Technique for pneumatic dilatation in achalasia complicated by "sigmoid" esophagus

The endoscopic passage of a guidewire to facilitate the placement of a pneumatic dilator is not widely practiced. We describe a patient with achalasia in whom marked "sigmoid" deformity of the distal esophagus prevented the placement of a dilator by the standard technique. Correct positioning was easily achieved by using a fiberoptic endoscope to pass a guidewire into the stomach. The pneumatic dilator with internal stiffener was attached to the guidewire and positioned fluoroscopically at the gastroesophageal junction. A clinically successful dilatation was then achieved.

Effect of domperidone, an extracerebral inhibitor of dopamine receptors, on thyrotropin, prolactin, renin, aldosterone, and 18-hydroxycorticosterone secretion in man

This study investigates the dopaminergic mechanisms involved in the control of corticosteroid secretion in normal subjects. TSH, PRL, PRA, aldosterone, and 18-hydroxycorticosterone (18-OHB) were measured before and after the administration of domperidone (10 mg, iv) to eight healthy males. Domperidone, a selective peripheral dopamine antagonist, stimulated TSH and PRL secretion. Plasma concentrations of aldosterone, 18-OHB, cortisol, and PRA were not altered by domperidone. This is in contrast to previous observations of aldosterone, 18-OHB, and PRA responses to metoclopramide, a dopamine antagonist which readily crosses the blood-brain barrier. Domperidone may fail to stimulate aldosterone, 18-OHB, and renin secretion because it does not cross the blood-brain barrier or does not function as an antagonist for adrenal dopamine receptors modulating 18-OHB and aldosterone secretion.

Interpretation of the Bernstein test: a reappraisal of criteria

We evaluated the esophageal acid infusion test (Bernstein test) in respect to the following questions: Does chest pain predictably disappear after cessation of acid infusion, and what is the relation between esophageal intraluminal pH and the degree of chest pain relief? Forty patients with subjective and objective evidence of gastroesophageal acid reflux, in whom esophageal acid infusion had reproduced substernal burning in a mean time of 3.1 minutes +/- 0.8 SE, graded pain relief after stopping acid infusion when saline was being infused. Complete pain relief occurred in 47.5% of patients over a 20-minute period. In six patients, esophageal pH was monitored for 30 minutes after administration of saline, antacid, placebo-antacid, and no treatment for a positive acid infusion test. Esophageal pH returned to normal (greater than 4.0) at the same rate (from 5.0 to 8.3 minutes) among patients in the four treatment groups, whereas chest pain continued and esophageal pH did not correlate with pain relief. The grading of pain relief was similar among the treatment groups, except at the 5-minute period when antacids resulted in significantly better relief than no treatment.

Progression of cimetidine-treated reflux esophagitis to a Barrett's stricture

A patient is described who developed a peptic stricture of the esophagus associated with Barrett's epithelium while receiving continuous cimetidine therapy. At this time, the role of cimetidine in the treatment of gastroesophageal reflux is evolving and, although it may provide symptomatic relief on some occasions, this report suggests that its role in improving the histological changes related to esophagitis or influencing complications of this disease has not been clarified.

Mechanism of histamine-induced excitation of the cat pylorus

Intravenous histamine causes high amplitude repetitive phasic contractions of the in vivo cat pylorus but has little effect on the antrum and duodenum. The genesis of this phasic response was studied using a pinned perfused catheter with openings at the pylorus, antrum, and duodenum. 2-Pyridylethylamine, an H1 agonist, produced phasic contractions similar to histamine whereas dimaprit, an H2 agonist, did not. Conversely, histamine-induced excitation is competitively antagonized by the H1 inhibitor diphenhydramine but not by the H2 inhibitor cimetidine. Thus histamine excitation is mediated through H1 receptor stimulation. Tetrodotoxin caused inhibition of the histamine response indicating that pyloric excitation is partly mediated through a neural pathway. To identify the nature of this pathway adrenergic and cholinergic blockers were used. Atropine, hexamethonium, and propranolol had no effect on the histamine response. Phentolamine and reserpine increased the magnitude of the histamine response. Conversely, phenylephrine blocked the histamine response. We conclude: histamine induces high phasic contractions in the pylorus; this effect is mediated through neural (nonadrenergic noncholinergic) and myogenic H1 receptors; alpha adrenergic stimulation inhibits the histamine response and alpha adrenergic blockade and catecholamine depletion increase it.

Diminished visualization of renal outlines in adult renal polycystic disease

Nephrotomographic and angiographic features of adult polycystic kidney disease (Potter type 3) are well documented, although comments on plain film findings are scant. In 34 patients with adult polycystic kidney disease, we found non-visualization of 75% or more of the renal outlines on the abdominal plain film. This finding should raise the possibility of underlying polycystic disease.

Esophageal disease in patients with angina-like chest pain

To assess the frequency of esophageal disease in patients with angina-like chest pain and normal coronary arteriograms, 16 patients underwent esophageal manometric studies, acid perfusion (Bernstein) tests, upper gastrointestinal series and cholecystograms. Five patients had evidence of esophageal diseases. Three of the five had manometric criteria of increased nonperistalsis; one patient had idiopathic diffuse esophageal spasm while the other two patients had acid infusion tests which reproduced the presenting chest pain and the manometric findings were regarded as a motor disturbance of the esophagus secondary to chronic gastroesophageal reflux. The remaining two patients had symptomatic gastroesophageal reflux--one with an acid infusion test positive for pressure like chest pain and the other with a decreased resting lower esophageal sphincter pressure associated with reflux of barium on upper gastrointestinal series. All five patients had improvement of symptoms during a follow up period of seven to 17 months. Manometric studies in 18 normal subjects of similar age revealed no evidence of esophageal disease. Since esophageal disorders capable of causing chest pain were diagnosed in one-third of the patients (5/16 or 31%), it is suggested that investigations for esophageal disease, specifically directed at gastroesophageal reflux-induced abnormalities and idiopathic diffuse esophageal spasm, be included in the evaluation of patients with angina-like chest pain of uncertain origin.

Tonic dopaminergic suppression of plasma aldosterone

To investigate the interaction between dopamine and aldosterone in man, either the dopamine antagonist, metoclopramide [methoxy-2-chloro-5-procainamide (M)], or a placebo was given by an iv bolus in a random, double blind fashion to nine supine volunteers on a hospital diet (mean urinary sodium excretion, 135 +/- 17 vs. 145 +/- 26 meq/24 h; P = NS). After M (10 mg), plasma aldosterone (PA) rose from 6.4 +/- 1.1 to 14.0 +/- 2.2 (SEM) ng/dl (P less than 0.01) within 15 min. PRA, potassium, and cortisol were unchanged. PRL increased 10-fold, but individual increments in PA and PRL did not correlate significantly. Oral M (10 mg) produced a rise in PA in only two of five volunteers. To determine whether the increase in PA was due to the dopamine antagonist properties of M, the iv study was repeated in four of the volunteers during an ongoing dopamine infusion. The integrated incremental change in PA during the hour after M administration was markedly blunted (399 +/- 56 vs. 69 +/- 32 ng/dl.min; P less than 0.05), and the PRL response was totally abolished. Assuming no major effects of M on the MCR of aldosterone, these data suggest a tonic inhibitory influence of dopamine on aldosterone secretion.

Interaction of levodopa and metoclopramide on gastric emptying

Dopamine is postulated as an inhibitory neurotransmitter in the alimentary tract. The purposes of this study were to determine the effect of levodopa on the rate of gastric emptying in man and to investigate the interaction of levodopa and metoclopramide (a putative dopamine antagonist) on gastric emptying. On separate days, 7 normal male subjects received oral levodopa, 1,000 mg, and placebo in a randomized double-blind fashion 20 min before taking a mixed solid-liquid test meal labeled with 99mtechnetium(Tc)-diethylenetriamine pentaacetic acid. Gastric emptying was measured over 90 min by a gamma camera technique. At 90 min, the mean percent isotope remaining in the stomach after placebo, 54.7 +/- 5.0%, was less than after levodopa, 85.1 +/- 4.9% (p less than 0.01). Four of these normal subjects were studied further, and received levodopa, 1,000 mg, and metoclopramide, 10 mg, by intramuscular injection, 20 min before the same labeled test meal. In these 4 subjects, at 90 min, mean percent isotope remaining in the stomach after the combination of levodopa and metoclopramide, 48.5 +/- 2.2%, was less than after levodopa alone, 83.3 +/- 7.0% (p less than 0.05), and in the same range as mean percent after placebo, 47.3 +/- 3.6%. It is concluded that (1) levodopa inhibited gastric emptying of isotope in a mixed solid-liquid meal in normal subjects; (2) metoclopramide antagonized this effect returning gastric emptying to normal; and (3) the data suggest the possibility that dopaminergic receptors have an inhibitory effect on gastric emptying of the human stomach.

Clinical experience with flexible sigmoidoscopy in asymptomatic and symptomatic patients

The purpose of this study was to evaluate the diagnostic yield of flexible sigmoidoscopy when performed as a routine procedure in asymptomatic patients over the age of 40 being referred for a complete physical examination. The preliminary results of this ongoing program are presented together with the diagnostic yield in 408 patients with symptoms and signs suggestive of colorectal disease who were of similar age (56.6 vs. 56.5 years) and sex distribution (79 percent male) to the asymptomatic population, and who underwent flexible sigmoidoscopy as an indicated part of their evaluation. In the 122 asymptomatic patients, the mean distance examined by the procedure was 50.8 cm with the instrument being advanced beyond the optimal rigid sigmoidoscopy distance of 20 cm in 100 percent of patients. Adenomatous and hyperplastic polyps were identified in 16 patients, 13.1 percent, in the asymptomatic group, a similar percentage to the symptomatic population, 15.4 percent. Adenomatous polyps were diagnosed in 7.4 percent of the asymptomatic subjects and 9.1 percent of the symptomatic group. Colonic cancer was diagnosed in 0.8 percent of asymptomatic patients vs. 3.2 percent of the symptomatic group (p < 0.05). Seventy-seven percent of the neoplastic polyps detected in the asymptomatic patients and 60 percent in the symptomatic group were beyond 20 cm from the anus. Diverticulosis was diagnosed in a similar percentage of patients, 13.1 percent in the asymptomatic and 10.0 percent in the symptomatic group. No complications were encountered and the procedure was well tolerated without analgesia. It is concluded that: (1) in an asymptomatic population over the age of 40, flexible sigmoidoscopy, as a routine examination, results in a diagnostic yield not possible with rigid proctosigmoidoscopy and which approaches that observed in a symptomatic population of similar age; (2) for the internist trained in this procedure, flexible sigmoidoscopy has a future role in the detection of colorectal lesions and as an interval screening examination for premalignant lesions and colorectal cancer in asymptomatic and symptomatic patients.

The role of urethrography in urethral disease. Part I. Accurate radiological localization of the membranous urethra and distal sphincters in normal male subjects

Radiological localization of the membranous urethra requires visualization of the whole urethra with dynamic retrograde urethrography and voiding cystourethrography. These methods are described together with a critical analysis of other methods of urethrographic examination, that is static retrograde urethrography alone and voiding urethrography alone. The normal radiological landmarks allowing accurate localization of the membranous urethra are described and correlated with anatomical dissections from 9 autopsy specimens.

The role of urethrography in urethral disease. Part II. Indications for transphincter urethroplasty in patients with primary bulbous strictures

We herein outline the radiological and clinical criteria that will aid the surgeon in deciding whether transphincter urethroplasty is required in patients whose primary stricture is in the proximal bulbous urethra. Sinc proximal bulbous urethral strictures are common the urologist frequently is called upon to make this important decision. The criteria described herein will help him to do so and, thus, avoid urethroplasty failure because of proximal stenosis in the membranous urethra. The concept of paradoxical dilatation of the membranous urethra on voiding urethrography also is described. Paradoxical dilatation means that in the presence of a primary obstructive bulbous urethral stricture the membranous urethra, although containing significant scar tissue, is dilated on the voiding study because of the distal obstruction. Relief of the bulbous urethral stricture alone may result in rapid contraction and stenosis of the previously dilated membranous urethra.

Effect of gastrin heptadecapeptide (G17) on oesophageal contractions in patients with diffuse oesophageal spasm

An intravenous bolus of pentagastrin significantly increased the amplitude and duration of oesophageal body contractions in seven patients with diffuse oesophageal spasm (DES) when compared with five normal subjects (P greater than 0.05). In order to determine whether this stimulation also occurred at physiological gastrin concentrations, the effect of an intravenous infusion of gastrin heptadecapeptide (G17), 25 pmol/kg-h, on oesophageal contractions was studied in DES patients. G17 had no significant effect on the amplitude and duration of oesophageal contractions compared with a saline control. This dose of G17 was near the D50 for gastric acid secretion and produced a rise in serum gastrin concentration comparable with a meal. G17 infusions at doses of 100 and 200 pmol/kg-h increased the amplitude and duration of oesophageal contractions, but the corresponding serum gastrin concentrations were higher than postprandial levels. Thus, endogenous fluctuations in serum gastrin heptadecapeptide, alone, are unlikely to alter oesophageal contractions in DES patients.

The adult male urethra: normal anatomy, pathology, and method of urethrography

Detailed knowledge of the normal anatomy of the urethra and adjacent structures is essential to an understanding of the normal radiologic landmarks on urethrography, and is prerequisite to the radiologic interpretation of the diseased urethra. The nature of fibrosis in the urethra must also be clearly understood, since radiologic interpretation of urethral scarring influences surgical management. No longer is it sufficient for the radiologist to delineate a tight structure in the urethra and leave the operative decision solely to clinical assessment. Dynamic retrograde urethrography allows the radiologist to direct the attention of the urologist to the membranous urethra and to the possibility that transsphincter urethroplasty may be required. While voiding urethrography is an integral part of the examination and may provide additional information, voiding urethrography without dynamic retrograde urethrography without dynamic retrograde urethrography may be misleading in that soft scarring of the urethra may be missed.

L-Dopa inhibits metoclopramide stimulation of the lower esophageal sphincter in man

Opossum lower esophageal sphincter smooth muscle contains inhibitory dopaminergic receptors. Since metoclopramide is a dopaminergic antagonist in many experimental situations, the present study was designed to investigate whether this mechanism could explain the lower esophageal sphincter (LES) stimulating action of metoclopramide in man. The interactions of (1) oral L-dopa, a dopamine precursor, and metoclopramide; and (2) L-dopa and the cholinergic agent, bethanechol, on lower esophageal sphincter pressure (LESP) in normal subjects were examined. Oral L-dopa significantly inhibited LESP response to either oral metoclopramide 20 mg (P less than 0.05), or intravenous metoclopramide 20 mg (P less than 0.05). In contrast, L-dopa did not inhibit the LESP response to subcutaneous bethanechol (0.07 mg/kg). Mean basal LESP measured 50 min after ingestion of 1000 mg L-dopa, 19.3 +/- 3.1 mm Hg, was significantly less than basal LESP after L-dopa placebo, 29.3 +/- 4 mm Hg (P less than 0.01). It is concluded that (1) L-dopa inhibited the metoclopramide-induced rise in LESP but not peak stimulation of LESP by bethanechol; (2) there is evidence for the possibility of LES dopaminergic inhibitory receptors in man; and (3) these data are consistent with the hypothesis that metoclopramide acts on the LES by blocking a dopaminergic pressure-lowering mechanism.

Effect of endogenous hyperprolactinemia on human lower esophagel sphincter pressure

The cause of gastroesophageal reflux occurring during pregnancy is not completely understood but may be related to changes in the hormonal environment specifically related to pregnancy. To evaluate the possible role of prolactin, one of the hormones elevated during pregnancy, we studied the effect of endogenously elevated serum prolactin concentrations, induced by I.V. thyrotropin-releasing hormone (TRH), on lower esophageal sphincter pressure (LESP) in normal subjects. Elevated prolactin concentrations (P less than 0.0001), did not change LESP over a 60-minute period. Serum gastrin concentration did not change significantly at any time during the study. We conclude: 1. acute elevations of serum prolactin comparable to the concentrations that occur during pregnancy did not change LESP; 2. there is no evidence that the hypothalamic regulating factor TRH affects serum gastrin concentration in man.