Occurrence of a cohort phenomenon in peptic ulcer mortality from Switzerland

The present study was undertaken to examine whether the cohort phenomenon of peptic ulcer mortality is unique to the British population or whether it is a common feature of peptic ulcer disease. The occurrence of a cohort phenomenon was also found in data on peptic ulcer mortality from Switzerland. Swiss birth-cohorts born around 1870 and 1900 had been exposed to a maximum risk of dying of gastric and duodenal ulcer, and they carried this risk throughout their lives. By the time lag between both ulcer types, a common early determinant precipitating both diseases is made unlikely. The British cohort phenomenon was thought to result from high-risk birth-cohorts suffering mostly from the early phase of urbanization, World War I, and world economic crisis. This explanation, however, does not pertain to the high-risk cohorts from Switzerland. The nature of the determinants of peptic ulcer that occur early in the life of a cohort remains unknown.

The effect of mental stress induced by noise on gastric acid secretion and mucosal blood flow

Mental stress is thought to promote the development of peptic ulcer. In the present study the effect of mental stress induced by noise on gastric acid secretion and mucosal blood flow was studied. A 90 dBA broad frequency noise applied by headphones increased diastolic and systolic blood pressure by 4 and 8 mmHg, but left acid secretion and mucosal blood flow unchanged.

[Intravenous infusions of fat emulsions containing medium and long-chain triglycerides have no effect on basal and secretin stimulated pancreatic secretion in man]

The effect of an intravenous infusion of a 10% fat solution containing 50 g/l medium chain triglycerides (MCT) and 50 g/l long chain triglycerides (LCT) on exocrine pancreatic secretion was studied in 18 healthy volunteers. Each subject was studied twice on separate days. In period I 0.9% NaCl was given intravenously on both days. In the following period II either a 10% solution of MCT-fat or 0.9% NaCl were given intravenously in a randomized order at a rate of 100 ml/h. Periods I and II lasted 150 minutes each. Throughout the experiment pancreatic secretion was stimulated by saline, 0.1 U/kg/h secretin, or 0.25 U/kg/h secretin in 6 subjects each. In period II, MCT/LCT infusions did not influence pancreatic outputs of volume, bicarbonate and enzymes when compared to the NaCl infusion in the control experiment irrespective of the type of stimulation. Therefore, intravenous infusions of MCT may be used in clinical situations where the pancreas should be kept at full rest.

Cohort and period effects in peptic ulcer mortality from Japan

Japan's death rate from gastric ulcer is far higher than that in any other country. The time pattern of peptic ulcer mortality between 1937 and 1980 was analysed in order to find out whether gastric ulcer in Japan, compared with Europe, shows other epidemiologic features which may indicate a different type of gastric ulcer disease. The age-adjusted death rates of both ulcer types and sexes have continuously decreased. In spite of the much higher death rates in the years 1937-80, the mortality of gastric ulcer shows a similar cohort phenomenon both in Japan and in Europe. The Japanese generations born in the last quarter of the 19th century ran the highest risk of dying from peptic ulcer and carried it throughout their lives. The cohorts with a high risk for duodenal ulcer lag 10 yr behind those with a high risk for gastric ulcer. Male and female cohorts with the highest risk were born at the same time. The cohort effects of both ulcer types are superimposed by period effects. The most obvious period effect during 1946-50 is seen in the short-timed increase of the death rates in all age groups, both sexes, and both ulcer types. The similarities between Japan and Europe suggest that worldwide, at the same time, the same environmental factors have precipitated the risk of dying from gastric and duodenal ulcer.

The influence of smoking and intravenous nicotine on gastric mucus

Smoking predisposes to peptic ulcer. Bound N-acetylneuraminic acid (NANA) is an essential constituent of mucus. In order to examine whether smoking changes gastric mucus secretion, the concentration of N-acetylneuraminic acid was measured in the gastric juice of 10 non-smokers and 10 smokers. Gastric juice was aspirated during intravenous infusion of 0.67 microgram/kg/hr pentagastrin given alone or together with 5 micrograms/kg/hr nicotine. Instead of intravenous nicotine, the 10 smokers smoked 5 cigarettes over a period of 2 hours. In the fasting gastric juice and during infusion of pentagastrin the gastric concentration and output of bound N-acetylneuraminic acid were similar in smokers and in non-smokers. Acute nicotine administered intravenously or by smoking left gastric output of bound N-acetylneuraminic acid unaffected. It is concluded that neither chronic nor acute consumption of nicotine affects gastric turnover or adherence of mucus to the mucosa.

Sonographic measurements of the normal liver, spleen, pancreas, and portal vein

Normal values and upper limits (95th percentile) of liver, spleen, pancreas, and portal vein size were determined prospectively with ultrasound in 915 healthy subjects. Sex, age, weight, height, and body surface area were determined in each case. Since correlation of longitudinal and transverse organ diameters with physical data was poor (r less than or equal to 0.3), the authors do not consider it necessary to correct the measurements accordingly. However, the liver is oriented longitudinally in slender subjects and transversely in heavy subjects; thus both longitudinal and anteroposterior diameters need to be measured, since the longitudinal diameter alone will give too high or too low a value, respectively.

Changing mortality of peptic ulcer disease in Germany

This study examines mortality of gastric ulcer and duodenal ulcer in the Federal Republic of Germany during the period 1952-1980. The data originate from tabulations of the German Federal Office of Statistics. In women, mortality due to gastric and duodenal ulcer increased; in men, duodenal ulcer mortality remained constant and gastric ulcer mortality declined. Overall mortality of peptic ulcer declined from 7.0 to 6.0 deaths per 100,000 inhabitants and year. Since 1952, the average age at death has increased for both ulcer types and sexes. This was due to an increase of mortality in the older age groups; in men, mortality concomitantly decreased in the younger age groups. Women died of peptic ulcer older than men. In the 1950s none but the group of women gastric ulcer patients died as old as the nonulcer subjects, all other groups of peptide ulcer (female duodenal ulcer, male gastric ulcer and duodenal ulcer) died younger than the nonulcer subjects. In more recent years, both male and female gastric ulcer and duodenal ulcer patients died at the same age or even older than nonulcer subjects. It is concluded that peptic ulcer has changed from a lethal disease of the mid- and old-age groups to a lethal disease predominantly in the old- and very-old-age groups. The time-course of peptic ulcer mortality is different in the Federal Republic of Germany from what has been described in other Western States, especially in the United States and England. This difference suggests that, similar to healing, mortality of peptic ulcer is characterized by geographic variations, and that the time-course observed in one country does not necessarily hold true for other countries.

Novel approach to quantify duodenogastric reflux in healthy volunteers and in patients with type I gastric ulcer

A new method is described which allows simultaneous measurement of gastric emptying and duodenogastric reflux and avoids transpyloric intubation. After intragastric instillation of a liquid lipid meal in six healthy volunteers the fractional gastric emptying rate was 2.9 +/- 0.3 in the upright and 2.5 +/- 0.6 SEM X 10(-2)/min in the supine position, respectively (p greater than 0.5). The duodenogastric reflux rate (expressed as fraction of the intraduodenal amount of duodenal marker) was 0.30 (range 0.03-0.81) and 0.22 (0.01-0.55) X 10(-2)/min, respectively (p greater than 0.2). Atropine (40 micrograms/kg) decreased the supine gastric emptying rate to 1.1 +/- 0.2 (p less than 0.05) and increased the supine duodenogastric reflux rate to 2.74 (0.04-9.80) X 10(-2)/min (p less than 0.05). Fasting duodenogastric reflux rate was similar in the supine and upright position, 0.49 (0.04-0.89) and 0.42 (0.06-0.97) X 10(-2)/min, respectively (p greater than 0.5). Fractional gastric emptying rate was similar in 10 volunteers and 17 patients with type I gastric ulcer (2.1 +/- 0.4 vs 1.7 +/- 0.2 SEM X 10(-2)/min, p greater than 0.2). Their duodenogastric reflux rates were also similar, 0.65 (0.01-5.24) vs 1.10 (0.01-10.83) X 10(-2)/min (p greater than 0.5). We conclude therefore that (1) gastric emptying and both fasting and postprandial duodenogastric reflux are independent of the posture; (2) fasting and postprandial reflux are of similar magnitude; (3) atropine shows gastric emptying and increases duodenogastric reflux; and (4) patients with type I gastric ulcer have neither slowed gastric emptying nor increased duodenogastric reflux.

[Preoperative diagnosis of intra-abdominal diseases. Reliability of sonography and computer tomography]

In a retrospective study the reliability of ultrasound and computed tomography was compared and evaluated using the subsequent intraoperative findings. The analysis comprised ultrasound and computed tomography data of 111 consecutive patients in whom both investigations were performed within one week and whose diagnoses could be ascertained intraoperatively within two weeks. The correct diagnosis was made preoperatively in 80 out of 111 patients by ultrasound (sensitivity 72%) and in 95 out of 111 patients by computed tomography (sensitivity 85%). The results show that computed tomography is superior to ultrasound in preoperative diagnosis of intraabdominal diseases (P less than 0.025). In particular, liver and adrenal tumours and diseases of the air-filled gastrointestinal tract can be diagnosed more reliably preoperatively by computed tomography than by ultrasound.

[Coincidence of peptic lesions in the upper gastrointestinal tract]

In 3935 patients who underwent upper fiberpanendoscopy in two Zurich hospitals the coincidence of different active peptide lesions has been investigated. There was an association of reflux esophagitis and duodenal ulcer in old age: in patients with reflux esophagitis aged over 60 years, duodenal ulcer was found twice as often as in elderly patients without esophagitis. No association of reflux esophagitis and gastric ulcer or of gastric ulcer and duodenal ulcer was observed.

Tumor promoter binding to rat mammary cell cultures: role of receptors in the inhibition of dome formation

We have studied the receptors for phorbol ester tumor promoters in a set of cultures of mammary cell lines derived from the same dimethylbenz(a)anthracene-induced tumor. These lines differ in cell morphology and in the ability to form domes either spontaneously or under the action of inducers. Tumor promoters inhibit dome formation. We asked whether receptors for tumor promoters could also mediate dome induction. We were unable to detect high-affinity receptors for the strong promoter, tetradecanoyl-12-phorbol-13-acetate (TPA) but could reveal receptors for the weaker promoter, phorbol-12, 13-dibutyrate (PDBU). Receptors were easily demonstrable during PDBU binding at 4 degrees; at 37 degrees, there was rapid disappearance of bound ligand, accompanied by its breakdown. Most cell lines have two classes of receptors with different affinities. Receptors for TPA could be demonstrated by competition with PDBU binding. In LA7 cells, prolonged exposure to PDBU caused down-regulation of the PDBU receptors with lower affinity. The half-effective doses of the dome-inhibiting effects are comparable to the KdS of the higher-affinity PDBU receptors measured by binding. TPA binds preferentially to the same class of receptors. This class of receptors, therefore, appears to be the one mostly involved in the anti-dome effect of either PDBU or TPA. Because dome inducers do not compete with PDBU binding, the PDBU receptors may not be responsible for dome induction.

Where have peptic lesions gone?

The endoscopic diagnoses of the GI unit of a hospital department and of the private practice of a gastroenterologist were compared in a prospective study. Peptic lesions were found twice as often during endoscopy of GI outpatients than of GI inpatients. The results suggest that nowadays diagnosis and treatment of peptic lesions are largely a domain of private practice.

Somatostatin reduces gastric mucosal blood flow in normal subjects but not in patients with cirrhosis of the liver

The effects of 1 and 4 micrograms/kg/h somatostatin on pentagastrin-stimulated gastric mucosal blood flow and acid secretion were investigated in 12 normal subjects and in 12 patients with cirrhosis of the liver. Each dose of somatostatin was given intravenously to six normal subjects and to six patients. Gastric mucosal blood flow was measured by the neutral red clearance of the stomach. Pentagastrin at a dose of 0.67 micrograms/kg/h stimulated acid secretion less in patients with cirrhosis of the liver than in normal subjects. In normal subjects 1 micrograms/kg/h somatostatin induced a parallel decline of gastric mucosal blood flow and gastric secretion; with 4 micrograms/kg/h somatostatin mucosal blood flow was inhibited more than gastric secretion. In patients with cirrhosis of the liver gastric mucosal blood flow remained unaffected by both doses of somatostatin, while acid secretion was slightly decreased. It is concluded that somatostatin can affect gastric mucosal blood flow independently of acid secretion. Somatostatin may be ineffective in the treatment of gastric haemorrhage in patients with cirrhosis of the liver.

Extrahepatic bile ducts in healthy subjects, in patients with cholelithiasis, and in postcholecystectomy patients: a prospective ultrasonic study

To determine the average diameter and the upper normal limit of the common bile duct in healthy man, 830 blood donors were examined by ultrasound. The mean diameter was 2.5 +/- 1.1 mm (SD) at the porta hepatis and 2.8 +/- 1.2 mm (SD) at the widest point, the regression coefficient between both diameters being r = 0.84. None of the healthy subjects had a diameter larger than 7 mm at any site, and in 95% of all subjects the diameters were less than 4 mm at both sites of measurement. The diameters were significantly correlated with age (r = 0.16) and weight (r = 0.11), but not with sex, height, and body surface area. In 73 patients with cholelithiasis and in 55 patients after cholecystectomy, all of whom lacked clinical or laboratory signs of biliary obstruction, the average diameters at the porta hepatis were 3.8 +/- 2.0 mm and 5.2 +/- 2.3 mm, and at the widest point 4.8 +/- 2.2 mm and 6.2 +/- 2.5 mm, respectively. It is concluded that a common bile duct with any sonographic diameter larger than 4 mm should be followed closely and evaluated further with clinical examinations such as intravenous cholangiography unless cholecystectomy has been performed.

Salivary secretion in reflux esophagitis

It has been speculated that impaired salivary flow and contents contribute to abnormal acid clearance in patients with reflux esophagitis. To test this hypothesis, salivary secretion of volume, bicarbonate, and N-acetylneuraminic acid was measured in patients with reflux esophagitis, in age- and sex-matched controls, and in healthy young volunteers. Resting saliva was collected by permitting the saliva to drip into a flask every 30 s. Parotid saliva was collected by means of a Lashley capsule during stimulation by oral infusion of 1 ml/min of 2% citric acid. Total mixed saliva was collected by a dental sucker during esophageal perfusion with water and 10-mM hydrochloric acid. The volume of resting saliva and its concentration of bicarbonate were similar in the three groups. The concentration and the output of N-acetylneuraminic acid were higher in the young volunteers than in the two other groups. The volume flow and the composition of stimulated parotid saliva were similar in the three groups of subjects. Volume of total mixed saliva and concentration of bicarbonate and N-acetylneuraminic acid during esophageal perfusion with water were higher in patients with reflux esophagitis than in age- and sex-matched controls and were similar to the values found in young healthy volunteers. Acid perfusion increased the secreted volume of total mixed saliva by 150% and the concentration of bicarbonate by 30% in healthy young volunteers, but not in patients with reflux esophagitis and in the healthy age- and sex-matched controls; the concentration of N-acetylneuraminic acid was left unaffected by acid perfusion in all three groups. These findings disprove the hypothesis of impaired salivation in reflux esophagitis. The age-related loss of salivary response to acidic esophageal perfusion might be the reason why reflux esophagitis with peptic lesions affects predominantly elder people.

Detection of Crohn's disease by ultrasound

The target appearance of grey scale ultrasound is thought to be a characteristic sign of gastrointestinal wall thickening. It consists of a strong echogenic center surrounded by a sonolucent rim. In a prospective controlled study, the sensitivity and specificity of the ultrasonic B-scan for Crohn's disease were investigated. Fifty-one patients with Crohn's disease and 124 control subjects were studied. Sensitivity and specificity of the ultrasonic target appearance for Crohn's disease were 76% and 88%, respectively. When additional ultrasonic signs of inflammatory bowel disease were considered, sensitivity and specificity rose to 84% and 91%, respectively. Both colon and ileum were affected in 85% of the true-positive and in 8% of the false-negative targets. The Crohn's disease activity index was 213 +/- 136 in patients with true-positive targets and 167 +/- 118 in patients with false-negative target appearances. Most false-positive target phenomena arose from gastrointestinal tumors. It is concluded that ultrasound is a suitable complementary method for the detection of Crohn's disease.

Effect of liquid meals on duodenogastric reflux in humans

In humans duodenogastric reflux and gastric emptying were measured simultaneously by a two-marker technique that avoids transpyloric intubation. The duodenal marker consisted of 99mTc-labeled Hepatobida and was infused intravenously at a constant rate. Hepatobida was cleared almost exclusively by the liver and entered the duodenum at a constant rate via the bile. The gastric marker consisted of 51CrCl2 and was used to measure total intragastric volume by the double-sampling technique. Duodenogastric reflux occurred both after meals and under fasting conditions. Reflux rate was on the average 13 times smaller than emptying rate. It was higher with a lipid than with a protein meal and was independent of the rate of gastric emptying. The gastric concentration and total amount of duodenal contents were higher after lipid than protein meals. Since gastric emptying of a protein meal was faster than emptying of a lipid meal, the increased gastric concentration and accumulation of duodenal contents after lipid meals are due to a slowed gastric clearing and increased reflux of duodenal contents. Under fasting conditions, the reflux was lower and the gastric concentration of duodenal contents was higher than with both types of meals. Hence regurgitated duodenal contents may cause more damage to the gastric mucosa under fasting conditions than postprandially.

Duodenogastric reflux in the dog

Duodenogastric reflux, gastric emptying, and gastric secretion were measured simultaneously by a double-marker technique after instillation of a liquid lipid meal (300 ml Intralipid) or a protein meal (300 ml Bactopeptone) in five trained mongrel dogs. A lipid meal was emptied slower and elicited less volume secretion than a protein meal. Duodenogastric reflux rate and intragastric accumulation of duodenal contents were similar with both meals. Intravenous infusion of atropine slowed gastric emptying and inhibited gastric volume secretion only in the case of protein meal. Atropine increased duodenogastric reflux rate and gastric accumulation of duodenal contents with both protein and lipid meals. The percentage of duodenal contents inside the stomach increased continuously during gastric emptying; it did not exceed 20% with both meals given alone and 40% with both meals given together with atropine. It is concluded that duodenogastric reflux and gastric accumulation of duodenal contents are common phenomena during gastric digestion of a meal. The degree of such accumulation does not depend on the type of meal. Intragastric accumulation of duodenal contents is increased when duodenogastric reflux rate is stimulated and when gastric emptying rate is inhibited simultaneously.

Effect of nicotine on gastric mucosal blood flow and acid secretion

The effects of an intravenous infusion of nicotine at a dose of 2 . 5, 5 . 0, 7 . 5, or 10 . 0 micrograms kg-1h-1 on pentagastrin-stimulated gastric mucosal blood flow and acid secretion were investigated in eight healthy male non-smokers. Each dose was tested in two males. Gastric neutral red clearance served as a measure of mucosal blood flow. Nicotine reduced volume secretion, acid secretion, and neutral red clearance in a dose dependent manner. In five healthy male smokers smoking of five cigarettes per two hours induced similar changes to the intravenous infusion of 5 micrograms kg-1h-1 nicotine. As volume secretion was inhibited more than neutral red clearance, it is concluded that nicotine increases blood supply to the gastric mucosa relatively to the reduced gastric secretion. Nicotine is either not associated with the development of peptic ulcers, or it exerts its ulcerogenic action via other mechanisms than change of acid secretion and gastric mucosal blood flow.

Gastric emptying and postprandial duodenogastric reflux in dogs with Heineke-Mikulicz pyloroplasty

A two-marker technique avoiding transpyloric intubation was used to measure the volume of gastric secretion, the rate of gastric emptying and the degree of postprandial duodenogastric reflux in 8 dogs, 5 without and 3 with Heineke-Mikulicz pyloroplasties. The stomach emptied after a liquid fatty meal at an overall rate of 4.9 ml/min +/- 0.2 s.e.m. in animals with a normal pylorus and 5.7 +/- 0.2 ml/min in those with pyloroplasties (P less than 0.05). Though mean fractional emptying rates were similar, the fractional emptying rate was greater in animals with pyloroplasties than in those without in the first 10 and in the last 20 minutes. The rate of duodenogastric reflux was likewise greater in animals with pyloroplasties than in those without (1.8 +/- 0.2 ml/min and 0.7 +/- 0.2 ml/min respectively, P less than 0.05). The rates of gastric secretion did not differ materially (2.2 +/- 0.3 ml/min and 2.1 +/- 0.2 ml/min), but a greater proportion of the gastric contents was emptied more than once in animals with pyloroplasties than in those without (7.7 +/- 1.5 per cent and 2.3 +/- 1.0 per cent, P less than 0.05).

The cost of knowing the truth-limitations to a cost-benefit analysis of upper GI endoscopy

In a prospective series of 284 upper gastrointestinal (GI) endoscopies, outcome was evaluated by a cost-benefit analysis. Two-thirds of the endoscopies had a negative result, or a diagnosis was found which was not worth the costs of the endoscopy. The overall diagnostic gain of 284 endoscopies, however, outweighed the costs by a factor of three. Since at least one-third of the decision to endoscope are made for reasons other than seeking specific diagnosis, the applicability of a cost-benefit analysis to upper GI endoscopy is limited.

When is esophagitis healed? esophageal endoscopy, histology and function before and after cimetidine treatment

In order to assess whether in reflux esophagitis morphological and functional disorders persist after macroscopic healing, cimetidine was given for 6-12 weeks at a dose of 1.6 g/day to 30 patients with acid gastroesophageal reflux and esophagitis. The mucosal defects healed in 6 patients, improved in 14 patients, and remained unchanged in 10 patients. Lower esophageal sphincter pressure, acid clearance, acid perfusion test, and histological signs of mucosal inflammation were assessed before and after treatment. The histological and functional findings did not improve after healing of the mucosal defects. Therefore, endoscopic normalization in patients with reflux esophagitis is not associated with the disappearance of inflammation and abnormal motor function. The persistence of these abnormalities might explain the tendency of esophagitis to recur after symptomatic and endoscopic "healing."

[Expected costs in the conservative and surgical treatment of uncomplicated cholecystolithiasis]

Three therapeutic strategies are possible in a patient with asymptomatic or mildly symptomatic cholesterol gallstones: Cholecystectomy, medical gallstone dissolution, and expectant attitude. The course of cholelithiasis under these three strategies was evaluated by three decision trees. The incidences of possible complications were taken from the literature. For every complication the costs of drugs, absenteeism, treatment as outpatient and inpatient were listed. The costs multiplied by the likelihood of the complication represent the expected costs of the complication under consideration. The sum of the costs due to the initial treatment and the expected costs of all possible complications corresponds with the expected average costs of a therapeutic strategy. It is 21 000,- DM with medical gallstone dissolution, 25 000,- DM with immediate cholecystectomy, and 27 000,- DM with expectant attitude, respectively. Gallstone dissolution becomes more expensive than cholecystectomy only when its efficacy drops below 40%. The data show that the costs are less important for the choice of the therapy in cholelithiasis. The advantage of the decision tree lies in the fact that it describes the history and the costs of a disease by figures. Thereby, disagreement on the effects of a therapy on the course of the disease can be analysed and discussed more distinctly.

[A method to transmucosal transport in the human esophagus (author's transl)]

A modified 9-luminal manometric tube served to perfuse the esophagus with 3.2 mmolar hydrochloric acid containing 2% polyethylene glycol (PEG) and to aspirate the esophageal contents. The esophageal secretion was calculated from the PEG dilution in the aspirates. Neutral red injected intravenously reddened selectively gastric juice. Red esophageal aspirates were discarded., In 6 health subjects esophageal secretion was 1.0/+-0.2 ml/min after 1 hour perfusion. It contained 38 /+-11 mmol/l na+, 3.3/+-1.4 mmol/l K+, 27/+-6 mmol/l Cl-, and 50/+-13 mumol/l N-acetylneuraminic acid (NANA). Thus this method allows measurement of the barrier function of the esophageal mucosa.