc-HMPAO scanning is as accurate as 111-In tropolonate scanning, and has several advantages including simplicity, availability, superior image quality, and reduced radiation dose. Both methods are more sensitive and specific than ultrasound for intra-abdominal abscess detection but ultrasound is advisable if a neutrophil infiltrate is not suspected.

Paradoxical lack of ultrasound attenuation with gross fatty change in the liver.

The cardinal features of hepatic steatosis on ultrasound examination are now accepted as increased echogenicity of the liver parenchyma with increased attenuation of the ultrasound beam. Three cases are presented of patients with gross diffuse fatty infiltration of the liver, who showed a paradoxical lack of posterior attenuation on ultrasound examination. These examples serve to illustrate the role of scattering in attenuation of the ultrasound beam seen in fatty livers.

Ultrasonic patterns in inflammatory bowel disease.

Ultrasound examination was performed in 90 patients with varying bowel pathology. Ultrasound reliably demonstrated thickening of the bowel. In addition, the pattern of abnormality seen in Crohn's disease and ulcerative colitis was different, and corresponded to the pathological changes seen in these disease processes. The pattern of bowel abnormality seen in other bowel diseases with an inflammatory aetiology generally corresponded to either the Crohn's or ulcerative colitic pattern. The appearances are described, together with findings in other non-neoplastic diseases of the bowel.

Comparison of liver histology with ultrasonography in assessing diffuse parenchymal liver disease.

To establish the accuracy of ultrasonography in assessing diffuse parenchymal liver disease we performed a prospective comparative study with histology in 50 patients with a wide range of liver disease. Liver biopsy was performed within 24 h of the ultrasound examination and ultrasonography was performed by a single operator who was unaware of clinical details of the patients. Histology was reviewed blind and the degree of steatosis graded mild, moderate or severe while increased portal fibrous tissue was graded mild, moderate or established cirrhosis. Thirty-six patients had steatosis and 31 patients had increased fibrous tissue on histology. Ultrasonography correctly identified steatosis in 32/36 (89%) patients including all patients with the severe grade. Increased fibrous tissue was correctly identified in 24/31 (77%) with a sensitivity of 100% in patients with moderate fibrosis and established cirrhosis. Specificity was 93% for steatosis and 89% for increased fibrous tissue. These results show that ultrasonography can provide a non-invasive prediction of liver histology which in moderate and severe steatosis and advanced fibrosis can be both highly sensitive and specific.

Impact of endoscopic duodenal biopsy on the detection of small intestinal villous atrophy.

Coeliac disease is underdiagnosed partly because of insufficient recognition of more subtle presentations and partly because of the relative difficulty of jejunal biopsy. We have compared new case detection of small intestinal villous atrophy in the 5 years following changing to endoscopic multiple biopsy with our preceding 9 year experience utilizing jejunal capsule suction biopsy. The detection rate for small intestinal disease doubled while the number of patients investigated by small bowel biopsy increased threefold. We recommend that endoscopic duodenal biopsy replace jejunal biopsy for routine diagnostic purposes.

Correlation of 111indium WBC scintigraphy with ultrasound in the detection and assessment of inflammatory bowel disease.

111Indium (111In) WBC scintigraphy is an accurate method of assessing the extent of inflammatory bowel disease. A prospective study was performed to determine the correlation of ultrasound scanning with 111In WBC scintigraphy in the assessment of inflammatory bowel disease. Eighty-three indium and ultrasound scans were performed in 57 patients. Forty-six patients had Crohn's disease and 11 patients had ulcerative colitis. The site extent of abnormality and the appearance of the bowel were recorded and compared to the findings on indium scintigraphy. Ultrasound detected 84% of indium-positive sites. If the rectum was excluded, sensitivity of detection rose to 91%. Three percent of indium-negative sites were positive on ultrasound.

Gallbladder wall thickening (congestive cholecystopathy) in chronic liver disease: a sign of portal hypertension.

A thickened gallbladder wall is often seen with ultrasound in alcoholic cirrhosis. Hypoalbuminaemia is thought to be the cause since there is a strong association between bowel wall thickening and low serum albumin. To determine the role of portal hypertension in producing gallbladder wall thickening we studied 40 consecutive stable patients-37 with cirrhosis and three with portal hypertension due to primary biliary cirrhosis. Ultrasound assessment of the gallbladder wall was made after an overnight fast using a Technicare autosector. Wall thickness 4 mm or greater was considered abnormal. Twenty-seven patients had a thickened gallbladder wall and all had evidence of portal hypertension. Hypoalbuminaemia was not an important factor since it was only present in six cases with thickened walls. In two cases reduction in portal pressure with oral propranolol was associated with a decrease in gallbladder wall thickness. These results suggest that portal hypertension, not hypoalbuminaemia, is the dominant factor causing gallbladder wall thickening in cirrhosis. Ultrasound demonstration of gallbladder wall thickening in chronic liver disease should suggest the presence of portal hypertension.

Thermodynamic effects of bile acids in the stomach.

The surface thermodynamic effects of bile acids in the stomach were assessed in 48 subjects who had undergone gastric surgery for peptic ulcer disease and in 52 controls with medically healed ulcers. We derived values for surface tension of gastric mucosa from contact angle using a goniometer and measured the surface tension of gastric juice by the drop-weight method. Subjects with gastric surgery had higher median fasting bile acid concentrations than controls (1.2 vs. 0.1 mmol/L; P less than 0.0001), higher mean mucosal surface tension (51.9 vs. 47.9 mN/m; P less than 0.0001), and lower mean surface tension of gastric juice (43.2 vs. 51.7 mN/m; P less than 0.0001). Subjects who had had a Billroth II gastrectomy (n = 19) had higher bile acid concentrations (5.8 vs. 0.6 mmol/L; P less than 0.01), higher mucosal surface tension (53.7 vs. 50.3 mN/m; P less than 0.05), and lower gastric juice surface tension (41.3 vs. 47.1 mN/m; P less than 0.05) than those who had a vagotomy and drainage procedure (n = 17). Overall, intragastric bile acid concentration correlated directly with surface tension of gastric mucosa (r = 0.51, P less than 0.0001) and inversely with that of gastric juice (r = -0.60, P less than 0.0001). In conclusion, the interfacial energy barrier at the surface of the gastric mucosa is overcome in the presence of intragastric bile acids.

Surface hydrophobicity of gastric mucosa in peptic ulcer disease. Relationship to gastritis and Campylobacter pylori infection.

The hydrophobicity of biopsy specimens of gastric mucosa in 228 dyspeptic subjects undergoing diagnostic endoscopy was assessed by measuring the plateau-advancing contact angle of saline drops using a goniometer. Subjects with duodenal ulcers (n = 49) and gastric ulcers (n = 17) had significantly lower mean contact angles than controls (n = 124) without ulcer (57 degrees in duodenal ulcer, 59 degrees in gastric ulcer vs. 66 degrees in controls; p less than 0.0001). There was no change in contact angle after healing with H2-receptor antagonists by comparison with pretreatment (59 degrees vs. 56 degrees for duodenal ulcer, n = 15; 57 degrees vs. 59 degrees for gastric ulcer, n = 5). Controls with gastritis had lower contact angles than those without (61 degrees, n = 50, vs. 70 degrees, n = 63; p less than 0.0001). The presence of Campylobacter pylori was associated with a significant decrease in contact angle in controls (59 degrees, n = 39, vs. 70 degrees, n = 75; p less than 0.0001).

Quantification of radiolabelled granulocyte migration in vivo.

Quantification of the tissue localisation of granulocytes is difficult, particularly in man. With the aim of facilitating such quantification, a technique is described which combines the micropore filter skin window technique with the infusion of autologous 111In-labelled granulocytes. The radioactivity in the removable micropore filters, placed on small forearm skin window abrasions, was compared with peripheral blood radioactivity following injection of 111In-labelled 'pure' granulocytes in normal subjects. Radioactivity in filters from abrasions which were made 8 h or more before injection of labelled cells followed the same time course as the cell-associated radioactivity in whole blood, but radioactivity in filters from abrasions made nearer to the time of labelled granulocyte injection increased to reach a peak 3-8 h after cell injection, at a time when cell-associated blood radioactivity had fallen to about 50% of its initial value. Exercise appeared to induce a transient decrease in radiolabelled granulocyte migration into the filters. This technique offers a means of studying the kinetics of granulocyte migration in vivo.

Thickened stomach--an ultrasound sign of portal hypertension.

Congestive gastrophy occurs with portal hypertension and is associated with vascular changes including dilatation and tortuosity of the submucous veins. Transabdominal ultrasound measurements of the stomach were made to determine whether these changes resulted in increased thickness of the stomach in patients with established cirrhosis and portal hypertension. Mean thickness of the antrum and body was 22.15 mm (range 13-31 mm) and 22.2 mm (range 13-31 mm) respectively in patients with portal hypertension: in the control group measurements of the antrum and body were 13.8 mm (range 8-20 mm) and 14.05 mm (range 11-19 mm) respectively (P less than 0.01 for both antrum and body). A thickened stomach may indicate the presence of portal hypertension.

Quadruple antimycobacterial chemotherapy in Crohn's disease: results at 9 months of a pilot study in 20 patients.

Twenty patients with active Crohn's disease, the majority refractory to conventional therapy, were treated with rifampicin, ethambutol, isoniazid, and pyrazinamide or clofazamine for 9 months. After this period, 10 were in remission (Crohn's disease activity index less than 150). Of the 10 not in remission, three had been at 6 months, but had relapsed on treatment. Nine of 10 patients on steroids at the beginning were off steroids at 9 months. Six patients came to surgery during the period, five for stricture formation without evidence of florid Crohn's disease outside the strictured segment. Three young patients with severe Crohn's disease facing total colectomy were spared surgery. No serious drug-related side-effects were encountered. The results of this pilot study suggest that controlled trials of antimycobacterial chemotherapy, using four or more of the best agents available, are worthy of assessment in Crohn's disease.

Measurement of the surface hydrophobicity of human gastrointestinal mucosa.

A technique has been developed for assessing the surface hydrophobicity of human gastrointestinal mucosa by measuring the plateau contact angle of saline drops applied to endoscopic biopsy specimens. The plateau contact angle was not affected by the mode of drying. The intraobserver and interobserver coefficient of variation was less than 5%. The gastric mucosal surface had a higher mean contact angle than the submucosal surface (69 degrees vs. 47 degrees, p less than 0.001). Glycerol drops gave lower contact angles than saline drops (55 degrees vs. 69 degrees) but gave the same derived values for surface free energy (42 vs. 41 mJ/m2). Regional values for contact angle were as follows: gastric body 70 degrees, antrum 70 degrees, duodenal bulb 62 degrees (p less than 0.01 vs. stomach), distal duodenum 50 degrees (p less than 0.001 vs. stomach and p less than 0.01 vs. bulb), and rectum 57 degrees (p less than 0.001 vs. stomach). We conclude that it is feasible to measure the surface hydrophobicity of human endoscopic biopsy specimens and that the stomach is relatively more hydrophobic than the duodenum and rectum.

Use of endoscopic biopsy for diagnosing congestive gastropathy.

The specificity of endoscopic biopsy specimens in diagnosing congestive gastropathy in 20 patients with portal hypertension, 20 patients with liver disease without portal hypertension, and 20 patients with a normal stomach at endoscopy without liver disease was examined. Histological assessment, which was performed without knowledge of the clinical details, showed changes previously reported to be indicative of congestive gastropathy in 9 (47%) of patients with portal hypertension. Similar changes were also seen in 17 (85%) of patients with liver disease without portal hypertension and in 16 (84%) of patients with normal endoscopies without liver disease. These results show that the histological changes seen in endoscopic biopsy specimens of congestive gastropathy are not specific for this condition and therefore cannot be used to diagnose objectively the disease or assess management.

Ultrasound detection of oesophageal varices--comparison with endoscopy.

In a prospective study of 100 patients for the detection of oesophageal varices, real-time ultrasound was both sensitive (sensitivity 82%) and specific (specificity 91%) compared with upper gastrointestinal endoscopy. All patients with large and medium sized varices were correctly identified by ultrasound. Ultrasound should be considered as an alternative to endoscopy and radiology for detection of oesophageal varices.

Recurrent paroxysmal complete heart block induced by vomiting.

A woman had a 40-year history of vomiting associated with syncope. Spontaneous and induced vomiting was predictably associated with sinus bradycardia, paroxysmal atrioventricular block, and ventricular asystole. The clinical and laboratory studies carried out to illustrate the mechanism of this unusual complication of vomiting demonstrated it to be due to a vagovagal reflex initiated by distension of upper esophagus.

Triolein breath test of fat absorption in patients with chronic liver disease.

We have compared the [14C]triolein breath test for fat malabsorption with fecal fat excretion corrected for marker pellet recovery in 23 subjects with chronic liver disease. The breath test identified 15 of the 17 subjects with abnormal fecal fat excretion (sensitivity 88%). However, four of the six subjects with normal fecal fat excretion gave abnormal breath test results (specificity 33%). While three of the four subjects with falsely abnormal breath tests had alcoholic liver disease, the explanation for the low specificity is unclear and may not be confined to patients with alcohol-related disease. We are therefore unable to recommend the breath test as a screen for steatorrhea in patients with chronic liver disease.