Cowden's disease: a case report and literature review

Cowden's disease, or multiple hamartoma syndrome, is an uncommon condition with characteristic mucocutaneous lesions associated with abnormalities of the breast, thyroid, and gastrointestinal tract. We describe a 51-year-old man with hyperplastic polyposis of the entire alimentary tract as the most prominent feature of this disease. We also present a review of 85 cases of this entity as reported in the English medical literature, and summarize the pertinent findings.

Comparison of potential cytoprotective action of sucralfate and cimetidine. Studies with experimental feline esophagitis

The potential mucosal protective effects of a liquid sucralfate preparation and the histamine (H2)-antagonist cimetidine on acid-induced esophagitis were studied. Esophagitis was induced in adult cats using a constant infusion of 0.1 N hydrochloric acid at 1 ml/minute for 20 minutes. Mucosal lesions were evaluated by blinded investigators using both fiber-optic endoscopy and light microscopy. Histology was scored for basal cell hyperplasia, intraepithelial leukocytosis, and subepithelial leukocytosis. Liquid sucralfate given prior to acid infusion consistently prevented acid-induced lesions, demonstrated by quantitative histologic scoring. Although cimetidine did not show the same degree of protection as sucralfate, the results did show a trend towards a cytoprotective effect.

Sucralfate treatment of nonsteroidal anti-inflammatory drug-induced gastrointestinal symptoms and mucosal damage

In a randomized, double-blind trial, sucralfate therapy, 1 g four times daily, was compared with placebo in 143 symptomatic patients to assess the treatment of gastrointestinal symptoms and gastric mucosal damage associated with nonsteroidal anti-inflammatory drugs (NSAIDs). All patients followed a fixed regimen of NSAIDs, were assigned to one of two groups based on the presence or absence of gastric erosions at baseline endoscopy, and were then assigned randomly to receive sucralfate or placebo for four weeks. Patients were then followed for up to six months while receiving open-label sucralfate 1 g twice daily to up to 1 g four times daily. After four weeks of double-blind therapy, patients taking either nonsalicylate NSAIDs or long half-life NSAIDs and who were treated with sucralfate experienced a significant reduction in both peptic symptom frequency and intensity (p less than 0.03) as compared with patients receiving placebo. Sucralfate-treated patients with baseline endoscopic lesions showed a significant reduction in lesion scores (p less than 0.005) at four weeks as compared with baseline, whereas no improvement was observed in gastric mucosal lesions of patients given placebo. Long-term sucralfate therapy resulted in continued improvement in gastrointestinal symptoms and gastric lesion scores in patients receiving all types of NSAIDs. The results indicate that sucralfate used in conjunction with NSAIDs may allow patients to continue therapy by relieving gastrointestinal symptoms and mucosal damage associated with NSAID therapy.

Radiographic evaluation of esophagus immediately after pneumatic dilatation for achalasia

Forty-one (98%) of 42 patients with achalasia of the esophagus had pneumatic dilatation performed successfully using the Brown-McHardy dilator. One to four dilatations (mean, 1.9) were done on each patient with inflation pressures of 8-15 psi (mean, 11.1 psi). Immediately after the procedure, all patients were examined radiographically by injection of contrast material into the lower esophagus through a nasoesophageal tube. Two immediate and two delayed perforations occurred. Six intramural hematomas were noted, five of which resolved spontaneously. The luminal diameter at the esophagogastric junction increased from a mean of 4.2 mm before dilatation to 7.5 mm following treatment. Four patients with previous Heller myotomy were dilated without complications. Perforation was more common in patients with a minimal change in the esophagogastric diameter. Thirty-five patients (85%) improved symptomatically within several days following pneumatic dilatation. Excluding patients with perforation, the postdilatation appearance of the lower esophagus poorly correlated with clinical response.

Esophageal radiography and manometry: correlation in 172 patients with dysphagia

Radiographic and manometric examinations of the esophagus were correlated in 172 patients with dysphagia. Esophageal manometry was abnormal in 66 (38%), with diagnoses of nonspecific esophageal motor disorder (26), achalasia (19), nutcracker esophagus (12), diffuse esophageal spasm (seven), and scleroderma (two). Compared with manometry, radiographic sensitivities were 95% (18 of 19) for achalasia, 71% (five of seven) for diffuse esophageal spasm, and 46% (12 of 26) for nonspecific esophageal motor disorder. Nutcracker esophagus was not diagnosed specifically on the radiographic examination. Overall radiographic sensitivity was 56% (37 of 66) but increased to 89% by excluding nutcracker esophagus and nonspecific esophageal motor disorders. In 106 manometrically normal patients, radiographic specificity was 91% with 10 false-positive diagnoses of nonspecific motor disorder. We conclude that radiographic examination of the esophagus is useful in patients with dysphagia for evaluating functional esophageal abnormalities, although detection rates vary widely with the type of motor disorder.

Clinical and genetic characteristics of upper gastrointestinal disease in rheumatoid arthritis

Clinical and genetic studies were analyzed in 47 patients with rheumatoid arthritis (RA) who had upper gastrointestinal (GI) endoscopies. Fifty-three percent of patients with RA had peptic ulcers and/or erosions. Sixty percent of patients with ulcers and/or erosions had a history of peptic ulcer disease. Although a greater number of patients with ulcers and/or erosions was taking regular aspirin or indomethacin, comparable numbers of patients with abnormal and normal endoscopies were using nonsteroidal antiinflammatory drugs. Nineteen of the 25 patients (76%) with ulcers and/or erosions had type O blood. Patients with abnormal and normal endoscopies had similar frequencies of GI complaints and fecal blood loss. GI symptoms and occult fecal blood loss, therefore, are not prominent features of upper GI disease in RA. ABO screening may be helpful in determining which patients with RA are at risk for developing peptic ulcers and/or erosions.

NSAID-induced gastric mucosal damage

Gastric mucosal damage is a common side effect of nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs may cause gastrointestinal symptoms, gastric erosions, peptic ulcers or upper gastrointestinal bleeding. Therefore, NSAIDs should be used cautiously in patients with a history of gastrointestinal lesions. Drugs that may be useful in preventing or treating NSAID-induced gastric mucosal injury are under intensive clinical investigation.

Esophageal manometry in 95 healthy adult volunteers. Variability of pressures with age and frequency of "abnormal" contractions

Although esophageal manometry is widely used in clinical practice, the normal range of esophageal contraction parameters is poorly defined. Therefore, 95 healthy volunteers (mean age: 43 years; range 22-79 years) were studied with a low-compliance infusion system and 4.5-mm-diameter catheter. All subjects were given 10 wet swallows (5 cc H2O) and 38 subjects also were given 10 dry swallows.

RESULTS

Amplitude, but not duration, was greater (P less than 0.05) after wet compared to dry swallows. Both distal mean contractile amplitude and duration of wet swallows significantly increased with age and peaked in the fifties. Double-peaked waves frequently occurred after both wet (11.3%) and dry (18.1%) swallows, but triple-peaked waves were rare (less than 1%). Nonperistaltic contractions were more common (P less than 0.001) after dry compared to wet swallows (18.1% vs 4.1%). This difference resulted from frequent simultaneous contractions after dry swallows (12.6% vs 0.4%).

CONCLUSIONS

Distal esophageal contractile amplitude and duration after wet swallows increases with age. Triple-peaked waves and wet-swallow-induced simultaneous contractions should suggest an esophageal motility disorder. Double-peaked waves are a common variant of normal. Dry swallows have little use in the current evaluation of esophageal peristalsis.

Esophageal testing of patients with noncardiac chest pain or dysphagia. Results of three years' experience with 1161 patients

Records from 910 patients referred to our clinical esophageal manometry laboratory for evaluation of noncardiac chest pain between January 1983 and December 1985 were reviewed and compared with records from 251 patients referred for dysphagia. Evaluation included baseline esophageal manometry, acid perfusion test, and edrophonium provocation. In the chest-pain group, 655 patients (72%) had normal esophageal motility and 255 (28%) had abnormal motility. Nutcracker esophagus was present in 48% of abnormal tracings, suggesting that it is a manometric marker for noncardiac chest pain. Of the total chest-pain group, 243 patients (27%) had their pain reproduced during provocative testing ("definite" esophageal pain); 192 patients (21%) had baseline manometric abnormalities but no pain during provocative testing ("probable" esophageal chest pain). The highest percentage of positive provocative responses (34%) occurred in patients with nutcracker esophagus on baseline manometry. Manometric abnormalities were statistically commoner (p less than 0.001) in patients with dysphagia, occurring in 53%. Achalasia (36%) and nonspecific esophageal motility disorders (38%) were the commonest abnormalities in this group, with nutcracker esophagus being infrequent (10%).

Long-term follow-up of symptomatic status of patients with noncardiac chest pain: is diagnosis of esophageal etiology helpful?

Questionnaires were sent to 119 patients with noncardiac chest pain, all of whom had previous detailed esophageal evaluations in which 63 were diagnosed as having pain from the esophagus. Mean follow-up period was 21.8 months. Patients diagnosed as having an esophageal etiology of their noncardiac chest pain usually continued to have recurrent pain. Furthermore, a specific diagnosis did not significantly increase the likelihood of pain resolution. However, patients who understood that the esophagus was the source of their pain were significantly less likely to feel disabled by their pain and to require continued physician evaluation. This finding was independent of any treatment program. This study emphasizes the importance of a careful evaluation of the esophagus as a potential source of pain and clearly communicating this information to the patient.

Relationship of radionuclide liquid bolus transport and esophageal manometry

Using simultaneous esophageal manometry and radionuclide transit studies, we compared liquid bolus transport with the various parameters of esophageal contractions. Study subjects included seven normal individuals, six patients with the "nutcracker esophagus" (mean distal peristaltic amplitude greater than 180 mm Hg), and three patients with spastic motility disorders. Manometric studies were performed when the subjects were in the basal state and after intravenous administration of edrophonium and atropine. Simultaneous radionuclide studies were done with subjects in the supine position by swallows of 250 mu Ci technetium Tc 99m sulfur colloid in 10 ml water. We found that normal liquid bolus transport (less than 15 seconds) is primarily dependent on the presence of a peristaltic wave front throughout the esophagus. Above a threshold pressure of 30 mm Hg, liquid transport was not affected by amplitude (33 to 500 mm Hg) or duration (3 to 15 seconds) of esophageal contractions. Repetitive wave forms also gave normal transit times as long as the wave front was peristaltic in onset. There was a significant inverse correlation (-0.65; P less than 0.001) between liquid transit time and peristaltic velocity. Prolonged radionuclide transport (30 to less than 50 seconds) was observed only with nonperistaltic contractions and very low amplitude (15 to 30 mm Hg) peristaltic waves.

Pneumatic dilatation of the achalasic esophagus requiring the aid of an endoscope

We describe a 65-yr-old man with achalasia, who had two previous Heller myotomies. He had a markedly dilated, tortuous esophagus, which defeated initial attempts at pneumatic dilatation. A method was improvised in which a Brown-McHardy dilator was attached by a string to a small caliber endoscope and both were successfully passed into the stomach. Pneumatic dilatation was then easily performed. Review of the literature and our experience with four patients suggests that pneumatic dilatation can be performed without substantial risk in patients after a failed Heller myotomy.

Antral varices

Varices of the gastric fundus, often associated with esophageal varices, are a common complication of portal hypertension or splenic vein occlusion. However, varices of the gastric antrum have been reported rarely. We describe a 61-yr-old man with antral and esophageal varices caused by portal hypertension due to hepatic cirrhosis.

Radiological evaluation of dysphagia

Radiological examination evaluates both structural and functional abnormalities of the esophagus in patients with dysphagia. Combined with the clinical history, the radiological results can guide the clinician to a specific diagnosis, such as carcinoma or stricture, or to additional studies, such as endoscopy or esophageal manometry. Based on cost and diagnostic efficacy, the radiological method, compared with endoscopy, is most useful as the initial screening examination in patients with dysphagia (Table 2). Its major limitations are poor detection of mild cases of esophagitis and occasional lack of specificity in diagnosing esophageal motor dysfunction. To achieve these results, however, effective radiological evaluation of the esophagus requires the meticulous use of a combination of examining techniques.

Radiographic efficacy in gastric ulcer: comparison of single-contrast and multiphasic examinations

The efficacies of single-contrast and multiphasic examinations of the stomach for gastric ulcer detection were compared in 90 patients with 102 gastric ulcers, and in a control group of 382 patients without gastric ulcer. Single-contrast and multiphasic sensitivities were 62% and 64%, respectively. Radiographic detection depended significantly on ulcer size: Only 24% of ulcers under 5 mm were detected, compared with 89% of ulcers 5 mm or larger. Radiographic specificities and positive predictive values were similar for both types of examination. Moderate variation of the sensitivities and specificities of the three radiologists was observed, with ranges of 53-69% and 90-98%, respectively. Results indicated that gastric ulcer detection is more related to ulcer size and to individual interpretive variations than to the type of examination.

Radiologic and manometric correlation in "nutcracker esophagus"

"Nutcracker esophagus" is a newly described esophageal motor disorder seen in some patients with chest pain and/or dysphagia and characterized manometrically by normal primary peristalsis with distal contractions of high amplitude. The radiographic and manometric examinations in 20 patients with nutcracker esophagus were correlated. Normal primary peristalsis was observed radiographically in 16 patients, and a nonspecific motor disorder was diagnosed in the remaining four patients. Mild-to-severe nonspecific tertiary activity was seen in about half of the patients, esophageal wall thickness was normal. It is concluded that nutcracker esophagus is primarily a manometric diagnosis made in the appropriate clinical setting, and that the radiographic findings are normal or nonspecific.

Radiographic and endoscopic sensitivity in detecting lower esophageal mucosal ring

Radiographic and endoscopic sensitivities were compared in 60 patients with lower esophageal mucosal ring. Barium esophagram detected 57 (95%) rings, all shown by the prone full-column technique. Double-contrast technique in 39 patients demonstrated only 18 (46%) rings. Endoscopy detected 35 (58%) of 60 rings. Endoscopic sensitivity depended on ring caliber with detection of 18 (82%) of 22 rings 13 mm or less in caliber, 14 (54%) of 26 14-19 mm rings, and three (25%) of 12 rings 20 mm or wider. Dysphagia was present in 13 of 25 patients with rings undetected by endoscopy. The caliber of the fiberoptic instruments used also affected endoscopic detection, with 47% of the rings being diagnosed with narrower endoscopes and 76% being diagnosed with larger instruments. Thus, the radiographic examination was more accurate in detecting lower esophageal mucosal ring and should be used initially in patients with dysphagia and suspected lower esophageal narrowing.

Radiographic magnification of colon polyps

Radiographic magnification was evaluated on conventional and remote control machinery using a phantom with steel rods positioned at different levels. Depending on the rod-film distance, the range of magnification was 8-47% on remote control and conventional overhead films and 11-82% on conventional fluoroscopic spot-films. Extrapolation to the colon based on cross-sectional anatomic correlation showed a 14-27% variation in the radiographic magnification depending on the machinery used, the segment of the colon considered, and the position of the patient. This implies that substantial inaccuracy in the measurement of colonic polyps is common by barium enema examination, particularly when a conventional fluoroscope is used.

Ambulatory 24-hour esophageal pH monitoring. Technology searching for a clinical application

The development of commercially available ambulatory 24 hour pH monitoring systems has expanded the potential use of this technique. In this article the use of these instruments is reviewed and direct comparisons between different techniques are made. Both the transnasal pH probes and the telemetric capsule have potential advantages and disadvantages for both the physician and the patient. Problems with the interpretation of pH recordings are discussed. A symptom index is developed in an attempt to provide a numerical assessment of the direct association between reflux events and symptoms in each individual patient.

Single-contrast vs double-contrast barium enema in the detection of colonic polyps

Radiographic and colonoscopic correlation in 139 patients with 234 colonic polyps compared the sensitivity of single- and double-contrast barium enema. Single-contrast barium enema detected 68 (80%) of polyps, with 72% of polyps under 1 cm and 94% of those 1 cm or over detected. Double-contrast barium enema detected 135 (91%) of 149 polyps, with 88% of polyps under 1 cm and 96% of larger polyps detected. Thus, the double-contrast barium enema was more effective than the single-contrast examination only for detection of polyps under 1 cm. The single-contrast barium enema was more likely performed on patients in poor physical condition and in those over 70 years old. The results suggest that for elderly patients, who may have difficulty in cooperating for a double-contrast enema, a properly performed single-contrast examination is an acceptable option.

Analysis of a multiphasic radiographic examination for detecting reflux esophagitis

Radiographic and endoscopic findings were correlated in 46 normal patients and in 49 with reflux esophagitis to assess the efficacy of a multiphasic examination employing mucosal relief full-column, and double-contrast techniques. Esophagitis was graded endoscopically as mild, moderate, or severe, and the quality and sensitivity of each technique and of the examination as a whole were determined. The radiographic specificity in the normal patients was 98%. The overall sensitivity was 65% for all grades of esophagitis, and 90% for the moderate and severe grades. Sensitivities of the individual techniques were: mucosal relief: 43%; full-column: 53%; double-contrast: 45%. These differences were not statistically significant. We conclude that a combination of radiographic techniques is needed to detect reflux esophagitis optimally.

Positive predictive value and examiner variability in diagnosing duodenal ulcer

The positive predictive value of a diagnosis of duodenal ulcer was studied in 255 patients with 274 ulcers diagnosed radiographically. Retrospective analysis of the radiographic examinations and correlation with endoscopy assessed examiner variability, ulcer size, duodenal bulb deformity, and the confidence level of the ulcer diagnoses. For all diagnoses, the overall positive predictive value was 57% with individual predictive values of 47%, 54%, and 70% among three examiners. The individual predictive values correlated directly with the average level of confidence of the diagnoses for each examiner. The sensitivity of the individual examiner for ulcer detection had an inverse relation to the examiner's positive predictive value, confirming that higher sensitivities are achieved at the expense of an increased false-positive rate.

Duodenitis: endoscopic-radiologic correlation in 272 patients

Potential radiologic findings of duodenitis were investigated in 272 patients, 157 with endoscopically diagnosed duodenitis and 115 endoscopically normal controls. The study assessed the value of four signs: folds more than 4 mm thick, mucosal nodules, bulbar deformity, and erosions. The most sensitive signs were thickened folds (72.0%) and nodularity (48.4%), while demonstration of erosions was the least sensitive (10.8%). Overall sensitivity (77.7%) approximated that for the radiologic diagnosis of peptic ulcer or esophagitis. Radiologic specificity (76.5%) was in the same range.

Predictive relationship of hiatal hernia to reflux esophagitis

The relationship between hiatal hernia and reflux esophagitis was compared in 93 patients who underwent both radiographic and endoscopic examination of the esophagus. In 46 patients with a normal esophagus shown endoscopically, hiatal hernia was present in 59%, while 94% of 47 patients with reflux esophagitis had hiatal hernia. The positive and negative predictive values for hiatal hernia in diagnosing or excluding esophagitis were 62% and 86%, respectively. Extrapolation of these data and review of the literature suggest that much of the confusion concerning the relationship between hiatal hernia and reflux esophagitis is based on reports of populations with considerable variation in the prevalence of esophagitis and in which the radiographic criteria for diagnosing hiatal hernia have not been uniformly applied.

Respiratory complications of gastroesophageal reflux

Gastroesophageal reflux (GER) and its many manifestations are extremely common problems. The pulmonary manifestations are the least well understood and are often unrecognized. We reviewed the available literature on the subject of respiratory tract symptoms secondary to chronic GER in an attempt to promote wider recognition of this relationship. We hope that this review will call attention to the potential importance of GER in those patients in whom such a mechanism might be responsible for pulmonary symptoms.

The radiologic detection of duodenal ulcers: effects of examiner variability, ulcer size and location, and technique

Study of 91 endoscopically verified duodenal ulcers compared the effects of examiner variability, ulcer size and location, and radiographic technique on ulcer detection. Radiologic sensitivity of 61.5% was found for the entire group of 91 ulcers. Examiner variability was the strongest determinant of success; sensitivities for individual examiners ranged from 44.4% to 80%. Ulcer size was a second factor in radiologic detectability; ulcers 5 mm or larger were detected at a higher rate (80.0%) than those less than 5 mm (64.5%). Sensitivities of 65.9% and 57.4% were recorded for single- and double-contrast examinations, respectively, a statistically insignificant difference.

Barrett esophagus as an extension of severe esophagitis: analysis of radiologic signs in 29 cases

Twenty-nine cases of Barrett esophagus verified by endoscopy and 16 cases confirmed by histology were reviewed for pertinent radiologic signs. All patients had barium-filled and mucosal relief films, and all but five cases had double-contrast films. Common radiologic signs in descending order were thickened and irregular mucosal folds (28/29), hiatal hernia (26/29), esophageal stricture (25/29), esophageal ulcer (20/29), distal esophageal widening (19/29), granular mucosal pattern (16/24), reticular mucosal pattern (9/24), and intramural pseudodiverticula (6/29), all of which are also recognized signs of reflux esophagitis. Midesophageal stricture, esophageal ulcer, and distal esophageal widening were particularly indicative of Barrett esophagus. Since there appears to be no specific sign of Barrett esophagus, a multifaceted approach is suggested concentrating on the association of Barrett esophagus with the radiographic signs of severe reflux esophagitis.

Edrophonium: a useful provocative test for esophageal chest pain

Esophageal motility disorders may be an important cause of noncardiac chest pain. To improve our diagnostic yield, we studied the use of edrophonium as a provocative test for inducing esophageal chest pain in 50 symptomatic patients without coronary artery disease and in 25 age-matched controls. Edrophonium (80 micrograms/kg of body weight, intravenous bolus) induced chest pain in 15 (30%) patients and in no controls. Edrophonium increased esophageal amplitude and repetitive contractions to a similar degree in all subjects, but the change in duration (101 +/- 13% [SE] was significantly greater (p less than 0.02) in patients in whom chest pain was induced. Drug specificity was assessed in 9 patients during cardiac catheterization, but no significant change was seen in coronary artery diameter, blood pressure, or heart rate. Further clinical testing using a placebo control confirmed a positivity rate of 28% in 125 unselected patients with chest pain referred to our laboratory; false-positive tests were infrequent (5.6%). No important side effects were seen. Edrophonium is useful for provoking esophageal chest pain.

Are esophageal motility abnormalities produced during the intraesophageal acid perfusion test?

Many years ago, it was proposed that the symptoms of heartburn correlated more closely with acid-induced esophageal motility abnormalities than with the presence of inflammation. This concept, however, has not been evaluated by modern manometric techniques. We monitored intraesophageal pressures during acid perfusion (O.1N hydrochloric acid) in 17 reflux patients with gross esophagitis and positive pain response and 17 age-matched controls. Using a low-compliance infusion system, amplitude, duration, velocity, and the presence of simultaneous and repetitive contractions in the body of the esophagus were evaluated. Amplitude did not change in either group. Duration did increase significantly during acid perfusion in reflux patients, but not in controls. Mean duration between groups, however, was similar before and during acid perfusion. No simultaneous contractions were observed, while three patients and two controls had repetitive contractions. A significant decrease in velocity was observed in both groups during acid perfusion. These studies indicate that acid-induced motor abnormalities are neither a common accompaniment nor necessary for the production of acid-induced pain in the esophagus.

Endoscopic sensitivity in the detection of esophageal strictures

Endoscopy was compared in 90 patients with a radiographic diagnosis of peptic esophageal stricture. Retrospectively, 78 strictures were classified as valid diagnoses giving a positive radiographic predictive value of 87%. Endoscopy diagnosed 74 (95%) of the 78 peptic strictures, detecting all 45 strictures under 10 mm in caliber, but failing to detect four (12%) of 33 broader strictures. Nine (75%) of the 12 radiographic false-positive errors involved misinterpretation of muscular or mucosal rings of the lower esophagus. We conclude that endoscopy and radiology are equally effective and complementary methods for evaluating patients with suspected peptic stricture.

Pneumothorax complicating enteral feeding tube placement

Two cases are presented of pneumothorax complicating enteral feeding tube insertion. A previous report describing three similar cases is noted. Neurologically impaired patients appear to be particularly at risk for this complication, which may be encouraged by use of a guidewire during tube insertion. It is suggested that enteral feeding tubes in neurologically impaired patients be inserted under fluoroscopic guidance using a tube specifically designed for this purpose.

Radiographic evaluation of the achalasic esophagus immediately following pneumatic dilatation

Sixteen patients with achalasia of the esophagus were treated by fluoroscopically guided pneumatic dilatation. All patients were examined radiographically immediately following dilatation. The caliber of the esophagogastric region increased from a pretreatment mean of 5.3 mm to 9.6 mm following dilatation. The margins of the dilated area remained smooth in 6 patients (38%) and became irregular in 10 (62%). Initial symptomatic improvement was found in 14 patients (88%) with a mean follow-up of 1.7 months. One (6%) perforation occurred, necessitating surgery. The radiographic appearance of the esophagogastric region following pneumatic dilatation, however, poorly predicted patient response.

The extent of successful colonoscopy: a second assessment using modern equipment

Records of 200 consecutive and unselected colonoscopies were reviewed to determine both the success in viewing the entire colon and the average extent of colon visualized, using the most modern equipment. Colonoscopy was completed to the cecum or ileum in 82.5% of studies, and an average of 93.8% of the colon was viewed. These data show considerable improvement compared to those previously reported by us. However, the significant number of incomplete colonoscopies still suggests that colonoscopy and barium enema examination must remain complementary for maximum detection of colonic lesions.

Esophageal radionuclide transit tests. Potential false-positive results

Esophageal radionuclide transit testing is a sensitive technique for assessing esophageal clearance. Experience with the technique in 150 patients has led to an awareness of several pitfalls which might lead to false-positive results. Potential problems may be grouped into technical factors, clinical aspects, and misinterpretations. Examples of these are presented and techniques to minimize such problems are discussed.

Clinical applications of oesophageal motility studies?

Technological advances in the investigation of oesophageal motility have resulted in progressive awareness of gastro-oesophageal reflux disease and motor disorders of the oesophagus as causes of obscure "noncardiac" chest pain, as well as for unexplained swallowing difficulties. Oesophageal motility studies should also be undertaken before surgery for reflux oesophagitis.

Protein III, a neuron-specific phosphoprotein: variant forms found in human brain

Protein III is a neuron-specific phosphoprotein which consists of two polypeptides, IIIa (Mr 74 kD) and IIIb (Mr 55 kD). This phosphoprotein has previously been shown to be associated with synaptic vesicles. In the present investigation, we have examined Protein III in human brain tissue. In contrast to observations in rat brain, where only one form of Protein IIIb (Mr 55 kD) has been found, in human brain tissue three variants of Protein IIIb, designated Protein IIIb1 (Mr 55 kD), Protein IIIb2 (Mr 57 kD) and Protein IIIb3 (Mr 59 kD), were observed by both biochemical and immunochemical assays. Protein IIIa from human brain also exhibited three variants in electrophoretic mobility. Peptide maps of Proteins IIIa and IIIb revealed that the differences in electrophoretic mobility of the variants of these proteins were preserved in variants (Mr 18kD, Mr20kD, and Mr22kD) of a smaller peptide fragment. These variant forms of Protein III were studied in brains from individuals without any history of neurological or psychiatric illness, as well as from individuals who had suffered from one of several types of neuropathological conditions, such as chronic alcoholism, Alzheimer's disease, multi-infarct dementia, and Parkinson's disease. Some differences were observed in the distribution of variants among the various clinical categories.

Inhibition by calmodulin of calcium/phospholipid-dependent protein phosphorylation

Calmodulin was previously found to inhibit the Ca2+/phospholipid-dependent phosphorylation of an endogenous substrate, called the 87-kilodalton protein, in a crude extract prepared from rat brain synaptosomal cytosol. We investigated the mechanism of this inhibition, using Ca2+/phospholipid-dependent protein kinase and the 87-kilodalton protein, both of which had been purified to homogeneity from bovine brain. Rabbit brain calmodulin and some other Ca2+-binding proteins inhibited the phosphorylation of the 87-kilodalton protein by this kinase in the purified system. Calmodulin also inhibited the Ca2+/phospholipid-dependent phosphorylation of H1 histone, synapsin I, and the delta subunit of the acetylcholine receptor, with use of purified components. These results suggest that calmodulin may be a physiological regulator of Ca2+/phospholipid-dependent protein kinase.

Sensitivity of single-contrast radiology in esophageal disease: a study of 240 patients with endoscopically verified abnormality

Single-contrast radiology of the esophagus was correlated with endoscopy in 240 patients with the following endoscopically verified abnormalities: esophagitis 170, rings 28, malignancies 19, varices 9, miscellaneous 14. For all the abnormalities except mild esophagitis, the overall sensitivity of the radiology in these 240 patients was 92%. All 19 cancers were diagnosed radiologically, whereas 90% of moderate and severe esophagitis was detected. The single-contrast examination thus reliably identified clinically significant disease of the esophagus. Comparison of these results to recent reports employing double-contrast technique suggests that claims of superiority for the double-contrast esophagram over the single-contrast study are not supported.

Colon polyp morphology on double-contrast barium enema: its pathologic predictive value

The morphologic appearance of 96 polyps seen on double-contrast barium enema was reviewed to assess the predictive value of various signs described to diagnose malignancy. Size, surface contour, basal indentation, and pedunculation were studied. Sessile polyps had an appreciable incidence of malignancy, with size being the best indicator of that risk. Pedunculation was found to be a reliable sign of benignity in predicting the absence of malignant invasion into the adjacent colonic wall. Polyps under 1 cm and having a smooth contour were invariably benign. Conversely, polyps larger than 1 cm with a lobulated contour and basal indentation had a significant incidence of malignancy.