[Long-term evolution of achalasia of the lower esophageal sphincter and intestinal paraneoplasic pseudo-obstruction revealing small cell lung carcinoma]. / Evolution à long terme d'une achalasie du sphincter inférieur de l'esophage et d'une pseudo-obstruction intestinale paranéoplasiques révélatrices d'un carcinome pulmonaire à petites cellules.

We report a case of a small cell carcinoma of the lung revealed by chronic intestinal pseudo-obstruction associated with achalasia of the lower esophageal sphincter. Tumoral remission was achieved for more than 21 months after chemoradiotherapy but this did not prevent the paraneoplasic syndrome from persisting and medical treatment was not successful in treating the intestinal pseudo-obstruction or the dysphagia, which was not improved by esophageal dilation.

[Slowly regressing acute pandysautonomia associated with esophageal achalasia: a case report]. / Pandysautonomie aigue lentement regressive associee a une achalasie de l'oesophage: a propos d'un cas.

Acute pandysautonomia is a rare acute autonomic neuropathy that mainly affects young women. We report a case of idiopathic acute pandysautonomia associated with an esophageal achalasia in a 30-year-old woman. The clinical features were inaugural dysphagia followed by signs of parasympathetic failure of the entire digestive tract, bladder and pupils. Twenty-four hours of electrocardiographic recording showed involvement of sympathetic adrenergic nerves. Esophageal achalasia was patent on esophageal manometry. Upper digestive tract motility was first involved and then extended to the entire digestive tract with intestinal obstruction, which required emergency ileostomy. Recovery of autonomic functions was slow. After 16 months, dysphagia and gut paresis improved and digestive continuity was restored. In case of subacute intestinal pseudo-obstruction associated with autonomic dysfunction, acute pandysautonomia should be suspected. In our report, the association with esophageal achalasia is uncommon.

Tioguanine in patients with Crohn's disease intolerant or resistant to azathioprine/mercaptopurine.

BACKGROUND: Tioguanine (TG) is an antimetabolite which may be regarded as an alternative to azathioprine (AZA)/mercaptopurine (MP) in patients with inflammatory bowel diseases. AIMS: : To evaluate the tolerance and efficacy of TG in patients with Crohn's disease, intolerant or resistant to AZA/MP. METHODS: An open prospective study was made on Crohn's disease patients treated with TG. Intolerance to AZA/MP was defined as a reaction occurring within 1 month after introduction of AZA/MP, including pancreatitis, abdominal pain, fever, arthralgia, myalgia, cutaneous rash, fatigue, alopecia, hepatitis and digestive intolerance. Resistance to AZA/MP was defined as the persistence of activity after at least 3 months of AZA/MP therapy. RESULTS: Forty-nine Crohn's disease patients (36 women, 13 men; intolerance: n = 39; resistance: n= 10) were treated with TG (20 mg/day). Clinical pancreatitis did not recur under TG. Five patients (10%) had to stop TG due to intolerant reactions observed 13-21 days after TG was started. No haematological side-effects were observed under TG. The probability of clinical remission without corticosteroids or infliximab at 6 and 12 months was 46% and 79%, respectively, in the 40 patients with active disease at baseline. The probability of clinical relapse during maintenance TG therapy at 6 and 12 months was 29% and 53%, respectively, in the 28 patients in remission at baseline or who had achieved remission on TG. CONCLUSIONS: TG is a possible alternative treatment in Crohn's disease patients, intolerant (especially for pancreatitis) or resistant to AZA/MP.

Evolution of clinical and radiological features at diagnosis of achalasia during a 19-year period in central France.

OBJECTIVES: Symptoms of achalasia are often misinterpreted, resulting in delayed diagnosis. The aims of our study were (1) to estimate the evolution of clinical and radiological features of a large population of achalasic patients between two successive periods; and (2) to determine the influence of symptoms on diagnostic delay. METHODS: Between 1980 and 1998, all achalasia patients treated in our unit were assessed at the time of manometric diagnosis for clinical and radiological features. These data were compared between two successive periods (1980-1994 and 1994-1998). Then, a correlation between the diagnostic delay, clinical and radiological data and symptoms was investigated. RESULTS: Three hundred and forty-five consecutive achalasia patients were assessed (mean age at diagnosis, 56 years; mean diagnostic delay, 5.7 years). The duration of the disease was correlated with the oesophageal diameter (P = 0.0001). Dysphagia, chest pain and heartburn were more frequent in young patients (respectively, P = 0.003, 0.0001 and 0.001). Women had 1.7 times the risk of men for suffering of chest pain (95% CI, 1.1 -2.6) and 2.2 times the risk for heartburn (95% CI, 1.2-4.0). Pulmonary involvement was more frequent when the oesophagus was dilated (P = 0.0002), and 3.4 times more frequent when associated with regurgitations (95% CI, 1.3-8.9). The oesophageal diameter was significantly smaller (38 vs 48 mm) in the last period, but we have not observed any significant shortening of the diagnostic delay. No symptoms influenced the diagnostic delay. CONCLUSIONS: Despite a smaller oesophageal diameter at the time of diagnosis, during the period 1994-1998, diagnostic delay was not reduced. No clinical features associated with late diagnoses could be identified.

[Fluorinated pyrimidines administered by percutaneous arterial perfusion in primary or secondary cancers of the liver]. / Les pyrimidines fluorées en perfusion artérielle par voie percutanée dans les cancers du foie primitifs ou secondaires.

The results of a study based on intraaterial therapy applied to 65 cases of hepatic cancers (among which 42 cases of metastases of recto-colitic origin and 8 cases of primitive hepatomas) are reported. The catheters are insected percutaneously through the left brachial artery. After achort term treatment with Fluoro-Uracil FUDR is given continuously for over 20 weeks on the average, in ambulatory practice, using a Watkins chronofusor. A subjective response is reported in 88 p. 100 of the cases, an objective one in 74 p. 100. The mean survival time reckoning from the date of diagnosis is 16.6 months (it is somewhat longer in the cases of primitive hepatoma). The signs of systemic toxicity are frequent but mild; they seldom compel to discontinue the treatment. No death due to therapy has been register-d. The results are at least as good and even better with transcutaneous catheters than with catheters surgically inserted in the abdomen. They should encourage a wide spread of the method.

[Primary non-Hodgkin's high grade malignant lymphoma of the digestive system. A prospective study of the combination of surgery-chemotherapy-radiotherapy]. / Lymphomes malins non hodgkiniens primitifs du tube digestif de haut grade de malignité. Etude prospective de l'association chirurgie-chimiothérapie-radiothérapie.

We report a prospective study concerning the association of surgery-chemotherapy and radiotherapy in the treatment of primary high grade digestive non-Hodgkin's lymphomas in 19 patients. The analysis of 11 stages IE, 5 stages II1E and 3 stages II2E allowed us to evaluate the efficacy and the tolerance of this triple therapeutic association. Fifteen patients are alive and well with a median follow-up of 54 months. One of these patients relapsed, but after autologous bone marrow transplantation is in second unmaintained complete remission. Four patients died of intercurrent aetiology although one death was related to treatment morbidity. Our results and the analysis of literature data lead us to recommend the triple association in the treatment of stage II2E high grade primary digestive lymphomas (PDL) and for PDL without complete resection. However, surgery and chemotherapy appear to be sufficient in the treatment of stages IE and II1E with complete resection.

[Monitoring of the permeability of the inferior esophageal sphincter using sound signals]. / Contrôle de la perméabilité du sphincter oesophagien inférieur á l'aide de signaux sonores.

An original method is described for graphic display of sounds arising from the cardia during the swallowing of saliva or water. Two dynamic microphones were placed on the skin of epigastric xyphoid area and simultaneously on the latero-cervical position. The following conditions must be filled: position of the subject (upright or lying), correct application of microphone with pressure (2 kPa), specially for the xyphoid situation. For graphic restitutions from magnetic signal, a time-recording paper was used, on line or off line, with an analogical device including Butterworth band active filter (optimal frequency range 0.8-1.2 kHz), amplifier and integrator (tau = 2 s). Occurrence of typical cardia sounds were 86-97 % for saliva and 95-100 % for water in two normal subjects for the evaluation of reproducibility (one man and one woman 35 and 47 years old respectively, n = 234 sequences, interval 20 s). Using the distance between the upper and lower microphones, the esophageal time transit can be measured. The signal was more unconstantly recorded for saliva 40 +/- 44 % in adults (n = 10) and 76 +/- 17 % in children (n = 7), than for 80 et 87 % for water respectively. The optimal interval between two swallows appeared to be 15-25 s. In patients with presumption of achalasia (n = 8), the two phonic signals were recorded during esophageal pressure measurement. The presence of esophageal sounds seems to be the sign of absence of achalasia.

Erythromycin elicits opposite effects on antro-bulbar and duodenal motility: analysis in diabetics by cineradiography.

We have previously demonstrated by cineradiography analysis that erythromycin (Ery) increases antral contractility and antropyloric coordination in diabetics. The aim of this study was to further characterize antro-bulbar and duodenal motility after Ery i.v. administration. Fourteen diabetic patients (mean age 61.2 years) were randomly allocated to receive either 100 or 500 mg of Ery intravenously 4 hours after a standard solid liquid meal. After ingestion of a barium sulfate suspension, a series of 15 fluorographic plates (one every two seconds) was performed. the same procedure was repeated twice for each subject with a delay of 3 days once before and once after Ery. Antral, bulbar and duodenal areas and evolution diagrams were calculated in baseline conditions and after Ery administration using a graphic table connected to a microcomputer. No differences were found between the two doses of the drug. Ery significantly decreased antral (1284 +/- 268 mm2 vs 704 +/- 181 mm2; P < 0.01) and bulbar areas (127 +/- 26 mm2 vs 73 +/- 21 mm2; P < 0.01). In contrast, duodenal areas were significantly increased after Ery (875 +/- 112 mm2 vs 575 +/- 112 mm2; P < 0.01). This study suggests that the known prokinetic effect of Ery on gastric emptying seen in diabetic patients could be related to an increase of motility in the antrum and in the bulb simultaneously with a relaxation in the duodenum.

[Carbohydrate-deficient transferrin and liver diseases. Study of 94 patients]. / Transferrine déficiente en acide sialique et maladies du foie. Etude de 94 malades.

OBJECTIVES AND METHODS: Carbohydrate-deficient transferrin has been proposed as a marker of alcohol consumption. The aim of this study was to evaluate the accuracy of the carbohydrate-deficient transferrin serum level, measured by ion exchange chromatography followed by radioimmunoassay (Kit CDTect), for the diagnosis of excessive alcohol intake in patients with liver diseases. Ninety-four patients (68 men, 26 women, age 21-71 years), 42 with alcoholic liver diseases and 52 with non-alcoholic liver diseases, were studied. Twenty-six patients consumed > or = 40 g alcohol per day (mean alcohol intake: 84 +/- 52 g per day) and were considered to be excessive drinkers. RESULTS: The sensitivity of carbohydrate-deficient transferrin for the diagnosis of excessive alcohol intake was 35%, and the specificity was 91%. By pairing carbohydrate-deficient transferrin with other markers of alcohol consumption, the sensitivity of the association of carbohydrate-deficient transferrin and gammaglutamyl transpeptidase was 96%, and the specificity was 59%. CONCLUSION: In patients with liver diseases, carbohydrate-deficient transferrin is a specific marker of excessive alcohol intake but a lack of sensitivity may limit its use.

[Merycism or gastroesophageal reflux: value of antroduodenal manometry]. / Mérycisme ou reflux gastro-oesophagien: place de la manométrie antro-duodénale.

Decrease in lower esophageal sphincter (LES) pressure and frequent acid reflux were observed in 3 of 5 adult patients with rumination syndrome confirmed by antroduodenal manometry. The role of the LES in the rumination syndrome is unclear but decreased LES pressure could be a determining factor. Antroduodenal manometric studies should therefore be performed during ordinary gastroesophageal reflux in order to determine the diagnostic value of antroduodenal manometry in the rumination syndrome.

[Gastric peristalsis and dyspepsia: value of cineradiographic analysis in men]. / Péristaltisme gastrique et dyspepsie: intérêt de l'analyse cinéradiographique chez l'homme.

Gastric peristalsis has not been studied extensively in patients with dyspepsia. The aim of our study was to further characterize gastric peristalsis in such patients using a newly described fluorographic method. Thirty-two patients with dyspepsia and 18 healthy volunteers were included in our study. Four hours after a standard solid-liquid meal, the subject swallowed 250 ml of a baryum sulfate solution and (100 mm x 100 mm) fluoroscopy of the stomach was performed every 2 s during 30 s. Spot films were analyzed using a graphic table and a amateur microcomputer program. For each subject, the instant velocity, vi, and mean velocity, V, of gastric peristalsis were calculated and used to generate a time-space diagram of contractions, a velocity histogram and an index of propagation, Ip. These parameters were compared to normal values (V = 2.2 +/- 0.2 mm/s; Ip = 2.2 +/- 0.4). When compared with normal values, 3 different motility patterns appeared in dyspeptic patients with a high correlation between V and Ip (P less than 0.01): normoperistalsis (n = 8; 1.8 less than V less than 2.6 mm/s); 1.4 less than Ip less than 30); hypoperistalsis (n = 7; V less than 1.8 mm/s; Ip greater than 3.0) and hyperperistalsis (n = 7; V greater than 2.6 mm/s; Ip less than 1.4). In a 4th group (n = 5), a retroperistalsis was effect observed with Ip less than 0. For 5 other patients, Ip or V was abnormal with atypical motor activity detected on the time-space diagram.(ABSTRACT TRUNCATED AT 250 WORDS)

[Fine needle cytopuncture of the pancreas. Apropos of 45 cases]. / Cytoponction pancréatique à l'aiguille fine. A propos de 45 observations.

In this report, we examined the sensitivity and specificity of pancreatic fine needle aspiration cytology in the diagnosis of pancreatic cancer. Aspiration cytodiagnosis was performed in 45 patients (36 cancers and 9 benign pancreatic lesions) using a 22 Gauge fine needle either percutaneously in 25 patients with real-time ultrasonic guidance or during surgery in 20 patients. Cytologic examination included a precise description and the classification in one of the 4 Papanicolaou classes, the fourth only being considered as positive in terms of cancer. No complication occurred with either technic. Overall sensitivity was 75 p. 100, 74 p. 100 percutaneously and 77 p. 100 intraoperatively, but specificity was 78 p. 100 due to two false-positive results recorded among the 9 benign lesions. Retrospective analysis of cytologic examinations of the 29 class IV lesions led us to differentiate cases with "sure malignancy" (20 cases) from those with "strong suspicion of malignancy" (9 cases including the 2 false-positives). Only class IV lesions with "sure malignancy" call for aggressive treatment, whereas a "strong suspicion of malignancy", which may result from carcinoma or severe cellular abnormalities occasionally found in inflammatory pancreatic lesions, should lead to a second pancreatic aspiration.

[Propagation of the gastric peristalsis in normal subjects and duodenal ulcer patients]. / Propagation du péristaltisme gastrique chez l'homme normal et chez l'ulcéreux duodénal.

The velocities of gastric peristaltic waves were measured on fluorographic series made in normal subjects and patients with duodenal ulcer. After an overnight fast, the subjects drank 250 ml of barium suspension. Sequential radiograms were taken every 2 s during 30 s after two pyloric ejections. Peristaltic waves were located and their displacements measured with an Apple Graphic Tablet. Wave progression diagrams and velocity histograms were drawn for each subject. The velocities were calculated every 2 s. A "spread index" Ip was determined for each subject, characterizing the irregularity of propagation. Mean frequency and mean velocity were greater in duodenal ulcer patients (3.6 c/min; 3.7 mm/s) than in normal subjects (2.9 c/min; 2.4 mm/s; p less than 0.001). Nevertheless, no significant difference was found between proximal or midcorpus and antral velocities, in ulcer patients as well as in normal subjects, contrarily to classical data. However, the velocities were not uniform along the stomach. The contractions spread unevenly and displayed transient slopes. The irregularities of propagation were more pronounced in normal subjects, ranging from 0 to 14 mm/s with 28 p. 100 of velocities less than 1 mm/s, then in ulcer patients (0 to 13 mm/s with 12 p. 100 of low velocities). The spread index Ip was greater in normal (ranged from 0.54 to 2.62) than in ulcer patients (ranged from 0.16 to 0.48; p less than 0.001). This study showed that the propagation velocity of the peristaltic waves and its regularity were different in normal subjects and in duodenal ulcer patients.

[Decrease of haptoglobin serum level in patients with chronic viral hepatitis C]. / Diminution de l'haptoglobinémie chez les malades atteints d'hépatite chronique virale C.

Serum levels of haptoglobin, an acute phase protein, in usually increased in patients with inflammation and decreased in patients with intravascular hemolysis. Changes in haptoglobin serum levels were also observed in patients with liver disease. The aim of this study was to evaluate the serum level of haptoglobin in patients with chronic viral hepatitis C. Haptoglobin serum levels were measured by rate nephelometry in 34 patients with histologically proven chronic viral hepatitis C and in 30 controls. Haptoglobin serum levels were lower in patients than in controls (0.56 +/- 0.36 versus 0.90 +/- 0.35 g/L, P < 0.001). In patients with chronic hepatitis but without cirrhosis, haptoglobin serum levels were decreased as well. Haptoglobin serum levels were positively correlated to prothrombin index (P < 0.001) and negatively correlated to the histology activity index of Knodell (P < 0.001), and especially to scores of fibrosis (P < 0.001) and periportal necrosis (P < 0.05). Red cell count, indirect bilirubin level, and reticulocyte count, as markers of hemolysis, were similar in patients and controls. We conclude that determination of haptoglobin serum levels may be useful in the evaluation and the follow-up of patients with chronic viral hepatitis C.

[Post-antibiotic diarrheas: role of Klebsiella oxytoca]. / Diarrhée post-antibiotique: rôle de Klebsiella oxytoca.

From May 1989 to January 1991, 20 patients were investigated for antibiotic-associated acute diarrhea. Colonoscopy or rectosigmoidoscopy was performed in each patient. Cultures of colonic mucosal biopsies were carried out using conventional culture grounds (cystine-lactose-electrolyte-deficient). The aim of this study was to investigate the role of a gram negative bacillus: Klebsiella oxytoca. Among the 20 patients with antibiotic-associated acute diarrhea, 11 had bloody and mucus diarrhea and colitis ranging from a right-sided hemorrhagic to diffuse acute ulcerative or erosive colitis, 7 had a grossly normal colonic appearance, while 2 had mucus diarrhea and pseudomembranous colitis. Of colonic biopsies cultures obtained from 36 control patients, 15 had a normal colonic appearance, 15 had ulcerative or crohn's colitis, 6 had well-tolerated amoxicillin therapy. Klebsiella oxytoca was never found in the 36 control patients; Klebsiella oxytoca was noted among 8/11 patients with mucus-discharging and bloody diarrhea. These results suggest that antibiotic-associated, non pseudomembranous colitis is frequently associated with Klebsiella oxytoca infection, which may be the cause of this type of colitis.

[Antro-pyloro-bulbar contractibility in diabetics studied by cineradiography. Effect of erythromycin]. / Etude de la contractilité antro-pyloro-bulbaire chez le diabétique par analyse de cinéradiographies. Effet de l'érythromycine.

We studied antropyloroduodenal contractility in diabetics and the effect of erythromycin IV (100-500 mg) using the non invasive Boiron cineradiographic method analysis. Fourteen diabetics and 22 controls were examined. Four hours after a standard liquid-solid meal, patients drank 250 mL baryum solution. Fluorographic plates (10 x 10 cm) were taken every 2 s during 30 s. Semi-automatic data processing analysis allowed to measure motility parameters including antral (CA) and bulbar (CB) contractility indexes; pyloric opening index (OP), gastric (FG) and bulbar (FB) frequencies. Three types of pylorus behaviour patterns were define: A and B related to antropyloric and antropyloroduodenal coordination respectively and N without coordination. In diabetics, CA, OP and FG were decreased vs controls (P < 0.01) (CA: 65.5 +/- 6.8 vs 83.1 +/- 2.4%; OP: 60.9 +/- 8.7 vs 84.8 +/- 1.9%; FG: 2.42 +/- 0.14 vs 3.08 +/- 0.04 c/min) and antropylorbulbar coordination altered (N was predominant; no bulbar cycles at 3/min). Antral hypocontractility was correlated with autonomic neuropathy. After erythromycin, radiological parameters returned to normal values (CA = 83.0 +/- 2.4%; OP = 86.0 +/- 4.7%; FG = 3.0 +/- 0.16 c/min) and coordination improved type N disappeared and FB = 3 c/min (58%). Cineradiographic analysis is simple, able to show antropylorobulbar contractile abnormalities, to study pharmacological effects, and in diabetics is capable of studying improvement of motility parameters with erythromycin.

[Acute reversible pan-dysautonomia: effect of erythromycin on gastrointestinal involvement]. / Pan-dysautonomie aiguë réversible: effet de l'érythromycine sur l'atteinte gastro-intestinale.

We describe a case of acute autonomic neuropathy in an 18-year-old woman. Gut dysfunction was sufficiently severe for the patient to undergo laparotomy for suspected mechanical-intestinal obstruction before the diagnosis was made. Apart from the gut, other organs affected included the pupils, sweat and lachrymal glands. Cardiovascular autonomic function tests showed the involvement of sympathetic adrenergic nerves. Small bowel barium X-ray showed resolution of gastric stasis and emergence of jejunum dilatation during intravenous administration of erythromycin but this treatment did not eliminate intestinal obstructive symptoms. The patient had an incomplete recovery in 3 months. Erythromycin might have therapeutic value in patients with intestinal motility dysfunction in acute dysautonomia.

[Exacerbation of an autoimmune thrombocytopenic purpura during treatment with interferon alpha in a woman with chronic viral hepatitis C]. / Exacerbation d'un purpura thrombopénique auto-immun au cours du traitement par l'interféron alpha chez une femme atteinte d'une hépatite chronique virale C.

We report the case of a 40-year-old woman with chronic viral hepatitis C and latent idiopathic thrombocytopenic purpura who developed severe thrombocytopenia during alpha interferon therapy. Platelet-associated IgG titers were elevated, and platelet antibodies were detected in the serum. Intravenous administration of high-dose polyvalent immunoglobulins was ineffective, but a normal platelet count was obtained after corticosteroid therapy. A history of idiopathic thrombocytopenic purpura could be considered a contraindication for alpha-interferon therapy in patients with chronic viral hepatitis.

[Complete remission of a mesenteric fibromatosis after taking sulindac]. / Régression complète d'une fibromatose mésentérique après prise de sulindac.

We report the case of a 22-year-old-man having a familial adenomatous polyposis coli treated by total colectomy with ileo-rectal anastomosis. Two years after the operation, an asymptomatic mesenteric fibromatosis appeared which was nonresectable due to mesenteric vessels infiltration. Nine years later, sulindac therapy was started for residual polyps in the rectal stump. This treatment was taken intermittently, during periods of 1 to 8 months, for 6 years. After 4 years of treatment, the tumor was no longer palpable. Four years after sulindac discontinuation, the patient was operated on for suspicion of intestinal adhesion. The mesenteric fibromatosis had completely disappeared and mesenteric vessels were free. This complete macroscopic regression of a desmoid tumor after sulindac therapy emphasizes again the interest of this treatment for mesenteric fibromatosis.

[Aneurysm of the portal vein associated with aneurysm of the splenic artery]. / Anévrysme de la veine porte associé à un anévrysme de l'artère splénique.

Portal vein aneurysm is very rare. A case of portal vein aneurysm without symptoms of portal hypertension is described. Ultrasonography demonstrated a hypoechoic mass at the isthmic region of the pancreas. Computed tomography demonstrated the vascular origin of the mass. Angiography showed a portal vein aneurysm, measuring 3 cm in diameter, at the junction of portal vein trunk and splenic vein. The association with a splenic artery aneurysm and absence of portal hypertension lead us to suggest that our case is congenital. Non-invasive diagnostic methods are useful to recognize the pathology of portal vein aneurysm and prevent complications especially those related to a possible portal hypertension.