Endoscopic sphincterotomy in 1000 consecutive patients

Between 1983 and 1988, endoscopic sphincterotomy was attempted on 1000 consecutive patients with a clinical diagnosis of bileduct stones in a centre with a policy to establish immediate bileduct drainage for retained stones. Endoscopic cholangiography was successful in 985 patients, of whom 782 had visible stones and 203 had a dilated bileduct but no visible stones. Endoscopic sphincterotomy was successful in 975 of these patients, with eventual bileduct clearance in 674 of 772 patients (87.3%) with visible stones; immediate bileduct drainage was achieved in 160 of the 161 patients (99%) in whom bileduct clearance failed at the first attempt. Overall, 771 of 797 patients (96.7%) with visible bileduct stones had successful bileduct clearance or drainage. Complications occurred in 6.9%, with a 30-day mortality rate of 1.2%, but procedure-related mortality was only 0.6%.

Serum pepsinogen I and IgG antibody to Campylobacter pylori in non-specific abdominal pain in childhood

A consecutive series of 51 children (mean age 11 years) who presented with recurrent abdominal pain were investigated by upper gastrointestinal endoscopy including three antral biopsies for microscopy, culture and urease testing. Serum IgG, IgA, and IgM antibodies to Campylobacter pylori (C pylori) were measured by the ELISA technique. Serum pepsinogen I was also measured. Thirty two children showed histological evidence of gastritis. All had C pylori on microscopy and or culture. Nineteen children showed no histological gastritis nor evidence of C pylori on microscopy, culture and/or urease testing. The IgG and IgA antibody levels to C pylori were significantly higher in C pylori positive children than in the negative group (p less than 0.001). Serum pepsinogen I concentrations were also significantly higher in C pylori positive children than in negative (p less than 0.001). Measurement of IgG antibody levels, combined with serum pepsinogen I estimation, predict the presence of C pylori associated gastritis in children with a sensitivity and specificity of up to 95%. It may be used therefore to predict gastritis and even peptic ulceration in children presenting with non-specific upper abdominal pain.

Is duodenal diverticulum a risk factor for sphincterotomy?

It is uncertain whether ERCP and associated procedures are more difficult when the papilla is inside or adjacent to a duodenal diverticulum. We have therefore reviewed the data from 2458 consecutive, prospectively reported ERCPs between November 1983 and March 1988. Three hundred and eight patients (12.5%) had periampullary diverticula and in 21 the papilla was located deep within the diverticulum of whom 227 had undergone endoscopic sphincterotomy (73.7%). Comparison was made with the 2150 patients without diverticula of whom 1223 (56.9%) had undergone sphincterotomy. The success rate of specific duct cannulation was 94.2% in the diverticulum group and 96.7% in those without diverticula (p less than 0.05). The overall success rate of endoscopic sphincterotomy was 95.2% in the diverticulum group, as compared with 98.0% in those without diverticula (p less than 0.05). The procedure related morbidity and mortality of sphincterotomy were 5.2%/0.9% and 4.0%/0.7% respectively (NS). If only those who had successful cholangiography were included there was no difference in sphincterotomy success between those with and without diverticula. The group of patients with papilla deep within diverticula had a slightly higher failure rate of pure endoscopic sphincterotomy (11.8% v 5.7%: NS) but did not have a higher complication rate. In the subgroup of patients with choledocholithiasis, duct clearance of stones was as successful after sphincterotomy in those with diverticula as in those without. Medium term complications (mean 26 months) occurred in 1.4% of patients with diverticula and in 0.7% of patients without diverticula. We conclude that diagnostic cholangiography is more difficult when the papilla is closely associated with a diverticulum but that if diagnostic cholangiography is obtained, sphincterotomy may be performed as successfully and as safely in those with or without diverticula.

Endoscopic therapy of the sump syndrome

Seventeen consecutive patients with the sump syndrome were treated at the Middlesex Hospital between November 1983 and December 1987. Fifteen were treated primarily by endoscopic sphincterotomy and two primarily by resective surgery because of coincident severe painful chronic pancreatitis. Endoscopic sump clearance was successful in thirteen out of fifteen cases (87%) with no morbidity or mortality. The two endoscopic failures were managed surgically. Follow-up (mean 18 months; range 2-48 months) has shown complete resolution of symptoms in twelve (71%), with mild or moderate ongoing symptoms in the remaining five. All patients with ongoing symptoms after sump clearance had abnormal retrograde pancreatograms at the time of ERCP. Endoscopic sphincterotomy is the treatment of choice for the sump syndrome, with the possible exception of patients with coincident painful severe chronic pancreatitis, who may require pancreatic resection. Indeed, the sump may be a factor in the development and perpetuation of an obstructive chronic pancreatitis, and a trial of endoscopic clearance may be indicated even in these patients. The sump syndrome should no longer be regarded as a major long-term disadvantage of side-to-side biliary bypass, provided that the condition is considered early in those with compatible symptoms after biliary bypass, and appropriate investigation and treatment is instigated.

Endoscopic endoprosthesis insertion following failure of cholecystojejunostomy in pancreatic carcinoma

Sixteen patients in whom malignant biliary obstruction recurred after failure of cholecystojejunostomy had attempted relief of obstruction by endoscopic insertion of an endoprosthesis. This treatment was successful in 13 patients, although one required percutaneous insertion because of duodenal distortion and one required a combined percutaneous-endoscopic approach. Median survival after stenting was 3.5 months (range from 2 weeks to 16 months). Of the three treatment failures, two patients had external drainage only and one succumbed before further treatment could be attempted. There were two complications associated with the procedure (one small bile leak and one episode of cholangitis) but the 30-day mortality rate of 12.5 per cent was related to disease progression rather than the procedure. Endoscopic stent insertion may achieve further worthwhile palliation of jaundice after the failure of surgery to relieve malignant biliary obstruction.

Amoxycillin plus tinidazole for Campylobacter pylori gastritis in children: assessment by serum IgG antibody, pepsinogen I, and gastrin levels

32 children (mean age 12 years, range 6-18) with non-specific abdominal pain and Campylobacter pylori positive gastritis received a six week course of daily oral amoxycillin (50 mg/kg) and tinidazole (20 mg/kg). Before treatment and one month after stopping treatment, endoscopic biopsy samples were taken from the antral mucosa and serum C pylori IgG antibody, pepsinogen I, and gastrin levels were measured in fasting blood samples. One month after treatment 30 children (94%) were cleared of C pylori and gastritis had resolved in 27 (84%) and was improved in the remaining 5. Serum IgG, pepsinogen I, and gastrin levels were significantly decreased after treatment. Of 12 children assessed at six months, 9 remained free of C pylori. Increases or decreases in IgG level indicated clearance or recurrence, respectively, of C pylori.

Endoscopic biliary therapy using the combined percutaneous and endoscopic technique

Between September 1985 and December 1987, 74 patients underwent attempted endoscopic biliary therapy using a combined percutaneous transhepatic and endoscopic transpapillary approach (combined procedure). All patients had had failed endoscopy-alone procedures and had contraindications to surgery. The indication was palliation of malignant biliary obstruction in 66 cases (41 common bile duct, 25 hilar), assistance with sphincterotomy for the removal of common bile duct stones in 6 cases, and management of benign biliary stenosis in 2 cases. The initial procedure was percutaneous transhepatic access to the biliary tree, which was successful in all but 1 case (99%). The bile duct was drained externally for an average of 3.4 days before the combined procedure. One patient died during this period from hemorrhage associated with liver puncture. Combined procedure was performed in 72 cases and was successful in 60 [53 malignant stricture (53/66 = 80%), five common duct stone (5/6 = 83%), two benign stricture (2/2 = 100%)]. Procedure-related morbidity and mortality, respectively, were 12.5% and 0% for benign disease and 36% and 3% for malignant disease. The total (initial endoscopy included) morbidity and 30-day mortality were 33% and 0%, respectively, for benign disease and 62% and 27% for malignant disease. Subsequently, stent change has been required on 16 occasions, with endoscopy-only successful in 13 (81%) and repeat combined procedure being required in three (19%). The combined procedure improves the ability of endoscopy to offer nonsurgical therapy to poor risk patients with both malignant and benign biliary disease but is associated with significant morbidity and disease-related mortality.

The source of Campylobacter pylori

Sera from 98 abattoir workers were tested for IgG as well as for IgA to Campylobacter pylori, C. jejuni and Klebsiella. Clerical workers had significantly lower C. pylori and C. jejuni antibody levels than any of the groups in direct contact with freshly cut animal parts. No difference was found for antibodies to Klebsiella. Twenty-nine non-clerical workers with high IgG antibody levels against C. pylori consented to upper gastrointestinal endoscopy. C. pylori associated gastritis was found in all 29, and 4 weeks of colloidal bismuth subcitrate (240 mg/twice daily) was prescribed. On repeat testing at 3 months, all showed a decrease in IgG antibody levels to C. pylori but not to C. jejuni, whereas 18 untreated non-endoscoped workers showed no change. These findings raise the possibility that C. pylori infection is a zoonosis.

Sclerosing cholangitis in acquired immunodeficiency syndrome. Case reports and review of the literature

Four patients with acquired immunodeficiency syndrome (AIDS) (CDC group IV) were investigated for biliary disease because of the presence of both severe upper abdominal pain and raised levels of serum alkaline phosphatase. None was clinically jaundiced. Upper abdominal ultrasound was abnormal in three. All had endoscopic retrograde cholangiographic evidence of both an intrahepatic sclerosing cholangitis suggestive of primary sclerosing cholangitis and an irregular suprapapillary common bile duct dilation suggestive of papillary stenosis. Three had evidence of gastrointestinal cryptosporidiosis and two of disseminated cytomegalovirus infection. Endoscopic sphincterotomy, performed in two patients, gave good pain relief. We propose the name 'AIDS sclerosing cholangitis' for this form of secondary cholangitis. The cause of this disorder remains unclear. Recent evidence is discussed which suggests that it is not due to HIV itself but to an opportunistic infection. Cryptosporidium appears to be the most likely candidate.

Interventional endoscopy in the pancreatobiliary tree

Since the advent of endoscopic retrograde cholangiopancreatography (ERCP) in 1970 and endoscopic sphincterotomy (EST) in 1974, there has been rapid proliferation of endoscopic techniques for the diagnosis and therapy of benign and malignant biliary and pancreatic disorders. The ability to biopsy under direct vision, reliably obtain a pancreatogram, exclude other upper gastrointestinal disorders, and reexamine with ease, combined with the lack of hepatic puncture, has given the endoscopic route an undeniable advantage over the percutaneous transhepatic route for these interventions. Although some have become routine procedures (EST for postcholecystectomy choledocholithiasis; transpapillary stent insertion for inoperable biliary stenoses), the exact place of many of these interventions remains unclear, and the subject of prospective controlled studies where possible. This review attempts to give an overview of present and developing ERCP- and EST-based diagnostic and interventive techniques and their application to the wide spectrum of pancreatobiliary diseases.

Campylobacter pylori in abattoir workers: is it a zoonosis?

Sera from 98 abattoir workers were tested for IgG to Campylobacter pylori, C jejuni, and klebsiella. Clerical workers had significantly lower C pylori and C jejuni IgG titres than any of the groups in direct contact with freshly cut animal parts. No difference was found for antibodies to klebsiella. 28 non-clerical workers with high-titre C pylori IgG consented to upper gastrointestinal endoscopy. C pylori associated gastritis was found in all 28, and four weeks of colloidal bismuth subcitrate (240 mg twice daily) was prescribed. On repeat testing at three months all showed a decrease in IgG titres to C pylori but not to C jejuni, whereas 18 untreated non-endoscoped workers showed no change. These findings raise the possibility that C pylori infection is a zoonosis.

Cancer of the gastric stump in Italy, 1979-1986

Sixteen thousand fiberoptic endoscopies were reviewed. Gastric stump cancer was found in 24 patients of 368 who had had gastric resection for benign peptic disease. A direct relation between the percentage of patients with cancer of the gastric stump and the postsurgical interval was observed. Patients with partial gastrectomy who are 15 to 20 years postoperative should have an endoscopy irrespective of presence or lack of symptoms. Multiple biopsies should be taken in view of the multicentric growth pattern of early carcinoma.

Natural infection of Swiss mice with mouse mammary tumor virus (MMTV): viral expression in milk and transmission of infection

Quantitative determinations of gp52, the main envelope glycoprotein, and p28, the main core protein, of MMTV, have been performed in about 1000 individual samples of milk of breeding females from our colony of MMTV-infected Swiss mice, a line characterized by a moderate incidence of mammary tumors. A computer analysis of the results showed: 1-- an important individual variation, ranging from 0 to 120 micrograms per ml of milk for p28, and from 0 to 320 micrograms per ml of milk for gp52; 2-- a variation of the release of both antigens during a single lactation, with a maximum on the 7--8th day of nursing; 3-- an increase of the release of both antigens with parity up to the 6th lactation, followed by a marked decrease during later lactations; 4-- a higher degree of infection in the offspring of 2nd and 3rd litters. The possible dependence of viral expression and transmission of infection upon factors such as cyclic activity of the mammary gland and progressive immunization of mice against MMTV is analyzed. The status of our laboratory line of MMTV infected Swiss mice is discussed in comparison with high and low tumor incidence strains.

Return of splenic function after splenectomy: how much tissue is needed?

Ninety patients whose spleen had been removed either because of trauma (41 cases) or as an elective procedure (49) were investigated for return of splenic function by counting pitted red cells and examining spleen scans made after injection of heat damaged 99mTc labelled red cells. There was no significant difference in the proportion of pitted red cells between the two groups of patients. Evidence of splenic tissue in scintiscans was not invariably associated with low pitted red cell values, suggesting that the presence of splenic tissue did not necessarily mean return of splenic function. In every patient whose proportion of pitted red cells was less than 16.2% the scintiscan showed splenic uptake. The proportion of patients with pitted red cell values below 16.2% was significantly higher in the group operated on for trauma, and it is concluded that this was due to splenosis. A high inverse correlation between pitted red cell counts and computed splenic volumes was found. Patients with pitted red cell values of less than 16.2% had computed volumes of 22-133 cm3; below this range the proportion of pitted red cells rose very sharply. These results confirm that splenosis occurs in adults, though less often than in children, and suggest that when splenic tissue is to be implanted a graft of at least 20-30 cm3 is needed to ensure satisfactory return of splenic function.

Peroral infection of suckling mice with milk-borne mouse mammary tumour virus: uptake of the main viral antigens by the gut

Persistence of mouse mammary tumour virus (MMTV) components in the digestive tract of suckling mice was investigated by immunoperoxidase staining of the main viral antigens and micro-immunoenzyme assays of gp52 and p28; these latter assays were also performed after ingestion of milk enriched in viral antigens using Cr2O3 as a marker for the alimentary bolus migration. When compared to the ingested antigens, the amounts of gp52 and p28 decreased during transit, p28 being more rapidly digested than gp52. The antigens were, however, destroyed to a much larger extent in the gut of the adult than in that of the newborn mouse. A fraction of the marker remained for a long time in the stomach; a prolonged retention was also observed with gp52 and especially with p28. Significant amounts of viral antigens were detected in the intestinal walls: both p28 and gp52 were found in the duodenum and small intestine. Moreover, the four viral antigens gp52, gp36, p28 and p8 were clearly observed in very large supranuclear vacuoles inside the epithelial cells of the distal part of the gut. Total particles can reach the intestine; the viral material could then be either destroyed or taken up in the epithelial cells by endocytosis, so that the intestinal epithelium might serve as a portal of entry for MMTV in the suckling mouse.

Effect of gluten-free diet on splenic hypofunction of adult coeliac disease

Splenic function has been serially measured by counting pitted red cells in 15 coeliac patients, before and during a gluten-free diet. The basal percentage values of pitted cells decreased significantly during treatment but no correlation was observed between the duration of the gluten-free diet and the percentage of recovery of splenic function over basal values. Out of six coeliacs with pitted cell values consistent with splenic hypofunction, three showed a total recovery after gluten withdrawal. Our data suggest that, contrary to recent reports, hyposplenism in adult coeliac disease is improved by a gluten-free diet, and that environmental factors may be important in determining and maintaining this complication.

Anti M-protein antibody response to type A or B natural influenza detected by solid phase enzyme linked immunosorbent assay and by complement fixation

Anti M-protein antibody response has been looked for in sera from individuals with serological evidence of A or B influenza infection using pure M-protein (M) in complement fixation tests (CF), in IgG and in IgA specific enzyme linked immunosorbent assays (ELISA). Mp ELISA (IgG specific) antibodies are not restricted to people with history of recent respiratory infection. Individuals under 15 years are less prone than those older to display M ELISA activity. Most M ELISA positive individuals are also nucleoprotein (NP) positive. There are more M than NP ELISA positives in the influenza A series whereas the reverse is observed in the influenza B series. Most of the M ELISA positives are also S CF (standard soluble antigen CF) positive indicating that M ELISA IgGs are related to recent infections. Some sera exhibit M ELISA activity with no other evidence of influenza experience than V CF (viral antigen CF) or HI (haemagglutination inhibition), suggesting that some recent influenza infections are better traced with M ELISA than with S CF. Amongst chronic bronchitis patients with V CF or HI antibodies to A2 influenza virus but no type A S CF activity, the proportion of M ELISA positives averages 40 per cent. This fact as well as two other features of that group i.e. cases with long lasting S CF activity and occasional virus isolation several months after the initial acute infection, suggest that influenza virus might cause prolonged infection in some patients with chronic bronchitis.