The natural history of cholelithiasis: the National Cooperative Gallstone Study

The National Cooperative Gallstone Study, a double-masked, placebo-controlled, therapeutic trial of chenodiol (chenodeoxycholic acid), provided an opportunity to study the natural history of cholelithiasis in patients who choose nonsurgical management. The major component of the study comprised 916 patients, 305 of whom were randomly assigned to receive a placebo for 24 months. Among these 305 patients, the probability of having biliary tract pain during the 24 months of prospective evaluation was significantly increased if the patient had had a history of biliary tract pain in the 12 months before entry into the study (69% versus 31%). Thirty-eight percent of patients had stone growth (greater than 0.5 cm3), and 18% had a spontaneous decrease in stone volume. Despite the high incidence of biliary tract pain, nonelective cholecystectomy was required in only 4% of patients during the 24 months.

Nutritional consequences of total gastrectomy

Nutritional status was investigated in 10 patients who had previously undergone total gastrectomy without evidence of malignancy. The ability of these patients to ingest and absorb adequate amounts of nutrients was examined. Metabolic balance studies were also performed to discover how effectively these patients could accumulate and use the absorbed nutrients. In the controlled hospital situation, the amount of food ingested was greater than the amount required for maintenance of Ideal Body Weight. Although mild malabsorption of fat and nitrogen was documented, weight gain and positive nitrogen balance occurred. In direct contrast, food intake significantly decreased when the patients returned to their home environment. While severe malabsorption may contribute to malnutrition in the individual patient, the most common mechanism responsible for postoperative malnutrition was inadequate intake. In the occasional patient with severe malabsorption, the universal demonstration of jejunal anaerobic bacterial overgrowth offers important therapeutic implications. The relative importance of pancreatico-biliary insufficiency in promoting malabsorption remains to be determined. Construction of a Hunt-Lawrence jejunal pouch was not found to favorably affect caloric intake, weight gain, degree of malabsorption, or dumping symptoms. Although some degree of malnutrition does result from total gastric resection, in most cases it is mild and potentially correctable. Avoidance of indicated total gastrectomy due to fears of progressive postoperative malnutrition is unwarranted.

Metoclopramide therapy in patients with delayed gastric emptying: a randomized, double-blind study

Twenty-eight patients with delayed gastric emptying as measured by an abnormal barium "burger" were treated with metoclopramide in a randomized, double-blind fashion. Five had diabetic gastroparesis, four had undergone vagotomy and pyloroplasty, and 19 were idiopathic. Patients received either metoclopramide or placebo for a three-week period and symptoms were scored prestudy, at weekly intervals, and at termination of the study. Ten of 17 patients on metoclopramide and four of 14 on placebo decreased their symptom score to a level below entry criteria, indicating a significant metoclopramide effect when compared to placebo. The mean total sumptom score for the metoclopramide group was 18.4 prestudy and 7.2 poststudy while for placebo was 19.1 prestudy and 12.9 poststudy. Although improvement on placebo was significant, these patients were still symptomatic. The improvement on metoclopramide was significantly greater than the improvement on placebo. Metoclopramide is an effective agent in treating the symptom complex of delayed gastric emptying.

Prevalence and prediction of osteopenia in chronic liver disease

To obtain information on the prevalence and clinical and laboratory correlates of osteopenia in patients with chronic liver disease, we measured bone densities and 30 selected laboratory variables in 133 subjects (70 men, 63 women) with liver disease. Thirty-two had alcoholic liver disease, 18 had primary biliary cirrhosis, 16 had primary sclerosing cholangitis, 48 had other forms of cirrhosis (cryptogenic, posthepatic) and 19 had chronic hepatitis or fibrosis without cirrhosis. Bone densities of the lumbar spine and three sites of the proximal femur (neck, Ward's triangle, greater trochanter) were estimated by dual-photon absorptiometry. Bone densities at all sites were significantly correlated to one another (r = 0.4 to 0.9; 95% confidence intervals = 0.24-0.54 to 0.81-0.90; p less than 0.0001 for all). Compared with an age- and gender-matched reference group, patients with liver disease had highly significant decreases in bone densities (greater than 2 standard deviations below control values; p less than 0.0008 at all sites). Decreases were particularly marked (24% to 42%) at Ward's triangle, the site of the femoral neck particularly prone to fracture. The prevalence of decreased bone densities ranged from 10% to 56%, depending on the site studied and the nature of the liver disease. Among 30 laboratory variables studied, there were significant (p less than 0.05) correlations with bone densities at more than one site for urinary creatinine (r = 0.21, 0.25), urinary calcium (r = -0.18, -0.23), serum total alkaline phosphatase (r = -0.18, -0.27) and the liver-1 isozyme of serum alkaline phosphatase (r = -0.19, -0.26).(ABSTRACT TRUNCATED AT 250 WORDS)

Potential role of microorganisms isolated from periodontal lesions in the pathogenesis of inflammatory bowel disease

A total of 20 patients with inflammatory bowel disease (IBD) (Crohn's disease, ulcerative colitis) were evaluated with regard to the role of infectious agents and host response. Patients were selected based upon oral manifestations of their disease, 10 with periodontal disease and 10 without. Microbiologic studies of the periodontal flora of IBD-affected patients revealed a unique microflora composed predominantly of small, motile, gram-negative rods, which were most consistent with the genus Wolinella. Further studies of the host response of these patients revealed a serum-mediated defect in neutrophil chemotaxis in all 10 patients with periodontal disease. Neutrophil phagocytosis was normal. In vitro studies of neutrophil function in response to Wolinella extracts and culture supernatants revealed inhibition of neutrophil chemotaxis in a dose-response fashion. The organism was chemokinetic for neutrophils but not chemotactic. The data suggest that unusual microorganisms colonizing the oral cavity of IBD patients potentially play a role in the pathogenesis of the disease as infectious agents or modifiers of the host response or both.

Epidermoid splenic cyst occurring in an intrapancreatic accessory spleen

This case describes a 40-year-old man with abdominal pain, nausea, and vomiting, who was found to have a cystic lesion in the tail of the pancreas. Distal pancreatectomy and splenectomy revealed a primary epidermoid cyst of the spleen lying in the substance of the tail of the pancreas. This represents the only report of a splenic cyst in an ectopic spleen that could be found in a search of the world literature.

Noncirrhotic portal vein thrombosis. Physiology before and after shunts

Controversy exists concerning the proper therapy for bleeding gastroesophageal varices secondary to noncirrhotic portal vein thrombosis. Disparity of opinion exists regarding the significance of hepatic portal blood flow and the consequences of total portal-systemic shunts in this condition. One patient is presented who developed severe, crippling encephalopathy 20 years after a central splenorenal shunt. This was associated with loss of portal flow to the liver and marked nitrogen intolerance. Closure of the shunt resulted in restoration of hepatic portal flow via collateral veins (HPI 0.36), clearance of encephalopathy and return to near normal protein tolerance. An additional patient was studied with hyperammonemia and early suggestive signs of encephalopathy eight years following a mesocaval shunt. Four patients were evaluated before and after selective distal splenorenal shunts. All had "cavernous transformation" of the portal vein with angiographic evidence of portal flow to the liver. Postoperative angiograms revealed continued hepatic portal perfusion and a patent shunt in each patient. Radionuclide imaging postoperatively gave an estimated portal fraction of total hepatic blood flow (HPI) of .39 and .60 in two of the four patients. We conclude that 1) there is significant hepatic portal perfusion in noncirrhotic portal vein thrombosis (cavernous transformation), 2) loss of this hepatic portal flow following total shunts can lead to severe encephalopathy, 3) the selective distal splenorenal shunt maintains hepatic portal perfusion and is the procedure of choice when there is a patent splenic vein and surgical intervention is indicated.

The effects of metoclopramide on postoperative ileus. A randomized double-blind study

Metoclopramide or placebo was administered postoperatively in a randomized, double-blind fashion to 115 patients undergoing laparotomy. The effect of metoclopramide on postoperative adynamic ileus (PAI) was evaluated. The patients were stratified into two groups: Group A--those with laparotomy without a gastrointestinal anastomosis or ostomy procedure, and group B--those with laparotomy undergoing an anastomosis or ostomy procedure. Metoclopramide reduced nausea and emesis postoperatively. However, the only significant effect on postoperative adynamic ileus was an earlier return to tolerance of solid foods in the patients in Group A.

Parenteral nutrition of adults with a 900 milliosmolar solution via peripheral veins

The objective of this study was to compare the nutritional value of three parenteral fluids: a conventional solution (400 milliosmoles/liter, containing Na, K, and Cl in 5% glucose); the concentrated hyperalimentation solution of Dudrick (1,800 milliosmoles/liter, containing Na, K, Cl, Mg, Ca, P, and amino acids in 20% glucose); and an experimental solution (900 millisomoles/liter, containing Na, K, Cl, Mg, Ca, P, and amino acids in 6.5% glucose). These three solutions are termed P400, C1,800, and P900, respectively. Preliminary studies showed that when 5 mg of cortisol/liter were added to P900, this fluid could be infused through peripheral veins for as long a time (average 114 hr) as P400 before local reaction necessitated changing the site. When P400 was infused in undernourished subjects without oral intake, balances of N, P, Mg, and Ca/70 kg of body weight per day were strongly negative (-4 g, -0.4 g, -6 mEq, and -0.2 g, respectively), whereas balances of K were about zero and those of Na and Cl were positive. Weight loss occurred. In the same patients, P900 containing 5 mg of cortisol/liter converted balances of N, P, Mg, and K to positive, and stimulated weight gain. Comparison of P900 (containing cortisol) and C1,800 in three emaciated subjects showed that the latter fluid caused a 2 to 4 times greater degree of positive balance in N, P, K, and Mg than the former. Comparison of P900 (containing cortisol) + 670-1700 cal by mouth with C1,800 in four undernourished subjects showed no statistically significant difference between these two programs.

CONCLUSIONS

by adding 5 mg of cortisol/liter to P900, the fluid can be infused through peripheral veins. P900 is intermediate in nutritional value between P400 and C1,800. P900 without oral supplement prevents negative balance of all elements except Ca. P900 + daily oral intake of 670-1700 cal is nutritionally equivalent to C1,800.

Small intestinal mucosal cell proliferation and bacterial flora in the conventionalization of the germfree mouse

The relationship between intestinal colonization and the small bowel mucosal cellular proliferation rate during conventionalization of the germfree mouse was examined. 16 mice were maintained under standard germfree conditions, and 54 others were conventionalized. Migration of the small bowel epithelial cells was followed by radioautography with administration of tritiated thymidine. Colonization was followed by qualitative and quantitative bacteriological fecal analyses. The percentages of the villi labeled (as determined by cell count) 24, 48, and 72 hr following thymidine administration showed immediate progression in the conventionalized animals from the germfree villus migration time (4 days) toward the conventional villus migration time (2 days). The epithelial migration rate of animals conventionalized for 8 days was comparable to that of conventional animals. After conventionalization, aerobic and anaerobic organisms undergo a period of extensive multiplication; however, 72 hr later the number of these microorganisms cultured in the stool decrease and are similar to those recovered from normal animals. Coliforms and streptococci are recovered in large numbers only in the first days after conventionalization, while the Bacteroides are first recovered in significant numbers on the fifth day of conventionalization. Except for smaller numbers of Bacteroides, the bacterial populations in the stools of the conventionalized animals are qualitatively and quantitatively similar by the eighth day of conventionalization to those of true conventional mice. Adaptive balance between cell proliferation and sloughing, and thus migration rate, begins immediately after conventionalization of germfree animals as bacterial populations establish themselves throughout the gastrointestinal tract, and results in a doubling of the mucosal cell turnover after 8 days. At this time both the small intestinal epithelial cell migration rate and the intestinal microflora are similar to those of conventional animals.

Low-dose chenodiol to prevent gallstone recurrence after dissolution therapy

Chenodiol is a safe and effective agent for the medical dissolution of gallstones in selected patients; however, after dissolution and cessation of treatment, gallstones recur. This study was done to determine the recurrence rate after successful medical treatment and cessation of chenodiol therapy; compare the efficacy and safety of low-dose chenodiol, as compared to placebo, for prophylaxis against recurrence; and identify factors predictive of recurrence. In a randomized, double-blind fashion, 53 patients with gallstone dissolution received either chenodiol, 375 mg/d, or placebo, for at least 2 years. Standardized oral cholecystograms were done at 6 months, 1 year, and then yearly thereafter. Routine laboratory testing was done every 6 months. The cumulative rate of recurrence (life-table) was 27% in patients followed for up to 3.5 years. Chenodiol, 375 mg/d, was ineffective in preventing the recurrence of gallstones. No demographic, clinical, roentgenographic, or biochemical characteristics were predictive of recurrence.

Primary hyperparathyroidism and the gastrointestinal tract

To determine the frequency of gastrointestinal symptoms in primary hyperparathyroidism, we retrospectively analyzed 100 consecutive patients seen at Emory University Hospital from Jan 1, 1977 through March 1, 1979. At the time of diagnosis, 28 patients complained of nausea, 19 of vomiting, 29 of abdominal pain, and 33 of constipation. One patient presented with acute pancreatitis and 14 had ulcer disease (two gastric and 12 duodenal ulcers). Hypercalcemia increases gastric acid secretion and may account for associated ulcer disease and the ulcer-like pain in primary hyperparathyroidism. The mechanisms causing the other gastrointestinal symptoms in hypercalcemia remain to be elucidated. These symptoms abate on correction of hyperparathyroidism.

Clinical application of the manofluorogram

The purpose of this paper is to illustrate the clinical usefulness of simultaneous fluoroscopy and manometry, as analyzed by the manofluorogram, in the evaluation of dysphagia. Four quantitative parameters calculated from the manofluorogram are analyzed and compared in six representative cases of dysphagia. The manofluorogram adds diagnostic information which cannot be obtained by barium swallow or standard manometry.

The surgical treatment of bile reflux gastritis: a study of 59 patients

Fifty-nine patients underwent duodenogastric diversion for bile reflux gastritis. Sixty per cent of 37 patients who underwent measurement of solid food gastric emptying had delayed gastric emptying. Patients were also assessed in terms of the degree of gastritis present endoscopically. Fifty-six patients were available for follow-up of from six months up to six years. The results demonstrated the following: Patients with delayed gastric emptying and reflux gastritis fared poorly after duodenogastric diversion; the greater the severity of gastritis visible by endoscopy, the better the results of diversion. Only 47% of patients achieved a satisfactory result of duodenogastric diversion.

Nasogastric hyperalimentation through a polyethylene catheter: an alternative to central venous hyperalimentation

We performed nasogastric hyperalimentation with polyethylene catheters and appropriate feeding solutions in 12 cachectic patients who had been referred as candidates for central venous hyperalimentation. Most patients had primary gastrointestinal disease. The duration of hyperalimentation averaged 31 days. Seven patients obtained rapid weight gain (average 0.3 kg/day) with the nasogastric hyperalimentation alone. An additional two were successfully repleted with the addition of parenteral fluids via peripheral veins. In the nine repleted patients, serum albumin rose by average 19%, 24-hr urine creatinine by average 21%, and triceps skinfold by average 46%. The nature of the weight gain in the nine successful cases was analyzed by the metabolic balance study technique. Average composition of the increment in weight was: 50% protoplasm, 48% extracellular fluid, 19% adipose tissue, and less than 1% bone. We conclude that nasogastric hyperalimentation can replace central venous hyperalimentation in a substantial proportion of patients now receiving the latter type of treatment.

Colon interposition for advanced nonmalignant esophageal stricture: experience with 40 patients

This report details our experience in 40 patients with benign strictures of the esophagus who underwent colon (or gastric) interposition with our without esophageal resection between 1972 and 1980. There were 23 men and 17 women ranging from 5 to 76 years old. Twenty-seven patients had fibrotic strictures secondary to reflux esophagitis including 12 after failure of antireflux procedures; 4 had caustic strictures; 3 had a Barrett's esophagus; 2 had systemic candidiasis; 2 had scleroderma; and in 2 the etiology was undetermined. the right colon was used in 27 patients, the left colon in 4, the transverse colon in 1, and the jejunum in 1. In 7 patients the stomach was employed because of vascular insufficiency of the colon. Three surgical approaches were utilized. Manometric studies were done post-operatively in 10 patients. Complications occurred in 7 patients: cervical leaks, 4; reflux colitis, 2; and a late cervical stricture, 1. There were 4 deaths, only 1 of which was related directly to technique. This report summarizes the beneficial effect of right colon interposition for long esophageal strictures. Its vasculature is adequate, and it functions properly to propel food into the stomach irrespective of the peristaltic orientation.