Dyspepsia in general practice in Denmark. A 1-year analysis of consulters in general practice

OBJECTIVE

To estimate the incidence rate of patients with dyspepsia in general practice, related to age, gender and dwelling and to classify the patients into dyspepsia subgroups.

DESIGN

In a background population of 123,610 persons under the National Health Insurance System a systematic, prospective registration of dyspepsia patients consulting in general practice was done. Each patient was subject to a structured interview covering 18 dyspepsia symptoms and six alarm symptoms. A diagnostic chart was used to classify the patients into subgroups.

SETTING

General practice: 93 general practitioners in 63 centres in Denmark.

PATIENTS

Patients consulting the general practitioner with dyspepsia as their main complaint.

RESULTS

4215 dyspepsia patients were registered within 1 year. The annual incidence rate of dyspepsia was 3.4%. Alarm symptoms were present in 11.7% of the patients. The highest incidence rates were related to middle age, female gender and rural dwelling. Of these 34% had dysmotility-like, 30% had reflux-like, 17% ulcer-like and 3% uncharacteristic dyspepsia, while 16% were classified into two or more groups. Dysmotility-like dyspepsia was predominant in women and reflux-like dyspepsia was predominant in men.

CONCLUSIONS

Within 1 year 34 patients out of 1000 will seek medical advise in general practice with a new episode of dyspepsia. Based on the registration of symptoms 28 of 34 can be classified into a single subgroup of dyspepsia; 4 of 34 patients will present with one or more alarm symptom.

Bile acids in health and disease

Over the last quarter of a century Danish research on bile acids has comprised studies of their physical and chemical properties, their physiology, pathophysiology, metabolism, and kinetics, and their clinical applicability. In the beginning of the period a major contribution was made to the understanding of the factors involved in the solubility of cholesterol in bile. The growing international understanding of the potential importance of the bile acids in health and disease gave raise to a substantial Danish contribution in the 1970s and 1980s in parallel with international achievements. Emphasis was on the possible clinical implications of bile acids. Studies on physiology and pathophysiology were in focus. Patients who have had an intestinal bypass operation for obesity served as a model for obtaining new knowledge on various aspects of the properties of the bile acids. Also the analytical methods were improved. Important physiological research on the mechanisms of hepatic bile flow was conducted. An intestinal perfusion model served as a tool providing information on absorption kinetics and on transmucosal water and electrolyte movements. The gallstone disease, liver diseases, inflammatory bowel disease, fat malabsorption, and other intestinal disorders were studied. The 'idiopathic ileopathy' as a cause for bile acid malabsorption causing diarrhoea was established as a new disorder. Thus, in the time period concerned, substantial Danish contributions emerged on major and minor topics of the bile acid field.

Effect of glycochenodeoxycholic acid on unidirectional transepithelial fluxes of electrolytes in the perfused human ileum

Perfusion studies of the terminal ileum were performed in healthy volunteers to define the influence of a dihydroxy bile acid, glycochenodeoxycholic acid (GCDC) 2.5 mmol/l, on the mechanisms of electrolyte transport. Net movements of water and electrolytes, bidirectional fluxes of sodium, potassium, and chloride, and the transmural electrical potential difference (PD) were measured simultaneously. The results supported the notion of an active mechanism for sodium and chloride transfer. GCDC evoked net secretion of water and electrolytes, and decreased the mucosa to serosa flux of chloride, There was a tendency that the latter also applied to sodium and potassium. During bile acid perfusion active secretion of chloride occurred. PD was 16 +/- 4 mV, lumen negative, and was not influenced by GCDC. In conclusion, we propose a model for the GCDC effect.

Longitudinal study of influence of Helicobacter pylori on current risk of duodenal ulcer relapse. The Hvidovre Ulcer Project Group

Seventy-four patients with duodenal ulcer were followed up longitudinally for 2 years after initial ulcer healing. Endoscopy including biopsy of the antral mucosa was performed every 3rd month and whenever clinical symptoms of relapse occurred. The presence of Helicobacter pylori in the biopsy specimens was scored as 0 (none), 1 (sporadic occurrence), 2 (clusters), and 3 (numerous bacteria found diffusely in the mucus layer). The incidence rates of ulcer relapse per patient-month, grouped in accordance with these scores, were (with 95% confidence intervals) 0.073 (0.048-0.111), 0.083 (0.052-0.133), 0.123 (0.096-0.157), and 0.069 (0.041-0.116), respectively. No significant differences in incidence rates across H. pylori scores were observed when taking into account the observation period after healing of the first ulcer, number of ulcer recurrence (1st, 2nd, 3rd), sex, age, smoking habits, peak acid output, time of healing of the preceding ulcer, treatment of the present ulcer (cimetidine, antacids, or no treatment), or type and degree of gastritis. Thus, although H. pylori is prevalent in patients with duodenal ulcer disease, the present study indicates that H. pylori does not have a substantial note in the precipitation of active duodenal ulcer.

[Extracorporeal shockwave crushing of gallstones. Preliminary report]

Extracorporeal shock wave lithotripsy (ESWL) was used for treatment of symptomatic x-ray negative stones in 23 patients. The number of ESWL sessions per patient was 1.8 (range 1-4). In 18 patients (78%), adequate fragmentation was seen comparable to results obtained elsewhere. Oral bile acid therapy was used after ESWL in the 18 patients mentioned and the mean follow-up period was five months (range 3-8 months). Four patients had by now passed all stones while 12 patients still had remaining stone fragments and one patient a gallstone. After ESWL, one patient was and one patient a gallstone. After ESWL, one patient was referred for cholecystectomy at his own request. Of the remaining five patients, cholecystectomy was performed in two and was scheduled for in three. Complications after ESWL were seen in two patients who developed acute pancreatitis. Thus, our preliminary experience shows that ESWL resulted in fragmentation and passing of gallbladder stones, but not without complications. Like the gallstone groups in Lyon, Montreal and Munich we are convinced that ESWL should be performed in accordance with prospectively designed protocols in order to establish optimal planning of indications and strategies for future treatment.

[Clinical continuing education of younger physicians. A pedagogic trial with postgraduate clinical training using the clinical decision process]

The aim of this study was to improve the clinical training of the staff of a department of internal medicine. A total of 16 clinical pathological conferences with patient demonstrations were given. The doctor in charge of the conference motivated his choice of patient and made a critical review of the clinical decision process according to a 16 item check list. The median time used for planning of the presentation was five hours, range 2.5-8 hours. Sixteen of the participants (94%) found the training programme of very high or high quality while 1 (6%) found it less good. Fifteen (88%) of the doctors indicated higher clinical skill after than before the conferences (p less than 0.01). The registrars revealed a significantly better improvement of their clinical skills than did the senior registrars and consultants (p less than 0.05). The median educational value of the items of the check list was stated to be 1.3 (0-2). Statement of the probability of the final diagnosis of the patient, value judgement in clinical decisions and costs of diagnostic examinations were considered of highest educational value, 1.5-1.6. Postgraduate clinical pathological conferences with patient demonstrations including systematic reviews of the clinical decision process are valuable in the clinical training of doctors.

Endoscopically inserted biliary endoprosthesis in malignant obstructive jaundice. A survey of the literature

Eighty-seven publications in English on endoscopic bile duct stenting for palliation of obstructive jaundice were electronically or manually retrieved. Only eight of these studies were found to represent series of more than 20 patients and to include only a single presentation of data from patients published more than once. These eight studies refer to data on 856 patients, of whom 702 are from four open series, whereas 154 are from four randomized trials comparing endoscopic insertion of endoprosthesis to percutaneous stents or surgical by-pass. Endoscopic insertion was successful in about 90% of the patients. Stent diameters were 7-12 French. Patient survival was not affected as it is governed by the natural history of the underlying malignant disease. Endoscopic endoprosthesis was superior to percutaneous stenting and equal to surgical by-pass, but probably less resource consuming. The most important unsolved problem is the tendency to cholangitis and clogging of endoprostheses. Some suggestions concerning questions to be addressed in a more uniform manner in future publications on this subject are presented.

Duodenal ulcer healing on 2 g of sucralfate daily at bedtime compared to 1 g four times daily

Seventy-seven patients with endoscopically verified duodenal ulcers were randomized to treatment with either 2 g sucralfate daily at bedtime or 1 g sucralfate q.d.s. in a controlled double-blind comparative study. After a 4-week treatment period, the healing rate was 68% for the former and 69% for the latter treatment.

The personality pattern of duodenal ulcer patients in relation to spontaneous ulcer healing and relapse

One hundred consecutive out-patients with duodenal ulceration from a hospital and a gastroenterological clinic were tested with the Minnesota Multiphasic Personality Inventory (MMPI). This was carried out in order to investigate whether neuroticism or other personality disorders were characteristics of duodenal ulcer patients, and whether the presence of such possible personality disorders might influence the prognosis of the disease. Neuroticism occurred in 53% of the patients, but only in 5% of controls (P less than 0.0001). Overall, personality disorders were present in 69% of the patients compared with 30% of the controls (P less than 0.0001). Neuroticism was connected with a high frequency of relapse (P less than 0.05) whereas failure of spontaneous ulcer healing had no certain relation to personality disorders. Patients with non-neurotic personality disorders had more frequently suffered stressful life events before entrance to the study (P less than 0.05) and, like the neurotic patients, they had lower ego-strength to cope with such events (P less than 0.05). The results indicate that personality assessments make it possible to distinguish between subgroups of duodenal ulcer patients with different course of the disease.

[Abdominal pain precipitated by thoracic segment syndrome]

Referred pain originating from a dysfunctioning thoracic facet joint may simulate abdominal pain. This pain syndrome, the facet syndrome, is probably quite common and perhaps accounts for about 10% of the cases of abdominal pain of unknown origin. Current concepts of the facet syndrome are reviewed and a clinically diagnostic evaluation programme is presented. A case report illustrates the diagnostic problems in daily practice and the need for the clinician to recognize and to look for the facet syndrome.

Low-dose cyclosporin for Crohn's disease: implications for clinical trials

Cyclosporin is a potent immunosuppressant, which has gained recent interest as a possible treatment for Crohn's disease. Chronic nephrotoxicity, however, has recently been demonstrated as a result of early treatment with high initial cyclosporin doses. We report the effect of a 3-month treatment with low-dose cyclosporin (5-7.5 mg kg-1 day-1) in 11 chronically active, therapy-resistant Crohn's disease patients. Eight of the 11 patients (72%) improved according to a clinical grading score and the Dutch Activity Index whereas 9/11 (82%) improved according to the Crohn's Disease Activity Index (P less than 0.05) after 1 month. Three patients were withdrawn despite clinical improvement. One developed arterial hypertension, one dropped out and one required surgical treatment due to a small bowel stricture. Five patients (45%) completed the treatment period with improved clinical scores. After tapering-off, two patients (18%) were better at follow-up. No serious side-effects were encountered and it is concluded that low-dose cyclosporin treatment should be further investigated in Crohn's disease.

The effect of i.v. indomethacin on the gastric mucosal electrical potential difference and blood flow in anaesthetized dogs

Indomethacin inhibits prostaglandin synthesis and causes gastric mucosal damage. The correlation between the gastric mucosal function and gastric blood flow was investigated. The intragastric liquid junction corrected potential difference (PD) across the stomach wall was used to characterize the gastric mucosal function. Mucosal blood flow was determined by the radiolabelled microsphere technique. Seven dogs were anaesthetized, intragastric PD was measured continuously and blood flow determined at basal condition during sympathetic activation, and after IV indomethacin (7.5 mg/kg). PD was unchanged during the basal period and during mild sympathetic activation. After indomethacin PD was reduced significantly (-40 +/- 6 mV to -20 +/- 5 mV, measured with gastric lumen negative, mean and SD, P less than 0.05). Mucosal blood flow decreased during sympathetic activation and a further significant reduction was seen after indomethacin. PD and flow reductions correlated (R = 0.92). As indomethacin given IV caused a parallel impairment of gastric mucosal function and blood flow, part of the indomethacin-related mucosal damaging effects might be due to the flow reduction.

Decomposition of wheat bran and ispaghula husk in the stomach and the small intestine of healthy men

Decomposition of dietary fibers in the stomach and small bowel was studied in 13 healthy male volunteers. Liquid control meals were compared with test meals, which in addition contained a source of fiber (wheat bran or ispaghula husk) in random order. Aspirations were collected from the stomach, the proximal jejunum, the mid gut and the terminal ileum. Radiolabeled polyethylene glycol-4000 was used as nonabsorbable water-phase marker, and the formation of free arabinose was used to quantify the hydrolysis of dietary fibers. Ingested fibers, aspirates and urine specimens were analyzed for monosaccharides, either free or fiber-bound, by gas-liquid chromatography. Both types of fiber were hydrolyzed in the stomach, but not in the small bowel. Of ispaghula husk, 1-6% was hydrolyzed, as was 5-8% of wheat bran. Intestinal absorption of free arabinose was 85-93%, but excretion of arabinose in the urine was not greater than after control meals. For further evaluation of gastric hydrolysis six additional healthy male volunteers were studied by serial aspirations from the antral part of the stomach. Hydrolysis was instantaneous for both fibers, and was significantly more pronounced for wheat bran than for ispaghula husk.

A new method for measurement of the electrical potential difference across the stomach wall. Clinical evaluation of the gastric mucosal integrity

PD, the electrical potential difference across the gastric mucosa, is a variable used frequently in experimental studies. Existing methods for PD measurements are, however, unstable, and variations in the pH of the gastric juice causes liquid junction potentials between gastric juice and the PD measuring probe. A new PD measuring system has been developed with high stability, easy handling, and correction for the liquid junction potentials. PD was measured between a stomach microelectrode and an intravenous reference electrode connected to a millivoltmeter. pH was measured by an intragastric microelectrode. The liquid junction potential was calculated by using the pH measured in the gastric juice and the Henderson equation and was then subtracted from the measured PD to provide a better approximation of the PD across the mucosa. The liquid junction potential calculated as stated above correlated with the liquid junction potential calculated from precise ion determinations made in gastric juice samples (y = x; r = 0.92; p less than 0.05). The reliability of the PD measuring system was tested in vitro and in vivo and was satisfactory. In conclusion, a new, reliable, and easily applied method for gastric PD measurements corrected for the liquid junction potential between gastric juice and the PD measuring probe has been developed.

The influence of ispaghula husk and lactulose on the in vivo and the in vitro production capacity of short-chain fatty acids in humans

To evaluate factors influencing the short-chain fatty acid (SCFA) concentrations in stools, three different experiments were performed: faecal concentrations of SCFA at defecation were determined by gas liquid chromatography in nine healthy volunteers on a free diet. SCFAs were 114 +/- 15.0 mmol/l (means +/- SD). The coefficient of variation (CV) of the assay was 4-15%, the intraindividual CV 12-33%, and the interindividual CV 11-29%. On incubation of faeces at 37 degrees C concentrations of SCFA doubled in 6 h and rose fourfold in 72 h. In three volunteers the experiments were extended by adding ispaghula husk or lactulose to the diet for two 14-day periods each; no change in faecal SCFA concentrations was seen, either at defecation or after incubation. When ispaghula husk or lactulose was added to faeces in an in vitro incubation system, the concentrations of SCFA were five times higher than those of controls. We conclude that instant handling of faeces is essential for determinations of SCFA concentrations to obtain interpretable and comparable results; that determination of total SCFA output is of limited value; that addition of fibre to the diet does not influence faecal SCFA concentrations; and that the capacity for SCFA production in faeces is large provided a sufficient amount of substrate is available.

Short-chain fatty acids and the irritable bowel syndrome: the effect of wheat bran

Short-chain fatty acids (SCFA) in faeces were examined in 18 patients with the irritable bowel syndrome (IBS) during treatment with wheat bran or placebo. In the placebo period, the patients could be classified in accordance with the faecal concentrations of SCFA into one group with low concentrations (mean, 40 mmol/l; range, 19-77 mmol/l; 10 patients) and another with high concentrations (mean, 168 mmol/l; range, 145-187 mmol/l; 8 patients). The concentrations of SCFA differed (P less than 0.001) in both groups from concentrations found in faeces from a reference group of nine normal individuals (mean, 114 mmol/l; range, 93-155 mmol/l). Patients with low levels of SCFA had lower (P less than 0.001) mean stool mass and longer (P less than 0.05) transit times than those with high concentrations of SCFA in faeces. Ingestion of bran, although a precursor of SCFA, did not change faecal concentrations of SCFA. Abdominal pain, distension, and rumbling were not correlated to low or high concentrations of SCFA in faeces, nor did bran improve these symptoms when compared to placebo. The level of SCFA was rather constant intraindividually and independent of the variability of the daily faecal mass. It is concluded that patients with IBS apparently have continuously abnormal concentrations of SCFA in faeces, either high or low, which are unaffected by the treatment with bran and which hypothetically may be of pathophysiologic importance.

Chronic ischemic gastritis reversed after revascularization operation

A patient with severe chronic gastritis and duodenitis that clinically and endoscopically disappeared after an intestinal revascularization procedure is reported. Chronic intestinal ischemia appears to be a cause of gastritis as seen in this patient.

Effect of enterocoated cholestyramine on bowel habit after ileal resection: a double blind crossover study

Ileal resection causes malabsorption of bile acid; the increased load of bile acids in the colon induces increased secretion of salt and water and hence diarrhoea. A study was carried out to test the effect of an enterocoated cholestyramine tablet designed to disintegrate in the colon and sequester the bile acids there, thereby minimising diarrhoea induced by bile acids while having no effect on malabsorption of bile acid and jejunal fat absorption. The study comprised 14 patients who had undergone ileal resection of 40-150 cm for Crohn's disease. A double blind crossover trial was performed with placebo and cholestyramine enterocoated with cellulose acetate phthalate. During treatment with cholestyramine the daily faecal output decreased, the number of defecations each week decreased, and the intestinal transit time increased. Acceptability of the tablets was high, in contrast with general clinical experience with cholestyramine powder. No change was observed in the total faecal output of bile acids or fat. Cholestyramine tablets caused a reduction in diarrhoea without noticeably interfering with the metabolism of fat or bile acid.

The effect of coarse wheat bran in the irritable bowel syndrome. A double-blind cross-over study

Dietary supplementation with wheat bran has been widely advocated as a first-line treatment of patients with the irritable bowel syndrome (IBS). Few controlled trials have been reported, and the results are, furthermore, contradictory. The present study comprised 20 patients with IBS, of whom 18 (14 women, 4 men) completed the trial. The two treatment periods of 6 weeks each, with a daily intake of 30 g coarse wheat bran or 30 g placebo bran, respectively, were randomized in a double-blind cross-over design. Wheat bran significantly (P less than 0.05) increased the stool weight and shortened the intestinal transit time but was without significant effect on the colonic motility index was shown. We conclude that coarse wheat bran used as the only treatment in IBS does not provide a sufficient effect in a 6-week period. However, wheat bran seems to be justified in the treatment of constipation.

Irritable bowel syndrome: current concepts and future trends

About five per cent of the adult population each year will see their doctor with complaints that are finally characterised as irritable bowel syndrome (IBS). The complaints are constipation (perhaps alternating with diarrhoea), abdominal pain (dull or colicky), abdominal distension, abdominal rumbling and flatulence. The diagnosis of IBS implies that a relevant examination has precluded any organic disease. The etiology is unknown and the syndrome probably does not represent a disease entity. It is therefore difficult, if not impossible, to produce a definite rationale of treatment. However, several aspects of the pathogenesis of the individual symptoms of IBS are well known: 1) chronic constipation is most likely due to fibre-depleted diet, psychological factors, local organic disorders (e.g., anal fissures, hemorrhoids, diverticulosis) and disturbance of the body fluid balance (e.g., high consumption of diuretic compounds such as coffee and tea); 2) pain is related to spasms and motility disturbances causing increased intraluminal pressure; 3) meteorism is not due to an increased amount of intestinal gas, but "air traps" and segmental accumulation of gas seem to occur. Furthermore, psychopathological factors and perhaps also food intolerance may play an etiological role. At present the rationale of treatment in IBS is: 1) management of constipation, 2) ease of spasms, 3) reduction of surface tension of intestinal contents, 4) ease of mental stress.

A computer model simulating the intestinal absorption of bile acids

Mathematical models were developed for assessment of the absorption kinetics of compounds passing down the length of a perfused intestinal segment. The models considered the intestinal segment as a cylinder composed of a large number of very small (infinitesimal) cylinders and described the concentration decline of the compound in situations with active, passive and combined active and passive transport. The maximal velocity of active transport, Vmax, the Michaëlis-Menten constant, Km, and the permeability coefficient, P, were calculated. A computer program was developed to operate the mathematical expressions. The models were validated by jejunal and ileal perfusions of various bile acids in six healthy volunteers. The fit between the mathematical models and the actually measured data showed an average standard deviation of 0.14 mmol/l (substrate infusion concentration ranging from 0.25 mmol/l to 3.0 mmol/l). It was concluded that the computer models were feasible for practical purposes. Moreover, the models reduced the number of perfusions necessary to determine the absorption kinetics of a given bile acid.

Spontaneous healing of duodenal ulcers

Ninety-one patients with duodenal, pyloric, or prepyloric ulcers were studied endoscopically. Spontaneous ulcer healing was seen in 29 patients within 2 weeks (rapid healing) and in 23 patients within 6 weeks (slow healing). More ulcers healed spontaneously in women than in men (P less than 0.05). Spontaneous healing in men was related to a low gastric peak acid output (P less than 0.05). During follow-up study for 2 years of patients with spontaneously healed ulcers 13 patients had no recurrence, whereas 19 patients had 1 or 2 recurrences, which also healed spontaneously; 11 patients had to be given active treatment, and 9 patients did not complete the study. Cigarette smoking was more frequently recorded in the group receiving active treatment than in the group with spontaneous healing. In men ulcers needing active treatment during the follow-up period were related to a high peak acid output (P less than 0.05).

Mucosal function of the perfused ileum in patients with and without diarrhoea and dumping after vagotomy and pyloroplasty

Perfusion studies of the terminal ileum were performed in patients who had previously had vagotomy and pyloroplasty performed for peptic ulcer disease and who at follow-up study had either diarrhoea or dumping, or no symptoms (the control group). The aim was to elucidate possible pathophysiological factors contributing to the sequelae. Net movements of water, electrolytes, and sugars, unidirectional fluxes of sodium and chloride, and the transmural electrical potential difference (PD) were measured simultaneously with and without the influence of chenodeoxycholic acid (CDC), 1.0 mmol/l, in the intestinal lumen. In patients without symptoms or with dumping, water and sodium chloride were absorbed during the control perfusion. Addition of CDC reduced the absorption or evoked secretion. In patients with diarrhoea the control perfusion disclosed a large spontaneous ileal secretion that was not influenced by CDC. The secretion was mainly due to a reduced mucosa-to-serosa flux of sodium and chloride and, to a lesser extent, to an increased serosa-to-mucosa flux. The diarrhoea patients showed an increased xylose absorption rate, suggesting an increased interepithelial leakiness. No change in PD was demonstrated. The effect of CDC on the unidirectional fluxes was identical in all three groups of patients. In conclusion, our findings suggest that the basic biological mechanisms are identical (and normal) in all patients, but the ileal epithelium of patients with diarrhoea secretes spontaneously and seems to be prestimulated by some at present unidentified agent.

Effect of oat bran on lithogenic index of bile and bile acid metabolism

Epidemiological studies lend support to the hypothesis that high-fibre diets might prevent and low-fibre diets might facilitate the formation of cholesterol gall stones. In the present study, the bile compositions after ingestion of oat bran 18 g/day and placebo 18 g/day for 2 X 2 weeks were compared in a randomized, double-blind cross-over study in 6 healthy volunteers. The lithogenic index of bile was not influenced, whereas the following changes (0.05 less than p less than 0.10) occurred: the cholic acid pool was enlarged, the relative proportion of chenodeoxycholate in bile was increased and that of deoxycholate reduced, while cholate remained unchanged. It is concluded that oat bran seems to influence the metabolism of bile acids.

Enzymatic determination of total 3 alpha-hydroxy bile acids in faeces. Validation in healthy subjects of a rapid method suitable for clinical routine purpose

A method for determining faecal bile acids, suitable for clinical purposes, is introduced. The analysis uses a 0.2-g stool specimen, a simple extraction procedure, and 3 alpha-steroid dehydrogenase determination. The method, which is rapid, has been validated by gas-liquid chromatography and by recovery of internal standards. Stool examination was done in 16 healthy volunteers on free diet and in 25 patients with non-gastrointestinal diseases who were on a fat- and fibre-fixed diet. No difference was found between the two groups, so the data were pooled, and the normal reference interval (mean +/- S.D.) for faecal bile acid output was calculated to be 0-975 mumol/24h.

Secretion rate of intestinal immunoglobulins, complement factor C3, "acute phase" reactants, and albumin in the perfused ileum and jejunum of normal man

A new method for assessment of the intestinal secretion rate of immunoglobulins and other proteins is evaluated. The procedure involves a combination of luminal perfusion of a defined intestinal segment and analysis of the aspirated perfusates by rocket immunoelectrophoresis. The technique is sensitive and reliable. A material from the normal human jejunum and ileum is presented. The method is proposed as an investigative tool for characterization of the local immunological system of the small intestine.

Bile acid metabolism after intestinal bypass operations

Intestinal bypass operation for obesity results in substantial weight loss only if the small bowel segment left in function is 50 cm or less. The anatomical changes induce interruption of the enterohepatic circulation of bile acids, which result in bile acid malabsorption. This review discusses the various aspects of the disturbed bile acid metabolism. A small number of controlled prospective studies have focused on the problems of the jejunoileal ratio (JIR) of the functioning segment in relation to the changes induced on the bile acid metabolism. 1:3 JIR results in a significantly: (1) lower bile acid pool size; (2) lower postprandial concentration of bile acid in the jejunum: (3) lower ratio of glycine to taurine conjugates; (4) higher cholesterol saturation index in bile, compared to 3:1 JIR. Thus, the studies mentioned have not only elucidated the changes in bile acid metabolism after jejunoileostomy, but also given support to a new hypothesis that a functioning upper jejunum is necessary for the bile acid synthesis as such. This hypothesis is further supported by the finding that 1:3 JIR at follow-up has a three fold higher rate of gallstones than 3:1 JIR (p less than 0.05).

Prophylactic effect of cimetidine in duodenal ulcer disease

Fifty-seven symptom-free patients with duodenal ulcer entered a double-blind trial to assess the prophylactic effect of cimetidine. Patients were randomly allocated to receive cimetidine 400 mg twice daily (29 patients) or placebo (28 patients). The trial was designed to imitate daily clinical practice, so duodenal ulcer disease was diagnosed by means of x-ray examination. Three patients from each group withdrew from the trial. All remaining patients continued to receive treatment for 12 months or until symptoms recurred. Three out of 26 patients suffered relapses during cimetidine treatment, compared with 20 out of 25 receiving placebo. No side effects were attributable to cimetidine. Long-term cimetidine treatment had no curative effect as relapses occurred soon after treatment was stopped. The estimated chance (cumulative remission rate +/- 2 SE) of remaining symptom-free 13 weeks after one year's cimetidine treatment had been completed was 47 +/- 21%. Maintenance treatment with cimetidine is a suitable alternative to elective in surgery in patients with duodenal ulcer subjects frequent relapses. Further study is needed to establish the optimal duration and safety of prolonged cimetidine treatment.

Cimetidine treatment of protein-losing gastropathy (Ménétrier's disease). A clinical and pathophysiological study

In a 47-year-old male with Ménétrier's disease (protein-losing gastropathy) the histamine-H2-receptor antagonist Cimetidine stops the protein loss and improves the clinical condition. Gastric perfusion studies on net and bidirectional ionic fluxes, protein secretion rates, and permeability, with simultaneous recording of the transmural electrical potential difference indicate that Cimetidine decreases a paracellular protein secretion by 'tightening' the tight junctions of the gastric epithelium.