Barrett's esophagus, high-grade dysplasia, and early adenocarcinoma: a pathological study

OBJECTIVES

In Barrett's esophagus, early adenocarcinomas are often missed on endoscopic biopsy. We therefore examined the distribution and extent of dysplasia and carcinoma in the resected esophagus for comparison with the preoperative biopsy findings.

METHODS

Patients whose endoscopy showed Barrett's esophagus but no visible cancer had four-quadrant esophageal biopsies taken every 2 cm. After resection for high-grade dysplasia or early adenocarcinoma, the esophagus was mapped histologically.

RESULTS

Nineteen patients had surgery for high-grade dysplasia; two of them (10.5%) had adenocarcinoma in the resected esophagus. Eleven patients had resection after a biopsy diagnosis of adenocarcinoma or suspicion of adenocarcinoma. Esophagectomy mapping confirmed carcinoma in only five of them. Median surface areas were: total Barrett's esophagus 32 sq cm, low-grade dysplasia 13 sq cm, high-grade dysplasia 1.3 sq cm, adenocarcinoma (seven cases) 1.1 sq cm.

CONCLUSIONS

Areas of high-grade dysplasia and microscopic carcinoma in Barrett's esophagus are often small. Biopsy differentiation between these lesions is difficult. A systematic endoscopic biopsy protocol will reduce the chance of missing early malignancy in Barrett's esophagus.

Adenocarcinoma of the esophagogastric junction and Barrett's esophagus

BACKGROUND & AIMS

Barrett's esophagus is associated with adenocarcinoma of the esophagus. The aim of this study was to find the prevalence of Barrett's esophagus in patients with adenocarcinoma of the esophagogastric junction.

METHODS

Consecutive, freshly resected surgical esophagogastrectomy specimens were examined, and multiple histological sections were made around the tumor periphery. Barrett's esophagus was defined as specialized columnar epithelium above the esophagogastric junction. Tumors centered < or = 2 cm from the junction were defined as junction cancers.

RESULTS

Barrett's esophagus was found in 9 of 9 (100%) esophageal adenocarcinomas compared with 0 of 8 (0%) squamous carcinoma controls (P < 0.001). Ten of 24 (42%) junction adenocarcinomas had a Barrett's esophagus. A Barrett's esophagus was found in 8 of 12 (67%) junction cancers < or = 6 cm in length but only 2 of 12 (17%) larger tumors (P < 0.05). Barrett's esophagus was significantly associated with junction tumors < 6 cm compared with squamous carcinoma controls (P < 0.02). In 5 specimens with junction cancer, the length of Barrett's esophagus was < 3 cm, and in 5 specimens it was > or = 3 cm. Specialized epithelium was often found below the esophagogastric junction in controls.

CONCLUSIONS

Adenocarcinomas of the esophagogastric junction are associated with short and long segments of Barrett's esophagus. Larger cancers probably overgrow and conceal the underlying specialized columnar epithelium from which they arise.

Isolation and cloning of a protein-serine/threonine phosphatase from an archaeon

A divalent metal ion-stimulated protein-serine/threonine phosphatase, PP1-arch, was purified approximately 1,000-fold from the extreme acidothermophilic archaeon Sulfolobus solfataricus (ATCC 35091). Purified preparations contained 40 to 70% of total protein as PP1-arch, as determined by assay-ing sodium dodecyl sulfate-polyacrylamide gels for protein phosphatase activity. The first 25 amino acids of the protein's sequence were identified, as well as an internal sequence spanning some 20 amino acids. Using this information, we cloned the gene for PP1-arch via the application of PCR and conventional cloning techniques. The gene for PP1-arch predicted a protein of 293 amino acids that bore striking resemblance to the members of the major family of protein-serine/threonine phosphatases from members of the domain Eucarya, the PP1/2A/2B superfamily. The core of the protein, spanning residues 4 to 275, possessed 29 to 31% identity with these eucaryal protein phosphatases. Of the 42 residues found to be absolutely conserved among the known eucaryal members of the PP1/2A/2B superfamily, 33 were present in PP1-arch. If highly conservative substitutions are included, this total reached 37. The great degree of sequence conservation between molecules from two distinct phylogenetic domains implies that the members of this enzyme superfamily had evolved as specialized, dedicated protein phosphatases prior to the divergence of members of the Archaea and Eucarya from one another.

Endoscopic esophageal manometry

OBJECTIVE

We performed through-the-scope-manometry of the esophagus on 12 patients referred for esophageal symptoms.

METHODS

A 3-lumen polyvinyl tube was passed through the biopsy channel of a standard video-endoscope. All patients underwent esophagogastroduodenoscopy with through-the-scope-manometry as well as a conventional laboratory-based manometric study; the sequence of the procedures was randomized.

RESULTS

Mean lower esophageal sphincter pressure was 18 +/- 11 mm of mercury by both methods. In the lower esophagus, mean wave amplitude was 60 +/- 25 mm of mercury by through-the-scope manometry and 82 +/- 28 by laboratory testing. In the upper esophagus, mean wave amplitude was 50 +/- 26 mm of mercury by through-the-scope manometry and 63 +/- 20 by laboratory testing. Wave duration tended to be lower by through-the-scope manometry than by laboratory testing in the lower and upper esophagus. In nine patients with normal esophageal motility, 54% of swallows resulted in a peristaltic wave by the endoscopic study versus 100% for the laboratory test.

CONCLUSION

Through-the-scope-manometry was able to accurately measure lower esophageal sphincter pressure compared with laboratory-based manometry. Peristaltic wave amplitude by through-the-scope manometry was reduced compared with laboratory-based manometry, most likely because of the use of dry swallows. Through-the-scope-manometry has promise as a screening test for esophageal motility disorders.

Peptidergic and nitrinergic denervation in congenital esophageal stenosis

Congenital esophageal stenosis (CES) is a rare disorder with narrowed esophageal lumen that presents as dysphagia from childhood and that is often associated with tracheobronchial remnants or webs. The pathogenesis of CES is unknown. The aim of this study was to examine the histological and immunohistochemical features of CES. Esophagi from 2 young adults with CES and 3 controls with no motility disorders underwent routine H&E staining, trichrome staining for collagen, and detailed immunocytochemical studies for general neuronal markers (protein gene product 9.5, neuron-specific enolase, and S-100) and neurotransmitters (vasoactive intestinal polypeptide, substance P, and galanin) and nitric oxide synthase by beta-nicotinamide adenine dinucleotide phosphate (NADPH)-diaphorase and a specific NO synthase antibody. Quantitative experiments compared the numbers of myenteric neurons and amounts of fibers at the circular muscle. CES esophagi showed infiltration of neutrophils in the myenteric plane, without any increase in collagen. NADPH-diaphorase histochemistry showed a significant reduction of myenteric nitrinergic neurons (7 +/- 3.4 vs. 2.7 +/- 1.8 neurons per high-power field) and fibers at the circular muscle. Other peptidergic neurons studied were not significantly reduced in CES. The specific total lack of NO inhibitory innervation may be an important mechanism in the pathogenesis of stenosis and aperistalsis of the esophagus in this disorder.

Primary leiomyosarcoma of the liver mimicking liver abscess

Primary hepatic leiomyosarcoma is a rare tumor, with fewer than 60 previously reported cases. The usual clinical presentation is painful hepatomegaly or a painful epigastric mass. We present the case of a 64-yr-old white man who presented with fevers, drenching night sweats, fatigue, leukocytosis, an elevated erythrocyte sedimentation rate, and an indistinct mass in the right lobe of his liver on CT scan. Although the clinical presentation was suggestive of hepatic abscess, a percutaneous biopsy was consistent with a smooth muscle tumor. Successful right hepatic lobectomy resulted in resolution of all the associated symptoms and signs. A review of the world literature produced 44 papers reporting a total of 54 cases. The male:female ratio was 25:26; mean age was 53.6 yr. The tumor tended to occur at an earlier age in women, with a group mean age of 49.0 yr compared with 58.4 for men. It was more common in the right lobe. Metastatic disease was present in 40.9% of patients. The outcomes for various therapeutic approaches were compared. Patients treated with comfort measures alone had a mean survival or follow-up of 0.87 yr. The best outcome seemed to be in those patients treated with a combination of surgery and chemotherapy, with a mean survival or follow-up of 3.3 yr.

Gastroesophageal reflux and chronic cough: which comes first?

We evaluated the relationship between gastroesophageal (GE) reflux and chronic cough using prolonged pH monitoring and the standard acid reflux study in a retrospective case review. Ten patients were referred to our clinical esophageal laboratory for prolonged pH monitoring to determine whether GE reflux was the cause of chronic cough. In addition, we report one patient referred for a standard acid reflux test as a clear example of spontaneous cough inducing GE reflux. Of the 10 patients having prolonged pH monitoring, 182 of 221 (80.9 +/- 4.6%) of cough episodes had no correlation with GE reflux (p = 0.0001). Of those cough episodes that appeared to be related to GE reflux, 27 of 39 (69.2 +/- 11.7%) occurred before GE reflux and 12/39 (30.8 +/- 10.3%) occurred after GE reflux (p = 0.06). In the single patient GE reflux after spontaneous cough occurred five of seven times during a standard acid reflux test. In our series, cough and reflux were not related in the majority of episodes. Where there was a relationship, it appeared that the cough preceded GE reflux twice as often as reflux preceded cough. We conclude that GE reflux does not appear to be a frequent cause of chronic cough.

Achalasia: prospective evaluation of relationship between lower esophageal sphincter pressure, esophageal transit, and esophageal diameter and symptoms in response to pneumatic dilation

The aims of this study were to investigate a group of patients with achalasia prospectively to determine (1) the relationship between changes in symptoms and esophageal motor function in response to pneumatic dilation and (2) the effects of the balloon size as well as the frequency and duration of inflation on the outcome of treatment. Fourteen patients with achalasia who were symptomatic for a median duration of 27 months participated in the study. The patients were randomized to one combination of the following pneumatic dilation conditions: a 30- or 35-mm balloon dilator, one or two balloon inflations, and 20, 40, or 60 seconds per balloon inflation. A comprehensive assessment of their symptoms and esophageal motility, transit, and diameter were performed before and 3 months after pneumatic dilation. Pneumatic dilation provided significant relief of dysphagia (P < 0.01), but other symptoms (heartburn, regurgitation, and chest pain) remained unchanged. Pneumatic dilation also caused a significant decrease in lower esophageal sphincter pressure and esophageal diameter and improved esophageal emptying of a solid bolus. Nevertheless, no significant association was detected between changes in the symptom score for dysphagia and changes in objective response measures as a result of pneumatic dilation. Changes in the symptom score for dysphagia or objective responses were similar regardless of the size of the dilator used or the frequency and duration of the balloon inflations.(ABSTRACT TRUNCATED AT 250 WORDS)

Increasing incidence of adenocarcinoma of the esophagus and esophagogastric junction

BACKGROUND

The aim of this study was to determine whether the incidence of adenocarcinoma of the esophagus and esophagogastric junction in a well-defined population was higher than previously recognized.

METHODS

Clinical records and original histological slides from patients residing in Olmsted County, Minnesota, were reviewed and compared with a previous study in the same population.

RESULTS

The incidence of esophageal adenocarcinoma rose from 0.13 for 1935-1971 to 0.74 for 1974-1989, and the incidence of adenocarcinoma of the esophagogastric junction rose from 0.25 to 1.34 per 100,000 person-years. Histological review of preserved surgical specimens showed associated intestinal metaplasia (Barrett's esophagus) in 2 of 2 esophageal and in 5 of 9 esophagogastric adenocarcinomas.

CONCLUSIONS

The incidence of adenocarcinoma in each location increased five to sixfold compared with the earlier study. This increase could not be explained by improved diagnostic methods or classification changes. The association with Barrett's esophagus and the parallel increased incidence of cancer in each location is evidence that adenocarcinoma of the esophagus and of the esophagogastric junction are related disorders.

Barrett's esophagus: age, prevalence, and extent of columnar epithelium

The development of Barrett's esophagus was studied using data from 51,311 patients undergoing upper gastrointestinal endoscopy between 1976 and 1989. Three hundred seventy-seven patients had greater than or equal to 3-cm columnar epithelium in the esophagus and no carcinoma. The prevalence of Barrett's esophagus increased with age to reach a plateau by the seventh decade. Half of the maximum prevalence was reached by age 40 years, the estimated median age of development of the disorder. Unlike prevalence, the mean length of columnar epithelium did not increase with age. No significant change in length was found in 21 patients followed up for a mean of 7.3 years (mean initial length, 8.29 +/- 0.85 cm; mean final length, 8.33 +/- 0.77 cm). The length of columnar epithelium did not increase in the presence of esophagitis or decrease when esophagitis was absent. Mean age at diagnosis of Barrett's esophagus was 63 years without carcinoma and 64 years in a separate group of patients with adenocarcinoma. The data are consistent with a fairly rapid evolution of Barrett's esophagus to its full length with little subsequent change. Barrett's esophagus may develop more than 20 years before the mean age of clinical recognition or the development of esophageal adenocarcinoma.

Prevalence of columnar-lined (Barrett's) esophagus. Comparison of population-based clinical and autopsy findings

In this study, two different methods were used to investigate the prevalence of columnar-lined (Barrett's) esophagus. First, a population-based study of clinically diagnosed cases was performed in Olmsted County, Minnesota. Twenty-five residents of this county, who had undergone endoscopy and biopsy between 1969 and 1986, were diagnosed as having Barrett's esophagus. On January 1, 1987, 17 of these patients were still living in the county, representing an age- and sex-adjusted prevalence rate of 22.6 cases per 100,000 population (95% confidence interval, 11.7-33.6 cases). A prospective search of Mayo Clinic autopsy material for Barrett's esophagus was conducted using the same diagnostic criteria as in the clinical study. Over an 18-month period ending in September 1987, 7 cases of Barrett's esophagus were found in 733 unselected autopsies. In 5 of the 7 cases, Barrett's esophagus was first detected at the time of autopsy. Using the age- and sex-specific prevalence from the clinically diagnosed study, researchers expected to find 0.19 cases of Barrett's esophagus at the 226 autopsies performed on Olmsted County residents, although 4 were actually observed (P less than 0.001). This approximately 21-fold increase (95% confidence interval, 5-54 cases) corresponds to an autopsy estimated prevalence of 376 cases per 100,000 population (95% confidence interval, 95-967 cases). In conclusion, a majority of cases of Barrett's esophagus, a condition that predisposes to esophageal malignancy, remains unrecognized in the general population.

Campylobacter pylori and Barrett's esophagus

Campylobacter pylori is thought to be confined to gastric mucosa; when detected in the duodenum in association with duodenal ulceration, the organism infects only areas of gastric metaplasia. Barrett's esophagus is a metaplastic condition of the esophagus, in which areas or islands of "gastric-type" epithelium are found. To determine whether C. pylori colonized the esophagus of patients with Barrett's esophagus, we studied retrospectively 23 unselected patients who had endoscopic and biopsy evidence of Barrett's esophagus. Mucosal biopsy specimens were stained by the Warthin-Starry silver technique and reviewed by an experienced, "blinded" histopathologist. Of the 23 patients, 12 (52%) had C. pylori in the esophagus. Patients with and those without C. pylori were of similar age and gender, had similar scores for acute and chronic inflammation, and had similar lengths of tubular esophagus with metaplastic gastric mucosa. These observations suggest that C. pylori commonly infects Barrett's esophagus. The clinical importance of this finding is unknown.

An unusually intractable Schatzki ring

Most patients with Schatzki's ring have dysphagia that can be relieved by esophageal dilation. We report an unusual case in which dysphagia caused by a Schatzki ring could not be managed conservatively. The obstructing ring was excised through a gastrotomy approached by a left-sided thoracotomy. An antireflux procedure was done after elimination of the ring. Five years later, the patient remained symptom free.

Linear gastric erosion. A lesion associated with large diaphragmatic hernia and chronic blood loss anemia

A prospective study was undertaken to identify mucosal lesions that might cause chronic blood loss anemia in patients with large diaphragmatic hernia. Patients with one-third or more of the stomach above the diaphragm on barium x-ray were examined by a gastroscopist who was given no clinical information. A total of 109 patients were included: 55 with anemia and 54 with a large hernia but no anemia. The incidence of esophagitis and peptic ulcer did not differ significantly in the anemic and nonanemic groups. Linear gastric erosions were found on the crests of mucosal folds at or near the level of the diaphragm in 23 anemic patients and 13 without anemia (p less than 0.05). Blood on the surface of a linear erosion was found in 14 anemic patients and 4 without anemia (p less than 0.05). We suggest that these erosions are due to trauma and can cause chronic blood loss anemia in hernia patients.

The incidence of adenocarcinoma in columnar-lined (Barrett's) esophagus

We evaluated the risk of adenocarcinoma developing in Barrett's esophagus (esophagus lined with columnar epithelium). Mayo Clinic records were reviewed, and all cases that met predefined histologic criteria for the diagnosis of Barrett's esophagus in 1979 or earlier were included. In 18 of 122 such cases, adenocarcinoma of the esophagus and Barrett's esophagus were diagnosed simultaneously. The status of the remaining 104 cases was determined after a mean interval of 8.5 years. During this time, adenocarcinoma of the esophagus developed in 2 patients, and 24 died from other causes. We conclude that although the incidence of esophageal adenocarcinoma is increased in patients with symptomatic Barrett's esophagus, it does not occur in the majority of such patients.

Bacterial reduction of fensulfothion and its hydrolysis product 4-methylsulfinyl phenol

Oxygen-limited cultures of Klebsiella pneumoniae reduced 4-methylsulfinyl phenol to 4-methylthiophenol. A study of the effect of 4-methylthiophenol on the growth of K. pneumoniae revealed that the specific growth rate was retarded by 40% in the presence of 200 micrograms of the phenol per ml. A soil bacterium, Hafnia sp., was isolated that could reduce the organophosphorus insecticide fensulfothion to fensulfothion sulfide.

Surgical management for recurrent pharyngoesophageal (Zenker's) diverticulum

Recurrent pharyngoesophageal diverticulum is uncommon after a one-stage diverticulectomy. Among 888 operations at the Mayo Clinic, recurrence has been noted after only 32 (3.6%). The present report outlines our management during a 19-year period of 44 patients operated on previously, including management of various late complications seen in 13 patients after diverticulopexy and diverticulectomy performed at other institutions. The study then focuses on the results in 31 patients in whom reoperation for symptomatic recurrent diverticulum was performed at the Mayo Clinic during the same period. Although reoperation posed a technical challenge, there was only 1 operative death (3.2%). Surviving patients experienced highly satisfactory late results, with only two recurrences. Early surgical morbidity was considerably higher than for primary operations, but this did not interfere with most patients having excellent to good late results.

Abdominal angina and neurofibromatosis

A young man with severe abdominal pain and weight loss due to intestinal ischemia was examined. At operation, the origins of the celiac and superior mesenteric arteries were found to be compressed by plexiform neurofibromatosis. Symptoms were relieved by reconstructive arterial surgery.

Physiopathology of lower esophageal diverticulum and its implications for treatment

This study attempted to define the esophageal motor disturbances and pathogenesis of symptoms in patients with lower esophageal diverticulum. Sixty-five patients were investigated by manometry in addition to roentgenography and endoscopy. Fifty had manometric evidence of abnormal motility, most often diffuse spasm or achalasia. Of the 15 patients with normal esophageal motility, 13 had hiatal hernia, and five of these had a high grade distal esophageal stricture. Pressures in the lower esophagus and lower esophageal sphincter in patients with lower esophageal diverticulum and motor disturbance were the same as for those in matched patients with motor disturbances but no diverticulum. Dysphagia, chest pain and regurgitation were common presenting symptoms. Of 46 patients with dysphagia, only ten had mechanical obstruction to explain this symptom. Of 32 patients with chest pain, only two had ulceration in the diverticulum as a possible cause of pain. We conclude that the development of lower esophageal diverticulum and its symptoms are associated with a motor disturbance of the esophagus in the majority of patients and with an organic obstruction in the minority of patients. The diverticulum itself is usually not the sole cause of the esophageal symptoms, although diverticula can produce symptoms in the absence of other definable conditions. When surgical treatment is indicated, the diverticulum should be excised and the underlying motor or mechanical obstruction should be corrected to prevent serious postoperative complications and recurrence of the diverticulum and its symptoms.

Association of myocardial cell necrosis with experimental cardiac hypertrophy

Cardiac hypertrophy was induced in rabbits by injecting thyroxine or isoprenaline, or by surgically constricting the abdominal aorta. An increase in heart weight was associated with a change in the ratios of bound to free forms of five lysosomal enzymes, a change in serum creatine phosphokinase and lactate dehydrogenase, and a change in the morphology of the myocardial cells. Isoprenaline treatment for 5 days induced a maximal change in heart weight, in the ratio of lysosomal enzymes, and in the serum enzymes. Thyroxine treatment was required for 15 days before maximal changes in heart weight, ratio, and serum enzymes were observed. In contrast, coarctation of the aorta caused a progressive change in heart weight, in the ratio of lysosomal enzymes, and in serum enzymes. These results suggest that necrosis of the myocardial cells does indeed accompany cardiac hypertrophy. It was further observed that autophagosomes, degenerating mitochondria in the myocardial cells during the induction of cardiac hypertrophy, and myofibril lysis were found, all of which confirms the suggestion of myocardial cell necrosis in the experimentally enlarged heart.

Metabolism of lipids in experimental hypertrophic hearts of rabbits

Cardiac hypertrophy was induced in rabbits by subcutaneous injection of thyroxine or isoprenaline or by surgically constricting the abdominal aorta. Alterations in lipid metabolism were observed in these hypertrophic hearts. Thyroxine or isoprenaline treatment increased the fatty acids in the serum and stimulated a marked increase in total lipids, triglycerides, and fatty acids in the hypertrophied myocardium. Coarctation of the aorta, in contrast, induced a significant increase in these lipids without significantly affecting serum free fatty acids. Histochemical and morphological studies confirmed an increase in neutral lipids. It is suggested that the observed increase in fatty acids in the heart following thyroxine or isoprenaline treatment is related to the increase in serum free fatty acids, which is followed by an increase in the removal of serum fatty acids by the heart. However, the amount of serum fatty acids that is removed exceeds the amount that is oxidized, which leads to an increase in lipid stores. The increase in lipid stores in the heart following coarctation of the aorta probably corresponds to the decrease in myocardial concentrations of carnitine. Serum lipid levels following coarctation were not significantly different from those of controls.

Barrett's esophagus occurring as a complication of scleroderma

Two patients had both scleroderma and a columnar epithelium-lined lower esophagus (Barrett esophagus). Features of Barrett's esophagus included high esophageal strictures in both patients and ulcer craters in the columnar area of one. Biopsy confirmed columnar epithelium in the lower esophagus of each patient. In these patients, the Barrett esophagus probably was a complication of scleroderma and resulted from long-standing gastroesophageal reflux.

The relationship between fibrosis and lactate dehydrogenase isoenzymes in the experimental hypertrophic heart of rabbits

Cardiac hypertrophy was induced in rabbits by injecting either thyroxine or isoprenaline or by surgically constricting the abdominal aorta. An increase in heart weight was associated with a change in the lactate dehydrogenase isoenzyme pattern and an increase in fibrosis (as measured by hydroxyproline concentrations). Isoprenaline treatment led to a moderate increase in heart weight, a marked decrease in the heart/skeletal muscle subunit ratio of lactate dehydrogenase, and a marked increase in hydroxyproline. Thyroxine treatment led to a small increase in both heart weight and hydroxyproline and a small decrease in the heart/skeletal muscle subunit ration. Coarctation of the aorta, in contrast, caused a marked increase in heart weight, a moderate decrease in heart/skeletal muscle subunit ratio, and a moderate increase in hydroxyproline. These results suggest that the decrease in the heart/skeletal muscle subunit ratio of lactate dehydrogenase in the experimental hypertrophic heart reflects the extent of myocardial fibrosis, rather than changes within the hypertrophied myocardial cells.

The value of gastroscopy in clinical diagnosis: a computer-assisted study

The additional information obtained by gastroscopy in patients already examined by upper gastrointestinal roentgenography was assessed. For this purpose, a data sheet for computer analysis was filled in at the time of gastroscopy and again at patient dismissal. Overall, gastroscopy resulted in an altered diagnosis in 18 percent of 1, 368 examinations, and in another 7 percent of cases there were findings of possible clinical significance. Gastroscopic findings differed significantly from x-ray findings in 7 to 35 percent of cases, depending on the indication for the procedure.

Hepatotoxicity in acetaminophen poisoning

Evidence of severe liver damage was found in a young women who ingested an overdose of acetaminophen in a suicide attempt. Clinical features included prolonged nausea and vomiting and pain and tenderness over the liver. Biochemical findings included an SGOT value of over 3,000 and a prolonged prothrombin time, with normal alkaline phosphatase and near normal serum bilirubin. Spontaneous recovery was complete.

Lactate dehydrogenase isoenzymes in the human hypertrophic heart

Lactate dehydrogenase isoenzymes have been measured in human hearts at autopsy. As compared with normal hearts, hypertrophic hearts and ischaemic hypertrophic hearts showed a shift in the isoenzyme distribution. This shift appeared to be more closely associated with an increase in the relative proportion of fibrous tissue than with changes in the myocardial cells.

Incidence of iron deficiency anemia in patients with large diaphragmatic hernia. A controlled study

The incidence of anemia in 259 patients with a diaphragmatic hernia large enough to be seen on a routine chest roentgenogram was compared with that in 259 age- and sex-matched controls. Eighteen patients with diaphragmatic hernia were anemic, compared to one control subject (P less than 0.001). In thirteen patients with diaphragmatic hernia and in one control the anemia was proven to be caused by iron deficiency. The findings provide additional evidence that a large diaphragmatic hernia can cause anemia secondary to chronic gastrointestinal blood loss, which is usually not the result of reflux esophagitis.

Aspirin and gastric ulcer

Although acetylsalicylic acid (aspirin) can cause acute damage to human gastric mucosa, its relationship to chronic gastric ulcer has been less documented. A study of the aspirin intake of 61 patients with gastric ulcer revealed that 32 (52%) took 15 or more aspirins each week, compared to 6 (10%) age- and sex-matched controls who took such amounts (P less than 0.001). This difference remained significant when patients who took aspirin for relief of alimentary symptoms or when patients whose symptoms preceded aspirin use were excluded. The regular use of aspirin was especially associated with ulcers in the prepyloric region of the stomach. Fewer patients who had combined gastric and duodenal ulcers were regular users of aspirin when compared with patients who had gastric ulcer alone. The findings suggest that aspirin may be a common cause of gastric ulcer in man.

Insulin response to carbohydrate ingestion after gastric surgery with special reference to hypoglycaemia

Factors responsible for spontaneous hypoglycaemia were investigated in 23 gastrectomy patients and two patients with vagotomy and pyloroplasty. Plasma insulin and capillary blood glucose levels were followed after giving 175 ml of 50% glucose orally. In gastrectomy patients a significant correlation was found between the height of the peak blood glucose and insulin levels for the same individual. Patients with high peak glucose and insulin levels were significantly more likely to develop hypoglycaemia later in the test. These findings are compatible with the suggestion that the major factor predisposing to hypoglycaemia is a faster than average rate of emptying of the gastric remnant, but this does not explain all the results. In two cases, hypoglycaemia followed an abnormally large insulin response to oral glucose. The results of insulin injection tests in 14 patients do not exclude the further possibility that in some cases hypoglycaemia is due to excessive insulin sensitivity.

Circulatory and metabolic effects of oxygen in myocardial infarction

The circulatory and metabolic effects of inhalation of oxygen in high concentration were investigated in 50 patients with acute myocardial infarction. The heart rate, arterial blood pressure, cardiac out-put, blood gas tensions, pH, and lactate and pyruvate levels were measured. In general, oxygen inhalation produced a fall in cardiac output and stroke volume and a rise in blood pressure and systemic vascular resistance. In a small number of patients with very low cardiac out-puts there was a rise in output. A substantial rise in arterial oxygen tension was obtained even in patients with low initial values. The raised arterial blood lactate levels which were frequently present were reduced after oxygen. The therapeutic implications of these effects are discussed.

Chronic milk-alkali syndrome after prolonged excessive intake of antacid tablets

Images