Incidence of peptic ulcer disease in Gothenburg, 1985.

OBJECTIVE: To determine the incidence and age distribution of peptic ulcer disease in adults in Gothenburg. DESIGN: Retrospective study of patients with symptoms over one year. SETTING: All gastroenterology and x ray departments. PATIENTS: Any patient found to have an active ulcer crater during 1985. MAIN OUTCOME MEASURES: Sex, age, past history of gastrointestinal ulcers, and smoking habit. RESULTS: In 1985, 1402 peptic ulcers were diagnosed in 1137 adults. Over half (403; 54%) of the ulcers in men and 393 (60%) ulcers in women were in patients aged over 60. All types of ulcer showed increasing incidence with age. The sex ratio of patients aged 40-50 with peptic ulcers was 1:1. Nearly half (109; 48%) of ulcers diagnosed for the first time in men and 129 (57%) of such ulcers in women were in patients aged over 60. Elderly men and women were also more likely to develop haemorrhage. CONCLUSIONS: In Gothenburg there is a surprisingly high incidence of peptic ulcer disease, which increases considerably with age, possibly explained by the availability of modern diagnostic techniques as 1121 (80%) ulcers had been diagnosed by gastroscopy. Compared with earlier studies there was no difference in the incidence between men and women aged 40-50.

Inhibitory effect of cimetidine on gastric acid secretion vagally activated by physiological means in duodenal ulcer patients.

Vagal activation of gastric acid secretion by modified sham feeding in six patients with duodenal ulcer produced a peak acid response amounting to 52% of the peak acid output after pentagastrin stimulation (PAOpg). Cholinergic reflex stimulation of gastric acid secretion by fundic distension in another six patients with duodenal ulcer produced a peak acid response of 45% of PAOpg. Intravenous infusion of cimetidine in a dose of 100 mg/h markedly inhibited the acid sham feeding response by 90-100% and almost abolished the acid response to fundic distension. The results suggest that gastric acid secretion evoked by physiological vagal activation in man is profoundly inhibited by H2-receptor blocking agents.

Surgery in patients aged 80 years and over. A retrospective comparative study from 1981 and 1987.

This is a retrospective study from a general surgical unit to evaluate the profile of surgery in patients aged greater than or equal to 80 years in the years 1981 and 1987. The proportion of admissions of such patients rose from 9.6% in 1981 to 15.7% in 1987. There was a twofold increase in emergency admissions and an increase of 30-40% in early (within 24 hours) interventions among the emergency cases of this age group. The postoperative mortality was concentrated to the emergency cases. In more than half of the admittances as well as of the postoperative fatalities the main diagnosis was a benign disease. The surgical procedure was considered to be curative or beneficial in 72% of the patients. To improve the efficiency of surgical therapy in this age group higher priority should be given to elective operations in order to avoid emergency interventions.

Persistent duodenal obstruction secondary to pancreatitis. Report of two cases.

Two male alcoholics with persistent duodenal obstruction due to relapsing acute pancreatitis are reported. Both patients were operated upon with gastrojejunostomy. One of the patients had a transient obstruction of the colon at the left flexure. The gut impairment has been followed roentgenologically and by gastroduodenoscopy. The literature concerning intestinal obstruction caused by pancreatitis is reviewed.

Lower-extremity ischemia in aortic dissection. Report of three cases.

Reports are presented of three hypertensive men with aortic dissection and signs of peripheral (leg) ischemia. The dissection was of type III b in two cases and type I in one case. Hypotensive medication was given in all cases, but in two of them peripheral vascular surgery became necessary to re-establish the circulation, while in the third case the hypotensive treatment sufficed for improvement of the leg circulation. Collaboration between thoracic and vascular surgeons can be of value in cases of aortic dissection with peripheral ischemia.

The effect of antral distension in healthy subjects on betazole-stimulated gastric acid secretion and the plasma concentration of immunoreactive neurotensin.

Antral distension in seven healthy subjects had the same inhibitory effect, approximately 20% inhibition, on gastric acid secretion stimulated by pentagastrin and betazole (Histalog). The plasma concentration of neurotensin in peripheral venous blood was unchanged during antral distension in healthy subjects. The plasma concentration of neurotensin in portal blood was also unchanged during antral distension in anaesthetized duodenal ulcer patients and in non-ulcer patients. The inhibition of pentagastrin-stimulated gastric acid secretion by balloon distension of the antrum was unchanged by preceding intramuscular injection of metoclopramide. The inhibitory effect of antral distension on gastric acid secretion in healthy subjects does not seem to be mediated by secretin, cholecystokinin, bulbogastrone, neurotensin, or a dopaminergic mechanism.

Gastric bile acids before and after Roux-en-Y transposition for bile reflux gastritis and in asymptomatic controls.

Eight patients with severe postgastrectomy syndromes for predominantly bile reflux gastritis were examined by quantification of bile acids in the gastric remnant before and after a standardized liquid meal. Gastroscopy with biopsy and determination of gastric acid secretion and gastric emptying were performed. Six of the patients were also studied 3 months after Roux-en-Y transposition. Controls consisted of six completely asymptomatic partially gastrectomized patients studied 4--11 years postoperatively and six healthy students without any history of gastrointestinal disease. The healthy subjects had virtually no reflux of bile acids in the fasting state or after a meal. Both the symptomatic and asymptomatic patients had reflux in the fasting state and postprandially. The reflux of bile acids was, however, significantly greater late in the fasting period and early in the postprandial period in the symptomatic patients than in those without symptoms. The Roux-en-Y transposition eliminated the bile acid reflux and the symptoms of bile reflux gastritis but did not change the gastric emptying pattern. In patients with reflux gastritis the acid disappearance in the gastric remnant was moderate and the maximal acid output was unchanged after Roux-en-Y transposition.

Evidence for a defective inhibition of pentagastrin-stimulated gastric acid secretion by antral distension in the duodenal ulcer patient.

Graded antrum distension by 50-, 100-, and 150-ml balloon volumes significantly stimulated gastric acid secretion in 6 duodenal ulcer patients, but had no stimulatory effect in 6 healthy subjects. Antrum distension by 150-ml balloon volume had no effect on the acid response to submaximal stimulation by a continuous intravenous infusion of pentagastrin in the duodenal ulcer patients, but significantly inhibited this response in the healthy subjects. The inhibition by antrum distension in the healthy subjects amounted to 20%. The results suggest that antrum distension elicits stimulatory as well as inhibitory mechanisms in man with inhibition of acid secretion predominating in healthy subjects and stimulation of acid secretion predominating in duodenal ulcer patients. The mechanism of inhibition is unknown.

Rupture of renal arterial aneurysm in pregnancy. Case report.

The case is described of a patient at term of her second pregnancy with spontaneous rupture of a renal arterial aneurysm, successfully delivered by caesarean section with primary repair of the renal artery. Sixteen cases have previously been reported, but only one was dealt with in a similar way. The literature is reviewed and the aetiology of pregnancy-related arterial aneurysm is discussed.

Hemodynamic findings before and after resection of abdominal aortic aneurysm.

A preoperative and postoperative hemodynamic study was performed in 20 consecutive patients undergoing elective resection of abdominal aortic aneurysm. Screening for venous thrombosis and pulmonary embolism with 125I uptake test, measurements of maximal venous emptying and pulmonary perfusion scintigraphy were also done before and after the operation. Only five patients complained of intermittent claudication preoperatively, but the laboratory investigations revealed signs of peripheral arterial insufficiency in 15 cases. Maximal venous emptying from the legs was markedly decreased on the first postoperative day and remained significantly below normal on the sixth day. Signs of postoperative thromboembolism appeared in eight patients. These patients did not differ from the others in regard to the pattern of maximal venous emptying. In the three-year follow-up period, the calf blood flow and the ratio of systolic toe pressure to systemic systolic blood pressure were further decreased, despite significant rise in systemic blood pressure.

A study of the effect of antral distension on gastric acid secretion in man.

In 30 healthy subjects distension of the antrum by a 150-cm3 balloon reduced the acid and volume responses to submaximal stimulation achieved by a continuous intravenous infusion of pentagastrin. The inhibition persisted during perfusion of the stomach with alkaline buffer. The plasma somatostatin concentration did not increase during distension and no somatostatin was detected in the gastric contents. Balloon distension of the antrum during laparotomy did not affect the concentration of somatostatin and gastrin in portal blood in patients with gallbladder disease or duodenal ulcer. The results confirm that antral distension stimulates acid secretion in duodenal ulcer patients without involvement of the gastrin mechanism. Moreover, the inhibition of acid secretion by antral distension in healthy subjects is independent of luminal pH and does not appear to be mediated by somatostatin.

The effect of antral distension on the endocrine pancreas in man.

Isolated antral distension by a 150 cm3 balloon in man significantly elevated the plasma concentrations of pancreatic polypeptide and glucagon in portal venous blood. The concentrations of plasma pancreatic glucagon, plasma insulin, and plasma glucose were unchanged in peripheral venous blood during antral distension with or without a background infusion of pentagastrin. Antral distension significantly increased the plasma concentration of pancreatic polypeptide in peripheral venous blood. Antral distension also inhibited basal and pentagastrin-stimulated gastric acid secretion in healthy subjects. The release of pancreatic hormones evoked by antral distension cannot explain the concomitant inhibition of gastric acid secretion. The results support and extend the concept of a gastro-pancreatic reflex to the endocrine part of the pancreas with release of at least pancreatic polypeptide and glucagon.

Vagovagal stimulation of pancreatic-polypeptide secretion by graded distention of the gastric fundus and antrum in man.

Previous studies have shown that pancreatic polypeptide (PP) secretion is regulated by efferent, vagal stimulation. In the present study the afferent part of a vagovagal pathway has been investigated in two different ways: (I) Graded fundic distention: in 8 patients with duodenal ulcer ballon distention with 150 ml of the fundus and the body of the stomach increased PP concentrations in plasma from 19 (17--26) to 41 (35--48) pmol/l, median and interquartile range. Distention by 300 and 600 ml did not further increase PP concentrations. After denervation of the fundus by proximal gastric vagotomy, no increase in PP levels was observed during distention with 50 and 300 ml whereas distention by 600 ml was followed by a small increase. (II) Graded antral distention: balloon distention with 50, 100 and 150 ml of the antrum increased plasma PP concentrations in 7 healthy subjects and 14 duodenal ulcer patients. Maximal PP response was achieved by distention with 100 ml, healthy subjects: from 14 (12--23) to 40 (26--44) pmol/l, and duodenal ulcer patients: from 25 (13--38) to 47 (22--63) pmol/l, median and interquartile range. It is concluded that a gastropancreatic reflex stimulating PP secretion through a long vagovagal pathway is present in man, and that this mechanism probably is involved in the initial PP response during a meal.

Peptic ulcer disease in older age groups in Gothenburg in 1985: the association with smoking.

The prevalences of peptic ulcer and smoking were assessed by a questionnaire sent to 6726 residents of Gothenburg selected at random from the birth cohorts 1945, -35, -25, -15, and -05. The point prevalence of peptic ulcer was in all age groups significantly higher among smokers than among non-smokers. The incidence of peptic ulcer in 1985 was deduced from records of ulcers detected at gastroscopy and/or radiography and/or emergency surgery (n = 1402). Smoking habits and previous episodes of peptic ulcer disease were evaluated. The estimated risk of getting peptic ulcer was significantly higher among smokers in all age groups and of both sexes than among non-smokers. Among non-smokers the risk of getting peptic ulcer was significantly higher in men than in women, whereas the risk among smokers showed no sex difference. In people aged 35-84 years, 25.4% (n = 101) of ulcers diagnosed for the first time and 42.0% (n = 246) of relapsing ulcers were estimated to be caused by smoking. The number of smoking years, however, could not be shown to influence the risk of peptic ulcer.

The effects of beta-adrenergic receptor blockade on the inhibition of gastric acid secretion, and the release of pancreatic polypeptide by antral distension in healthy subjects.

In a randomized double-blind study of seven healthy subjects an intravenous injection of metoprolol and propranolol did not change the submaximal gastric acid response to pentagastrin. The inhibition of pentagastrin-stimulated acid secretion by balloon distension of the antrum was unchanged by a preceding intravenous injection of metoprolol or propranolol. The plasma level of pancreatic polypeptide in peripheral venous blood showed a significant rise during antral distension. This rise was unaltered by a preceding injection of metoprolol and slightly depressed by propranolol. We conclude that the inhibitory effect of antral distension on gastric acid secretion in healthy subjects is not mediated by beta 1 or beta 2-adrenergic mechanisms. The reflex release of pancreatic polypeptide by antral distension may possibly involve a weak beta 2-adrenergic component.

Mixed endocrine gastric tumors associated with hypergastrinemia of antral origin.

A patient with atrophic gastritis and excessively raised serum gastrin concentrations (4000 to 5000 pg/ml) was found to have multiple polypous tumors of the gastric corpus mucosa. Following gastrectomy, serum gastrin concentrations decreased to undetectable levels. The tumors consisted of a mixed population of endocrine cells. The majority of tumor cells were of the ECL type, but, in addition, enterochromaffin cells of various subtypes as well as agranular cells were found. The tumors were locally invasive and invaded the walls of submucosal blood vessels. The surrounding mucosa showed a severe atrophic gastritis with intestinalization and contained numerous goblet cells, enterochromaffin cells, and cholecystokinin cells. Cholecystokinin cells do not occur in the normal oxyntic mucosa. Hence, the observation of this cell type in intestinalized gastric epithelium suggests that "intestinalization also is associated with changes in endocrine cell populations. Gastrin has been shown to affect the function of the ECL cells. Indications for a trophic action of gastrin on these cells have been obtained. It is discussed whether greatly raised serum gastrin levels in patients with atrophic gastritis may be associated with increased risks for the development of certain types of gastric tumors.

Osteoporosis, metabolic aberrations, and increased risk for vertebral fractures after partial gastrectomy.

A case-control study compared 129 men with earlier partial gastrectomy (operation during the period 1952-1961) with 216 men from a community-based population study. All were born 1910-1915 and the mean age was 72 years. Men with a previous partial gastrectomy had vertebral fractures in 19% compared with 4% (P < 0.01) in the control population. Bone mineral density (BMD) in the right calcaneus measured with dual energy photon absorptiometry was 20% lower in men with a Billroth II operation (P < 0.001) and 8% lower with a Billroth I operation (ns). In comparison with the controls, the men subjected to partial gastrectomy had higher serum concentrations of osteocalcin and alkaline phosphatase activity, a lower serum concentration of 25-hydroxyvitamin D (25OHD) and a lower body mass index (BMI). There were no difference in serum concentrations of free calcium, intact parathyroid hormone (PTH), or free thyroxine. The smoking prevalence was significantly higher in men with partial gastrectomy than in controls. Smokers had significantly lower serum concentrations of intact PTH and 25OHD than nonsmokers and also lower BMD and BMI. The relationships between intact PTH on one hand, and ionized calcium (inverse relationship) and osteocalcin (direct relationship) on the other were preserved in smokers, however. Gastroscopy was performed in 78 men with multiple biopsies in the gastric remnant and also in the small intestine. All but two subjects had chronic gastritis. Examination of sternal bone marrow smears showed that 40% of the Billroth-operated men lacked bone marrow reticular iron.(ABSTRACT TRUNCATED AT 250 WORDS)