Levels of zinc and thymulin in plasma from patients with Crohn's disease

Levels of zinc in plasma from patients with Crohn's disease were significantly lower than those of sex and age matched controls. We also measured the level of plasmic thymulin, a hormone released by the thymus gland, which in its active form binds one zinc molecule. The zinc unbound form of thymulin is biologically inactive and its level in the blood is a very sensitive marker of even marginal zinc deficiency. Levels of active thymulin were significantly reduced in plasma from patients with Crohn's disease, whereas plasma concentrations of the inactive form was higher than in controls. The in vitro addition of zinc ions restored thymulin activity in plasma from patients with Crohn's disease, and induced the disappearance of the inactive form. These findings suggest the existence of a zinc dependent alteration regarding the biological function of thymic hormones in patients with Crohn's disease. Such a defect might explain some of the immunological abnormalities observed in these pathological conditions.

The esophagus as a possible cause of chest pain in patients with and without angina pectoris

In a series of 18 patients with angina pectoris, in whom treatment over at least 3 years with nitroderivatives and Ca-antagonists had become partially ineffective on chest pain, and in 18 patients with angina-like non-cardiac chest pain, the following examinations were carried out: upper gut x-ray and endoscopy, acid perfusion test, esophageal manometry, 24-hour esophageal pH monitoring associated with Holter recording. The presence or absence of coronary insufficiency was established by means of scintigraphic and ECG tests, Holter monitoring and coronary arteriography. In both groups the majority of patients had abnormal esophageal function, but in patients with angina pectoris treated for a long period of time the motility changes were prevalently reflux-related. With respect to the origin of chest pain, the esophagus was found to be the likely cause in 4 patients with angina pectoris, and the probable cause in another 10 of the same group; it was the likely cause in 7 patients without angina pectoris, and the probable cause in another 7 of the same group. As nitroderivatives and Ca-antagonists decrease the LES tone and the amplitude of esophageal pressure waves, long-term treatment with these drugs may be taken into account in the genesis of gastro-esophageal reflux and related changes, including esophageal pain.

Diabetic retinopathy in chronic pancreatitis

Using fluorescein angiography, we studied the prevalence and characteristics of diabetic retinopathy in 40 patients with chronic pancreatitis complicated by diabetes and in 40 type 1 diabetics with comparable duration of diabetes. Retinopathy was found in 19 pancreatitis patients (47.5%) and in 20 type 1 diabetic patients (50%); it was background, minimal, or mild to moderate, without impairment of visual function, in all 19 pancreatitis patients and in 17 of the 20 type 1 diabetics. In the remaining three idiopathic diabetics, retinopathy was background of severe degree in two and proliferative, with impairment of vision, in one. No differences between patients with and without retinopathy were observed in fasting blood glucose, glycosylated hemoglobin, serum cholesterol, or triglyceride levels. The only significant difference (p less than 0.001) was the greater duration of diabetes in patients with retinopathy when compared with those without it (10.8 +/- 5.7 vs. 5.2 +/- 3.9 yr in pancreatitis patients; 11.2 +/- 5.0 vs. 5.1 +/- 3.5 yr in type 1 diabetics; mean +/- SD). Contrary to what is generally believed, the results indicate that the risk of retinopathy and the characteristics of this complication in patients with chronic pancreatitis and secondary diabetes are similar to those in patients with idiopathic diabetes.

Assessment of portal hypertension by endoscopic ultrasonography

Endoscopic ultrasonography (EUS) was performed in 40 patients with portal hypertension (PH) and in 48 control subjects. The azygous, splenic, mesenteric, and portal veins were displayed in both groups. However, esophageal and gastric varices, periesophageal and perigastric collateral veins, and submucosal gastric venules were displayed only in patients with portal hypertension. EUS was inferior to endoscopy in detecting and grading esophageal varices (p less than 0.0005), but EUS was superior in the detection of varices in the fundus of the stomach (p less than 0.0005). Detection of periesophageal veins by EUS increased with increasing diameter of esophageal varices at endoscopy (57% in grade 1, 89% in grade 2, and 100% in grade 3), and there was a direct correlation between endoscopic grade and the diameter of the periesophageal collateral veins at EUS. The diameter of the azygous vein by EUS at its distal and proximal margins was significantly greater in patients with PH (p less than 0.001); the EUS diameter of the azygous vein was significantly larger with variceal grade 2 compared with grade 1 (p less than 0.02 and p less than 0.01, respectively). In portal hypertensive gastropathy, endoscopic and EUS detection were coincident. No correlation was found between the presence of portal hypertensive gastropathy, endoscopic grade of esophageal varices, and detection of gastric varices at EUS.

Topical treatment with 5-aminosalicylic in distal ulcerative colitis by using a new suppository preparation. A double-blind placebo controlled trial

Sixty-two patients with ulcerative colitis localised to the distal sigmoid colon and rectum (less than 20 cm) entered the trial. Thirty-two were treated with 5-ASA 500 mg suppositories (Asacol) 3 times a day for 1 month while 30 received a placebo given in the same regime. Clinical, sigmoidoscopic and histological assessment was carried out before, after 15 days and after 1 month of treatment. At the end of the study 5-ASA suppositories showed significantly better results in all the parameters recorded than placebo (p less than 0.01). There were no unwanted effects related to the use of suppositories. This treatment should therefore be offered as a first choice for patients with distal rectosigmoiditis.

Pericarditis: a probably overlooked complication of endoscopic variceal sclerotherapy

Two cases of acute pericarditis following endoscopic variceal sclerotherapy (EVS) that were resolved with conservative management are described. This complication arose respectively one and three days after EVS. The possible pathogenesis is the involvement of the pericardium in an inflammatory reaction that develops in the esophageal wall and surrounding tissues. Only five cases have been previously reported in the literature; the authors suppose that this fact may be due to the mild symptoms presented by the patients, which may result in underestimation of this complication. The technical details of EVS in the seven patients with pericarditis were analyzed, but no common etiologic factor was found. The authors strongly advise regular checks for clinical and instrumental signs of acute pericarditis after every session of EVS, so that appropriate management can be undertaken in an early phase and, if necessary, further EVS sessions delayed, in order to avoid cardiac tamponade or constrictive pericarditis.

Relationship between intestinal permeability to [51Cr]EDTA and inflammatory activity in asymptomatic patients with Crohn's disease

The relationship between intestinal permeability to an oral dose (100 mu Ci) of [51CR]EDTA and the inflammatory activity of Crohn's disease was studied in 63 adult patients (32 unresected and 31 resected) who underwent 162 evaluations. The results of the [51CR]EDTA test were compared with the serum levels of the acute-phase reactant proteins (APRP) and with the result of the [111In]leukocyte scanning, respectively, as an indirect and direct method to assess intestinal inflammation. In a group of healthy adult controls, the upper normal value for the 24-hr urinary [51CR]EDTA excretion was 3.61 (97.5% percentile) and the mean coefficient of variation was 21%. Sensitivity and specificity of the [51CR]EDTA test in identifying active inflammation expressed by increased serum levels of APRP were, respectively, 97% and 54% in the unresected group and 68% and 52% in the resected group of patients. The low specificity of the test was due to the presence of increased [51CR]EDTA urinary excretion in about half the cases with normal serum levels of APRP. The [111In]leukocyte scanning was performed in a subgroup of 11 patients (three unresected and eight resected) with normal serum levels of APRP, six with increased and five with normal [51CR]EDTA urinary excretion. All six patients with increased intestinal permeability had a positive 111In image of mild to moderate degree of activity. A positive 111In scan was present in two of the five patients with normal permeability; these were two resected patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[The Boario project. A study of the prevalence of lithiasis in a spa population]

In order to better evaluate some epidemiological findings observed during previous studies on large samples of free living populations we carried out a case-control study on a randomly selected group of subjects in a health spa, Boario Terme. Seven-hundred and thirty subjects, aged 40-69 years, participated in the study. The study protocol included an ultrasonographic examination of the upper abdomen, a physical examination, a questionnaire, and a blood sample. Prevalence of gallstone disease was two times higher in females (37.2%) than in males (19.7%) (RRMH = 1.88). Fifty out of the 80 gallstone subjects were not aware of the disease prior the study (62.5%), and 60 did not experience any specific biliary symptom (colic) in the 5 years prior the study. The so-called "nonspecific symptoms" were not found related to gallstone disease. Gallstone disease was positively related to number of pregnancies, obesity, and economical status. In conclusion the present study confirmed some results observed during previous epidemiological studies. In regards to symptoms present data suggest that biliary colic is the only specific symptom for gallstone disease. In addition, the high number of asymptomatic gallstones observed in this study suggests the need of more investigations on high-risk populations in order to make earlier diagnosis and eventually to prevent the disease.

Diagnosis of islet cell tumor by means of endoscopic ultrasonography

A 31-year-old man with recurrent attacks of hypoglycemia was hospitalized with the clinical suspicion of an insulinoma. Computed tomography and conventional (transabdominal) ultrasound were doubtful, showing a small solid low-density mass probably originating from the tail of the pancreas. Selective angiography and transhepatic venous sampling for pancreatic hormone assay were not discriminant. Finally, an endoscopic ultrasonographic examination, allowing a better visualization of the pancreas, established with certainty the origin of the lesion from the tail of the gland. This was subsequently confirmed at operation.

Assessment of portal hypertension by endoscopic ultrasonography

Endoscopic ultrasonography (EUS) was performed in 40 patients with portal hypertension (PH) and in 48 control subjects. The azygous, splenic, mesenteric, and portal veins were displayed in both groups. However, esophageal and gastric varices, periesophageal and perigastric collateral veins, and submucosal gastric venules were displayed only in patients with portal hypertension. EUS was inferior to endoscopy in detecting and grading esophageal varices (p less than 0.0005), but EUS was superior in the detection of varices in the fundus of the stomach (p less than 0.0005). Detection of periesophageal veins by EUS increased with increasing diameter of esophageal varices at endoscopy (57% in grade 1, 89% in grade 2, and 100% in grade 3), and there was a direct correlation between endoscopic grade and the diameter of the periesophageal collateral veins at EUS. The diameter of the azygous vein by EUS at its distal and proximal margins was significantly greater in patients with PH (p less than 0.001); the EUS diameter of the azygous vein was significantly larger with variceal grade 2 compared with grade 1 (p less than 0.02 and p less than 0.01, respectively). In portal hypertensive gastropathy, endoscopic and EUS detection were coincident. No correlation was found between the presence of portal hypertensive gastropathy, endoscopic grade of esophageal varices, and detection of gastric varices at EUS.

Rectal cell proliferation and colon cancer risk in ulcerative colitis

Cell proliferation kinetics of 30 patients affected by extensive ulcerative colitis in remission have been studied with autoradiography of rectal biopsies incubated with tritiated thymidine. The results have been compared with those of 20 control subjects without evidence of colonic diseases, and of 16 patients with multiple nonfamilial colonic adenomas. The labeling index was similar in the three groups (P = NS). On the contrary, the labeling frequency (SEM) in the upper 40% of the crypt (phi h value) was 0.04 +/- 0.01 in controls, 0.16 +/- 0.02 in ulcerative colitis, and 0.10 +/- 0.01 in adenoma patients (P less than 0.001 ulcerative colitis versus controls, P less than 0.01 adenomas versus controls, P = NS ulcerative colitis versus adenomas). The distribution of phi h values in ulcerative colitis showed a bimodal trend with 22 patients having mean phi h values similar to adenoma patients (0.10 +/- 0.01) and 8 with higher values (0.30 +/- 0.02). No relationship was found between phi h values and duration of colitis, age of patients, or age at onset of symptoms. These data show that cell kinetics studies can detect patients at particularly high risk of colon cancer, and that additional factors should determine colon cancer risk level in ulcerative colitis.

An evaluation of arbaprostil at multiple doses for the treatment of acute duodenal ulcer: a randomized double-blind placebo-controlled international trial

Six hundred and thirty patients were enrolled in a randomized double-blind placebo-controlled trial evaluating two arbaprostil dosages (25 micrograms and 50 micrograms) qid for 4 wk for the treatment of acute duodenal ulcers. The healing rates in the placebo, 25-micrograms, and 50-micrograms treatment groups were 39%, 51%, and 60%, respectively. Smoking was found to adversely affect the healing rates in all the treatment groups. Pain severity was less with either arbaprostil treatment. The only side effect found was diarrhea: 10%, 14%, and 32% in the placebo, 25-micrograms, and 50-micrograms treatment groups, respectively. Severe diarrhea occurred in 1% of those patients who received the 50-micrograms dosage regimen, but in none of the other two groups. Arbaprostil at these two dosage levels, when given for 4 wk, appears to be a safe and efficacious agent for the treatment of acute duodenal ulcers.

Endoscopic assessment of acute inflammation of the ileal reservoir after restorative ileo-anal anastomosis

Forty-seven patients, undergoing ileo-anal anastomosis for ulcerative colitis (42) or familial polyposis (5), were endoscopically examined after protective ileostomy or after restorative ileo-anal anastomosis. The neorectum and the ileum above were examined in all cases and multiple biopsies were taken. No symptoms of pouch inflammation were found in 41 subjects; 80.5% of these had non-macroscopic lesions and 19.5% had focal lesions such as congestion, petechiae, mucous hypersecretion (5), or single ulcers (3). None of these developed pouchitis. Pouchitis was observed in the other six subjects, who all underwent surgery for ulcerative colitis and developed 14 clinical episodes of pouchitis during the follow-up. In these cases the entire neorectum mucosa was always affected by the lesions which, in 50%, also extended to the ileum above. The most common endoscopic features (71.4%) were congestion, potechiae, oozing areas, mucous hypersecretion, and multiple superficial ulcers. In half the remaining cases (14.3%) the neorectum showed the features, described above, while the upper ileum was affected by deep round or irregular ulcers within normal mucosa; Crohn's disease was excluded in these cases. In the remaining 14.3%, pouchitis showed a pseudomembranous feature. In our experience, the endoscopic pattern of pouchitis is polymorphic. Although an ulcerative colitis-like feature prevails, pseudomembranous and Crohn's ileitis-like features may also be present.

Role of rectal formulations: enemas

Clinical experience with mesalazine enemas in the treatment of ulcerative colitis is reviewed. After rectal administration, plasma mesalazine levels remain low, and 15% of the administered dose is recovered in the urine. Enemas containing 2 and 4 g of mesalazine have been shown to be effective, safe, and well tolerated by patients with mild and moderate ulcerative colitis. Patients who cannot tolerate sulfasalazine and patients who do not respond to other treatments have been successfully treated with mesalazine enemas. Suppositories of mesalazine are more suitable for patients with disease confined to the distal region of the colon, whereas mesalazine enemas should be used in patients with more extensive disease. Mesalazine enemas have also been used for maintenance therapy in ulcerative colitis.

Acid gastroesophageal reflux and symptom occurrence. Analysis of some factors influencing their association

In 17 patients with esophagitis (degree I = erythema, N = 10; degree II = erosions, N = 7) esophageal pH was measured at 5 and 10 cm above the esophagogastric junction to assess whether the extension of acid reflux and the severity of the mucosal lesions could influence the association between reflux and symptoms. A minority of the refluxes were related with symptoms (4.0% and 7.7% in degree I, 14.1% and 12.0% in degree II at 5 and 10 cm respectively), whereas 65.4% and 100% of the symptoms were related with reflux in degrees I and II, respectively, with 76.5% and 35.7% occurring during refluxes reaching the proximal recording site. A relationship of symptoms with reflux is shown, particularly in erosive disease. Some reflux characteristics (extension, duration, acidity) seem to influence symptom occurrence mainly in mild esophagitis; however, more than 85% of the acid reflux episodes are symptom-free, regardless of the severity of the mucosal injury.

Esophageal electromyography in scleroderma patients with functional dysphagia

Simultaneous recordings of myoelectric and manometric activities of the esophagus were made in two groups of patients with scleroderma. Group A consisted of patients who suffered from functional dysphagia that had appeared recently, and who had a normal size esophagus when examined radiographically. Patients in group B had complained of functional dysphagia for several years and showed a dilated hypotonic esophagus on x-ray. A control group of five normal subjects was also examined in the same manner. The study was carried out by means of a peroral probe with two pairs of suction-needle electrodes and two manometric side-hole catheters positioned at the same levels as the electrodes. Standard manometric examination of the esophagus was carried out in all patients. Normal subjects after each deglutition showed a propagated burst of spikes in correspondence with the ascending phase of the peristaltic wave, whereas, in the period between deglutitions, rare spikes and no pressure waves were recorded. Group A patients were characterized by the frequent appearance during the interdeglutitive period of spontaneous rhythmic sequences or bursts of spikes associated with pressure waves. In these patients, repetitive nonpropagated spike bursts with a higher than normal amplitude and duration were observed after deglutitions in association with high-amplitude nonpropagated repetitive pressure waves similar to those observed in diffuse esophageal spasm (DES). Five of the seven group B patients showed spike bursts and pressure waves with both amplitude and duration markedly lower than normal. The remaining two patients from group B presented no spike bursts or pressure waves at all. Standard manometry demonstrated findings equivalent to those obtained via electromyography (EMG) in all patients of group B and in only two patients of group A. In conclusion, the functional dysphagia of patients with scleroderma can be attributed to two different motor disorders. The first one is characterized by disorganized myoelectric hyperactivity and may have a manometric appearance similar to that of diffuse spasm. The second one is characterized by a marked decrease in myoelectric activity and corresponds to the classic manometric finding of scleroderma involvement of the esophagus. Both these myoelectric patterns seem to be related to subsequent stages of esophageal scleroderma involvement.

Effect of somatostatin on plasma amino acid uptake by human pancreas

We studied the effect of somatostatin on amino acid uptake by pancreatic acinar cells in 12 healthy male volunteers, aged 20-48 yr. Pancreatic amino acid uptake was assessed by measuring free plasma amino acid concentration before and during pancreatic stimulation with secretin (1 CU/kg body wt.h) and cerulein (50 ng/kg body wt.h). Pancreatic stimulation with these peptides caused a significant decrease in plasma amino acid concentrations. Somatostatin, given at the dosages of 0.15 and 1.35 micrograms/kg body wt.h, significantly diminished this decrease. The effect of the higher dose of somatostatin was more marked than that produced by the lower dose, compatible with dose dependence. The results suggest that somatostatin is able to inhibit the amino acid uptake by the pancreatic acinar cells. This inhibitory effect could be an important mechanism by which the peptide decreases pancreatic enzyme secretion.

Endoscopic ultrasonography in the diagnosis of gastric submucosal tumor

Endoscopic ultrasonography contributed to a correct diagnosis in 24 of 25 patients with gastric submucosal tumor, including 10 extrinsic compressions and 14 intraparietal growths. Leiomyoma and lipoma were easily recognized. In one case, an unusual group of gastric varices was clearly differentiated from a pedunculated polyp prior to polypectomy. In gastric submucosal tumors, endoscopic ultrasonography can greatly reduce the need for aggressive and risky biopsy techniques or exploratory laparotomy.

Gallstone recurrence after successful oral bile acid treatment. A 12-year follow-up study and evaluation of long-term postdissolution treatment

Recurrence is a major problem in the medical treatment of gallstones but its extent is still uncertain. The aim of this study was to determine the magnitude of this event and to assess the effectiveness of a postdissolution treatment in preventing it. We evaluated the long-term recurrence rate after 96 confirmed dissolutions observed in 86 subjects (71 women, 15 men) over a 12-yr follow-up period. A low-dose postdissolution treatment (ursodeoxycholic acid, 300 mg/day) was administered to 36 subjects, whereas in the remaining 60 cases no postdissolution treatment was given. By actuarial life-table analysis, the cumulative proportion of gallstone recurrence was 12.5% at the first year, rising to 61% at the 11th year. Postdissolution treatment was effective in reducing the frequency of gallstone recurrence (p = 0.0067), but this was mainly related to its effect on younger subjects (less than or equal to 50 yr old). In older subjects the recurrence rate was unaffected by treatment. The probability of gallstone recurrence was significantly higher in subjects with multiple stones before dissolution treatment than in those who had had solitary stones (p = 0.0091). No other factor predictive of gallstone recurrence could be identified.

Sonography of chronic pancreatitis

Morphologic alterations detectable by US in CP may be schematically classified as: (1) size increase or decrease; (2) variations in shape with particular regard to contour irregularities; (3) changes in the parenchymal echo-texture; (4) presence of calcifications; (5) dilatation of the MPD; (6) presence of fluid collections; (7) dilatation of the biliary tree; and (8) obstruction of the portal venous system. These findings are associated in various combinations and occur with differing frequencies. Changes in pancreatic size may be found in many physiologic and pathologic conditions other than CP. The pancreas is usually larger during and shortly after acute relapses, whereas gland atrophy occurs in more advanced cases. A diagnosis of CP cannot generally be made only on the basis of a diffuse enlargement of the gland without changes in the echo-texture or in the MPD. Abnormalities of the parenchymal echo-texture are relatively sensitive but nonspecific for the diagnosis of CP. Calcifications can often be missed by US, and CT is clearly superior. Dilatation of the MPD is the most reliable sign of pancreatic disease. In CP, it generally has irregular walls, which is a distinctive finding that aids in differentiation of MPD dilatation occurring in pancreatic cancer. Changes in the MPD that are not visible under basal conditions may become evident under maximal hormonal (secretin) stimulation. Cysts and pseudocysts complicating the course of CP may present various shapes, contain necrotic debris, and even show a completely solid pattern. Dilatation of the CBD may also be seen as a consequence of a stricture of the intrapancreatic portion of the duct. Other complications, such as obstruction of the portal venous system, ascites, and pleural effusion, occur more rarely and are easily visualized by US. Despite the great technologic improvement of US in recent years, there is still general agreement that the US diagnosis of CP remains difficult owing to the polymorphism of anatomic changes and the relatively high incidence of false-negative results in early stages of the disease. It is, however, accepted that in clinical practice US currently is the first diagnostic step when CP is suspected.

Benfluorex action on metabolic control and insulin sensitivity in type 2 non-insulin dependent diabetics

In this study, 16 overweight or obese NIDDM patients with a long period of stable weight and dietary surveillance were treated with 150 mg t.i.d. of Benfluorex per os for 3 months. A significant improvement occurred in the fasting and post-meal glucose levels and in the HbA1C values, regardless of weight changes that occurred throughout the study. No significant changes were found in the fasting or meal-stimulated insulin (IRI) levels and in the glucose:IRI molar ratios. On the contrary, there were no significant variations in C-peptide levels while the glucose:CPR ratio appeared to decrease while on Benfluorex. In basal conditions, 11 patients presented insulin insensitivity (as measured by the glucose-insulin-somatostatin technique) which was unaffected by the pharmacological treatment. Benfluorex may therefore ameliorate metabolic control in overweight or obese NIDDM patients, but our data do not clarify whether its effects are mediated by an improvement in the action of insulin in peripheral tissues.

Effect of meal on portal hemodynamics in healthy humans and in patients with chronic liver disease

The effect of a standard Italian meal on portal hemodynamics was evaluated in 12 normal subjects, in 11 patients with chronic active hepatitis and in 11 patients with liver cirrhosis using duplex Doppler ultrasound, which allows a noninvasive assessment of portal blood flow. In the fasting state, the portal vein caliber was significantly higher in patients with liver cirrhosis than in normal subjects and patients with chronic active hepatitis, whereas the mean flow velocity in the portal vein was significantly lower in this group. Basal flow volume of the portal vein was greater in patients with liver cirrhosis than in normal subjects and patients with chronic active hepatitis. Sixty minutes after the standard meal, we observed both in normal subjects and in patients with chronic active hepatitis a significant increase of mean caliber, mean velocity and flow volume in the portal vein, whereas in patients with liver cirrhosis, these parameters remained almost unchanged. In addition, the examination of individual patterns showed that flow velocity and flow volume in the portal vein decreased in some cirrhotic patients after the meal. This behavior is probably related to the hypertensive state in the splanchnic venous bed and diversion of splanchnic blood flow into spontaneous portosystemic collaterals.

Impaired response of main pancreatic duct to secretin stimulation in early chronic pancreatitis

In the present study we compared sonographic measurements of the main pancreatic duct (MPD) following maximal secretin stimulation (75 CU intravenous in 1 min) in 15 chronic pancreatitis patients (CP) with those of 18 normal control subjects. The mean caliber of the main pancreatic duct was 1.2 +/- 0.4 mm in controls and 1.8 +/- 0.9 in patients with chronic pancreatitis (P less than 0.025). In the control group a dilatation of the duct with a peak at the third minute was found. In patients with chronic pancreatitis a flatter profile of the response curve with a slower increase and inconstant return to basal values was found. A statistically significant difference was found between absolute variations of MPD caliber over basal values (1.7 +/- 1.06 in controls vs 0.8 +/- 0.69 in CP, P less than 0.005) and the dilatation index [(Dmax - D)/D] (1.31 +/- 0.6 in controls vs 0.66 +/- 0.69 in CP, P less than 0.005). The mean percent increase at the third minute was 131% in control subjects vs 53% of patients with CP (P less than 0.0005). In the five cases of CP showing a caliber increase greater than 100%, a persistent dilatation (100-200%) was found 15 min after secretin administration. At this time, the mean percent increase over basal value in controls was 25%.(ABSTRACT TRUNCATED AT 250 WORDS)

Cell renewal and cancer risk of the stomach: analysis of cell proliferation kinetics in atrophic gastritis

We examined cell proliferation kinetics of gastric mucosa in 28 patients affected by chronic atrophic gastritis by means of autohistoradiography of biopsies incubated with tritiated thymidine. The results have been compared with those obtained from 12 patients with normal gastric mucosa. In chronic atrophic gastritis, patients showed a proliferative pattern similar to controls. The remaining patients had an increased number of replicating cells together with an expansion of the proliferative compartment towards the surface of the mucosa. These results suggest that in chronic atrophic gastritis, as far as cell proliferation is concerned, two subgroups of patients with two different levels of risk of developing gastric cancer exist. The first one, showing an expansion of the proliferating area, probably is at higher risk. As a matter of fact, such an abnormality expresses an alteration of cell growth control similar to that observed in preneoplastic conditions of the colon and in gastric mucosa of animals treated with carcinogenic substances.

5-Aminosalicylic acid suppositories in the management of ulcerative colitis

5-aminosalicylic acid (5-ASA) suppositories have been used in the author's out-patient clinic in Bologna for the treatment of distal ulcerative colitis (UC). One hundred fifty-six patients with mild or moderate attacks of UC were treated using different protocols for controlling active disease. Improvement was observed in 88.5 percent of the therapeutic cycles after one month. A small preliminary maintenance study using only 400-mg suppositories of 5-ASA twice a day for 6 or 12 months showed a remission percentage similar to salicylazosulfapyridine (SASP).

Inter and intra-observer variation in ultrasonographic detection of gallstones: the Multicenter Italian study on epidemiology of cholelithiasis (M.I.COL.)

Inter and intra-observer agreement in classifying the presence of gallstones by ultrasonographic images according to established criteria was studied. A film recording of 50 routine ultrasonographic examinations of the gallbladder was read by each of the 46 observers who participated in the Multicenter Italian Study on Epidemiology of Cholelithiasis (M.I.COL.). The overall Kappa score for inter-observer agreement was 0.649, while intra-observer agreement was "good" or "excellent" (Kappa scores greater than 0.60) in 75% of the observers. No statistical difference for inter-observer agreement between "novices" and "expert" echographers was found in the overall Kappa statistic or in category-specific Kappa scores (gallstone, no gallstone, doubtful and inconclusive examinations) The present study suggests that the development of explicit criteria by a group of trained echographers does not eliminate inter- and intra-observer disagreement in categorizing subjects for gallbladder stones.

Gastric acid secretion and gastric emptying of liquids in 99 male duodenal ulcer patients

Gastric acid hypersecretion and accelerated gastric emptying are commonly considered as possible determinants of duodenal ulcer, but the relative frequencies of these gastric dysfunctions have never been evaluated in a homogeneous group of patients. We studied basal and pentagastrin-stimulated gastric acid secretion and gastric emptying of a radiolabeled caloric liquid meal in 99 consecutive male patients with endoscopically proven, active, uncomplicated duodenal ulcers. Compared to matched healthy subjects, ulcer patients presented increased basal and stimulated acid secretion (P less than 0.001). Sixty-nine patients had peak acid output values above the 95% confidence limits of the control population (14.2-30.6 meq/hr). Cigarette smoking was correlated with gastric acid hypersecretion. No significant difference was found between duodenal ulcer patients and controls in mean gastric emptying times. Ulcer patients showed a greater variance of gastric acid secretion and emptying values than healthy subjects. This reflects varied gastrointestinal function among ulcer patients. No significant correlation was found between gastric acid output and gastric emptying times. These findings suggest that gastric acid hypersecretion, but not accelerated gastric emptying of liquids, play a relevant role in the pathogenesis of duodenal ulcer.

Role of serum pancreatic enzyme assays in diagnosis of pancreatic disease

The serum behavior of amylase, pancreatic isoamylase, lipase, trypsinogen, and elastase 1 was studied in 145 patients with pancreatic disease and in 66 patients with abdominal pain of nonpancreatic origin, for the purpose of evaluating the relative diagnostic utility of their assays. In 34 patients with acute pancreatitis, serum lipase, trypsinogen, and elastase 1 were elevated in all 34, pancreatic isoamylase in 33 (97%) and amylase in 30 (88%). Ten of these acute pancreatitis patients were followed sequentially for seven days: the variations in their serum enzyme levels were parallel, although the lipase, trypsinogen, and particularly the elastase 1 elevations persisted longer than did those of amylase and pancreatic isoamylase. Among the patients with chronic pancreatitis, either in painful relapse (N = 19) or with pancreatic cysts (N = 15), the respective percentages of enzymes elevations were: 79 and 80% for elastase 1, 68 and 67% for trypsinogen, 63 and 73% for pancreatic isoamylase, 58 and 60% for lipase, 53 and 60% for amylase. In the 52 chronic pancreatitis patients studied during clinical remission, serum enzyme behavior varied greatly, and a majority of the assays (60%) were normal; even in the case of severe pancreatic exocrine insufficiency, normal as well as abnormally high and low enzyme values were seen. Highly variable enzyme behavior was also seen in the 40 patients with pancreatic cancer, and elastase I was the most frequently (35%) elevated enzyme in this group as well. Among the patients with abdominal pain of nonpancreatic origin, abnormally high enzyme levels were present in percentages ranging from 6% for lipase to 21% for trypsinogen.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical and hormonal characteristics of obese amenorrheic hyperandrogenic women before and after weight loss

We studied a group of obese hyperandrogenic amenorrheic women to determine the effects of weight loss on anthropometry, hormonal status, menstrual cycles, ovulation, and fertility. Fourteen women had polycystic ovaries, two the hyperandrogenism-insulin resistance-acanthosis nigricans syndrome, one hirsutism of adrenal origin, and three idiopathic chronic anovulation. The duration of amenorrhea before the study ranged from 3-17 months [mean, 8.6 +/- 4.5 (+/- SD)]. All women ate a hypocaloric diet for a period of 8.0 +/- 2.4 months. Weight loss ranged from 4.8 to 15.2 kg (mean, 9.7 +/- 3.1 kg; 1.35 +/- 0.56 kg/month) and the waist to hip ratio, which was used as a measurement of body fat distribution, decreased from 0.86 +/- 0.1 to 0.81 +/- 0.06 (P less than 0.0001). The women's mean plasma testosterone and LH concentrations decreased significantly (P less than 0.001 and P less than 0.005, respectively). A significant positive correlation was found between the decreases in plasma testosterone levels and the decreases in glucose-stimulated insulin levels. Moreover, the decreases in the waist to hip ratio correlated positively with the decreases in glucose-stimulated insulin levels and inversely with the decreases in plasma 17 beta-estradiol. No relationships were found between weight loss and the changes in plasma insulin, steroid, and gonadotropin concentrations. The responsiveness to the weight reduction program was evaluated by comparing the number of menstrual cycles during the study period with the number reported before it. Eight women had significantly improved menstrual cyclicity (responders), while 12 did not (nonresponders). The clinical characteristics and hormone values were similar in responder and nonresponder women. In the group as a whole, 33% of the menstrual cycles during the study were ovulatory, and 4 pregnancies occurred. Hirsutism improved significantly in more than half of the women, as did acanthosis nigricans when present. We conclude that weight loss is beneficial in all obese hyperandrogenic women regardless of the presence of polycystic ovaries, the degree of hyperandrogenism, and the degree and distribution of obesity.

Interrelationships between body weight, body fat distribution and insulin in obese women before and after hypocaloric feeding and weight loss

The effects were investigated of weight loss on the relationship between hyperinsulinemia, body weight and body fat distribution in two groups of women with central-type obesity (CTO) (waist-to-hip ratio WHR greater than 0.85) or peripheral-type obesity (PTO) (WHR less than 0.85). An oral glucose tolerance test was carried out before and after a hypocaloric nutritional treatment lasting 4 months. Both groups were matched for age, body mass index and amount of body fat. At the basal condition, group CTO had fasting and glucose-stimulated insulin levels significantly higher than group PTO; fasting (but not stimulated) C peptide levels were also higher in CTO compared with PTO. Weight and fat loss were significantly higher in CTO than in PTO women. Moreover, unlike PTO, CTO subjects significantly reduced their WHR values. In both groups weight loss led to a significant drop in fasting and glucose-stimulated insulin and C peptide levels. However, PTO women reduced their C peptide levels significantly less than CTO. In conclusion, weight loss only modified body fat distribution in women with CTO, who appeared to be prone to a greater weight loss than the PTO women. Compared to PTO, CTO women were characterized by higher insulin levels and peripheral insulin resistance, which improved during hypocaloric feeding probably due to the combined effect of weight loss and the change in body fat distribution.

Interdigestive gastroduodenal motility in patients with active and inactive duodenal ulcer disease

The interdigestive gastroduodenal motility was studied by means of a manometric probe in 6 patients with active duodenal ulcer and acid hypersecretion, in 6 patients with ulcer disease in remission (inactive) and normosecretion and in 8 healthy subjects with normosecretion. After a basal recording period sufficient to record at least two activity fronts of the migrating motor complex (MMC), an intraluminal infusion of isotonic NaHCO3 was carried out for 180 min in patients with active duodenal ulcer, whereas in patients with ulcer in remission an HCl solution was infused for 180 min. Patients with active duodenal ulcer showed a basal motility with a longer than normal MMC cycle and a shorter than normal activity front, while patients with ulcer in remission showed a cyclic motor activity not significantly different from that of normal subjects. The NaHCO3 infusion in patients with active ulcer restored a near-normal motility, whereas the HCl infusion in patients with ulcer in remission induced a motility similar to that of patients with active ulcer. These data indicate that the increase in gastric acid secretion is responsible for the decrease in frequency and duration of MMC activity fronts, which have the function of cyclically clearing the gastroduodenal lumen. Consequently, acid and bacteria may remain a longer than normal time in contact with the gastroduodenal mucosa, which, in this manner, may be greatly exposed to the risk of peptic lesions.

The possible utility of steroids in the prevention of relapses of Crohn's disease in remission. A preliminary study

In Crohn's disease, prednisone is believed to be ineffective for relapse prevention. Because all patients with Crohn's Disease Activity Index lower than 150 and with some altered lab tests (erythrocyte sedimentation rate, C-reactive protein, alpha-1-acid glycoprotein, alpha-1-acid antitrypsin, and white blood cell count) had a clinical relapse in 18 months of follow-up, we tried to ascertain whether methylprednisolone could reduce the risk of clinical relapse in such patients. Eighteen patients were included in a controlled study against placebo. Nine patients were treated with methylprednisolone at a dosage of 0.25 mg/kg daily for a period of 6 months; treatment was discontinued if disease relapsed or if lab tests were normalized. During the steroid treatment, 1 of 9 patients showed a clinical relapse; in 7, the normalization of lab tests was obtained; in 5 of these 7 patients a relapse occurred within 1 month after the suspension of the treatment; in 1 patient, lab tests remained altered. In those 9 patients on placebo, relapses occurred in 7. We conclude that methylprednisolone was effective in the prevention of relapses for patients in clinical remission but with altered lab tests.

Tripotassium dicitrate bismuthate and ranitidine in duodenal ulcer. Healing and influence on recurrence

One hundred patients were entered into a double-blind, double-dummy comparison of tripotassium dicitrate bismuthate (TDB) versus ranitidine, to evaluate short-term healing rates, and successfully healed patients were then entered into a follow-up phase to observe relapse rates. At 4 weeks 84% of patients treated with TDB and 68% of those treated with ranitidine had healed. At 8 weeks these figures had risen to 96% and 90%, respectively (p = NS). After a year's follow-up study 84% of patients healed initially with ranitidine had relapsed, whereas in the case of patients healed initially with TDB the relapse rate was 67% (p less than 0.05). The results confirm that in the short term, TDB is as effective as ranitidine, whereas the significantly better protection against relapse offered by TDB compared with ranitidine underlines the importance of restoring mucosal defence, an approach that to date has been somewhat overlooked.

Treatment of chronic hepatitis B with human lymphoblastoid interferon: results of a controlled trial

The aim of this study was to evaluate the efficacy of human lymphoblastoid interferon (Wellferon) in the treatment of chronic hepatitis B virus (HBV) infection. To date 70 patients have entered the study, 33 randomized to receive interferon at doses of 5 MU/m2 i.m. daily for the first 4 weeks and three times weekly for 5 months thereafter and 31 acted as controls. Seventy-nine per cent of the treated group permanently cleared HBV DNA compared with 48% of the control group (p = 0.01): 69% of the treated patients and 38% of the controls who eliminated HBV DNA cleared HBeAg, HBeAb (p = 0.02). Twenty-four per cent of the treated patients and 3% (p = 0.01) of the control group had clearance of HBsAg and seroconversion to HBsAb. From these results it was concluded that interferon had a therapeutic effect on Italian heterosexual patients with chronic hepatitis B viral replication.

Lactose malabsorption in adult patients with Crohn's disease

In order to evaluate, in adult patients with Crohn's disease (CD), the prevalence of lactose malabsorption and intolerance, and the percentage who can tolerate a physiologic amount of milk in their diet, we tested 37 patients with CD (19 with intestinal resection, and 18 without) and 67 healthy controls (C) with the H2-breath test after they had ingested increasing loads of lactose as 10% solution (12.5 g, 25 g, and 50 g). Patients with malabsorption after the 12.5-g dose were tested further with 250 ml of milk. In the total group of patients and in the subgroup of those with resection, the prevalence of malabsorption was higher than in controls at all lactose loads; in patients who had not undergone resection, no significant difference was observed with the 12.5-g dose. Eleven of 18 patients who were malabsorbers with the 12.5-g dose had malabsorption also with 250 ml milk; however, only three of them (8% of the total group) experienced symptoms of intolerance. We conclude that, in adult patients with CD, 1) the prevalence of lactose malabsorption is increased, 2) in patients who have undergone intestinal resection, malabsorption occurs at a lower dose of the sugar than in patients who did not, and 3) since only 8% of patients experienced symptoms of intolerance after the ingestion of milk 250 ml, this amount can be empirically inserted in the daily diet of an adult with CD.

Efficacy of addition of exogenous lactase to milk in adult lactase deficiency

The efficacy of lactase by Kluyveromyces lactis in hydrolyzing milk lactose and reducing milk intolerance symptoms was tested in 52 proved lactose malabsorbers. The enzyme was added to milk administered to the patients, and H2 breath excretion (as an index of carbohydrate malabsorption), was determined by gas chromatograph technique, and milk intolerance symptoms were recorded. H2 mean excretion was 78.3 +/- 5.49 ppm after administration of intact whole milk 500 ml (test A), 43.5 +/- 4.99 ppm when lactase 2000 U was added to milk 500 ml immediately before administration (test B); 36.7 +/- 5.01 ppm when milk 500 ml was incubated for 12 h with lactase 1000 U (test C), and 29.7 +/- 4.35 ppm when the incubation was prolonged for 24 h (test D). Symptoms score was: test A = 5.85 +/- 0.56, test B = 3.71 +/- 0.45, test C = 2.77 +/- 0.63, test D = 1.7 +/- 0.68. A correlation index of r = 0.44 (p less than 0.01) was obtained between reduction in H2 mean excretion and reduction in symptoms score of a single individual. The addition of this lactase to milk seems to be effective in correcting lactose malabsorption, thus representing a convenient approach in milk intolerance.

Effect of cessation of alcohol use on the course of pancreatic dysfunction in alcoholic pancreatitis

Exocrine pancreatic function was studied sequentially by means of the secretin-cerulein test in 32 patients with alcoholic chronic pancreatitis to elucidate the long-term course of pancreatic dysfunction, and to determine whether the cessation of alcohol use had any influence on the natural history of pancreatic functional changes caused by this disease. At initial studies, 5 patients had normal pancreatic function, and the remaining 27 had pancreatic insufficiency, which was mild to moderate in most subjects. The final studies, carried out at an average of 7.3 yr (range, 4-11 yr) after the first, showed a significant deterioration in pancreatic function, both in patients who stopped alcohol after the initial study (n = 18) and in those who did not (n = 14). The deterioration, however, was significantly less marked in patients who stopped drinking alcohol than in those who continued. These data indicate that pancreatic functional changes caused by alcoholic pancreatitis progress even after cessation of alcohol use; however, the progression is slower and less severe when alcohol intake is stopped.