Platelet aggregation in patients with peripheral vascular disease

Platelet aggregation has been studied in 28 control subjects and 46 patients with peripheral vascular disease. The platelets from the patients with peripheral vascular disease were significantly more sensitive to the aggregating effects of adenosine diphosphate and adrenaline than those from the control group (P less than 0.001). In addition, spontaneous platelet aggregation was observed in vitro in several of the vascular patients; this response was not apparent in the control group. Increased platelet aggregation could add to the vascular impairment in the unoperated subject and might also play a part in premature graft failure. Platelet function studies should perhaps be included as a routine in the assessment of patients with peripheral vascular disease.

The long term results of profundaplasty in femoropopliteal arterial occlusion

The long term results of profundaplasty in the treatment of femoropopliteal arterial occlusion have been reviewed. Fifty patients have been studied with a mean follow-up period of 4 years (range 6 months to 8 years). Intermittent claudication was abolished or substantially improved in 5 of the 25 cases (20 percent); rest pain was relieved in 10 of the 25 cases (40 per cent), the remainder requiring a major amputation. Lumbar sympathectomy produced little additional benefit in either group. The mortality rate in the rest pain group was high and only 5 patients survived for more than 3 years with both legs intact. The state of the distal 'run-off' and the degree of preoperative profunda stenosis appeared to have little influence on the clinical outcome. After operation pedal pulses were restored in 16 per cent of those presenting with claudication. Profundaplasty was without significant effect on the ankle systolic pressure index both in patients with claudication and those with rest pain.

Gastric emptying in control subjects and patients with duodenal ulcer before and after vagotomy

The emptying of a solid meal labelled with Indium 113mDTPA from the stomach was studied with a gamma camera in 26 normal subjects, 27 patients with duodenal ulcer, on 41 occasions after truncal vagotomy and pyloroplasty and 38 times after highly selective vagotomy. Applying the method of principal component analysis to the results, differences were detected between control and duodenal ulcer subjects and two probable subgroups of duodenal ulcer were observed. Half emptying times did not reveal these patterns. After vagotomy, delayed emptying was general at one week. At one month, patients after highly selective vagotomy had a more normal result than those with truncal vagotomy and pyloroplasty (TV), but by six months no significant difference in overall emptying rate was found, although changes in the pattern of gastric emptying persisted in some patients after TV.

Effect of vagotomy on the gastric secretory response to intraduodenal osmotic agents in man

The effect of intraduodenal infusion of hypertonic saline and glucose on pentagastrin-stimulated gastric secretion was investigated in 35 normal subjects, 32 duodenal ulcer patients and 32 patients after truncal vagotomy and pyloroplasty. A significant gastric inhibitory response occurred after 0.51 M saline and 1-03 M glucose in the normal subjects and duodenal ulcer patients but after vagotomy there was no inhibition. This finding suggests that the inhibitory effect of these agents depends, at least in part, on a vagal reflex in man. The response to very high glucose concentrations persisted after vagotomy and it seems likely that a humoral mechanism may be involved in this situation.

Effect of vagotomy on secretin release in man

The release of secretin by intraduodenal acid has been measured by means of a highly sensitive radioimmunoassay in 12 normal subjects, 23 duodenal ulcer patients, and 14 vagotomized patients (6 TV + P; 4 SV + P;4 HSV). A highly significant response occurred in all three groups. There was no significant difference between the groups either in the magnitude or timing of this response, though the absolute values for pre-stimulation and peak secretin were significantly smaller in preoperative duodenal ulcer patients than in either the normal subjects or the vagotomized patients. The secretin response was similar after truncal, selective, and highly selective vagotomy. These results suggest that secretin release is not dependent on intact vagal innervation of the small intestine in man.

Failure of secretin release in patients with duodenal ulcer

The release of secretin was studied in 12 normal subjects and 23 patients suffering from proved duodenal ulceration. After infusing acid directly into the duodenum mean plasma levels (plus or minus S.E.M.) of secretin rose in normal subjects to 52.6 plus or minus 4.8 ng/1 at six minutes but to only 37.5 plus or minus 3.6 ng/1 in duodenal-ulcer patients, a significant difference. The impairment of secretin release was as great in patients with a recent onset as in those who had had symptoms of a duodenal ulcer for a long time, raising the possibility of it being a primary defect. Patients who smoked 20 or more cigarettes a day had a particularly reduced secretin release, in accord with the greater incidence of ulcers in heavy smokers.

The role of secretin in the inhibition of gastric secretion by intraduodenal acid

The effect of intraduodenal acid on pentagastrin-stimulated gastric secretion has been investigated in 12 normal subjects and 23 patients with chronic duodenal ulceration. Plasma secretin levels were monitored during each test using a highly sensitive radioimmunoassay. Significant inhibition of gastric secretion occurred in the normal subjects and duodenal ulcer patients. A significant rise in plasma secretin was observed in both groups after intraduodenal acid though there was a complete lack of correlation between the magnitude of the secretin response and the degree of gastric inhibition. Ten subjects received intraduodenal acid and a subsequent intravenous infusion of exogenous secretin (0.125-0.25 units/kg over six minutes). Gastric inhibition occurred after the acid instillation but not after secretin infusion despite plasma secretin levels greatly in excess of those produced by intraduodenal acid. These results suggest that release of secretin by itself cannot explain the gastric inhibitory response to intraduodenal acid in man.

The effect of vagotomy on the inhibition of gastric secretion by intraduodenal acid

Acid in the duodenum is known to inhibit gastric secretion in man but whether this response is a humoral or a vagal phenomenon is unknown. If a vagal reflex is involved then selective and highly selective vagotomy, by preserving the duodenal nerve supply, could offer advantages over truncal division. This study was designed to investigate this claim.

The effect of intraduodenal hydrochloric acid on pentagnstrin-stimulated gastric secretion was stimulated in 17 control subjects, 32 preoperative duodenal ulcer patients and 28 vagotomized patients (16 truncal vagotomy and pyloroplasty; 6 selective vagotomy and pyloroplasty; 6 highly selective vagotomy). Inhibition of acid output occurred in 15 control subjects, and the mean inhibition for the group was 2.68 + 0.39 mEq/10 minutes (P < 0.001). Inhibition occurred in 22 duodenal ulcer patients, and the mean reduction in acid output for the entire group was 2.26 ± 0.46 mEq/l0 minutes (P < 0.001). Intraduodenal acid failed to produce a response in the vagotomized patients irrespective of the presence or absence of a duodenal nerve supply.

These results suggest that gastric secretory inhibition by intraduodenal acid is a vagal phenomenon in man; selective and highly selective vagotomy do not appear to carry any particular advantage over truncal section in terms of preserving this response.

The effect of vagotomy on the inhibition of gastric secretion by intraduodenal fat

It has been suggested that the inhibition of gastric secretion by intraduodenal fat is a vagal phenomenon in man. Selective and highly selective vagotomy, by preserving this reflex, could offer advantages over truncal vagal section. This paper reports the effect of intraduodenal fat on pentagastrin-stimulated gastric secretion in duodenal ulcer patients before and after truncal vagotomy.

Marked inhibition of gastric secretion occurred in all the patients. In the postoperative group gastric secretion was almost totally abolished following fat infusion despite the absence of an abdominal vagal supply. The results suggest that inhibition of gastric secretion by intraduodenal fat is mediated by a nonvagal mechanism in man; from this point of view, therefore, there is little advantage in attempting to preserve the nerve-supply to the duodenum at vagotomy.

Superficial abscess formation: an unusual presenting feature of tuberculosis

Tuberculous abscess formation in the absence of underlying osteo-articular, tendon-sheath, or lymphnode infection is uncommon in this country, but is likely to become more important with increasing immigration. Details are reported of 32 patients notified to the City of Birmingham Public Health Department between January, 1964, and December, 1968. The disease was encountered mainly in immigrants attending casualty and surgical out-patient departments.

The presenting feature in all cases was a superficial, fluctuant, relatively painless swelling of several weeks' duration. Lesions were widespread although there was a tendency for the chest wall to be involved (15 patients). Chest radiographs showed evidence of pulmonary disease in approximately one-third of the case and an elevated erthroyte sedimentation rate with a normal white-cell count were constant findings. Prompt chemotherapy combined with either aspiration or incision and primary suture achieved rapid and complete resolution in nearly all patients. Incision without closure was inevitably followed by sinus formation and delay in healing.

Late results of oesophageal and oesophagogastric resection in the treatment of oesophageal cancer

Oesophageal resection with oesophagogastric anastomosis is said to be followed by severe oesophagitis. Little is known, however, of the late results of this technique in patients with oesophageal carcinoma and the present communication records our experience with 23 long-term survivors. Except for one patient with recurrent carcinoma, all were in good health and taking a normal diet. Loss of weight, which is a normal sequel to oesophagogastric resection, was prevented by inserting two extra meals a day. Anaemia was not a problem and there was no evidence of vitamin B₁₂ or folate deficiency. None of the patients had any symptoms of oesophagitis, though all exhibited free reflux on recumbency. After operation patients are advised to sleep propped up and to avoid stooping or lying flat. These measures are thought to be largely responsible for the absence of oesophagitis in our series. Five patients were achlorhydric and 10 hypochlorhydric in response to intravenous pentagastrin (6 μg/kg per hour). Mean basal output was 0·6 mEq/hour and mean maximal output 8·8 mEq/hour.

Oesophageal reflux and gastric secretion

In the study to be described confirmation of the findings of Giles, Clark, and Buchan (1968) that the presence of acid in the lower oesophagus may stimulate gastric secretion has been sought. Also the influence of hiatal repair on the response to acid has been examined. The presence of acid in the lower oesophagus stimulates gastric secretion in man. The response to acid perfusion is greater in symptomatic hiatus hernia patients than in controls. Basal and perfusion outputs are lower in hiatus hernia patients with oesophagitis than in those without inflammatory change. Hiatal repair diminishes the gastric response in both groups; this effect is particularly marked in patients with oesophagitis.

The assessment of oesophagitis in hiatus hernia patients

The incidence of oesophagitis has been determined in 108 patients with sliding hiatus hernias using endoscopic, histological, and radiological criteria. Particular consideration has been given to the relationship between inflammatory disease and clinical symptoms. All the patients were attending a thoracic surgical clinic and the spectrum of disease encountered was fairly severe; over half of the cases had established strictures when first seen. The incidence of oesophagitis based on endoscopic evidence was 76·9%, while inflammatory change was noted on biopsy in 56·2% and at barium swallow in 58·3% of the patients. Oesophagoscopy proved to be the most satisfactory method of assessment; biopsy specimens were either inadequate or correlated poorly with other criteria while barium swallow was of diagnostic value only in severe oesophagitis. The main symptoms were pain, heartburn with regurgitation, dysphagia, and bleeding. Dysphagia was common due to the preponderance of patients with strictures, while obvious bleeding was very uncommon. Endoscopic oesophagitis was found in 75% of the patients with specific retrosternal pain and in 60% of those with heartburn and regurgitation. The inability to equate heartburn with oesophagitis is emphasized. The incidence of inflammatory change in patients with dysphagia was 87·2%; nearly all the cases in this group showed stricture formation.

Duodenal inhibition of gastric secretion by osmotic agents in normal subjects and patients with duodenal ulcer

Gastric secretion in man is inhibited by the presence in the duodenum of hyperosmolar and hypoosmolar solutions. Both acid and pepsin outputs are affected. There is no change in hydrogen, sodium, or potassium ion concentration in the gastric juice. Pepsin concentration, however, is reduced by all inhibitory stimuli. Inhibition is thought to act directly upon parietal and chief cells, and a possible basis for this mechanism is discussed. The response is similar in control subjects and duodenal ulcer patients; there is in particular no evidence of impaired inhibition in the ulcer group. An anomalous feature is the relatively small inhibition of acid output after hypertonic saline in control subjects compared with the duodenal ulcer patients.