Gastrin sensitivity in duodenal ulcer

The sensitivity to pentagastrin measured as D50C, the dose required for half maximal acid output (MAO) corrected for basal acid output, in 200 patients with active duodenal ulcer was significantly (p less than 0.001) higher than that in 36 age- and sex-matched controls, and was above the normal limit in 27% of the patients. The distribution of D50C was significantly different between early onset and late onset patients, defined as patients whose ulcer symptoms started at respectively age less than or equal to 30 years and age greater than 30 years. Among patients whose MAO/kg body weight was within 2 SD of the normal mean as established previously in 100 normal subjects, gastrin sensitivity was significantly greater in late onset than in early onset patients, and in those who were positive than in those who were negative for familial ulcer dyspepsia. Among patients with abnormally large MAO, the reverse was true, gastrin sensitivity being greater in early rather than in late onset patients, and in patients negative rather than in those positive for familial ulcer dyspepsia. These findings suggest that gastrin hypersensitivity is a distinct physiological abnormality in duodenal ulcer, the increased gastrin sensitivity in some patients with normal MAO has a genetic basis but the lateness in onset of their disease also suggests an environmental origin, and the increased gastrin sensitivity in some patients with abnormally large MAO is related to environmental factors encountered early in life.

Randomised crossover trial of tripotassium dicitrato bismuthate versus high dose cimetidine for duodenal ulcers resistant to standard dose of cimetidine

Of 212 patients with duodenal ulcer treated with four weeks of one gram daily cimetidine, 25 had ulcers which underwent no reduction in size despite treatment. The effects of tripotassium dicitrato bismuthate (TDB) tablet four times a day or cimetidine 1.6 g daily on the healing of these cimetidine resistant ulcers were compared in a randomised crossover trial. Ten of 12 patients on tripotassium dicitrato bismuthate and five of 13 patients on high dose cimetidine had complete healing (p less than 0.02). On crossing over, seven of the eight ulcers not healed by high dose cimetidine completely healed with TDB in another four weeks, and one of the two ulcers not healed by TDB healed with high dose cimetidine. Overall, TDB healed 85% of cimetidine resistant ulcers, whereas high dose cimetidine healed 40% (p less than 0.006). Tripotassium dicitrato bismuthate is recommended for cimetidine resistant duodenal ulcers.

Recovery of malignant tumor cells from the right atrium during hepatic resection for hepatocellular carcinoma

Tumor cells were recovered from the right atrium in three of five patients during hepatic resection for hepatocellular carcinoma. Mechanical factors during blunt mobilization and rotation of the hepatic tumor appeared to be responsible for tumor dislodgement into the venous circulation. Tumor embolization to the lungs may be one of the important reasons for the poor results of surgery in this disease. Two possible technical and therapeutic modifications are suggested to prevent or neutralize this phenomenon.

Gastric acid secretion and its predictive value after vagotomy for perforated duodenal ulcer

In a prospective randomized clinical trial, gastric acid secretion was compared in patients after simple closure, proximal gastric vagotomy with closure, or truncal vagotomy with pyloroplasty performed for perforated duodenal ulcer. The basal and pentagastrin- and insulin-stimulated acid outputs were similar after either proximal gastric or truncal vagotomy; they were also comparable with the postoperative acid values after corresponding procedures performed electively for chronic duodenal ulcer. Conversely, the basal and maximum acid outputs after simple closure of perforation were no different from the preoperative acid outputs of a group of duodenal ulcer patients matched for age and sex. The efficacy of acid reduction by emergency proximal gastric and truncal vagotomy was shown by the respective ulcer recurrence rate of 3% (1/34) and 6% (2/32) compared with 43% (15/35) after simple closure (p less than 0.01). Acid secretory data and serum gastrin levels did not predict ulcer relapse in patients after simple closure of perforation.

Accurate prediction of duodenal-ulcer healing rate by discriminant analysis

Previous studies have shown that approximately 50% and 70% of duodenal ulcers heal after 2 and 4 wk, respectively, of cimetidine, and at least one-third heal after 4 wk of placebo. In order to identify these groups of ulcers before treatment, a two-phase study was performed, including an initial double-blind trial of cimetidine vs. placebo in 120 patients, and a subsequent open study with identical protocol of cimetidine vs. no cimetidine in another 60 patients. Forty clinical, personal, physiologic, and endoscopic characteristics were prospectively obtained in each patient, and were analyzed by stepwise discriminant analysis at the end of phase 1. This identified the discriminants against healing after 2 wk of cimetidine as late onset disease, body weight, and ulcer diameter; those after 4 wk of cimetidine as analgesic consumption, neurosis, low fasting serum gastrin, low pentagastrin D50 and ulcer diameter; and those after 4 wk of placebo as back pain, bleeding, and alcohol consumption. Based on the discriminant scores derived, the sensitivity, specificity, and efficiency of prediction for complete healing as determined endoscopically were 74.4%, 90%, and 82.3% for 2-wk cimetidine, 100%, 87.5%, and 97.5% for 4-wk cimetidine, and 85.7%, 83.3%, and 84.2% for 4-wk placebo treatment. In phase 2, correct predictions were made in 36 of 40, 39 of 40, and 17 of 20 patients treated, respectively, for 2 and 4 wk with cimetidine, and 4 wk without cimetidine. Accurate prediction of duodenal-ulcer healing rate with and without cimetidine is thus possible by discriminant analysis. As many medical and surgical modalities of treatment are now available, this approach should have the potential of selecting the appropriate form of treatment for a given patient.

Early- and late-onset duodenal ulcers in Chinese and Scots

Two unselected series of 528 Chinese and 539 Scottish patients with duodenal ulcer were compared. In both races, early-onset patients (symptoms began before age 30 years) in contrast to late-onset patients (symptoms began after age 30 years) constituted significantly more males, more patients with positive familial dyspepsia, more acid hypersecretors, and more gastrointestinal bleeding, but, unlike late-onset patients, there was no significant blood group O predominance, and their females did not have an older onset age than males. Among early-onset patients, Scottish patients developed symptoms at a significantly later age and had significantly more acid hypersecretors than Chinese, whereas among late-onset patients the Scots had significantly more patients with positive familial dyspepsia, in whom the frequency of acid hypersecretion was increased. These findings indicate that (i) early and late-onset duodenal ulcers are distinct subgroups, with many features common to both Chinese and Scots despite different ethnic backgrounds, suggesting the occurrence of similar pathophysiological mechanisms in the two races, (ii) for early-onset disease, these mechanisms appear to operate sooner in the Chinese, (iii) in the Scottish patients, familial late-onset duodenal ulcers with acid hypersecretion form a substantial and distinct subgroup.

Trends in hospital admission, perforation and mortality of peptic ulcer in Hong Kong from 1970 to 1980

During 1970-1980, admissions for peptic ulcers per 100,000 population to all government and government-assisted hospitals in Hong Kong increased by 21% from 152 to 185. At the same time, peptic ulcer perforations per 100,000 population increased by 71% from 9.3 to 15.9. The percentage of men greater than 60 yr of age with ulcer perforation rose from 18.1 to 24.4, while that in the general population rose from 2.9 to 3.9. However, the male/female ratio has remained stable at approximately 6:1. During the same period, mortality rate per 100,000 population due to peptic ulcer declined by 26% from 4.2 to 3.1. Thus, while the hospitalization and perforation rates for peptic ulcer appeared to be falling in the United States and the United Kingdom over the past decade, the opposite has occurred in Hong Kong.

Proximal gastric vagotomy, truncal vagotomy with drainage, and truncal vagotomy with antrectomy for chronic duodenal ulcer. A prospective, randomized controlled trial

The relative merits of proximal gastric vagotomy (PGV), truncal vagotomy with drainage (TV + D), and truncal vagotomy with antrectomy (TV + A) in the treatment of chronic duodenal ulcer were evaluated and compared in 152 patients in a prospective, randomized and controlled clinical trial. One death occurred after TV + A, resulting in an operative mortality of 2% after gastrectomy and 0.7% for the entire series. After one to six years, stomal and duodenal ulcers proven by endoscopy occurred in eight patients after PGV (16%) and in six patients after TV + D (11.8%); the difference was not statistically significant (p greater than 0.5). One additional patient developed a gastric ulcer nine months after PGV. There was so far no ulcer recurrence after TV + A. Majority (13 patients) of the recurrent ulcers were discovered within three years after surgery. Patients after PGV experienced significantly less unwanted side effects than those after either TV + D or TV + A; particularly, dumping, epigastric fullness, and diarrhea. When the functional status was graded according to a modified Visick system that excluded ulcer recurrence, significantly more PGV patients were placed in the near-perfect grade (82.1%) than TV + A patients (58%). Patients after TV + D fared better than patients after TV + A; but the differences were not significant. However, when ulcer recurrence was included in the functional assessment, the advantage of PGV was lost.

Immediate definitive surgery for perforated duodenal ulcers: a prospective controlled trial

A prospective, randomized, double-blind trial was conducted in 101 patients to evaluate the safety and benefits of immediate definitive surgery for perforated duodenal ulcers. These patients, who were judged by predefined criteria to be medically fit and to have perforations in chronic ulcers, were randomized to undergo simple closure (35 patients), truncal vagotomy and drainage (VD) (32 patients), or proximal gastric vagotomy with closure (PGV) (34 patients). Patients were followed with endoscopic assessment for up to 39 months. There was no mortality and only a few minor postoperative complications. At 39 months follow-up, the cumulative rates of recurrence were 63.3%, 11.8% and 3.8% after closure, VD, and PGV, respectively (p less than 0.001). With the exception of the one recurrence after PGV, all relapses were symptomatic, and eight of these 18 required reoperation. Relapse rates and Visick scores between VD and PGV were significantly different. Both safe as well as effective, immediate, nonresective, definitive operation is indicated for good-risk patients who have perforations in chronic duodenal ulcers.

Mucoepidermoid carcinoma of the bile duct

Three patients with mucoepidermoid carcinoma of the bile duct are described. In two patients the tumor arose from the common hepatic duct. Mucoepidermoid carcinoma of the extrahepatic bile duct has not been previously reported. The clinical features and pathologic behavior of this rare type of tumor are similar to the usual biliary adenocarcinoma. The coexistence of Clonorchis sinensis infestation and primary pyogenic cholangitis raises the possibility of an etiologic association.

Survival after surgery for advanced carcinoma of the stomach other than the cardia

The survival of 103 patients operated on for advanced carcinoma of the stomach other than the cardia was assessed. The median duration of survival for patients subjected to palliative partial gastrectomy, total gastrectomy, gastrojejunostomy, and biopsy only was 24, 22, 11, and 10 weeks, respectively. All of these patients had definite residual tumor. In the 27 patients with preoperative signs of incurable tumor, the high operative mortality rate (19 percent), the low rate of resectability (26 percent), and the short duration of survival in the patients who had resection (median 11 weeks) combined lead to the conclusion that exploration for the possibility of resection is not worthwhile.

Selective coating of gastric ulcer by tripotassium dicitrato bismuthate in the rat

Controlled clinical trials have shown that tripotassium dicitrato bismuthate healed duodenal and gastric ulcers significantly better than placebo. One mechanism suggested is that it forms a protective coat at the ulcer base. We studied this coating action in rats with chronic gastric ulcers produced by a standardized technique for mucosal wounding at the fundoantral junction. Bismuth was identified by histochemical staining using Castel's reagent, the specificity of which was verified in vitro against 13 other metallic compounds and chemicals. Our results showed that tripotassium dicitrato bismuthate had a coating affinity for the ulcer base, but not for the adjacent normal mucosa. All rats treated with tripotassium dicitrato bismuthate 1, 2, 4, and 6 h previously, but not the control rats treated with water or those treated with four other bismuth compounds, manifested a layer of bismuth that coated the ulcer base. Light and electron microscopy of the tripotassium dicitrato bismuthate-treated ulcers--but not their controls-revealed an abundance of macrophages, which had ingested the bismuth. This unique bismuth coat may insulate the ulcer base from acid-pepsin digestion, while the influx of macrophages may expedite reparative processes.

Cimetidine versus surgery for recurrent ulcer after gastric surgery

The efficacy of cimetidine vs. surgery in the treatment of recurrent ulcers after definitive surgery for chronic duodenal ulcer was evaluated in two comparable groups (23 each) of patients. Cimetidine 1 g daily healed 79% and 91.6% of recurrent ulcers, as assessed endoscopically, after 6 and 12 weeks respectively. At the end of one year, maintenance treatment with cimetidine (400 mg nocte) prevented relapse in 89.5% of the healed ulcers, while surgery was successful in 94.4% (p greater than 0.1). The cimetidine group experienced significantly (p less than 0.05) less side effects than the surgical group, with respectively 10% and 50% of patients having Visick grade II and above. After one year of maintenance treatment, cimetidine was withdrawn, and ulcer recurred in 71.4% within six months. The relapse rates between the two groups were significantly different by life-table analysis (p less than 0.01). We conclude that cimetidine was as effective as surgery in preventing relapse of postsurgical recurrent ulcers and had fewer side effects, but indefinitely prolonged therapy appeared necessary.

Brainstem-evoked responses of guinea pigs exposed to high noise levels in utero

Pregnant guinea pigs were exposed to loom room noise at 115 dB A for 7.5 hr/day for various periods during the last one-third of pregnancy. When the hearing of their offspring was tested by auditory brain stem-evoked response techniques at 6-dB intervals, peak IV latencies of exposed pups were found to be significantly longer than those of otherwise similar control pups. The latency differences corresponded to a 5-dB increase in stimulus at medium stimulus levels and 10-12 dB near threshold. The results indicate that it is possible for noise-induced loss to occur in utero in mammals whose auditory maturation process is complete, or nearly so, before birth.

Carcinoma of the gallbladder

A retrospective study of 100 proved cases of primary carcinoma of the gallbladder admitted to the University Surgical Unit, University of Hong Kong, over a 20-year period was undertaken. The female to male ratio was 1.4 to 1. The peak incidence was in the seventh decade for the females and the sixth decade for the males. Preoperative diagnosis was made in 10 patients. "Curative" cholecystectomy was performed in 20 patients with a 5-year survival rate of 10 per cent. Palliative procedures were performed in 44 patients with a median survival of 8 weeks, which was not significantly different from that in the 30 patients who were not operated upon or had laparotomy and biopsy only. Radical resection was carried out in 6 patients, all of whom died in hospital. Gallstones were found in only 26 patients. The gallbladders of 3 patients had associated benign tumours, one of which had malignant transformation at multiple sites. One patient had chronic typhoid infection. The incidence of clonorchis infestation and primary pyogenic cholangitis in these 100 patients was not different from that of our general hospital population.

A series of hexahydro[1,4]oxazino[3,4-a]isoquinolines as potential neuroleptics

The synthesis and stereochemistry of trans-N,N-diethyl-9,10-dimethoxy-1,3,4,6,7,11b-hexahydro[1,4]oxazino[3,4-a]isoquinoline-3-carboxamide hydrochloride (16) and a series of analogues are described. 16 and its (+) isomer had neuroleptic properties in the Sidman avoidance test in gerbils. A few closely related amides of the trans series were active but cis amides were inactive as neuroleptics.

Spontaneous perforation of the bile ducts in infancy

The clinical features of spontaneous perforation of the bile ducts in infancy differ sufficiently from those of other causes of neonatal jaundice to allow early preoperative diagnosis as demonstrated by a report of this condition in a 6-week-old infant. Despite its rarity, the clinician should be aware of this entity because early recognition and surgery will ensure cure in almost all cases. The cause of spontaneous perforation of the bile ducts is unknown. Trauma, congenital weakness and abnormal bile are considered as possible etiologic factors.

A human/mouse hybrid model for the study of human genetic factors influencing tumor cell growth

Somatic cell hybridization (fusion) was carried out between cells of the murine lymphoma L-5178Y(r) and peripheral human lymphocytes. The L-5178Y(r) line is deficient in hypoxanthine-guanine phosphorybosyl transferase (HGPRT). Using a selective medium system, it was possible to isolate hybrid cell clones having the complete complement of murine chromosomes as well as the human X chromosome on which the gene for HGPRT is located. This model system may be used to study the effect of the human X chromosome on the phenotype of the murine lymphoma.