Importance of sputum differential cell counting in the diagnosis of airway diseases

We examined the sputum of 114 subjects by noninvasive methods (voluntary coughing or induced cough with hypertonic saline) to determine whether sputum examination could be used to separate patients with episodic wheezing, dyspnea or cough of unknown origin into different diagnostic categories. An increased percentage of sputum eosinophils was seen in 92% (48/52) of asthmatics, 36% (9/25) of patients with chronic obstructive pulmonary disease (COPD) and 28% (7/25) of chronic coughers, but not in any of the 12 patients with congestive heart failure (CHF). Eight patients with combined symptoms of COPD and asthma (mixed COPD subgroup) showed above average diurnal peak expiratory flow variation (10.3 +/- 2.1% vs 2.5 +/- 1.4%, p < 0.05) and an above average percentage of sputum eosinophils (19.8 +/- 9.1 vs 2.1 +/- 3.2, p < 0.01) than those in the pure COPD group. After therapeutic corticosteroid trial, all of the mixed COPD patients and six of the 17 pure COPD patients were steroid responders. Seven of the 25 chronic coughers had sputum eosinophilia, but no asthmatic symptoms. The cough symptoms subsided in five of these seven patients after steroid treatment but not in the other 18 chronic coughers. Further study is indicated to determine if simple eosinophilic bronchitis is an early stage of asthma. In conclusion, sputum differential cell counting is a useful noninvasive diagnostic tool in differentiating diseases with episodic wheezing or chronic cough.

Value of ultrasonically guided needle biopsy of pleural masses: an under-utilized technique

Thirty-six patients with pleural masses underwent ultrasonically guided needle biopsy (UGNB), including ultrasonically guided aspiration biopsy (UGAB) in all 36 patients and ultrasonically guided cutting biopsy (UGCB) in 13 patients. Using UGAB alone, the diagnostic rate for pleural masses was 64% (23/36); carcinomatous pleural masses were more easily diagnosed than non-carcinomatous pleural masses (87% vs 23%, p < 0.01). If both UGAB and UGCB were used, the diagnostic rate was 89% (32/36); thus, selective UGCB was valuable in improving the diagnostic rate of non-carcinomatous pleural masses (from 23% to 69%). In patients with pleural effusions (n = 19), 11 underwent cytologic examinations of the pleural effusion (3 also undergoing pleural biopsy) without conclusive diagnosis; however, the diagnosis was made from pleural masses by UGAB (n = 7) or UGCB (n = 4). In patients without pleural effusions (n = 17), 12 had only pleural masses (3 also having multiple peripheral pulmonary nodules and 4 having mediastinal tumors) and could not be diagnosed by conventional bronchoscopic and sputum examinations. However, the diagnosis was rapidly confirmed by UGAB (n = 5) or UGCB (n = 3) from the pleural masses in 8 patients. We conclude that UGNB is a useful and valuable diagnostic tool, not only detecting the pleural masses hidden by pleural effusions but also for rapidly diagnosing the pleural masses.

Ultrasound-guided fine-needle aspiration biopsy of lung cancers

One hundred eighty-eight patients with 191 lung cancers were collected retrospectively to evaluate the diagnostic results and to determine the accuracy of cytologic diagnoses obtained from ultrasound-guided fine-needle aspiration biopsy (US-guided FNAB), and to discuss the necessity of large-bore tissue core needle biopsy. All 188 patients underwent US-guided FNAB, and 20 patients with 21 lung tumors also underwent US-guided tissue-core needle biopsy. Using US-guided FNAB alone, the positive cytologic results and correct cytologic diagnoses were 91% (174 of 191) and 71% (37 of 52). If both US-guided FNAB and selected US-guided tissue core needle biopsy (n = 21) were evaluated, the positive cytologic or histologic results and correct cytologic or histologic diagnoses were 94% (180 of 191) and 80% (45 of 57), respectively. Analyzing the disagreement between the cytologic results and histologic diagnoses (n = 15), we found that the disagreement usually occurred in the specimens with poorly differentiated carcinomas (nonspecific cell type) (53% [8 of 15]); of these, two patients (13% [2 of 15], small cell carcinoma) would have a change in treatment. The complications of US-guided FNAB were pneumothorax (n = 3), hemoptysis (n = 1), hemothorax (n = 1), and suspected tract metastasis (n = 1). We conclude that US-guided FNAB has a high diagnostic yield in lung cancers, and US-guided tissue core needle biopsy is only necessary in patients whose cytologic results are negative or who have poorly differentiated carcinomas.

Ultrasound-guided fine needle aspiration biopsy of small pulmonary nodules abutting to the chest wall

BACKGROUND

Ultrasound (US)-guided needle biopsies in peripheral pulmonary lesions are widely applied. Most pulmonary lesions had a large size. We report our results in evaluating the availability of US-guided fine needle aspiration biopsy (US-guided FNAB) in diagnosing small pulmonary nodules abutting to the chest wall.

METHODS

Forty patients, whose chest radiographs showed peripheral pulmonary nodules of diameter smaller than 3.0cm, received chest sonographic examination and US-guided FNAB. Of those, six patients had no definite diagnoses; the remaining 34 patients with pulmonary nodules, we divided into three groups. There were four tiny nodules of diameters smaller than 1.0cm, 11 nodules between 1.1 and 2.0cm, and 19 nodules between 2.1 and 3.0cm. We evaluated the diagnostic yields and rates of complication in relation to the size or nature of the nodule.

RESULTS

In the enrolled 40 patients, six were lost to surveillance and had indeterminate diagnoses. Of the remaining 34 patients with proven pathological diagnoses and compatible clinical conditions, the diagnostic yields of US-guided FNAB achieved 88% (30/34) which include 96% (26/27) in malignancies and 57% (4/7) in benign nodules. According to the nodular size, the diagnostic rate achieved 100% (4/4) in tiny nodules, 91% (10/11) in nodules between 1.1 and 2.0cm, and 84% (16/19) in nodules between 2.1 and 3.0cm. Only one patient with a 2.5-cm nodule developed pneumothorax after the US-guided FNAB procedure.

CONCLUSIONS

US-guided FNAB is a useful and safe diagnostic tool for small pulmonary nodules abutting to the chest wall. The nodular nature, but not size, affects the diagnostic yields and rates of complication.

Superior vena cava syndrome in lung cancer: an analysis of 54 cases

Traditionally, superior vena cava syndrome (SVCS) has been recognized as an oncologic emergency, and with clinical suspicion of the syndrome, tissue diagnosis was often delayed due to possible complications in diagnostic procedures and immediately threatening of life. Previously, local radiotherapy was regarded as the best immediate strategy for management of the condition. We have analyzed 54 lung cancer patients with SVCS in the past 6 years. Our results show that dyspnea (34 cases, 63%) and facial swelling (29 cases, 54%) are the two most common symptoms. The most frequent physical finding was venous distension of the neck (35 cases, 65%). The chest X-ray findings also showed a large ratio of superior mediastinal widening (26 cases, 48%). Fine needle aspiration of palpable lymph node (20 cases, 37%) and trans-thoracic needle aspiration guided by ultrasound (US) (8 cases, 14%) made diagnosis of at least half of the cases possible (28 cases, 51%). Both of these procedures are safer and easier than other invasive methods of examination. Of the 54 patients, small cell carcinoma constituted the majority of the cases (23 cases, 43%) and, with combination chemotherapy, there was a good response rate and a longer survival time (7.4 months) as compared to that of non-small cell carcinoma (3.7 months) treated by radiotherapy. We conclude that lung cancer with SVCS could be quickly and safely diagnosed by needle aspiration of the palpable lymph node or trans-thoracic needle aspiration guided by US, and that with combination chemotherapy the SVCS in small cell carcinoma can be effectively relieved.

Ultrasonically guided needle biopsy of anterior mediastinal masses: comparison of carcinomatous and non-carcinomatous masses

Thirty-three patients with anterior mediastinal masses underwent percutaneous ultrasonically guided needle biopsy (UGNB), including ultrasonically guided aspiration biopsy (UGAB) in all 33 patients and ultrasonically guided cutting biopsy (UGCB) in 13 patients. Using UGAB alone, the diagnostic rate of anterior mediastinal masses was 52% (17/33); if both the UGAB and UGCB methods were used, the diagnostic rate could achieve 79% (26/33). If the anterior mediastinal masses were divided into carcinomatous (n = 15) and non-carcinomatous (n = 18) groups, we found that the carcinomatous group was more easily diagnosed by UGAB than the non-carcinomatous group (87% vs 22%, p < 0.01) and UGCB was more valuable and helpful than UGAB in the diagnosis of non-carcinomatous mediastinal masses (75% vs 22%). One episode of injury to the aortic wall occurred after a UGCB. Our results show that carcinomatous mediastinal masses can be easily diagnosed by UGAB, and UGCB is often necessary in the diagnosis of non-carcinomatous mediastinal masses.

Ultrasound-guided biopsy of thoracic masses

BACKGROUND

Fine needle aspiration cytologic examination may be sufficient for managing patients with primary lung cancer. However, the procedure is not reliable for benign lesions and metastatic lung cancers. An attempt was made to find the influence of cell type on the results of fine needle aspiration and cutting biopsy.

METHODS

One hundred and sixteen patients with thoracic nodules or masses underwent chest ultrasound examination and percutaneous ultrasound-guided needle biopsy. All patients underwent ultrasound-guided fine needle aspiration biopsy (UGAB) and thirty-eight of them also underwent ultrasound-guided cutting biopsy (UGCB). Thoracic lesions were divided into seven groups.

RESULTS

Using UGAB alone, the diagnostic rate varied from 56% (mediastinal tumor) to 91% (lung mass). When both methods of UGAB and UGCB were evaluated, the diagnostic rate varied from 67% (pulmonary nodule) to 100% (collapsed lung with mass and pancoast tumor). When thoracic lesions were divided into carcinomatous neoplasms (n = 88) and noncarcinomatous lesions (n = 21), a higher diagnostic rate was found in the carcinomatous group than in the noncarcinomatous group (92% versus 53%, p < 0.001). Correct histologic results between both groups had no statistical significance (64% versus 56%, p > 0.05).

CONCLUSIONS

Ultrasound-guided needle biopsy has a high diagnostic yield of thoracic tumors, and carcinomatous masses can be easily diagnosed by UGCB. Noncarcinomatous masses and benign tumors frequently need UGAB to obtain a histologic diagnosis.

The clinicopathological spectrum of renal amyloidosis

BACKGROUND

Renal amyloidosis is an uncommon cause of nephrotic syndrome. The clinical conditions in Chinese people remain obscure. This is a retrospective review of the clinicopathological spectrum of 12 cases diagnosed in Taichung Veterans General Hospital from October 1982 to November 1993.

METHODS

Charts and renal pathological slides were reviewed retrospectively. A scoring system was set to evaluate the degree of amyloid deposition in the renal tissue. The clinical profile, immunological data, pathological picture and final outcomes are presented and discussed, with literature review.

RESULTS

There were 12 cases of primary amyloidosis including 1 case of multiple myeloma. All were confirmed by renal biopsy. The cases were all male with mean age of onset as 53.3 +/- 11.3 (range: 32 to 65 years). The mean follow-up duration was 22.9 +/- 32.8 months. The initial average creatinine clearance was 66.7 +/- 42.7 ml/min; mean daily urine protein was 7.0 +/- 4.1 grams. Nephrotic syndrome was the main clinical manifestation, present in all 12 cases. Other presenting symptoms and signs included: malaise in 7 cases; hypertension and anorexia in 4 cases; limb numbness in 3 cases; low back pain, dizziness and microhematuria in 2 cases each; anemia, headache, stroke, restrictive cardiomyopathy, hepatomegaly, syncope, body weight loss, dysphagia and skin itching in one case individually. Amyloid cardiomyopathy was present in 4 of the 8 patients who received echocardiography. The mean serum albumin level was 1.9 +/- 0.7 mg/dl, globulin level 3.1 +/- 1.1 mg/dl. Urinary Bence-Jones protein examination was performed in 8 cases; none revealed positive response. The mean immunoglobulin (Ig) level for the patients included: IgG 1018 +/- 901 mg/dl, IgA 262.0 +/- 313.8 mg/dl, IgM 104.8 +/- 84.2 mg/dl. There were at least 4 cases with high levels of one Ig but depressed levels in the others. M-component was shown by immunoelectrophoresis (IEP) in 90% of the cases. IEP impression in 10 cases revealed 2 cases of IgA lambda, 2 cases IgA kappa, 3 cases IgG lambda and 1 case IgG kappa monogammopathy, 1 case free lambda myeloma and 1 case negative. The ratio of kappa to lambda chain was 3:6. Bone marrow biopsy performed in 8 cases found only 1 case with multiple myeloma, one with amyloidosis; the other 6 cases were unremarkable. Mesangium was the site of heaviest amyloid deposition, followed by tubular basement membrane, artery and interstitium. The median survival time for those whose total score was lower than 3 points was 97.5 months; 3 to 5 points, 14 months; 6 points or more, 18.5 months. The median survival time was 21.6 months and 3-year-survival rate was 32.7%. The 2 cases with long-term survival were of 111 months and 84 months. The possible reason included: 1) Organ-limited renal amyloidosis; 2) Light amyloid deposition; 3) Younger age; 4) Other undetected favorable factors.

CONCLUSIONS

1) Renal amyloidosis is not a frequent diagnosis of nephrotic syndrome in Taiwan, but it should be suspected in every patient over 50 years old with a recent onset of proteinuria. 2) Renal amyloidosis can be diagnosed only by renal biopsy. 3) Primary renal amyloidosis is a disease of poor prognosis.

Thin basement membrane nephropathy: a report of two cases

Two cases of thin basement membrane nephropathy were collected from 233 renal biopsies which contained adequate material for diagnosis. Both patients had presented with persistent hematuria. Thin glomerular basement membrane was the sole significant abnormality found in their renal biopsies. A complete workup of renal biopsy including light microscopy, immunofluorescence study and electron microscopy is mandatory for patients with unexplained hematuria.

Coughing frequency in patients with persistent cough: assessment using a 24 hour ambulatory recorder

Cough is an important symptom of many respiratory disorders. We determined the frequency and diurnal variation of cough in normal subjects and in patients with asthma or with persistent cough of unknown cause. We used a portable, solid-state, multiple-channel recorder to record cough sounds over a 24 h period. The audio-signal was recorded from a unidirectional microphone strapped over the chest wall, and electromyographic (EMG) signals from the lower respiratory muscles were simultaneously registered with surface electrodes. The recorded digital data were examined on an IBM-compatible computer, and the typical signals induced by cough (as assessed by voluntary or experimentally-induced cough) were counted. In 12 normal subjects, only 0-16 coughs were recorded over 24 h. In 21 stable asthmatics with a history of chronic cough ("asthma") the median number was 282 (ranges: 45-1,577), and in 14 patients with the predominant symptom of daily dry coughs ("chronic coughers") the median number was 794 (64-3,639). In both groups of patients, there was a diurnal variation of coughs, such that the least numbers occurred between 2 and 5 a.m. (< 3% of total). In the asthma group, there was no significant correlation between forced expiratory volume in one second (FEV1) (% predicted) or diurnal variation of peak expiratory flow and cough frequency. In the chronic coughers, there was a significant correlation between daytime cough numbers and daytime cough symptoms scores but not for the night-time values. Our data show that cough frequency is not determined by the severity of asthma in relatively stable asthmatics on inhaled steroids, and is reduced during sleep in both asthmatics and chronic cough patients. This portable cough recorder may be useful in the assessment of drug therapy for chronic cough.

Apical malignancies diagnosed by ultrasound-guided fine needle aspiration biopsy

Sixteen patients with apical malignancies, including 12 with Pancoast tumors and four with metastatic apical pleural masses, underwent chest ultrasound (US) examinations and direct percutaneous fine needle aspiration biopsy (FNAB). Of those, 15 patients were proven to have malignancies by FNAB and the remaining patient (only revealing necrosis by FNAB) was also proven to have a Pancoast tumor after surgical intervention. Percutaneous FNAB was performed through the supraclavicular approach (n = 10) or through the upper back (n = 6). The sonographic appearances of the apical malignancies were homogeneous hypoechoic (n = 8), homogeneous isoechoic (n = 3) or heterogeneous (n = 5). No complications occurred after the FNAB. Our limited experience showed that a convex probe was convenient and useful in the detection of apical malignancies. Apical malignancies, diagnosed previously by percutaneous needle aspiration under fluoroscopy or surgical intervention, can be easily diagnosed by percutaneous FNAB, especially when the FNAB is performed using the supraclavicular approach.

Pentazocine addict nephropathy: a case report

Medical complications associated with narcotic addiction include bacterial endocarditis, pneumonia, pulmonary embolism and renal disease. Renal disorders associated with pentazocine abuse are rarely reported. They vary with method of administration, dosage, and duration of abuse. We describe a 33-year-old male addict, using intravenous pentazocine for 6 years. He has nephrotic syndrome with a rapid deterioration of renal function to a uremic stage within 3 weeks. The laboratory data includes: IgG 1270 mg/dl, IgA 369mg/dl, IgM 326mg/dl, C'3 65.2 mg/dl, C'4 16.3 mg/dl, and serum soluble interleukin-2 receptor level (sIL-2R) greater than 6000U/ml. A renal biopsy revealed membranoproliferative glomerulonephritis (MPGN) type I with tubulointerstitial nephritis. Immunofluorescent (IF) study revealed granular deposition of C'3 and IgM in mesangium and the glomerular capillary wall. The pathogenesis of glomerular disease in drug addicts is discussed, and the literature reviewed.

[Intraoperative pleural lavage in lung cancer patients]

In lung cancer patients, pleural effusion may or may not be present even if cancer cells have invaded the pleura. Using the traditional staging methods, not all pleural metastasis can be detected before the presence of pleural effusion. We performed intraoperative pleural lavage on 38 patients who underwent a thoracotomy due to tumors of the lungs. The first lavage (lavage 1) was performed just after the pleural cavity was open; the second lavage (lavage 2) was performed after all surgical procedures were completed (including lung resection and mediastinal lymph node dissection). Totally 12 of the 32 primary lung cancer patients were found to have positive lavage 1 cytology; 13 had positive lavage 2 cytology. In 13 patients whose visceral pleura was invaded by tumor, 11 had a positive lavage 1, 10 had a positive lavage 2. For prediction of positive lavage 1 cytology from visceral pleural involvement, the accuracy was 90.6%, the sensitivity was 84.6%, the specificity was 94.7%, the positive predictive rate was 91.7%, the negative predictive rate was 90.0%. For lavage 2, the accuracy was 81.2%, the sensitivity was 76.9%, the specificity was 84.2%, the positive predictive rate was 76.9%, the negative predictive rate was 84.2%. Stage of disease and cell type seemed to have no relationship to the incidence of positive lavage fluid cytology. Further investigation is recommended to evaluate the prognosis of patients with positive lavage fluid cytology.

Detection of mass lesions in the collapsed lung by ultrasonography

Ultrasonography is useful in the detection of mass lesions in the collapsed lung, using the collapsed lungs as a "sonic window". Twenty-four patients suspected of having a tumor causing lung collapse, as shown on their chest radiographs, were examined by ultrasonography. Eighteen out of 24 patients were found to have mass lesions in their collapsed lungs. Thoracic computed tomography (CT) was also performed in 12 of these 18 patients; of those, 11 showed compatibility with sonographic findings in the detection of mass lesions in their collapsed lungs. The remaining six of these 24 patients with no mass lesions detected by ultrasonography were proven to have collapsed lung due to sputum impaction (n = 2) and lung cancer (n = 4). The fact that four patients had lung cancer that was not detectable by ultrasonography, might have been due to relatively small mass lesions at deep locations (main or intermediate bronchus) and narrowing of the "sonic window" (partial lung collapse). Though it has some limitations, ultrasonography is helpful in detecting mass lesions in collapsed lungs. Sono-guided fine needle aspiration biopsy (SGFNAB) can also be performed simultaneously, smoothly and without any major complications. In our series, SGFNAB was performed in eight out of 18 patients to make a cytopathologic diagnosis. We recommend this safe, convenient, and noninvasive method to screen for lesions in the collapsed lung, especially when bronchoscopic examination is impossible.

Insulinoma: a case report

Insulinoma is a rare disease, which frequently causes hypoglycemic symptoms and signs or even shock. However, other diseases that produce similar symptoms and signs should firstly be ruled out. We describe a 63 years old male veteran who suffered from repeated episodes of seizure and conscious disturbance upon fasting, on and off for 8 years. Serial examinations led to the suspicion that this might be a case of insulinoma; the suspicion was later confirmed by pathologic examination after the tumor had been excised, and his problems disappeared. After six years, a follow-up examination showed that his condition was still stable.

Embryogenesis and plant regeneration from anther culture of bamboo (Sinocalamus latiflora (Munro) McClure)

Embryogenic callus was initiated from bamboo (Sinocalumus satiflora (Munro) McClure) anthers cultured on N6 medium supplemented with 1 mg/l 2,4-D, 1 mg/l BA, 2 g/l charcoal, 0.8% agar (Sigma) and 9% sucrose. Anthers with microspores at miduninucleate to early-binucleate stages showed better rate of response for callus induction. Prolonged culture of these embryogenic calli on the original medium or subculture to an auxin-free medium resulted in embryoid formation and their subsequent germination to form rooted plantlets. Chromosome counts from root-tip cells of anther-derived plant indicated that they were haploid (N=36).

[Giardiasis with malabsorption syndrome: report of one case]

A 10-year-old mentally retarded girl was sent to our hospital due to generalized edema, vomiting and poor appetite for several days. Serum albumin level was low, but no proteinuria was detected. Her stool was bulky and foul. Stool examination for parasite with formalin-ether concentration method revealed negative result. Trypsin activity test of stool revealed low trypsin activity as compared with normal specimen. Daily fecal fat exceeded upper normal limit. The diagnosis of giardiasis was confirmed by duodenal juice examination. Intestinal histology revealed mild shortening of the villi with increased mononuclear cell infiltration in the lamina propria. The daily stool amount decreased markedly after treatment with metronidazole 250 mg three times a day for 7 days. The edema subsided during the treatment. Serum albumin bevel returned to normal after the treatment. Giardiasis with malabsorption syndrome has often been overlooked in Taiwan. It is advised that in case of malabsorption syndrome giardiasis should be included in the list of differential diagnosis.

Acute duodenal ulcer

A series of 31 infants and children with acute duodenal ulcer verified by endoscopy was studied over an eight year period. Eighteen (58%) of them were under 2 years of age. The most common symptom was upper gastrointestinal bleeding (n = 27, 87%). Twenty nine patients (94%) had a preceding illness characterised by diarrhoea, upper respiratory tract infection, or fever, which was not necessarily treated with antipyretic drugs. Initial endoscopy showed that ulcer lesions were solitary in 14 patients and present on the anterior wall (n = 11), posterior wall (n = 2), or both (n = 1). Multiple ulcers were found in 17 patients, and present in the bulb with (n = 6) or without (n = 11) extension into the second part of duodenum. The most conspicuous finding was the irregularly shaped ulcers seen in eight young children with similar clinical and endoscopic features. Sixteen patients were re-endoscoped one to two weeks after the initial examination; the ulcers had entirely disappeared in 13, and there were only small residual ulcers in three. Thirty patients were treated medically and only one (with uncontrollable haemorrhage) required operation. Most patients were symptom free two to six years after the initial diagnosis. Our results suggest that young children may develop acute duodenal ulcers after viral illnesses whether or not they are treated with drugs, mainly antipyretics. This kind of acute duodenal ulcer usually heals quickly irrespective of the morphology, site, and number of ulcers.

[Achalasia: report of two cases]

The first case, a two-month-old female infant, had frequent vomiting since 5 days of age. Dilated esophagus with narrowed distal end was noted on barium meal study. Panendoscopic examination revealed dilated esophagus and a pin-head sized, stenotic lumen at 15 cm from the incisor. Under the impression of esophageal stenosis, gastrostomy was performed for feeding. Esophagogram made at 6 months of age demonstrated good patency of the esophagus without stenosis and gastrostomy was subsequently closed at the age of 1 year. Unfortunately, swallowing disturbance had bothered her intermittently since. Barium esophagogram and panendoscopy made 8 years later again revealed distal esophageal obstruction with dilated proximal esophagus. The second case was a two and half year old boy who suffered from frequent regurgitation of undigested food for 6 months. Dilated esophagus with narrowing of the lower end of esophagus was noted on barium meal study. After admission, panendoscopic examination revealed the esophagus was very narrow at 25 cm from incisor and the proximal esophagus was dilated. The esophageal dilatation with mercury-weighted bougies was performed intermittently. At present he is doing well, and a barium meal study showed adequate esophageal emptying.

Chronic duodenal ulcer in children: clinical observation and response to treatment

Chronic duodenal ulcer is diagnosed more frequently in children since recent advances in panendoscopy techniques. From 1976 to 1986, chronic duodenal ulcer was diagnosed in 33 children in this hospital. There was a marked male preponderance (male: female = 4.5:1). Family history for peptic ulcer was positive in 36% of the patients. The important element of emotional stress was identified in 39% of the patients. Thirty patients received medical treatment, and 26 were observed for more than 1 year (1-10 years). In 11 children, medication was changed because of symptom recurrence and change in the mode of treatment. The patients were divided into three groups with different treatment regimens: antacid (12 cases), cytoprotective agent (sucralfate, 17 cases), and histamine H2-receptor antagonist (cimetidine, eight cases). The response to short-term (eight-week) therapy was similarly good (83-94%) in the three treatment groups. However, sucralfate is superior to antacid in the ongoing maintenance therapy of chronic duodenal ulcer in childhood. Because chronic duodenal ulcer recurred frequently, it is crucial to give long-term maintenance therapy.

Endoscopic findings in pediatric patients with Henoch-Schonlein purpura and gastrointestinal symptoms

We report the gastrointestinal endoscopic findings in nine patients with Henoch-Schonlein purpura. Eight patients underwent upper gastrointestinal endoscopy, which revealed erosive gastritis in one patient, hemorrhagic-erosive duodenitis in four, and both findings in one. The rectum and the sigmoid colon were examined in six patients. Aphthoid ulcers were noted in two. In one of these patients, a rectal ulcer was also noted. Severe inflammatory changes and angiitis were found in the biopsy specimens obtained from the duodenum and the colon. The vascular abnormalities in the gastrointestinal mucosa are similar histologically to those found in the skin in Henoch-Schonlein purpura.

Gastroduodenal motility in neonates: response to human milk compared with cow's milk formula

It is known that breast milk empties more quickly from the stomach than does infant formula. We studied the difference in gastroduodenal motility between neonates fed with human milk and those fed with infant formula. Twenty-four five- to 36-day-old neonates were fed with mother's breast milk or with a cow's milk-based formula. Postprandial gastroduodenal contractions were recorded manometrically for three hours. Repetitive, high-amplitude nonmigrating contractions were the dominant wave form during the postprandial period. The number of episodes, duration, amplitude, and frequency of nonmigrating contractions were not different following the different feedings. The migrating myoelectric complex, which signals a return to the interdigestive (fasting) state, appeared in 75% of breast milk-fed infants but only 17% of formula-fed infants (P less than .05) within the three-hour recording period. Because contractions were similar following the two meals, but a fasting state recurred more rapidly in breast-fed infants, we conclude that factors other than phasic, nonpropagated antroduodenal contractions were responsible for the differences in gastric emptying between breast milk and formula.

Lactose malabsorption and small-intestinal lactase in normal Chinese children

A total of 852 healthy Chinese children from 1 month to 14 years of age were investigated for lactose malabsorption using the breath hydrogen test. A lactose load of 2 g/kg was administered to 528 children and 1 g/kg to another 324 children. The incidence of lactose malabsorption was significantly different among various age groups and between the two different lactose dosages. While the incidence of malabsorption increased strikingly from the age of 3 to the age of 5 years, the age effect remained constant after the age of 6 years. The lactose load of 2 g/kg induced a higher incidence of malabsorption in study subjects than 1 g/kg did, and the dose effect increased for those aged below 5 years and decreased above 5 years. Small-intestinal lactase was also studied in 34 children aged from 2 months to 15 years. The lactase activity was highest in children 2 years old or younger, gradually decreasing with increasing age. In conclusion, lactase activity in Chinese children decreases gradually after 3 years of age, a finding that correlates well with the results of the breath hydrogen test.

Statistical analysis of symptoms and signs in pediatric patients with peptic ulcer

It is not well known which symptoms or signs related to peptic ulcer are crucial for its diagnosis in children. In order to clarify this problem, we evaluated the sensitivity, specificity, and positive and negative predictability of 13 ulcer-related symptoms and signs. The data of 160 patients, who were suspected of having peptic ulcer and had undergone endoscopic examinations, were studied. It was significant that five symptoms, i.e., presence of pain in the epigastrium, relationship between the time of pain and that of eating, family history, vomiting, and bleeding, were frequently found in ulcer patients. There was, however, no symptom or sign that predicted by itself precisely the existence of a peptic ulcer. Thus, we computed a discriminant function by combining the data by multivariate analysis. With this score, we could predict the existence of ulcer more precisely. Finally, it was concluded that epigastric pain, food-related pain, vomiting, bleeding, and family history were crucial factors for the diagnosis of peptic ulcer in childhood and that an overall consideration of symptoms and signs was needed for the evaluation of these factors.

Endoscopic examination of the upper gastrointestinal tract in infancy

Forty endoscopic examinations of the upper gastrointestinal tract were performed in 38 infants with an age range from 2 days to 12 months. The main indications were upper gastrointestinal bleeding, chronic intractable vomiting, and small intestinal biopsy. Duodenal ulcer, hemorrhagic gastritis, and gastric erosions were the most common causes of upper gastrointestinal bleeding in infancy. An acute viral infection with fever, aspirin ingestion, and diarrhea frequently preceded gastrointestinal bleeding from duodenal ulcer and gastric erosion. Four of the 27 bleeding patients demonstrated no abnormality endoscopically.

Protein requirements of normal infants at the age of about 1 year: maintenance nitrogen requirements and obligatory nitrogen losses

With 34 normal, healthy male infants aged 9-17 months, a total of 61 nitrogen (N) balance studies was conducted with N intake between 12 and 180 mg/kg/day. By regression analysis, the crude N maintenance requirements, either with whole egg or cow's milk protein, were estimated to be about the same, 106 and 103 mg/kg/day, respectively. The 97.5% confidence limits for the requirements were 128 (egg) and 142 (milk) mg/kg, respectively. Sums of the obligatory urinary and fecal N for the egg and milk protein series were 75 and 71 mg/kg as compared with 76 mg/kg of actually measured figure. Ratio of the maintenance N requirement to the obligatory N loss was 1.4. In another 15 N balance study, for which N intake from milk formulae ranged between 220 and 320 mg/kg/day, the mean apparent N retention was 25% of the intake. Total integumental N losses (skin + hair + nail) of infants fed 217-522 mg N/kg/day amounted to 7.8 +/- 2.9 mg/kg daily. Egg protein had somewhat higher digestibility than cow's milk protein, 92 versus 87%, but has lower biological value, 76 versus 82. Net protein utilization (NPU) estimated from the regression line was about the same for both proteins, 71 and 69, respectively.