Omeprazole and ranitidine in treatment of reflux oesophagitis: double blind comparative trial

One hundred and sixty two patients with endoscopically proved reflux oesophagitis stratified for severity, 66 with grade 1 disease (erythema and friability) and 96 with grade 2 or 3 disease (including erosions or ulcerations), were allocated at random to double blind treatment with omeprazole 40 mg in the morning or ranitidine 150 mg twice daily for up to 12 weeks. A patient could be evaluated sooner if symptomatic relief and endoscopically normal mucosa (grade 0) were noted after four to eight weeks' treatment. Patients treated with omeprazole responded significantly more rapidly than those treated with ranitidine (p less than 0.0001), cumulative healing rates at four, eight, and 12 weeks being 90%, 100%, and 100% respectively for those with grade 1 disease and 70%, 85%, and 91% respectively for those with grade 2 or 3 disease in the omeprazole group. Corresponding rates in the ranitidine group were 55%, 79%, and 88% (grade 1) and 26%, 44%, and 54% (grade 2 or 3). Relief of the major symptoms of heartburn, regurgitation, and dysphagia and improvements in the histological appearance of the mucosa occurred earlier and were again more pronounced during treatment with omeprazole than with ranitidine. This observed superiority of omeprazole 40 mg in the morning over ranitidine 150 mg twice daily in the short term treatment of reflux oesophagitis was obtained without major clinical or biochemical side effects, but further research is needed into longer term use of omeprazole and the effects of the acid inhibition it induces.

Follow-up after radical surgery for colorectal cancer. Design of a randomized study

The value of different follow-up examinations after radical surgery for colorectal cancer has not been proven. The risk of such programmes, including invasive examinations, may invalidate the possible benefit from early diagnosis of recurrent and metachronous cancer. The present trial is a randomized study, evaluating possible benefit from a very detailed programme compared to that of virtually no follow-up. The design is presented, but so far no more than 207 of the 600 patients wanted for trial, have been included. Differences in mortality rates, survival and morbidity will be evaluated and the influence of repeated polypectomy upon risk of metachronous colorectal cancer will also be estimated.

Histology of the anal canal

The normal gross and microscopic morphology of the anal canal is described, including the more common variants. Constant problems in the literature are the confusing terminology and the relation of the histological zones to the so-called cloacal membrane. For this reason, the review includes remarks on the history, embryology, and nomenclature.

Prognostic evaluation of planned follow-up in patients with colorectal adenomas. An interim report

Between 1978 and 1986 colorectal adenomas without invasion were removed in 552 patients under 76 years of age. Patients were randomly allocated to different follow-up groups with intervals of colorectal examination varying from 6 to 48 months after the initial polypectomy. A large bowel carcinoma developed in three patients and new adenomas in 87 patients. Based on the morphology of the initial adenomas possible relationships between prognostic factors and the risk of new adenoma formation were assessed using life-table analysis. The advantage of a possible decrease in the risk of developing carcinoma was offset by the disadvantage of eight severe complications occurring in 1818 colonoscopies, one of which proved fatal. The occurrence of one of the three carcinomas was considered a failure of the follow-up programme.

Initial mass screening for colorectal cancer with fecal occult blood test. A prospective randomized study at Funen in Denmark

A Danish study allocated at random 30,970 persons to screening with Hemoccult-II and 30,968 as controls in a population of 140,000 between 45 and 74 years old. Persons with known colorectal cancer, adenoma, and distant spread from all types of cancer were excluded. The test was completed in 20,672 persons from August 1985 to September 1986, and 215 (1%) were found to be positive. Colonoscopy in 203 and double-contrast barium enema in 6 detected 37 persons with cancer and 86 with adenomas. Dukes A cancer was detected in 19 in the screening group, in contrast to 2 among controls. Synchronous adenomas were found in 23 with a positive test and 10 controls. Interval cancer was found in nine persons within 1-11 months after a negative test. Eighteen persons got cancer before invitation and six defectors as well. In all, colorectal cancer was detected in 70 persons in the screening group and in 38 controls; the figures for adenomas alone were 103 and 38, respectively. The study is designed to detect a possible reduction in mortality from colorectal cancer of 25% within 5 years after three screenings with intervals of 2 years. The second screening will begin in September 1987. It remains to be shown whether a reduction may be obtained both in mortality and in incidence of colorectal cancer.

Intraepithelial neoplasia in the anal canal. The appearance and relation to genital neoplasia

Anal canal intraepithelial neoplasia (ACIN) in the form of squamous dysplasia and carcinoma in situ is a rare condition. In this paper we present all 19 cases diagnosed in Denmark in a two-year period. The incidence was 0.2/10(5)/year compared to 0.7/10(5)/year for variants of squamous carcinoma in the anal canal. Most cases of ACIN were incidental findings at minor anal surgery. Histologically, one half of the lesions were located in the anal transitional zone above the dentate line. Two of the 19 patients died from colo-rectal carcinoma and 17 were alive 5 years later. Nine of the patients were controlled by biopting, and 4 recurrences of the intraepithelial changes were found among these, all with an initial lesion of ACIN III. None of the patients developed invasive carcinoma of the anal canal during the 5 years, but one half of the females had previous or accompanying neoplasia of the vulva and perineum.

Do synchronous adenomas influence prognosis after radical surgery for colorectal carcinoma? A prospective study

From 1978 to 1983, radical surgery for colorectal cancer was performed in 319 consecutive patients who were included in a prospective evaluation of perioperative and repeated postoperative colonoscopy with polypectomy. Synchronous adenomas were found and removed in 87 patients. The probability of survival without recurrent cancer and of not dying from local and/or distant spread was significantly higher (p less than 0.02) in patients with synchronous adenomas than in those without. This unexpected finding could only to a minor degree be explained by a greater prevalence of well differentiated cancers and fewer poorly differentiated cancers in patients with synchronous adenomas. Detailed analysis revealed only one other major difference between the two groups, namely a higher risk of adenomas developing during follow-up of patients with synchronous adenomas (p less than 0.001). The present results may be relevant to future prospective clinical studies in which perioperative and regular postoperative colonoscopy is included.

Benign colonic neoplasm at the site of ureterosigmoidostomy

A benign colonic polyp with epithelial dysplasia developed in a young male at the site of ureteral implantation in the sigmoid colon following ureterosigmoidostomy for urinary incontinence. Patients with ureterosigmoidostomy represent a high-risk cancer group, and a review of the literature suggests the necessity of a life-long follow-up in these patients. A follow-up plan with Hemoccult test each year and a sigmoidoscopy every 3rd year is proposed.

Accessory ovary

A case is reported of an accessory ovary in a 46-year-old woman. Accessory ovaries are frequently small and may therefore be overlooked at laparotomy. The present case was presumably discovered due to gonadotropic hyperstimulation caused by the menopause or the previous bilateral ovarian resection.

Precancerous changes in the anal canal epithelium in resection specimens

Systematic histological examination for precancerous changes was carried out on 139 anal canals resected for anal or colo-rectal tumours or for inflammatory bowel disease. Severe squamous dysplasia or carcinoma in situ were found in 13 of 16 anal canals harbouring variants of squamous carcinoma but not in others. The lesions were mainly or totally located to the anal transitional zone (ATZ) in 11 cases and only in 2 cases exclusively to the squamous zone below the dentate line. Dysplastic areas separate from the tumour were found in 6 of the 13 cases. Junctional melanocytic activity and atypical melanocytic hyperplasia located in the ATZ as well as the squamous zone were present in 1 of 3 cases of malignant melanoma. The findings underline the close relationship between dysplasia and invasive carcinoma in the anal canal. Further they support the concept that basaloid, mucoepidermoid and some ordinary squamous carcinomas arise in the ATZ, and that this may also be the point of origin for malignant melanoma. A search for precancerous changes for anal canal tumours should therefore include the whole ATZ, i.e. in some cases up to 2 cm above the dentate line and it should be borne in mind that the lesions may be spotty.

Reproducibility and diagnostic value of Hemoccult-II test. A colonoscopic evaluation in asymptomatic patients

Inter-observer agreement rate in double readings of 246 Hemoccult-II tests was 0.88 (Kappa analysis). The slides were not rehydrated. The Hemoccult-II test was performed immediately before 748 total colonoscopies in asymptomatic patients after previous polypectomy or radical surgery for cancer to estimate the diagnostic value of the test in mass screening, accepting a higher prevalence of neoplasia in the study group but realizing that colonoscopy can only be performed in high-risk groups. Another purpose was to investigate the possibility of replacing colonoscopy with Hemoccult-II in surveillance after previous adenoma or cancer. The 79 colonoscopies after a positive test showed cancer in 3, adenomas in 13, and other intestinal pathology in 34 cases. The 669 colonoscopies after negative tests showed cancer in 1, adenomas in 67, and other pathology in 141 cases. In conclusion, the test cannot be used as a guideline for colonoscopy in follow-up programs for patients who have had adenomas, since it missed 84% of the new cases in the present series. The test does not exclude the presence of colorectal carcinoma, but the risk of cancer is probably several times less in patients with negative tests (1 of 669) than in patients with positive tests (3 of 79), which may justify the use of the Hemoccult-II test for mass screening in asymptomatic populations.

Arthritis and collagenous colitis. Report of a case with concomitant chronic polyarthritis and collagenous colitis

A 26-year-old woman simultaneously developed chronic seronegative non-destructive polyarthritis and chronic watery diarrhoea. Biopsies from the colorectal mucosa showed a thickened subepithelial collagen layer consistent with collagenous colitis. The combination of these conditions has not, to our knowledge, been described previously. On the basis of only one patient it is too early to determine whether or not this case represents a new type of enteropathic arthritis.

The value of the hospital autopsy. A study of causes and modes of death estimated before and after autopsy

Among 312 consecutive deaths in a Danish Central Hospital autopsy was performed in the pathology department on 266 cases, i.e. 85%. Retrospectively, the underlying causes of death were estimated from the clinical information alone by an experienced clinician and subsequently compared with the autopsy report. The definite cause of death was determined jointly by the clinician and the pathologist. The clinician's diagnosis was thereby confirmed as incorrect in 18% of the cases if small differences in site and type of malignant tumours were not considered. This is less than in many other investigations, but it is stressed that this could partly be because formal errors in completing the death certificate were avoided. The main causes of death were ischaemic heart disease and neoplasia. Clinical diagnosis of malignant diseases was never found to be erroneous. There was a slight tendency to clinically overestimate ischaemic heart disease, but in general the different errors outweighed each other, so that the total number of different causes of death before and after autopsy was nearly the same. The original death certificate was investigated in 12 accidental cases. Hereby it was found that the mode of death was originally stated erroneously as natural in 7 cases, i.e. 4.5%. It is concluded that hospital autopsy is still needed for the control and correction of causes of death, and it is stressed that clinicians as well as pathologists should be more aware of cases with a trauma in the history to avoid errors in the mode of death. Such errors can imply legal as well as insurance problems.

Endocrine cells and melanin-containing cells in the anal canal epithelium

The epithelium of the anal canal from 22 humans was studied in order to demonstrate the possible presence of endocrine cells and melanin-containing cells. Histochemical methods aimed at demonstrating reducing substances, biogenic amines, argyrophilia and melanin, were used. Enterochromaffin cells, and possibly other types of endocrine cells, were demonstrated above the dentate line both in colo-rectal type epithelium and in the anal transitional zone. Melanin-containing cells could also occasionally be found in the anal transitional zone. The presence of endocrine cells in the anal canal epithelium opens up the possibility that carcinoids can originate in this region. Further, the presence of melanin-containing cells might explain the occurrence of malignant melanomas arising above the dentate line.

Stereomicroscopic Investigation of the anal canal epithelium

Macroscopic specimens on the anal canal from 22 patients with colorectal carcinoma and 5 patients with anal canal carcinoma were investigated by stereomicroscopy after whole-mount staining with alcian blue. The specimens were thereafter cut up systematically and prepared for conventional light microscopy to correlate stereomicroscopic and histologic findings. The results show that different surface relief and colour intensity correspond to different types of surface epithelium. Stereomicroscopy, however, did not show differences between various histological types of anal canal carcinoma.

Mucin histochemistry of the anal canal epithelium. Studies of normal anal mucosa and mucosa adjacent to carcinoma

The epithelial lining of the anal canal is of colo-rectal type in the upper part and squamous in the lower part, while the middle zone is called the anal transitional zone (ATZ). This zone is characterized by an epithelium which bears a resemblance to that of the anal glands and shows little mucus secretion. The histochemical properties of the mucins in the epithelium of 39 anal canals, resected for ano-rectal adenocarcinoma, basaloid carcinoma, squamous carcinoma and malignant melanoma were investigated. The study reveals that (1) the mucin composition of the ATZ epithelium corresponds to that of the anal glands, being characterized by a mixture of sulpho- and sialomucins with scarcity or absence of O-acylated sialic acids; and (2) cases with carcinomas located near the dentate line show changes in the mucin composition of the adjoining anal canal epithelium, regardless of tumour type. In colo-rectal type mucosa, these mucins consist of increasing amounts of sialomucins with a predominance of N-acyl derivatives, and in the anal glands of increasing amounts of sulphomucins and O-acyl derivatives of sialomucins. No changes could be detected in the ATZ epithelium. It is concluded that rectal and anal glands in the anal canal are exposed to stimuli which alter the normal process of glycoprotein synthesis and secretion. The changes seem to be secondary to tumour growth and independent of the histological type of tumour.

Dysplastic changes in the anal canal epithelium in minor surgical specimens

A ten-year consecutive material of 306 minor surgical specimens from the anal canal showed squamous dysplasia in 2.3 per cent. None of the patients developed carcinoma during an average observation time of 27 months. The average age was 64 years for dysplasia and 67 years for a corresponding series of 12 cases of anal canal carcinoma. It is concluded that all material from the anal canal should be investigated histologically.

Flow cytometric DNA analysis of anal canal epithelium and ano-rectal tumours

Flow cytometric DNA analysis was performed on mucosal biopsies from the various epithelial types normally present in the anal canal, i.e. colo-rectal epithelium, ATZ-epithelium and squamous epithelium as well as from rectal and anal adenocarcinomas and squamous carcinomas of the anal canal. Normal colo-rectal mucosa show homogeneous cell populations with diploid DNA values, while adenocarcinomas contain diploid as well as aneuploid cell populations, regardless of location in the rectum or in the anal canal. The ATZ-epithelium shows a dominating normoploid population with a small "hyperdiploid" peak. Polyploid nuclei were not found. The findings indicate that the ATZ-epithelium is related to metaplastic epithelium rather than to urothelium. The variants of squamous carcinoma in this study were rather poorly differentiated, but the FCM-analysis showed a near diploid population with a high proliferative activity. The number of cases, however, is too small to be conclusive.

The anal transitional zone: a scanning and transmission electron microscopic investigation of the surface epithelium

The ultrastructure of the anal transitional zone (ATZ) is described by means of scanning and transmission electron microscopy. The technique used permits histologic reexamination of the scanning electron microscopic biopsies. The surface of the ATZ shows, in addition to areas of normal colorectal mucosa and squamous epithelium, a characteristic picture: there are cells of varying size, arranged in a cobblestone pattern, and a surface covered with short microvilli that tend to form rows, indicating beginning microridge formation. This corresponds histologically to the so-called ATZ epithelium, and it is suggested that this might be metaplastic squamous epithelium rather than urothelium. The deepest part of the epithelium contains endocrinelike cells with granules of at least two types.

A three-day doxycycline regimen for treatment of gonorrhea

Patients with uncomplicated gonorrhea were given three 300-mg capsules of doxycycline, one of which was to be taken after the heaviest meal of the day, on each of three consecutive days. A total of 560 men and women were treated by this method. Of the 355 patients who returned for tests of cure within seven to ten days, all but seven (2%) responded favorably to the treatment. The effectiveness of the regimen was similar to that of other accepted treatments. Adverse effects were inconsequential or absent, providing that the medication was taken after meals. This treatment option simplifies considerably the directions to be followed by the patient and minimizes the risk of noncompliance in the treatment of gonorrhea with tetracyclines.

The anal transitional zone. Location and extent

The location and extent of the anal transitional zone (ATZ) were investigated in the age group typical for anal canal carcinomas. The methods used were macroscopic determination after whole-mount staining with Alcian-dyes as well as conventional histological technique. The results show that the epithelial variants may be found over a larger area than previously reported, namely from 6 mm below to 20 mm above the dentate line. Variations in location and extent of the ATZ are described, as well as the frequent finding of mature squamous epithelium high in the anal canal. The significance of the findings in relation to the special types of anal canal carcinomas is discussed, and on the basis of the macroscopic definition of the canal, as well as the histological observations in this study, it is proposed that anal canal carcinomas should be defined as tumours partly or totally located within a distance of 2 cm above the dentate line.

Histochemical characteristics of mucins in the small intestine. A comparative study of normal mucosa, benign epithelial tumours and carcinoma

The histochemical properties of the mucins in seven benign epithelial tumours and 15 carcinomas distributed along the duodenum, jejunum and ileum were investigated and compared with normal controls. This study reveals that (a) goblet cells in normal small intestine contain neutral and sialomucins but no sulphated material; (b) the proportion of the different types of mucins in the goblet cells vary along the crypts and villi with an increasing amount of sialomucins towards the villus top; (c) mucin composition also changes from duodenum to ileum particularly in the proportions of sialic acid types and in the presence of traces of sulphomucins in the ileal mucosa close to the ileo-caecal valve, suggesting a gradual transition through the small intestine to the colon; (d) benign tumours show the same mucin pattern as normal mucosa; (e) the adjacent to carcinoma shows increasing amounts of sialomucins and sulphomucins; (f) carcinomas present a variety of mucin patterns, and thus the study of mucins seems to be of no value in differentiating tumours of the small intestine from those elsewhere in the gastrointestinal tract. A working hypothesis based on the Unitary Theory of the origin of the intestinal epithelial cells is proposed to explain the variations in glycoprotein synthesis with cell differentiation and carcinogenes.

The anal transitional zone. A method for macroscopic demonstration

The anal canal extends from the upper to the lower border of the internal sphincter. The canal can histologically be divided into three zones according to the epithelial lining, being of colo-rectal type in the upper part and squamous in the lower part, while the middle part, where the epithelium varies, is called the anal transitional zone (ATZ). This zone can be demonstrated macroscopically using whole mount staining with Alcian dyes, which reveal it as light green or blue, contrasting to the dark stained rectal type mucosa above and the unstained squamous epithelium below. Comparison with histological section shows that this zone corresponds with reasonable accuracy to the anal transitional zone.

Pathology of the anal glands with special reference to their mucin histochemistry

The anal gland pathology comprises cystic anal glands (so-called anal gland cyst hamartomas), anal gland carcinomas, and anal fistulas with or without carcinoma. The differential diagnosis of these conditions from other cysts and carcinomas of the anal region can be difficult. The authors have therefore compared conventional history with mucin histochemistry in normal and pathological anal glands. In contrast to normal rectal mucosa the mucus of anal glands was characterized by strong PAS-reactivity that was completely abolished after periodate borohydride saponification indicating scarcity of absence of O-acylated sialic acids in the anal gland mucus. A pattern similar to this was found in one of two tumours classified histologically as anal gland carcinomas, in four of eight colloid carcinomas arising in preexisting fistulas, and in two cases of mucoepidermoid carcinoma of the anal region. The results indicate that the method in some cases may be of value in differentiating between carcinomas arising in anal gland epithelium and in rectal mucosa. The cystic anal glands showed decreased secretion but no qualitative histochemical differences from anal glands. On the basis of the patients' histories it is suggested that the so-called anal gland cyst hamartoma at least in some cases could be an inclusion cyst of anal glands on the inflammatory basis.