British Society of Gastroenterology - Gut

Gut, 1991,32, A1203-A1260

British Society of Gastroenterology

The 1991 Autumn Meeting of the British Society of Gastroenterology was held at the University of Warwick from 9-11

September under the presidency of Professor Sir Robert Shields. Below are printed the 323 abstracts selected by the

Programme Committee of the Society for oral and poster presentation.

COLORECTAL: SURGERY, INFLAMMATION ANDNEOPLASIA

Obstructed colon: do metalloproteinaseshave a role in anastomotic dehiscence?

D L P LACOMBE, F J SAVAGE, R M HEMBRY, P BBOULOS (Department of Surgery, UniversityCollege and Middlesex School of Medicine,London and Strangeways Research Laboratory,Cambridge) Indirect evidence suggested thatcollagenase is a factor in colonic anastomoticleakage. This study examined immunohisto-chemically the distribution of collagenase, andother metalloproteinases: stromelysin andgelatinase and their inhibitor, tissue inhibitorof metalloproteinases (TIMP) in a rabbitcolonic anastomosis.An anastomosis was formed after transection

(group 1 n= 12), after resection of a 3 cmsegment of distal colon (group 2 n= 12) andafter obstruction by a silicone ring placed theday before resection (group 3 n= 12). Rabbitswere killed 0 5, one, three, and seven days laterand tissue taken from the anastomosis (A),distal (D) and 3 (P0), 5 (P1), and 20 (P2) cmproximally.

In all groups, intra- and extracellular enzymeand TIMP were present at the anastomosis. Ingroup 3 only,intracellular gelatinase occurredin the submucosa of the resected segmentand all postoperative tissue, extracellularcollagenase, gelatinase, stromelysin, andTIMP were seen in the mucosa of D, A, P0,and P1 but at seven days they were restricted tothe anastomosis.

In the obstructed colon changes in the metal-loproteinases are less confined and may justifyreluctance for primary anastomosis in humans.

An anal plug for use in anorectal incontinence

T J O'KELLY, M SMILGIN HUMPHRIES, N IMCCMORTENSEN (Department of Surgery, JohnRadcliffe Hospital, Oxford) We have developeda new disposable anal plug for use in anorectalincontinence. Two tulip shaped designs (largeand small) have been trialled. Fourteen incon-tinent patients (idiopathic 10, post anal surgery2, spina bifida 2) median age 61 years (range18-82 years) used the plugs for two weeks,keeping a diary of plug performance.

Patients used more of the small plugs (small12-1 (0.9) (mean (SEM)) v large 9-6 (1-0); p=0-046 Wilcoxon signed rank test) but, therewas no difference in overall (small 133 (16) hrsv large 97 (15) hrs) or individual plug use time(small 11.1 (141) hrs v large 10.3 (1.1) hrs).There was no correlation between duration ofplug use and anal canal pressures or sensation.In the 10 patients who preferred the small plug,maximum resting anal canal pressure (MRP)was lower than in those who liked the largerplug (small 39 (9.5) cm H20 v 91 (9.0) cm H20;p=0034 Student's t test). Maximum voluntary

The accuracy of the data in these abstracts is theresponsibility of the authors since the abstracts have notbeen subject to peer review.

contraction and anal canal electrosensitivitywere not significantly different.

Plugs were judged easy to insert (82% ofuses) or remove (88%) and leakage occurredduring 20% of uses. Eleven patients would use

the plug if it became commercially available.The anal plug may have a role in the

management of patients with anorectal incon-tinence. Success depends on patient preferencerather than underlying anorectal physiologicalparameters.

Failure of internal sphincter relaxation: thecause of fissure?

R FAROUK, G S DUTHIE, D C C BARTOLO, A B

MACGREGOR, R MILLER (Departments ofSurgery,Royal Infirmary ofEdinburgh and Bristol RoyalInfirmary) We carried out ambulatory measure-

ments of internal anal sphincter electromyo-gram (EMG) with anal pressures using a

computerised system to determine whetherfailure of internal sphincter (IAS) relaxationwas the cause of anal fissures.

Fifteen patients (median age=36 years

(interquartile range 26-40); eight male) withanal fissures and 11 normal volunteers (age= 36years (25-71); six male) underwent fine wireanal sphincter electromyography and analmanometry. The median (range) IAS EMGfrequency was fissure=0-45 Hz (0.31-05),normal=0-41 Hz (0.25-0-44; p<0-01*).Median anal pressures were fissure=118 cm

H20 (89-127), normal=90 cm H20 (60-130;p<0002*). A direct linear relation between theIAS EMG frequency and resting anal pressure

was seen in both groups. The median numberof anorectal sampling episodes per hour was

fissure=2 (1-4), normal=5 (4-6; p<0-01*).Fewer episodes of sampling occurred at nightin both groups. Anal ultra-slow wave activitywas noted in seven patients with fissures butnot in the normal group.The IAS EMG frequency is higher than

normal in patients with anal fissures and corre-

lates directly with higher resting anal pres-

sures. Internal sphincter relaxation occurs on

fewer occasions in patients with fissures com-

pared with controls.*Mann-Whitney U test.

Polymorphic DNA probes and predictivediagnosis of familial adenomatous polyposis:a population based study

D G MORTON, F MACDONALD, M RINDL,R CULLEN, J HAYDON, J GIBSON, C McKEONN,J NEOPTOLEMOS, M KEIGHLEY, M HULTEN

(University Department of Surgery, RegionalGenetic Services and East Birmingham Depart-ment of Ophthalmology, Birmingham) Theputative gene for familial adenomatous poly-posis (FAP) has closely linked flankingmarkers which can be used for predictivediagnosis, but their value in population basedscreening is poorly defined. Therefore,we undertook a study of 42 families (261individuals) from a circumscribed populationof 5 5 million, using probes I1227, CIIPII,ECB27, and YN5.

The results showed that 95% of affectedindividuals (40/42) were informative with atleast one probe (diagnostic accuracy 90-98%).Some 45% were informative for flankingmarkers (diagnostic accuracy >99%).Altogether 82% of at risk individuals (27/33)were informative for one or more probes. In 22cases prior risk had been reduced by bowelexamination. Only one had the high risk allele.Of 11 unscreened individuals, six had the lowrisk allele, three carried the high risk allele, andtwo were uninformative.

In conclusion, DNA analysis can accuratelyidentify high risk family members. In conjunc-tion with clinical assessment it can also be usedto considerably reduce an individual's risk.This information can be used to reduce thefrequency of subsequent bowel screening. Inour study population, 16/42 families (38%)could benefit from DNA analysis. Develop-ment of preserved tissue DNA analysis fromdeceased relatives would make a further16 families potentially informative. Directmutation probes would be needed for analysisin the remaining 10 families, which comprise ofisolated cases.

Reduced mucosal proliferation after ileorec-tal anastomosis in familial adenomatouspolyposis may explain rectal polyp regression

K C R FARMER, R K S PHILLIPS (St Mark'sHospital, London and Professorial Surgical Unit,St Bartholomew's Hospital, London) Rectalpolyp regression occurs in familial adenoma-tous polyposis (FAP) after ileorectal anastomo-sis (IRA). Because neoplasia and epithelial cellturnover are related, we determined the effectof IRA on rectal mucosal proliferation in FAP.

Endoscopic biopsy specimens of flat rectalmucosa were taken from eight FAP patientsbefore colectomy and 12 FAP patients with anestablished IRA. Mucosal proliferation wasassessed by flash labelling proliferating cellswith bromodeoxyuridine. Labelled cells werevisualised on paraffin sections using an anti-bromodeoxyuridine monoclonal antibody.Twenty crypt columns were analysed. Micro-adenomas were excluded. Statistics: Mann-Whitney U test.The mean labelling index (mean (SD) per-

centage labelled cells/crypt of FAP precolec-tomy patients (13-2 (2.5)%) was significantlygreater than that of FAP patients with estab-lished IRAs (7.0 (1-4)%); (p=00002). Beforecolectomy, more labelled cells were in themiddle and upper zones of the crypt(p<0005); by contrast more labelled cells werein the lower zone after IRA (p<0 005).

Colectomy and IRA in FAP is associatedwith a significant reduction in rectal mucosalcell proliferation. These findings may explainboth polyp regression in FAP after IRA andalso the low rectal cancer risk.

P53 and the adenoma-carcinoma sequence

N SCOTT, P SAGAR, J STEWART, G E BLAIR, M F

DIXON, P QUIRKE (Departments of Pathology,Surgery and Biochemistry, University of Leeds,Leeds) p53 is a tumour suppressor gene which

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encodes a 53kD nuclear phosphoprotein.Mutations in conserved regions of the genehowever, result in over-expression of a mutantprotein which acts as a classic oncoprotein.We have used immunohistochemistry to

detect mutant p53 in 5% of 38 sporadic adeno-mas and 44% of 100 adenocarcinomas of thelarge bowel. We conclude that p53 mutationis a late event in the adenoma-carcinomasequence comparable with chromosome 17pdeletions and deletions of the DCC gene.Analysis of a subset of the adenomas for K-rasmutations showed a 2 cm diameter benigntubulovillous polyp with both a mutated p53gene and mutation at codon 12 of the ras gene.

Although this is sufficient in vitro to trans-form primary rat fibroblasts, other changes areclearly required in vivo to produce malignanttransformation in an adenoma.

Endogenous hypergastrinaemia stimulatescolonic mucosal polyamine biosynthesis andepithelial proliferation

M R GRAY, R S NAGRA, H M WALLACE, J NEMETH,A N KINGSNORTH (University of Liverpool,Departments of Surgery and Physiology andDepartments of Medicine, Therapeutics andPharmacology, Aberdeen) Whether gastrinstimulates colonic mucosal proliferation is thesubject of conflicting evidence. Pentagastrinadministration stimulates colonic polyaminebiosynthesis, a finding often linked to pro-liferative events. Other investigators havefailed to show evidence of mucosal hyperplasiain the colon of fundectomised rats.We have measured left colonic mucosal

polyamine content by HPLC, crypt cell pro-duction rate by vincristine metaphase arrest,and crypt height in four groups of 10 rats. Allresults median (range) were compared byMann-Whitney U.

In rats receiving 200 mmol omeprazole/kg/day postoperative serum gastrin rose 12 foldfrom 23.6 (11-9-37.4) to 255 (173-445) fmol/ml (p<0 01). After 30 days treatment totalpolyamine content rose by 74% from 14 6 to25.4 nmol/mg protein (p<0 001). Cryptheight, 2.3 (1.9-2.62) v 2.18 (1 9-2.42) mm,was unaffected. In a separate experiment, cryptcell production rate was increased by 7% from6 19 (0.0068) CCPH (r=0.989) to 6.61 (0.005)CCPH (r=0.988) (p<0 001 Student's t testcomparison of regression gradient).We conclude that colonic mucosa responds

to endogenous hypergastrinaemia by anincrease in polyamine biosynthesis and a smallbut significant acceleration in cell turnover.

Detection of malignant cells in peritonealfluid in colorectal cancer

A J M LEATHER, C Y YIU, G KOCJAN, W HU, P B

BOULOS, J M A NORTHOVER, R K S PHILLIPS

(ICRF Colorectal Cancer Unit, St Mark'sHospital, London, Department oJ Cvtology,Middlesex Hospital, London, Departments ofSurgery, University College and MiddlesexSchool of Medicine and St Bartholomew'sHospital, London) The impiantation of malig-nant cells in the peritoneal cavity is a likelycause of local recurrence after curative resec-tion in colorectal cancer. Detection of thesecells by conventional cytology is difficult andmay be assisted by immunocytochemistry. Inthis study suitable antibodies were selected andused to detect exfoliated malignant cells inpatients undergoing colorectal cancer resec-tion.

Cytospin preparations from two humancolorectal cancer cell lines (LoVo, SW480), 10ascitic fluids and cryostat sections from nine

colorectal cancers were stained with AUA 1,CAM 5.2, Ber EP4, 8.134, PR1A3, PR3B10,HMFG2, 41.2, ICR2, anti-CEA. AUA1 andBer EP4 were selected as both stained the celllines (2/2), colorectal cancer cryostat sections(9/9), malignant ascites (5/5) and were negativefor benign ascites (0/5).

In 25 patients, 400 ml of normal saline wereinstilled into the peritoneal cavity at the begin-ning and end of the operation, aspirated afterthree minutes and malignant cells isolated on ahistopaque density gradient before cytospinpreparations were stained by an indirectimmunoperoxidase technique using AUA 1,Ber EP4, and by cytology using the May-Grunwald-Giemsa stain.

Malignant cells were identified in 11 patients(44%); before and after resection washings innine and post resection washings in two. Of the20 positive samples the antibodies contributedessential diagnostic information in seven (35%).

Immunocytochemistry did assist conven-tional cytology in identifying malignant cellsand may play a role in investigating localrecurrence.

Adjunctive intraoperative photodynamictherapy for colorectal cancer

A M ABUAFI, J T ALLARDICE, R DEAN, M GRAHN,N S WILLIAMS (The Surgical Unit, The RoyalLondon Hospital, London) A major source oflocal recurrence of colorectal cancer afterostensibly curative resections (OCR) is micro-scopic residual disease in the tumour bed.Twenty one patients (two with Dukes's A, 12Dukes's B, and seven Dukes's C) who under-went OCR were treated with intraoperativephotodynamic therapy (IOPDT), a novelapproach which can destroy malignant cells inthe tumour bed. The tumour bed (surface arearange 95-371 cm 2) in all patients receiveddoses ranging from 35-70 J cm 2 of green (510nm) laser light via specially constructed lightdelivery systems. Mean (SEM) laser irradiationtime was 22.3 (2.6) (range 1155-52.8) minutes.There were no postoperative complicationsdirectly related to IOPDT, however, threepatients developed skin photosensitivity reac-tions. Follow up ranged from 3-26 (median 12)months. Sixteen of 21 tumour specimens hadcircumferential resection margin (CRM)examined histologically for tumour involve-ment. Eight were positive and eight werenegative. Of eight patients whose tumoursinvolved the CRM who inevitably woulddevelop local recurrence, one did so at threemonths. Eight patients whose tumours did notinvolve CRM and five patients whose tumourswere not examined for CRM involvementremain free of local recurrence.

These results suggest that IOPDT is afeasible and safe approach and does not signifi-cantly prolong surgery. It may have the poten-tial of reducing local recurrence.

In vitro and in vivo characteristics of tumouractivated killer lymphocytes in colorectalcancer

R I SWIFT, M THOMAS, J GAER, S TEBBUTT, C B

WOOD (Hammersmith Hospital, London)Adoptive immunotherapy with Lymphokineactivated killer cells. or tumour infiltratinglymphocytes has produced clinical responses inmetastatic melanomas. However, the therapyrequires high doses of interleukin 2, whichcause unacceptable side effects. We report thein vitro development and in vivo characteristicsof tumour activated killer lymphocytes (TAK).From 80 ml of venous blood, peripheral bloodmononuclear cells were collected by Ficoll

paque centrifugation, the cells were culturedwith autologous colorectal cancer cells at a ratioof 100:1 tumour cell and 100 U of interleukin 2for three to four weeks. The tumour cellnumbers, lymphocyte numbers and lympho-cvte cvtotoxicitv were assessed at weeklyintervals.

Control cultures of tumour cells and inter-leukin 2 alone grew exponentially but in themixed cultures all the tumour cells were killedby four weeks. The lymphocyte numbers fell inthe first two weeks, thereafter increasing 10 to100 fold. The proportion of cytotoxic lympho-cytes increased from 10-24%'o to a maximum of78%'o at three weeks. In separate cultures, theTAK cells were collected, labelled withII1Indium tropolonate, and then re-injectedinto autologous patients. The patients werescanned at regular intervals to examine thebiodistribution of TAK cells in five patientswith metastatic colorectal cancer. The imagesconfirmed a uniform distribution of cells ineach patient, to lung (for four hours only),liver, and spleen, with metastatic lesions beingvisible 24-48 hours after injection.

This work confirms the cytotoxic character-istics of TAK cells, and illustrates their in vivoability to localise sites of autologous metastaticcolorectal disease.

Interleukin 2 production in patients withadvanced colorectal carcinoma immunisedwith a human anti-idiotypic monoclonal anti-body

G W L DENTON, R A ROBBINS, I G DURRANT, E B

AUSTIN, J D HARDCASTLE, R W BAI DWIN (Depart-ment of Surgery and Cancer Research CampaignLaboratories, Nottingham University) 105AD7 isa human anti-idiotypic antibody which is aninternal image of a human colorectal carcinomasurface antigen. It is currently being usedto treat patients with advanced colorectalcarcinoma. Serum interleukin 2 (IL 2) concen-trations were measured as an assessment of theinduction of a cellular immune response.

Six patients have been treated, withindividual patients receiving up to fourimmunisations. Serial weekly serum samplestaken for six weeks after immunisation havebeen analysed for circulating IL 2 using acommercially available IL 2 ELISA (Dupont).IL 2 was detected in the plasma of four of thesix patients, after eight out of nine immunisa-tions. The response ranged from one to fiveweeks (median three weeks) and the peak levelsof IL 2 detected ranged from 3 to 7 U/ml(median 4 5 U/ml). No antibody or IL2 relatedtoxicity has been observed.The production of this amount of endo-

genous IL 2 after immunisation is noteworthy.To obtain similar steady serum levels of IL 2 atherapeutic infusion of exogenous IL 2, withattendant toxicity, would be needed. Thissuggests that immunisation has induced aspecific T cell response and potentially mightinduce a IAK mediated anti-tumour response.

Anal smear or microanoscopy to identify analintraepithelial neoplasiaP S CARTER, A DE RUTTER, C WHATRUP, D KATZ,G KOCJAN, A MINDEI, J M A NORTHOVFR (ICRFColorectal Unit. St Mark's Hospital, London,Academic Departments of G-U Medicine, Histo-pathologv, and Cvtologv, Middlesex Hospital,LIondon) Studies have shown that both homo-sexual men and HIV positive men with analcondylomata have a high prevalence of analintraepithelial neoplasia (28'S in both groups).The first of these two groups is already large(approximately 750000 in the UK) and the

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second of these two groups continues toincrease in size.The malignant potential of anal intra-

epithelial neoplasia (AIN) is as yet unknownbut may parallel that of cervical intraepithelialneoplasia with progression through the gradesof dysplasia to invasive carcinoma in a smallpercentage of cases.

This study has assessed 145 patients for AINusing anal smear and microanoscopy (procto-scopy using an operating microscope). Ninetynine patients had an adequate smear before fullmicroanoscopic assessment. Cytology on these99 patients showed HPV infection in 54 (55%),AIN in 38 (38%), and only seven (7%) had noabnormality. Twenty nine (29%) of the 99patients showed histological evidence of AIN.Only 13 of the 29 patients with AIN onhistology were heralded by AIN on smear (falsenegative rate of 55%), 25 patients with AIN onsmear had no micro-anoscopic or histologicalevidence ofAIN (false positive rate of 66%).We conclude that the low sensitivity and

specificity of anal smear makes it unsuitable asa screening test for AIN.

Ileal pouch dialysate is cytotoxic to I-407 andHT-29 cells: bile may be the active factor

M N MERRETT, B J CROTTY, N MORTENSEN, D PJEWELL (Gastroenterology Unit, The RadcliffeInfirmary, Oxford) A raised crypt cell produc-tion rate (CCPR) has been observed in the ilealpouch. This occurs in the first three monthsafter ileostomy closure. Our hypothesis was

that a factor in the faecal stream may increaseileal CCPR.

Eight ileal pouches were dialysed in vivo forfour hours using Visking dialysis tubing con-

taining 10 ml of 10% Dextran in normal saline

(Rheomacrodex). The effect of serial dilutionsof dialysate was assessed on I-407 (embryonicsmall intestine) and HT-29 (colon cancer) cells.Proliferation assays using 3H uptake showed a

dose related fall in proliferation (p=0-0001) forboth cell lines. Cytotoxic assays using 51 Crrevealed dose related cytotoxicity (p=0-0001)probably accounting for the antiproliferativeeffect. The effect was observed at both dialy-sate pH (mean=5.95) and corrected pH (7.4).

Limited characterisation showed that thecytotoxic factor has a MW - 1000, is resistantto extremes of temperature (-20'C to 100°C)and pH (2-12), and is significantly inhibited bycholestyramine. Furthermore gall bladder bileis noticeably cytotoxic to both cell lines.These results show that ileal pouch dialysate

is cytotoxic to intestinal epithelial cell lines.Thus, stasis within the pouch may result inprolonged exposure to the cytotoxic factor(probably a bile acid) with subsequentepithelial cell loss. In vivo, a response to thisinsult may be an increase in CCPR.

Raised rectal leukotriene B4 and throm-boxane B2 values after pelvic radiotherapy -

specific targets for therapy?

A T COLE, K SLATER, M SOKAL, B FILIPOWICZ,L KURLAK, C J HAWKEY (Department of Thera-peutics, University Hospital, Nottingham andRadiotherapy Department, General Hospital,Nottingham) Pelvic radiotherapy often causes

an early proctitis. If eicosanoids mediate thisinflammation, specific inhibitors may havetherapeutic potential. We therefore measuredthe effects of radiotherapy on rectal levels ofleukotriene B4 (LTB4) and thromboxane B2(TXB2).

Eight patients, aged 57 to 78, were studiedby rectal dialysis before and immediately after afour to six week course of pelvic radiotherapy.

Five were studied again four to six weeks later.The median maximal rectal dose was 55 Gray(range 32-64). Dialysis was for two hours usingVisking tubing 12 cm by 0.6 cm filled with 10%dextran and 0.9% sodium chloride. LTB4(extracted) and TXB2 were assayed by radio-immunoassay.

Validation of LTB4 against HPLC gave acorrelation r=0-92 (p=0-015) and of TXB2against GCMS r=0-736 (p=0.037). Radiationincreased LTB4 by a median of 0-8 ng/ml(range 0 to 3.78) from median 0 (0 to 0 64) tomedian 1-01 (0 to 4.0) p=0-0018 (Wilcoxon)and increased TXB2 by median 0-78 ng/ml(0.05 to 2.72) from median 0-41 (0 to 0 88) to1 15 (0-26 to 2.92) p=0-018. Symptom scoresrose by median 0 5 (0 to 2) points. One monthafter therapy LTB4 values fell in all patients bymedian -0-64 ng/ml; TXB2 fell by median-0-21 ng/ml.These data are consistent with increased

rectal production of LTB4 and TXB2 withpelvic radiotherapy. This may contribute to theinflammation of early radiation proctitis andspecific inhibitors may have therapeuticpotential.

OESOPHAGEAL DISEASE

Role of smoking and alcohol in metaplasiaand neoplasia in Barrett's columnar linedoesophagus

M R GRAY, R J DONNELLY, A N KINGSNORTH(University of Liverpool, Department of Surgeryand The Cardiothoracic Centre, Liverpool) Westudied the alcohol and smoking habits ofpatients with severe reflux oesophagitis (SRO)(n=24), columnar lined oesophagus (CLO)(n=58), and adenocarcinoma arising in CLO(Adeno) (n=23).Age (median 65 years) and duration of

symptoms (median 10 years) were similar ineach group. CLO median smoking history was5 pack years (0-45 pack years) which was lessthan both the SRO (median 46; 0->100 packyears) and Adeno groups (median 54; 0->100pack years) (p<0-001). Total pack-yearsmoking history was similar in SRO andAdeno. Adenocarcinoma patients had smokedfor more years in total (median 39; 0-54 years)and started smoking earlier (median age 18)than CLO (median 9; 0-55 years) (p<0.001)(median age starting 27) (p<0-001). SROexceeded CLO (p<0 002). Of the SRO group50% drank more than 40 units/week whereasCLO patients were often non-drinkers (median3; 0-100 units/week) (p<0 02). Adeno medianalcohol consumption was 10 (0-100 units/week) (p<0-02 v CLO).Smoking and alcohol consumption do not

predispose to development of metaplastic CLOin patients with severe gastro-oesophagealreflux but are strongly associated withdevelopment of adenocarcinoma in Barrett'soesophagus.

Differential endocrinology of intestinal andgastric type Barrett's oesophagus

A J RITCHIE, C F JOHNSTON, J McGUIGAN, J R P

GIBBONS, K D BUCHANAN (Department ofMedicine, Queen's University of Belfast andDepartment of Cardio-Thoracic Surgery, RoyalVictoria Hospital, Belfast) Barrett's oesophagusis a metaplasia in which a previously squamousepithelium develops into a columnar epithe-lium with up to 240 times increased risk ofdeveloping oesophageal carcinoma which is

associated with a 2% two year survival. Otherworkers have consistently found the dysplasiawhich develops to be gastric in type with amixed endocrine cell population. We haveinvestigated the endocrinology of Barrett'soesophagus using immunohistochemicalmethods.

Thirteen patients who underwent oesopha-geal resection had Barrett's changes aroundtheir tumours. In five patients in this groupwith intestinal type dysplasia, as opposed tothe more common gastric type dysplasia, wedetected cell populations for GIP, CCK,secretin, and motilin, whereas the gastric typedysplasia expresses gastrin, serotonin, pan-creastatin and somatostatin. Neither typeexpressed lower small bowel or colonic markerssuch as enteroglucagon, neurotensin, or PYY.The carcinomas themselves are generallydevoid of endocrine cells.

This study indicates that endocrinologicaltyping of Barrett's oesophagus may help indetecting impending development of oesopha-geal carcinoma.

Squamous regeneration in experimentalBarrett's oesophagus: effect of antirefluxsurgery

H LI, T N WALSH, G O'DOWD, P MARKS, P J BYRNE,S JAZRAWI, T P J HENNESSY (Departments ofSurgery and Pathology, St James's Hospital,Dublin) Regression of Barrett's epitheliumafter antireflux treatment is disputed. Thisstudy examined the effect of antireflux therapyon regression in an animal model.Nine adult mongrel dogs had a 1 cm mucosal

strip defect created in the lower oesophagusleaving a surrounding 1 cm squamous barrier.A Wendel cardioplasty and hiatus hernia werefashioned and hyperacidity induced by penta-gastrin (100 [ig daily). Acid reflux was con-firmed by two hour intraoesophageal pHmonitoring. At three months the healingmucosa was excised leaving further stripdefect. An antireflux procedure was performedand omeprazole (20 mg) was given daily tosuppress acid secretion.No control animal had columnar mucosa in

the oesophagus. Six of nine animals developedBarrett's mucosa after the reflux inducingprocedure but squamous islands were notidentified. After repeat epithelial stripping andantireflux therapy all five dogs developedBarrett's oesophagus. Regenerating islands ofsquamous epithelium were identified, partiallyreplacing columnar epithelium in all five.

This study suggests that a squamous defectin the oesophagus is repaired by columnarepithelium in the presence of reflux but that'islands' squamous regeneration occurs wherereflux is adequately controlled.

Oncogenes and oncosuppressor genes inadenocarcinoma of the oesophagus

J JANKOWSKI, G COGHILL, D HOPWOOD, K G

WORMSLEY (Departments of Medicine andPathology, University ofDundee) The activationof proto-oncogenes has been implicated in thedevelopment and progression of cancer. Theirrole in the development of oesophageal adeno-carcinoma is unknown. We studied 15 cases offreshly resected oesophageal adenocarcinomas,15 cases of Barrett's oesophagus, and pairedbiopsy specimens from normal stomach. Thesespecimens were all snap frozen and subse-quently stained with monoclonal antibodies tothe following oncogenes: c-erbB2 (neu and

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CE-1) (external domain), c-erbB2 (NCL-CB1 1) (internal domain), C-src, c-ras, c-myc,c-fos c-jun, and the oncosuppressor gene - P53.

All tumours were well differentiated adeno-carcinomas arising from the lower third of theoesophagus. Twelve cases showed strongmembranous staining with both c-erbB2 (neu)and c-erbB2 (CBL-CB1 1). Seven cases showedstrong nuclear staining with P53 oncosuppres-sor gene. Three cases were positive for c-ras.

In Barrett's epithelium, 10 cases werepositive for c-erbB2 (neu and CBl 1), two caseswere positive for c-ras, and one was positive forc-fos. None of the gastric mucosal biopsyspecimens showed any demonstrable oncogeneexpression.The frequency of positive staining for

c-erbB2 and P53 is very high compared withother tumours. We conclude that errors in theoncosuppressor gene P53 and the external andinternal domains of c-erbB2 may be implicatedin the progression of adenocarcinoma of theoesophagus.

Diffuse oesophageal spasm - a conditionwhich is missed by the clinician and theradiologist

W J OWEN, A ANGGIANSAH, N F BRIGHT(OesophagealLaboratory, DepartmentofSurgery,Guy's Hospital, London) Diffuse oesophagealspasm (DOS) is an uncommon but disablingcondition. Diagnosis depends on the clinician,the radiologist, and also on a referral foroesophageal manometry. In order to investi-gate problems of diagnosis, 42 patients subse-quently diagnosed as suffering from DOS,were reviewed in order to establish:

1 The principal presenting complaints andduration of symptoms; 2 The number ofreferrals before the diagnosis was made; 3 Theaccuracy of barium swallow examination.Twenty three patients (55%) complained

of chest pain and dysphagia, 14 (33%) ofdysphagia alone, and five (12%) of chest painalone. The duration of symptoms varied fromthree months to 30 years (mean duration=6years). The number of referrals per patientvaried from two to 15 (mean number ofreferrals per patient=3-8). Barium swallowexamination was reported as normal in 15(36%), DOS in 10 (24%), hiatus hernia in six(14%), strictures in five (12%), diverticulum inthree (7%), and achalasia in three (7%).Thus ODS may evade diagnosis for many

years despite repeated consultations. The in-accuracy ofradiology in this condition points tothe need for earlier referral of suspicious casesfor oesophageal manometry.

A clue to the mechanism of abnormaloesophageal sensory perception in non-cardiac chest pain

A J MEHTA, J S DE CAESTECKER, T C NORTHFIELD(Department of Medicine, St George's HospitalMedical School, London) Lower pain thresholdsfor oesophageal stretch have been reported innon-cardiac chest pain (NCCP), but themechanism is unknown. Gesophagealmechanonociceptors can be sensitised bynoxious stimuli in NCCP (Gut 1991; 32: A599).Our aim was to test the hypothesis that in thosewith an oesophageal cause for chest pain, (ieabnormal motility or provocation tests) sensiti-sation has already occurred.We studied 20 patients with NCCP; of these

eight had abnormal (ABN) and 12 had normal

(NOR) oesophageal tests. All underwent adouble blind crossover study of oesophagealperfusion with 300 ml of 0-1 N HCI or 0 9%saline on two separate days. A latex balloon ona manometry catheter and an oesophagealpacing electrode were placed 5 cm above thelower oesophageal sphincter. Graded balloondistension followed by pacing at increasingcurrents with ECG monitoring, were per-formed before and after fluid perfusion. Theminimum balloon volume (V) and pacingcurrent (P) reported as painful were recorded.Basal V was lower in ABN than NOR (9-2 mlv. 12-2 ml, p<0 05). After acid, mean Vdecreased in NOR (12-2 ml to 9-1 ml,p<0-001); but not in ABN (9-2 ml to 8-5 ml,NS). There were no changes of V after saline,and no significant differences of P in eithergroup after either fluid.We conclude: (a) ABN have a lower basal

pain threshold for distension than NOR; (b)distension but not pacing threshold in NOR islowered by acid, implying acid inducedreceptor sensitisation; and (c) this effect is notfound in ABN suggesting that nociceptors mayalready be sensitised.

Mechanisms of gastro-oesophageal refluxunder ambulant conditions

C P BARHAM, D C GOTLEY, D ALDERSON(University Department ofSurgery, Bristol RoyalInfirmary, Bristol) The mechanisms that pre-cipitate gastro-oesophageal reflux (GOR) inambulant patients remain largely unknown.A portable system has been developed to

study oesophagogastric pressure activityimmediately preceding the onset of acid GORin normal subjects (group I, n= 10), refluxpatients without (group II, n= 10) and with(group III, n= 10) endoscopically proved oeso-phagitis during 24 hours of normal activity.Manometric data were recorded at 5, 10, 15 cmabove and 8 cm below the lower oesophagealsphincter (LOS) and pH 5 cm above the LOS.A total of 1234 acid GOR episodes wereclassified as spontaneous, oesophageal motorrelated, belch associated, stress/strain induced,or unclear.

Gastro-oesophageal reflux was more fre-quent during the day than at night in all groups(p<0.05*). Belching as a cause of GOR wasgreater in group I than group III (p<0 05).Spontaneous GOR were more common ingroup III compared with groups I (p<005)and II (p<0 05). Stress/strain induced GORbecame more common as a cause of reflux fromgroup I to II to III but did not reach statisticalsignificance.Under ambulant conditions, GOR is precipi-

tated by a variety of mechanisms. Belching isthe predominant mechanism in normal sub-jects, while 'spontaneous' GOR dominates inpatients with oesophagitis. Future studies todetermine mechanisms ofGOR should concen-trate on ambulant patients.*Wilcoxon signed rank test.

HELICOBACTER PYLORI

Helicobacter pylori increases release ofinterleukin 8: a potent attractant ofneutrophils

R GUPTA, S MOSS, D M THOMAS, F ABBOTT, A REES,J CALAM (Departments ofGastroenterology, Histo-

pathology, Renal Medicine, Royal PostgraduateMedical School, London) It is not known howHelicobacter pylonr damages epithelia to causegastritis and ulceration. Neutrophils, attractedbyH pylori, probably damage tissues by releas-ing enzymes, superoxide, hydrogen peroxideand bioactive lipids. We considered how Hpylori attracts these cells. Interleukin 8 (IL8) isa newly discovered highly potent attractant ofneutrophils. We, therefore, studied the effectofH pylori on its release from antral tissue.

Antral biopsy specimens were taken frompatients with normal endoscopic appearances.H pylori was detected by biopsy urease test andhistology in 10 patients, but not by either in 15.Biopsy specimens were each incubated in 2 mlRPMI 1640 culture medium for two hours at37°C, gassed with 95%O2:5%C02. IL8 wasmeasured in culture media by double ligandsandwich ELISA. Neutrophil infiltration inthe same biopsy specimens was then gradedfrom 0=nil to 3= severe. Results are expressedas median (range).

Despite normal endoscopic appearances,neutrophil infiltration was greater in H pylori+ve patients; 2 (0-2), grade 2 in 63%, than inH pylori -ve patients; 0 (0-1), grade 0 in 63%(p<005). IL 8 secretion (pg/mg tissue) was 2.5(0-7-1) in H pylori +ve patients; detectable in80%, compared with 0 (0-5.6) in H pylori -vepatients; undetectable in 67% (p<0 05).

In conclusion,H pylori greatly increases localrelease of IL8. This may be the major attractantof neutrophils and thus important in tissuedamage byH pylonr.

Is Helicobacter pylori related hyper-gastrinaemia due to the bacterium inhibitingparietal cell function?

R S CHITTAJALLU, J HARWOOD, C A DORRIAN,K E L McCOLL (University Department ofMedicine and Therapeutics, Department of Bio-chemistry, Western Infirmary, Glasgow) Themechanism by which chronic Helicobacterpylonr infection raises serum gastrin is notknow. H pylon inhibits parietal cell function invitro. We have investigated the possibility thathypergastrinaemia in chronicH pylori infectionrepresents a compensatory response to main-tain acid secretion in the presence of mildinhibition of parietal cell function by thebacterium. The acid response to 45 minuteinfusions of pentagastrin at each of the follow-ing sequential doses ([tg/kg/h) 0, 0 031, 0-062,0-124, and 0.6 was compared before and onemonth after eradication of H pylori in eightduodenal ulcer patients in clinical remission.The median acid outputs (mmol/h) with therespective infusions were 5 0, 13-0, 26-3, 31-2,39 0 when H pylon +ve and similar at 4-6, 7-8,25-0, 35 6, 43-3 after eradication. The esti-mated dose of pentagastrin required to produce50% maximal response was similar before(0.054 [sg/kg/h) and after (0-061 [tg/kg/h)eradication ofH pylori. The estimated maximalresponse to pentagastrin (mmol/h) was alsosimilar before (43.2) and after (43.7) eradica-tion of the organism.

This study shows that the parietal cellresponse to pentagastrin is unaffected bychronic H pylori infection and that the hyper-gastrinaemia cannot be explained by thebacterium inhibiting parietal cell function.

Gastrin, gastric acid and pepsin responsesduring intragastric titration in duodenal ulcer

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patients; effect of suppressing Helicobacterpylon

S MOSS, K AYESU, S K LI, J CALAM (Gastro-enterology Unit, Royal Postgraduate MedicalSchool, Hammersmith Hospital, London)Helicobacter pylori positive duodenal ulcer(DU) patients have high basal and meal stimu-lated plasma gastrin values and peak acidoutput. After H pylori eradication plasmagastrin values fall but meal stimulated acidsecretion has not been measured. DU patientshave been reported to have a specific loss of theinhibition of acid secretion by luminal acidi-fication. We therefore used intragastrictitration to measure gastric acid and pepsinsecretion and gastrin responses to the intra-luminal instillation of 4% peptone at pH 2-5and 5 5 in 11 DU patients before and aftersuppression ofH pylori.

Plasma gastrin values were significantlyhigher at pH 5-5 compared with pH 2-5, and atpH 2-5 compared with basal values, bothbefore and after treatment. Gastrin values werealso significantly higher (p<005) in all casesbefore H pylori suppression than afterwards;median basal 9-2 (range 3.7-23) pmol/1 beforecompared with 5-1 (1-7-15) after, at pH 2-5median 11-3 (3.8-29) before and 5.9 (5.7-61)after treatment and at pH 5-5 median 15-2(3.9-32) before and 7-15 (6-1-14) afterwards.In marked contrast outputs of acid and pepsinat each pH were not altered by suppression ofH pylori.We conclude, that suppression of H pylori

decreased gastrin independent of luminal pH.Outputs of acid and pepsin were unchanged.This suggests that H pylori decreases thesensitivity of the gastric mucosa to gastrin.

Serum pepsinogen A and C values before andafter treatment of Helicobacter pyloninfection

R A VEENENDAAL, I BIEMOND, A S PENA,J KREUNING, C B H W LAMERS (Departmentof Gastroenterology-Hepatology, UniversityHospital, Leiden, The Netherlands) Serumpepsingogen A and C values have been shownto vary in different forms of gastritis. Sincethere is a strong relation between chronicactive gastritis andH pylori infection we studiedserum values of pepsinogen A (PGA), pep-sinogen C (PGC), and their ratio (A:C) beforeand after eradication ofH pylori infection.Twenty one patients with H pylon positive

gastritis were studied before and three monthsafter treatment with 'triple' therapy (bismuthsubcitrate 120 mg qds for 28 days, amoxycillin500mg qds and metronidazol 500 mg qds for 10days) or 'double' therapy (bismuth subcitrate120 mg qds for 28 days and tinidazol 500 mgqds for 10 days). The presence ofH pylori wasevaluated by culture, histology of gastricbiopsy specimens, and serological tests beforeand three months after treatment. Serum con-centrations of PGA and PGC were determinedby sensitive and specific radioimmunoassays,validated in previous studies.

In the patients (n= 17) in whom H pyloriinfection was eradicated, there was a significantdecrease of serum pepsinogen A (median(range) 61 (27-176) ,ug/ml v 42 (18-93) jig/ml,p<0-01) and pepsinogen C (median (range) 51(12-169) v 16 (6-86) ig/ml, p<0-01) valueswhile there was a significant increase of theserum pepsinogen A:C ratio (median (range)1-5 (0-5-3-1) v 2-1 (10-3-8), p<0-01). In thefour patients in whom H pylon infection wasnot eradicated, there was no decrease in pep-

sinogens (PGA 95 (37-164) and 103 (35-273),PGC 34 (24-56) and 35 (20-117), A:C ratio 2.9(1 1-3 2) and 2-3 (1-3-3-3)) before and aftertreatment, respectively. Histological examina-tion of gastric biopsy specimens before andafter treatment showed improvement only inthe patients with eradication of H pyloriinfection.We conclude that after eradication of H

pylori infection, there is a significant fall ofserum PGA and even more pronounced fall ofserum PGC values accompanied by a rise inA:C ratio.

One week's treatment for duodenal ulcer

R P H LOGAN, P A GUMMETT, J J MISIEWICZ, M MWALKER, R J POLSON, N Q KARIM, J H BARON(Parkside Helicobacter Study Group, CentralMiddlesex and St Mary's Hospitals, London) Assuccessful eradication ofH pylon after healingof duodenal ulcer (DU) can prevent subse-quent recurrence of DU, wouldH pylon eradi-cation alone heal active DU? In patients withDU (>5 mm diameter) H pylon was detectedby histology (H&E/Gimenez stains), CLO test,culture (selective/non-selective media), and3C urea breath test (13C-UBT, positive result=excess 613C02 excretion >5 ppm) beforetreatment with a one week eradication regime(Denol tablets 1 qds and amoxycillin 500 mgqds for seven days, with metronidazole 2 gdaily on days five to seven. The 13C-UBT wasrepeated immediately after finishing treatmentand a repeat OGD performed to assess ulcerhealing. Healed ulcers were followed by 13C-UBT alone at one, three, six, and 12 months,while unhealed ulcers had a third OGD onemonth after finishing treatment.Twenty seven patients (13 men, seven

smokers, median age 42 years; range 16-70)with DU were studied and 26 are available forfollow up. Mean pretreatment excess 613C02excretion was 25.6 ppm, which fell to 2-4 permil immediately after finishing treatment. Atthe second OGD (median interval 12 days,range 8-30) 17/26 (65%) DUs had healed.The other nine ulcers were smaller (mediandiameter 3 mm), and two weeks later five ofthese nine had healed (85%). Only four of the26 patients had unhealed ulcers after fourweeks and in each pre-treatment metronidazoleresistantH pylori (MRH pylori) were found. Intwo patients whose ulcer initially healed (withclearance of H pylon), ulcers later recurred(both had MR H pylon). H pylon was eradi-cated in 15/26 (58%) patients (median follow up4-1 months, range 1.8-6 2).

Eighty five per cent of DUs healed bytreating H pylori. The one week treatmentregime used was successful in eradication andhealing only in patients whose H pylon wassensitive to metronidazole.

DNA characterisation of helicobacter pyloristrains in three generations of a duodenalulcer disease family

C U NWOKOLO, J BICKLEY, A R ATTARD, R J OWEN,I A FRASER Departments of Gastroenterology andSurgery, Walsgrave Hospital, Coventry,National Collection of Type Cultures, CentralPublic Health Laboratory, Colindale, London)The aim of this study was to investigate thehypothesis that familial duodenal ulcer (DU)disease may be a cluster infection by a singleputative ulcerogenic strain ofH pylori.Nine members of a DU family were studied

by interview, examination of hospital records,endoscopy, and antral biopsy. H pylori wasconfirmed by CLO test, histology, and culture.DNA extraction from pure isolates ofH pylon'was possible in six family members. Straintyping was performed by restriction fragmentlength polymorphism with 11 endonucleases.Southern blotting and DNA hybridisationwere also performed using a cDNA probecomplementary to bacterial rRNA cistrons.

Eight of the nine family members (90%)were H pylori +ve by CLO test and histology.Strain typing was successful in six members (atleast one member from each generation). Eachstrain was genetically unique. Four strainswere isolated from family members with severeduodenal ulcer disease, the other two strainsfrom members with no disease.

In conclusion, DU families may be excep-tionally susceptible to H pylori infection.Members may be colonised by differentstrains. Family members may develop DUdisease irrespective of the colonising strain ofH pylori.

Do teeth predispose to duodenal ulcerrelapse?

M A K KHANDAKER, A SCOTT, M A EASTWOOD, K RPALMER (GI Unit, Western General Hospital,Edinburgh) Eradication of Helicobacter pylorifrom the stomach prolongs remission in duo-denal ulcer (DU) disease, but gastric reinfec-tion is common and could lead to DU relapse.In order to identify the reservoir of H pylon'infection, tooth pickings were cultured from 18dentulous and three edentulous DU patientsand from 21 matched dentulous, non-ulcercontrol subjects.

Fifteen DU patients had H pylori associatedgastritis, and H pylori was shown by histology.H pylori was cultured in Skirrow's media fromtooth pickings in seven and in 18 from antralbiopsy specimens. Four control subjects had Hpylori gastritis andH pylori shown by histology;two of these had positive cultures from toothpickings and four from antral biopsy speci-mens. H pylon was not cultured from dentalplates in edentulous individuals, nor was itisolated from tooth pickings in individuals whodo not exhibitH pylori gastritis.

Gastric re-infection by H pylon seems tooriginate from a reservoir of infection in theteeth and gums. Relapse of DU after tripletherapy for H pylori may be influenced bydental status.

MUCOSAL GROWTH AND PROLIFERATION

Growth regulatory peptides in gastric mucosa

J JANKOWSKI, H J AL-RAWI, D A JOHNSTON,D HOPWOOD, M I FILIPE, G COGHILL, K GWORMSLEY (Departments ofGastroenterology andPathology, Ninewells Hospital, Dundee andDepartment of Pathology, Guy's Hospital,London) Epidermal growth factor (EGF) andthe related peptide transforming growth factora (TGFa) have been implicated in the stimula-tion of gastric mucosal proliferation. Weassessed the immunohistochemical distribu-tion of these peptides and their receptor epider-mal growth factor receptor (EGF-R) in mucosafrom the antrum and body of the stomach from28 patients. Twenty five of the 56 biopsy

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specimens were histologically normal (12antrum and 13 body) while the other 31 showedvarying degrees of inflammation.EGF, TGFa, and EGF-R have maximal

density of distribution on the basolateral andapical surfaces of the superficial epithelial cellsbut are also expressed to a lesser extent on theneck and body cells of the glandular tissue.We also showed that EGF is found in greater

concentrations in the epithelial cells ofinflamed mucosa compared with normalmucosa (p<0 05). In addition, the expressionof EGF was associated with the presence oflymphocytes but not neutrophils (p<0 05).We conclude that EGF may be induced by

cytokines released by mocosal lymphocytesand that epithelial EGF may play a role inmaintaining mucosal integrity in gastritis.

Measurement of human gastric mucosa pro-liferation combining histochemistry and flowcytometry

S PATEL, D A REW, A COOPER, I TAYLOR, C SPOTTEN (University Surgical Unit, SouthamptonGeneral Hospital, Southampton and CRCDepartment of Oncology, Manchester) Bromo-deoxyuridine (BRdU) labels gastric mucosalcells in the S phase. Computer aided histo-chemical analysis shows static indices, includ-ing the crypt labelling index (LI), the peaklabelling position, and the crypt growthfraction. Flow cytometry (FCM) yields the Sphase duration (tS) of mucosal cells and hencethe crypt turnover time (CTR).

Specimens of histologically normal gastricbody (GB, n= 14) and antral mucosa (GA n=10) were obtained from 24 patients with gastriccarcinomas who received a bolus dose of 250mg BRdU before surgery. Mucosal tissuesections were stained by a peroxidase methodand subjected to detailed counting of 50 longi-tudinal crypts per sample. The length ofconvoluted crypts was calculated by a gridcounting method. Nuclear suspensions wereanalysed by MFCM to measure tS.A significant difference existed between GA

and GB mucosa by a number of criteria. Themedian lengths were 137 cells (GB) and 188cells (GA). The median peak labelling positionswere cell 25 (GB) and cell 58 (GA) from themouth of the crypt. The median crypt label-ling indices were 1-6% (GB) and 2-8% (GA).The mean tS of GA cells was 7-7 hours and ofGB cells was 10-8 hours. The median CTT wasestimated to be 6-7 days forGB and 2- 1 days forGA crypts.The technique advances the study of prolif-

eration in human gastric mucosa, and may be ofvalue in the assessment of the response of theproliferation compartment to certain drugs.

'Genotoxicity', unscheduled DNA synthesisand omeprazole

R A GOODLAD, C Y LEE, M R ALISON, C SARAFF,N A WRIGHT (Imperial Cancer Research FundHistopathology Unit, London and Department ofHistopathology, Royal Postgraduate MedicalSchool, London) It has been claimed thatomeprazole stimulates unscheduled DNAsynthesis (UDS) in a rat stomach genotoxicityassay (Burlinson, et al Lancet 1990; 335: 419).The Burlinson assay (Carcinogenesis 1989; 10:1425) was applied to PVG rats gavaged withomeprazole or the carcinogen MNNG, with orwithout hydroxyurea (HU) injection to blockscheduled DNA replication. Tritiated

thymidine was injected to label cells synthesis-ing DNA.The whole basis of the Burlinson assay is that

non-proliferating surface gastric cells can beselectively digested away by controlled diges-tion with proteinase; however, parietal cellsand proliferating cells in semiconservativeDNA synthesis could be shown in the digeston several separate occasions. Scanningelectron microscopy also showed that thedigests selectively denuded patches of mucosa.Analysis of thymidine uptake by quantificationof the number of silver grains over the nucleishowed that there was no increase in low levellabelling following omeprazole administration,indicating that there was no 'unscheduledDNA synthesis.'The conclusions of this study are that the

assay does not selectively remove surface cells,so that any unscheduled DNA synthesis wouldbe overwhelmed by contamination with cells inregular scheduled DNA synthesis. In addition,a different approach, namely grain countanalysis, does not support the contention thatomeprazole induces unscheduled DNAsynthesis in the rat stomach.

Trefoil gene expression is induced in intest-inal goblet and endocrine cells in Crohn'sdisease

N A WRIGHT, R POULSOM, G W H STAMP, S VANNOORDEN, P A HALL, R JEFFERY, J LONGCROFT, GELIA, C PIKE, M-C RIO, P CHAMBON (ICRFHistopathology Unit London, Department ofHistopathology, Royal Postgraduate MedicalSchool, London, and Laboratoire de GenetiqueMoleculaire des Eucaryotes, Strasbourg, France)Trefoil peptides share a cysteine rich consensusdomain which is highly conserved. Thecanonical molecule is pS2, which is highlyhomologous to the gastrointestinal peptidehormone pancreatic spasmolytic peptide (PSP)and its human counterpart hSP, in which the 5-cysteine domain is tandemly repeated. PSPinhibits intestinal muscular contraction andalso gastric acid section. A further member,'intestinal trefoil peptide' (ITP) has beenidentified in the theca of intestinal goblet cells.We have defined an ulceration associated celllineage (UACL) in the human gut, induced bychronic ulceration, which secretes epidermalgrowth factor/urogastrone (EGF/URO), andalso shows pS2 and hSP gene expression(Nature 1990; 343: 82-5; J Pathol 1990; 162:279-284.) We have demonstrated pS2 geneexpression in normal intestinal lineagesadjacent to the UACL in small intestinalCrohn's disease; pS2 gene product is present inthe subthecal cytoplasm of goblet cells,apparently in the Golgi apparatus, while in situhybridisation showed pS2 mRNA in the samearea. pS2 protein is also present in the apicalcytoplasm of gut endocrine cells, again only inthe vicinity of the UACL, associated withendocrine cell hyperplasia in crypts adjacent tothe UACL. hSP gene expression was notdemonstrable.We propose that EGF/URO secreted from

the UACL induces pS2 gene expression ingoblet and endocrine cell lineages in theadjacent mucosa. The findings of two trefoilpeptides, one in the theca and another (pS2) inthe Golgi, indicates that these peptides areimportant in goblet cell function, and in endo-crine cell modulation, in Crohn's disease.

Small and large bowel mRNA in the intestinal

adaptation of growth hormone transgenicmice

R H DOWLING, R FULLER, M H ULSHEN, EZIMMERMANN, P KAY LUND (Departments ofPhysiology and Medicine, UNC Chapel Hill,North Carolina, USA) Little is known aboutthe effects of growth hormone on the gut andnothing is known about the molecular biologyof this adaptive response. Therefore, in sixgrowth hormone transgenic (GHTG) mice andsix litter mate wild type (WT) controls, wemeasured body, intestinal and abdominalvisceral weights and indices of intestinalmucosal mass, extracted jejunal, ileal andcolonic poly A' RNA and hybridised northernblots with cDNA, oligomer, and riboprobes toglucagon, IGF-I, ornithine decarboxylase(ODC), S-adenosyl methonine decarboxylase(SAM-DC), sucrase/isomaltase, and ubiquitin.Compared with WT controls, the GHTG

animals showed marked increases in bodyweight (mean 88%), in liver (71%), jejunal(45%), ileal (24%), and colonic (57%) wetweights and in intestinal length (17%) withcorresponding changes in indices of mucosalmass, villus height and crypt depth. IFG-ImRNA increased from mean (SEM) 2-46(0.42) arbitrary units in the jejunum of the WTto 335 (0-41) in the GHTG and from 5-11(1 -49) to 7.90 (1-24) in the colon. There was nosignificant difference in jejunal ODC mRNA(2-40 (0-16) v 2-37 (0.29) U respectively) butcolonic ODC mRNA increased from 1-12(0-11) to 1-66 (0-18). There were no obviousdifferences in SAM-DC, sucrase/isomaltase, orubiquitin mRNA values.These results show that growth hormone

excess not only increases body and liverweights but also stimulates increases in gutlength and weight and provide the first mRNAdata on growth hormone induced intestinaladaptation.

INFLAMMATION

Crohn's sera enhance tissue factor expressionby endothelial cells

M HUDSON, D P CARR, A J WAKEFIELD, A K HALL,A M SAWYERR, M SMITH, A P DHILLON, R EPOUNDER (University Departments of Medicineand Histopathology, Royal Free Hospital Schoolof Medicine, London) Endothelial cell tissuefactor (ECTF) is the cellular initiator of theextrinsic coagulation cascade; it is not normallyexpressed on vascular endothelial cells but isinducible by cytokines and bacterial lipopoly-saccharide (LPS). We have studied the effect ofhuman sera on ECTF induction on bothunstimulated and tumour necrosis factor(TNF) stimulated human umbilical vein endo-thelial cells (HUVEC), the sera came from 24Crohn's disease patients (n= 124 tests) and 19normal subjects (n=68). The results are com-pared with Crohn's disease clinical activity, asdetermined by the Harvey-Bradshaw score(HBS).

Coincubation of HUVEC with patients sera(1:5 dilution) for six hours induced signifi-cantly more ECTF (median 2-6 range (0-120)mU/10' cells) than in normal subjects (median0 range (0-10) mU/105 cells), p<0001).Coincubation of TNF (2 U) stimulatedHUVEC with patients' sera induced signifi-cantly more ECTF (median 85 (7 6-700) mU/105 cells) than in normal subjects (median 58

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(2-9-210) mU/105 cells), p=0.003. In theCrohn's disease patients this correlated signifi-cantly with the HBS by linear regression; r=0-203, p<005. Pretreatment of HUVEC withCrohn's sera for 24 hours before addition ofLPS (2 jig for six hours) significantly enhancedECTF (median increase 200% (130-400%))compared with normal sera.

In conclusion, this study suggests that localimmune induction of tissue factor at the endo-thelial cell surface may account for the systemicthrombogenesis in Crohn's disease.

Antiendothelial cell antibodies in inflam-matory bowel disease: are they related tovascular injury?

T R J STEVENS, D S RAMPTON (GI ScienceResearch Unit, The London Hospital MedicalCollege, London) Antibodies against endo-thelial cells (AECA) are common in vasculitis.Crohn's disease (CD) may be a chronicmesenteric vasculitis. We have measuredAECA values in patients with ulcerative colitis(UC) and CD, compared them with circulatinglevels of von Willebrand factor (vWF), amarker of vascular injury, and assessed theirability to mediate endothelial cell (EC)cytotoxicity.AECA were measured in sera diluted 1/25 by

radioimmunosorbent assay using confluenthuman umbilical vein EC. vWF values weremeasured in sera diluted 1/40 by ELISA.Complement dependent EC cytotoxicity wasdetermined by "'1Indium release.AECA positivity (>mean+3 SD of control

group) was more common in patients with UC(15/27: median 43-9 arbitrary units; range16-5-100) than CD (6/29: 27-0; 13.5-66.2) orcontrols (1/16: 18-5; 106-42.0). AECA valueswere higher in UC (p<00001) and CD(p<0005) than control but were unrelated todisease activity or treatment. AECA occurredin both IgG and IgM fractions of sera. AECAvalues were directly related to serum vWFconcentrations in UC (R=0-42, p<005) butnot CD (R=-0-25; pL=02). AECA positiveserum were not cytotoxic to EC with or withoutadded complement.

In conclusion, raised serum AECA valuesare common in UC and CD. The correlationbetween AECA and vWF in UC suggests anassociation between endothelial cell injury andAECA. However, the inability of AECA tomediate complement dependent cytotoxicity ofendothelial cells makes a major pathogenic rolefor AECA in IBD unlikely.

Increased expression of cell adhesionmolecules in active ulcerative colitis

M BALSITIS, Y MAHIDA, C J HAWKEY (Departmentsof Pathology and Therapeutics, UniversityHospital, Queen's Medical Centre, Nottingham)Interaction between endothelial cells andleukocytes via cytokine activated cell adhesionmolecules is an important event in the develop-ment of inflammation. Since we have pre-viously shown increased mucosal production ofinterleukins 1 and 8 in active ulcerative colitis,we investigated whether expression of inter-cellular adhesion molecule-i (ICAM-1),endothelial leukocyte adhesion molecule-i(ELAM-1), and vascular cell adhesionmolecule-i (VCAM-1) was increased in activeulcerative colitis. Cryostat sections fromuninflamed colonic mucosa (8) and from activeulcerative colitis (6) were stained using a

standard indirect immunoperoxide technique,with monoclonal antibodies to ICAM-1,ELAM-1, and VCAM-1.Normal mucosa showed expression of

ICAM-1 by capillary endothelium in the regionof lymphoid aggregates but not at other sites.The inflamed mucosa showed widespreadexpression of ICAM-1 and ELAM-1 by endo-thelium within mucosa as well as superficialsubmucosa. The endothelial cells also showedaltered morphology (swelling). There wasmoderate endothelial expression of VCAM-1,especially in the region oflymphoid aggregates.The intensity of expression of ELAM-1appeared to correlate with the severity of acuteinflammation as assessed by neutrophilicinfiltrate.We conclude that in colonic mucosa, cell

adhesion molecule expression is restricted toareas of inflammation or immune activity(lymphoid aggregates). This expression islikely to be important in the genesis of inflam-mation and offers targets for therapeutic inter-vention.

"'In whole body retention: a new method forquantification ofdisease activity in inflamma-tory bowel disease

MS CARPANI DE KASKI, A M PETERS, D KNIGHT,A W j STUTTLE, J P LAVENDER, H J F HODGSON(Departments ofMedicine and NuclearMedicine,Royal Postgraduate Medical School, Hammer-smith Hospital, London) Accurate objectivequantification of disease activity in patientswith inflammatory bowel disease (IBD) can beachieved by measurement of "'In white cellfaecal excretion (FE). This method, however,is cumbersome and has practical difficultieswhich limit its routine application. We evalu-ated the quantification of "'In whole bodyretention (WBR) as an alternative method inpatients with IBD. After the reinjection of"1'In labelled granulocytes the patient stood infront of an uncollimated y camera and countswere collected over two minutes. Afterapproximately 96 hours, the patient wasrecounted and the % of "1'In counts retainedwas calculated. Results were expressed as % ofinjected counts that had been excreted (100-WBR, normal value . 10%).

Thirteen patients underwent white cell scan-ning and measurement ofFE and 100-WBR. Agood correlation between WBR and FE wasfound (r=0-96; n= 13; p<0 05). In 45 studies100-WBR was compared with gradings ofabnormalities of image: 100-WBR was7-8+4-9% in five normal scans, 9-8+16% inthe 15 (+) scans, 21-4+7-9% in the 17 (++)scans and 57±16% in the 8 (+++) scans. Infive cases 100-WBR results were not concor-dant with imaging, supporting the notion thatfor detection of IBD imaging is more sensitivethan WBR and FE.However, our results indicate that when

quantification of disease activity is required,WBR is an accurate, reliable alternative to FE.

Cytokine production by human colonicintraepithelal lymphocytes in controls andinflammatory bowel disease

H R DALTON, P HOANG, H J DE SILVA, D P JEWELL(Gastroenterology Unit, The Radcliffe Infirmary,Oxford) The function of human intraepitheliallymphocytes (IEL) remains enigmatic. Theaim of this study was to determine the cytokineproduction profile of human colonic IEL in

control subjects and patients with inflammatorybowel disease (IBD).IEL were isolated from the macroscopically

normal mucosa of colonic resection specimensfrom nine control (eight carcinoma, one polyp)and six IBD patients using DDT, EDTA, andtwo step Ficoll density centrifugation. TheIEL were cultured for 72 hours with andwithout 10 sg/ml of PHA, and the culturesupernatant harvested. Concentrations ofy interferon (yIFN) and interleukin 2 (IL2) inthe culture supernatants were measured usingan enzyme amplified sensitivity immune assay.

Control IEL had a median CD4/CD8 ratio of0-22 (range 0 10-0 33) and IBD IEL 0-20(range 0.12-0-30). When cultured alone, themedian cytokine production by IEL was (con-trol v IBD): yIFN 0.3 U/ml (range 0-06) and0.5 U/ml (range 0-0 7); IL2 1 U/ml (range0-20) and 0 U/ml (range 0-10). After stimula-tion with PHA the median cytokine productionby IEL significantly increased (p<0 05) to(control v IBD): yIFN 3 9 U/ml (range 0-9-26)and 0 85 (range 0-3-10. 1); IL2 15 U/ml (range0-30) and 5 5 U/ml (range 0-50). There was nosignificant difference in cytokine productionbetween controls and IBD patients.These data show that human colonic IEL can

produce yIFN and IL2 after stimulation withPHA. This is of particular interest, given thefact that IEL do not proliferate in response tolectins. There is no difference in production ofthese cytokines in control and IBD subjects.

GALL BLADDER MOTILITY AND DISEASE

Non-adrenergic non-cholinergic inhibitoryinnervation in human gall bladder muscle

M McKIRDY, C D JOHNSON (University SurgicalUnit, Southampton General Hospital, South-ampton) Non-adrenergic non-cholinergic(NANC) inhibitory nerves are presentthroughout the gut in man and in the gallbladder of several species, but they have notbeen found in human gall bladder. We havesought evidence for NANC nerves in strips ofgall bladder muscle from gall stone patientsundergoing cholecystectomy.

Gall bladder muscle strips were suspended inan organ bath and subjected to repeatedelectrical field stimulation (EFS: supramazimalvoltage, 10 Hz, 0-3-0.5 ms pulse width for 5seconds) which depolarises nerves but notmuscle. Adjacent strips of gall bladder musclewere given a multifactoral histological score forfibrosis (0-4) and inflammation (0-15).

All 30 strips responded to 15 nM CCK byincreased tone. Twenty one strips contractedafter EFS; non-responders had high histo-logical scores and low response to CCK.Responsive strips were exposed to atropine (1tmol/1), CCK8 (50 nmol/l) and guanethidine

(1 [imolll). EFS produced relaxation in ninestrips in these conditions. L-nitro-arginine (10[tmol/l) was added to four strips showingNANC relaxation. The NANC persisted inthree.We have shown NANC inhibitory innerva-

tion in human gall bladder muscle. Inflam-mation and fibrosis impaired the neurallymediated responses to EFS, including NANCrelaxation. Neural mechanisms may helpregulate gall bladder filling and emptying inman.

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Effect of hyperglycaemia on gall bladdermotility and plasma hormone secretion

S Y DE BOER, W F LAM, M C W JEBBINK, A A MMASCLEE, J B M J JANSEN, C B H W LAMERS(Department of Gastroenterology-Hepatology,University Hospital, Leiden, The Netherlands)Acute hyperglycaemia has been shown tosuppress oesophageal and gastric antralmotility. The aim of this study was to investi-gate the effect of acute hyperglycaemia on gallbladder motility and endogenous chole-cystokinin (CCK) and pancreatic polypeptide(PP) secretion in response to modified shamfeeding (MSF) and meal ingestion. Six healthyvolunteers were studied twice, in random orderwith blood glucose values stabilised at 5 and 15mmol/l using a modified glucose clamp tech-nique. Gall bladder volumes, measured byultrasound, were determined every 15 minutesfor 90 minutes after MSF and subsequently for60 minutes after feeding of the same meal (onehamburger, bread, butter, tea). At regularintervals blood was drawn for measurement ofCCK (RIA), a major hormonal stimulus of gallbladder contraction and PP (RIA) as anindirect measure of vagal-cholinergic tone.The MSF and feeding induced gall bladder

contractions during hyperglycaemia (9+2%and 30±8%, respectively) were significantly(p<0 05) reduced compared with those duringeuglycaemia (22±1% and 60±6%, respect-ively). Plasma CCK levels after MSF remainedunchanged. The integrated CCK secretionafter feeding during hyperglycaemia (29+5pM.60 minutes) was significantly (p<0 05)reduced compared to that during euglycaemia(58-± 10 pM.60 minutes). The MSF and feed-ing induced PP secretion during hyper-glycaemia (235+90 pM.90 minutes and1040±270 pM.60 minutes, respectively) werealso significantly (p<0.05) reduced comparedwith that during euglycaemia (430±70 pM.90minutes and 1960±220 pM.60 minutes,respectively).We conclude that gall bladder motility and

secretion of CCK and PP in response to shamand regular feeding are related to blood glucosevalues. Hyperglycaemia impairs MSF andfeeding induced gall gladder contraction andCCK release. Hyperglycaemia reduces plasmaPP values suggesting impaired vagal-cholinergic activity during hyperglycaemia.

Impaired gall bladder motility in acromegaly

S M CATNACH, J V ANDERSON, G M BESSER, J A HWASS, P D FAIRCLOUGH (Departments of Gastro-enterology and Endocrinology, St Bartholomew'sHospital, London) Octreotide has recently beenused to suppress growth hormone secretion inacromegaly. It has been suggested that longterm therapy with this drug is associated withan increased prevalence of gall stone formation,possibly due to an inhibitory effect ofoctreotide on gall bladder emptying. Usingultrasound, we have studied gall bladderemptying after a standard liquid meal (Ensure,250 ml, 250 Kcal) in 30 untreated acromegalicpatients and 16 on octreotide.

In untreated acromegalic patients, fastinggall bladder volume was not significantlydifferent to the value in normal subjects (33-6(2.7) v 26-2 (2.6) ml). However, maximalpercentage emptying and the rate of emptyingafter the meal were significantly impairedcompared with normal subjects (maximum %emptying 34 (4 0) v 64 (28)%, rate constant ofemptying -0.011/min v -0 04/min) and the

postprandial residual gall bladder volume wasincreased (21-7 (2-1) v 9.0 (0.9) ml). Aftertreatment with octreotide, gall bladder fastingvolume was not significantly increased (45 0(3.0) v 33-6 (2.7) ml). Octreotide did notsignificantly alter maximal gall bladder empty-ing, but the rate of emptying was reduced andpostprandial residual gall bladder volumefurther increased (36-8 (3.9) v 21 7 (2 1) ml,p<O OOl).We have shown that gall bladder emptying in

untreated acromegalic patients is impaired.Octreotide treatment further reduces gallbladder emptying with an increase in post-prandial residual gall bladder volume; this maybe a factor in the increase in gall stone preval-ence seen in these patients.

Abnormal gall bladder motility in gastro-enterostomy

H DALVI, K R PALMER, C FERRINGTON,M CHAPMAN, M V MERRICK (GastrointestinalUnit, Department of Nuclear Medicine andDepartment of Radiology, Western GeneralHospital, Edinburgh) It is believed that thegall bladder contracts as CCK is released inresponse to fat entering the duodenum. Ingastroenterostomy the duodenum is bypassedand this could affect gall bladder motility,predisposing to gall stones and maldigestion.

Gall bladder contraction and gastric empty-ing were measured simultaneously in sevenpatients who had undergone gastroenteros-tomy without vagotomy (group 1) for pepticulcer and in seven matched control subjects(group 2). Gastric emptying was assessed usinga dual labelled test meal with liquid (water) andsolid (omelette) components. Gall bladder con-traction was measured by ultrasound.Mean (SEM) liquid T was 9 (2) minutes

in group 1 and 19 (2) minutes in group 2(p<005). The mean lag phase for solid empty-ing was only 6 (5) minutes in group 1 comparedwith 35 (7) minutes in group 2 (p<005). Incontrast, the subsequent mean linear phase ofgastric solid emptying was very similar in bothgroups, 0.37 (0-1) and 0.40 (0-08)%/minutes.Gall bladder contraction began in both groupsas soon as food entered the stomach. Emptyinghad two linear components, in group 1 themean rate of the first phase of contraction wassignificantly greater than that seen in group 2,2.5 (0.8) compared with 1 (0-4)%/minute(p<005). The second phase of gall bladderemptying was identical at 0 54 (0-4)%/minutein both groups.

Rapid gastric emptying in gastroenteros-tomy is principally due to loss of the lag phaseand this defect is not a result of vagal denerva-tion. Gall bladder emptying is increased ingastroenterostomy, presumably because ofrapid gastric emptying and enhanced jejunalCCK release.

Gall stones in people who are not obese maybe explained by slow colonic transit

K W HEATON, P M EMMETT, C L SYMES, F E MBRADDON, A 0 HUGHES (University Departmentof Medicine, Bristol Royal Infirmary, Bnrstol)Artificially slowing down intestinal transitincreases biliary deoxycholate and thecholesterol saturation index of bile (Gut 1986;27: 550). We therefore speculated that slowtransit might be a feature of people with gallstones, at least of those without the major riskfactor of obesity. Whole gut transit time

(WGTT) was measured in all consenting sub-jects whom we discovered to have gall stones(n= 54) in an ultrasound survey of the popula-tion, and in age matched controls. Two con-secutive stools were x rayed after oral ingestionof multiple, differently shaped, radio-opaquepellets.

Overall, WGTT was similar in cases andcontrol subjects. However, in the 10 non-obesewomen (BMI --25 kg/M2), WGTT greatlyexceeded that of the 18 obese women with gallstones (median 78 v 46 hours, p<0 001). Inmen, a similar trend emerged in relation totruncal obesity. In nine slim men (waist <0 92x hip circumference) WGTT tended to belonger than in 17 fatter men with gall stones(median 63 v 49 hours, p=0 059). In gall stonesubjects, but not controls, WGTT wasinversely related to obesity (women r=-0 52,p<001; men r=-041, p<005). Bowel habitand stool form on a validated 1-6 scale wereboth significantly shifted towards the consti-pated end of the spectrum in the non-obesepeople with gall stones.We conclude that slow colonic transit is a

feature of non-obese people with gall stonesand could explain their disease.

CHRONIC LIVER DISEASE

Natural history of autonomic neuropathy inchronic liver disease

M T HENDRICKSE, P J THULUVATH, D R TRIGER(Department of Medicine and Pharmacology,University of Sheffield) To examine the naturalhistory of autonomic neuropathy in chronicliver disease we have evaluated 60 patients (19alcoholic, 18 primary biliary cirrhosis, 23chronic active hepatitis; 57 Child's A, threeChild's B) using standard cardiovascular tests,and followed them prospectively for a medianof 50 months. Somne 45% (27/60) had vagalneuropathy on initial testing. Ten patients died(eight liver related, one cerebrovascular, onerespiratory death), eight of whom had vagalneuropathy. Life table analysis showed asignificantly reduced survival associated withvagal neuropathy with a 30% v 6% four yearmortality in those without vagal neuropathy(p<002). There was no significant differencein hepatic function or aetiology of liver diseasebetween the two groups. Patients who died hada significantly higher number of abnormalcardiovascular tests (p<0002), and a lowerValsalva ratio (p<0028), deep breathing heartrate change (p<0033), and lying standing ratio(p<0002). Thirty seven patients had repeattests (mean interval between tests 40.7 months)of whom 15 had vagal neuropathy on initialtesting. Five developed abnormal tests whilstthree reverted to normal on follow up.These results indicate that although mild

cases may be reversible the presence ofautonomic neuropathy in chronic liver diseaseis associated with a significantly worseprognosis.

Intrahepatic portal occlusion by micro-spheres: a new model of portal hypertensionin the rat

V JAFFE, B ALEXANDER, R T MATHIE (Departmentof Surgery, Royal Postgraduate Medical School,London) Available experimental models of

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portal hypertension (PHT) are based either oncirrhosis or externally applied portal vein (PV)constricting devices. These have proved dis-appointing because the models are unstableand the PV pressure increases variable andunreliable. We have devised a new method ofraising PV pressure which uses intraportallyinfused microspheres to block intrahepaticportal radicles. The resultant PHT modelwould have the advantage of normal liverfunction and a more clinically relevant intra-hepatic obstruction to PV flow.

Measured aliquots of microspheres (15, 25,50, and 90 im) or control equivalent volumesof saline were injected into a peripheral PVtributary (caecal vein). The resultant changesin arterial, PV, and splenic pulp pressures weremonitored in a total of 33 rats. Sequentialmicrosphere injections produced graduatedrises in PV pressure up to a mean peak of18-9+0-9 mm Hg (9.5±0 9 mm Hg increase)which declined gradually to a steady statepressure of 13-8±0-3 mm Hg (4.4±0.3 mm Hgincrease). There was no significant differencebetween increases produced by differingmicrosphere sizes. Splenic pulp pressures,though usually damped, closely paralleledthose measured in the PV.PHT can therefore be produced by blocking

PV radicles with microspheres. The maximumpressure achieved, however, is substantiallyless than that obtained by total PV occlusion(60 mm Hg). This suggests the existence notonly of pressure dependent extrahepatic shuntsbut also functional intrahepatic portal systemicshunts not previously described in the normalliver.

Is anaemia a feature of hypertensivegastropathy?

F GRANAI, H SMART, D R TRIGER (Department ofMedicine and Pharmacology, University ofSheffield, Royal Hallamshire Hospital, Sheffield)Although haemorrhagic gastropathy is animportant cause of bleeding in portal hyperten-sion, its contribution to the anaemia of stablechronic liver disease is unknown. We havestudied 72 consecutive patients with portalhypertension undergoing diagnostic endo-scopy or maintenance sclerotherapy. Sevenpatients receiving propranolol for previousbleeding gastropathy were excluded fromanalysis, as were patients with documentedbleeding varices within the previous 3 months.Anaemia (Hb greater than 2 SD below the

normal mean), was found in 49% ofthe patients(overall median: Hb 12-5 g/dl). Hb was lowerin more advanced liver disease (Child's A: 12-7g/dl (n=39), B: 11-9 g/dl (n=19), C: 9-7 g/dl(n=7); p<005), but there were no differencesaccording to variceal size, previous varicealbleeding, number of bleeds, or sclerotherapysessions. The Hb did not differ (p=0.78)between patients without gastropathy (12-7g/dl, n= 17), those with mild gastropathy(erythema or mosaic pattern) (12-7 g/dl, n=39)or those with severe gastropathy (cherry redspots) (11-7 g/dl, n=9). Median Hb in 22Helicobacter pylori positive patients was 11-7g/dl compared with 12-6 g/dl in 43 who wereH pylori negative (p=0 36).We conclude that although patients may

present with acute bleeding due to severegastropathy, it does not seem that portal hyper-tensive gastropathy is a major cause of chronicanaemia in portal hypertension.

Prevalence of anti-neutrophil antibody inprimary sclerosing cholangitis and ulcerative

colitis using an alkaline phosphatase tech-nique

S K LO, P CUSICK, K A FLEMING, R W G CHAPMAN(Department ofGastroenterology, J3ohn RadcliffeHospital, Oxford and Nuffield Department ofPathology and Bacteriology, University ofOxford) We have recently reported thepresence of an anti-neutrophil nuclear anti-body in primary sclerosing cholangitis (PSC)and ulcerative colitis (UC). The methodologyhas been refined to give more specific detectionof antibody in PSC using an alkaline phos-phatase method. Normal human neutrophilswere cytocentrifuged, ethanol fixed, and thenincubated with coded patients' sera. Rabbitanti-human immunoglobulin conjugated withalkaline phosphatase was used to detect thebound antibody. The reaction was visualisedusing fast red. Twenty three of 30 PSC patientsshowed positive granular cytoplasm staining(some in a perinuclear distribution) with fila-ments surrounding the neutrophils (type 1pattern). Fifteen of 45 UC patients and one ofthree chronic active hepatitis patients (CAH)showed a similar staining. The immuno-globulin class was predominantly IgG. Nocorrelation was found between antibody titre,clinical activity or liver histology within thePSC group. Fourteen other UC patients, two ofthree CAH patients, five of 14 primary biliarycirrhosis, four of 18 alcoholic liver diseasepatients, six of 32 Crohn's disease patients, oneof two coeliac disease, and three of six largeduct obstructive jaundice patients were alsopositive but showed a diffuse pattern of cyto-plasmic labelling with no surrounding fila-ments (type 2 pattern).

This method of detecting ANA is morespecific than those described in recent reportsand may be of diagnostic significance in PSCand of prognostic significance in UC.

Enhanced brain serotonin metabolism, inhuman hepatic encephalopathy

H ALMARDINI, E HARRISON, P INCE, K BARTLETT,C 0 RECORD (Gastroenterology Unit, RoyalVictoria Infirmary and MRC NeurochemicalUnit, Newcastle General Hospital, Newcastleupon Tyne) An excess of the neuroinhibitorytransmitter serotonin could be responsiblefor the impaired consciousness in hepaticencephalopathy (HE) and increased brain 5-HIAA has been a consistent finding in variousanimal models of the condition.

In the present study, using HPLC withflurometric detection, we have examined brainserotonin and its precursors and metabolites in15 patients with HE complicating acute andchronic liver disease and 13 matched controlsubjects. Serotonin was significantly increasedin thalamus (p=0-041) while the degradationproduct 5-HIAA was increased in thalamus(p=0-048) globus pallidus (p=0-004), andputamen (p=0 002). The tryptamine degrada-tion product indoleacetic acid was increased infrontal cortex, caudate nucleus, globuspallidus, putamen, and thalamus (p<0O001)The precursor amino acid tryptophan wasincreased in globus pallidus (p=0.003),putamen (p=0 009), thalamus (p=0 023),frontal cortex (p=0-014), and caudate nucleus(p=0 033) while 5-hydroxytryptophan wasalso increased in all brain areas studied(<o ool).This is the first finding of disordered

inhibitory neurotransmission in the thalamus,an area of importance in the regulation ofconsciousness alertness and attention in man.

OESOPHAGUS

Twenty four hour ambulatory oesophagealpH monitoring in uncomplicated Barrett'soesophagus

C S NEUMANN, R J L HERON, B T COOPER(Gastroenterology Unit, Dudley Road Hospital,Birmingham) All but one of the five previousstudies on acid reflux in Barrett's oesophagus(BO) concluded that it was greater than inreflux oesophagitis (RO). These studies camefrom surgical units, three of five studiesincluded Barrett's patients with complications,and in two of five studies, BO patients wereolder than RO patients. In our study, acidreflux in 15 patients with uncomplicated BOfrom a medical gastrointestinal unit wascompared with that in 21 patients with mildreflux oesophagitis, 16 patients with moresevere reflux oesophagitis, and 10 controls, ofcomparable age. All patients had 24 hourambulatory oesophageal pH monitoring(Synectics) within one week of endoscopy.

Results showed that controls differed signifi-cantly from the other groups with respect tototal % time and the number of episodes >5minutes that oesophageal pH was <4 over 24hours, but there were no differences betweenpatients with RO and with BO. Within eachdisease group patients >50 years of age hadmore acid reflux than patients <50 years.We conclude that severity of acid reflux in

patients with uncomplicated BO is no greaterthan in patients with RO of comparable age.Our results suggest that other factors must beimportant in the development of Barrett'soesophagus.

Treatment of advanced adenocarcinoma ofthe oesophagus and stomach with epirubicin,cisplatin, and continuous 5-fluorouracil

R C MASON, M HIGHLEY, N BRIGHT, M HILL,S BARKER, D CUNNINGHAM, P HARPER (Depart-ment of Surgery and Oncology, Guy's Hospital,London and Royal Marsden Hospital, London)This study describes our early results withepirubicin, cisplatin, and fluorouracil (ECF)chemotherapy in 10 assessable patients to date(16 entered) with advanced adenocarcinoma ofthe oesophagus and stomach. Patients hadeither locally advanced disease, nodal or livermetastasis confirmed by biopsy specimenswhich were assessable by computed tomo-graphy. All patients had ECOG scores 0-2.5-Fluorouracil was administered by contin-uous iv infusion via a minipump and Hickmancatheter in a dose of 200 mglm'/day, E-50 mg/m2 and C-60 mg/m2 were given by iv bolus in athree weekly cycle.

Assessment of response was made after threecycles. Response (>50% reduction of all para-meters on computed tomogram) was seen inseven (70%) patients, with stasis in one andprogression in two. All had symptomaticbenefit especially with regard to dysphagia,requiring less laser treatment than is usuallyseen in such patients. The treatment was welltolerated with significant problems seen in lessthan 10% of treatment cycles.

If these early results showing high activity inadvanced disease are confirmed, then its use inan adjuvent setting in 'early disease' mayimprove the poor prognosis which currentlyexists for this form of cancer.

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Open access endoscopy for acute dysphagiain Leicestershire

B TREGASKIS, P NAIR, Y CHUAH, A C WICKS, J FMAYBERRY (Department of Gastroenterology,Leicester General Hospital, Leicester) In 1990, anopen access service for people with dysphagiawas established. General practitioners in thedistrict and surrounding areas were invited torefer all patients for early endoscopic assess-ment. Referrals could be made at any timethroughout day and night. Outside officehours, messages were recorded on a telephoneanswering serice. During the first sevenmonths of operation 50 patients were referred.Their mean age was 64 years (range 16-93).Significant new pathology was detected in 44(86%) cases. Nineteen patients (38%) hadstrictures in the oesophagus.

Oesophageal pathology detected: 11 pepticstrictures (22%); eight malignant strictures(16%); eight oesophagitis (16%) (two Barrett's,three hiatus hernia); three hiatus hernia alone(6%); one impacted food bolus (2%); onepharynx ulceration (2%); one Candida oeso-phagitis (2%); 17 normal structurally (34%).Of the patients with a structurally normal

oesophagus, only six had completely normalendoscopies. One patient had a gastric funduscarcinoma and one pyloric stenosis, two gastriculcers, two duodenal ulcers, one duodenitis,two gastritis, two duodenal polyps.We found 19 strictures requiring treatment

(38%) and significant oesophageal pathologyresponsible for dysphagia in 66% of patients.The service led to early diagnosis and treatmentand has been well received by patients andgeneral practitioners.

Such a service should now become routine inunits concerned with an efficient patient orien-tated service.

Oesophageal symptoms in the population: asurvey by a group of 50 general practitionerson 2200 patients

L BENINI AND THE VERONA GENERALPRACTITIONERS STUDY GROUP (Divisione diGastroenterologia, COC di Valeggio sM,Universitd di Verona and Servizio SanitarioNazionale, Verona Italy) The prevalence ofoesophageal symptoms in the general popula-tion was investigated. A questionnaire wascompleted by 50 general practitioners on 2200patients over 18 years seen consecutively ontwo days to record the frequency, severity, andassociation of oesophageal symptoms withfood, beverages, or smoking. Mean (SD) ageand male/female ratio were 48.5 (18- 11) yearsand 0-6 respectively. Heartburn was present(P) in 31-1%, frequent (F) or daily (D) in 6-2and 1-9% of all cases respectively. Its severitywas moderate or severe in 14-5%. In 29% ofpatients, heartburn was not associated withmeals, in 33% it was worse before and in 37%after meals. A particular food was the cause in15-7% of cases (wine 8%, spirits 5.5%, coffee9.3%, smoking 3%). Similar data were foundfor dysphagia (P 22-8% of cases, F 41%,D 04%), regurgitation (P 39-2%, F 723%, D0.6%), odinophagia (P 10-7%, F 2-1%, D0 4%), bolus (P 12-8%, F 3.7%, D 0 7%), andpain after retching (P 8-8%, F 1-5%, D 0.2%).The frequency of dysphagia, regurgitation andodinophagia increased with age but this was notthe case with heartburn, bolus, or pain afterretching (analysis of variance). As many as43% of patients did not contact their general

practitioner because of frequent or dailydysphagia.

In conclusion, only a small proportion ofoutpatients presented with frequent or severeoesophageal symptoms; an investigation ofoesophageal function in these patients istherefore feasible. Even daily and potentiallyominous symptoms are often not reported andbecome evident only after specific questioning.

Primary immotile oesophagus in youngpatients

S M ALLEN, D E VAN RAEMDONCK, I P ADAMS,H R MATTHEWS (East Birmingham Hospital,Birmingham) Since oesophageal manometrywas introduced groups of patients havebeen identified with disordered motility, forexample achalasia and diffuse oesophagealspasm.

Since 1984 we have seen 14 young patientswith loss of oesophageal motility which isunexplained in terms of reflux, neurological, orsystemic disease. Mean age at presentation was33 years (range 20-42) and nine were female.Barium swallow was normal in eight patientsand showed minor abnormalities in six. Theonly endoscopic abnormality was minimaloesophagitis in three patients, and pH studieswere all normal. Upper oesophageal sphincterpressures and cervical motility were normalexcept in one patient. Motility in the body ofthe oesophagus was severely reduced in allpatients with a mean amplitude of 10 mm Hg.Lower oesophageal sphincter resting pressureswere reduced in 11 patients, with incompletesphincter relaxation in three. All patients havebeen followed up for at least three yearswithout progression of their symptoms or thedevelopment of a secondary cause. Sevenpatients have undergone repeat studies with nochanges in their characteristics.We conclude that there is a group of young

patients who seem to undergo severe primaryloss of oesophageal motility for reasons thathave not yet been identified.

Oesophageal function assessed by endo-scopic video recording

H TZATHAS, P M SPRINGETT, P E T ISAACS

(Gastroenterology Department, Victoria Hospital,Blackpool) An endoscopic assessment of oeso-phageal function was made in 72 consecutivepatients (41 F, 31 M, aged 23-88 years) withoesophageal symptoms but no oesophagitis,stricture, or other lesion. Scores of loweroesophageal sphincter (LOS) function, restingmotility (RM), and peristalsis (P) were made atendoscopy. Video scores were made in 45patients by 'blind' review of video recordings.Scores were compared with function tests - 24hour pH monitoring (PHM) for LOS functionand perfusion manometry for RM and P.

Endoscopic LOS score had a sensitivity of82% and specificity of 61%; video increasedsensitivity to 92% and specificity wasunchanged (63%). Endoscopic RM score had asensitivity of 36%, specificity 98%; videoincreased the sensitivity to 100% and specificityfell to 81%. Endoscopic P score had a sensi-tivity of 48%, specificity 86%; video increasedthe sensitivity to 87%, specificity wasunchanged.We conclude that simple endoscopic assess-

ment of oesophageal function may easily beperformed during routine endoscopy and pro-vides data comparable with that obtained from

full oesophageal function tests. Review ofendoscopic video tapes significantly enhancesthe accuracy of interpretation.

Symptoms dictate the salivary bicarbonateresponse to intraoesophageal acidification

C M BROWN, B SLEE, L SANDLE, W D W REES

(Hope Hospital, Salford and Trafford GeneralHospital, Manchester) Since swallowed salivarybicarbonate contributes to acid neutralisationwithin the oesophagus, basal secretion andresponse to oesophageal acidification wereexamined in seven healthy subjects.A 10 cm segment of oesophagus was per-

fused with saline (pH=7 0, 5 mt/minute)containing a non-absorbable marker (3H-polyethylene glycol). Saliva was collected bycontinuous dental aspiration, pooled at 15minute intervals, and bicarbonate output wasdetermined by measurements of volume, pH,and pCO2. Swallowed salivary bicarbonate wasdetermined by appearance of amylase in oeso-phageal aspirates and marker dilution. After abasal period with saline, the oesophagus wasperfused with 0 1 N hydrochloric acid. Fivesubjects experienced heartburn during acidperfusion and mean (SEM) salivary bicarbo-nate secretion increased from 2848.2 (1480-4)to 4362 1 (1393-6) [smol/hour (p=0-017). Thisresulted from an increase in salivary volume(149-6 (39 2) to 208-8 (44.4) ml/hour, p=0 0053), and increased bicarbonate concentra-tion (14-5 (4.3) to 19-3 (2.4) [tmol/ml, p=0.23). Two subjects with higher basal salivarybicarbonate secretion did not experiencesymptoms during acid perfusion and a reduc-tion in salivary bicarbonate secretion occurredwith oesophageal acidification (means=53585to 2882 1 imol/hour).Symptom perception therefore seems

important in enhancing salivary bicarbonatesecretion in response to oesophageal acidifica-tion.

Non-cardiac chest pain - is it gastro-oesophageal reflux?

A ANGGIANSAH, J CHAMBERS, R COOKE, N F

BRIGHT, K SUMBOONNANONDA, W J OWEN

(Departments of Surgery and Cardiology, Guy'sHospital, London) Thirty seven patients whohad been admitted to the coronary care unitwith suspected myocardial infarction werereferred to the oesophageal investigation unitafter detailed cardiological assessment withnormal coronary angiography.

Oesophageal motility was studied with base-line manometry (Aspen Medical). Provocationtesting with hyperventilation, Bernstein acidperfusion, and iv edrophonium (80 [sg/kgBW) was used during manometry in an attemptto maximise the diagnostic yield. Following themotility studies, all patients underwent 24 houroesophageal pH monitoring (Synectics) todetect abnormal gastro-oesophageal reflux(GOR).

Baseline manometry was abnormal in fourpatients (10-8%) (two diffuse oesophagealspasm (DOS), two non-specific motility dis-orders (NSMD)). Provocation testing resultswere as follows: hyperventilation test, fivepositive (13.5%) (no manometric changes);Bernstein acid perfusion test, 12 positive(32.4%) (seven GOR, one DOS, one NSMD,and three normal); edrophonium test, fourpositive (10-8%) (two GOR, two normal).

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Oesophageal pH monitoring showed that 14patients had GOR (38%).

In conclusion, oesophageal abnormalitieswere found in 18 patients (48 6%) and GORwas the commonest finding (38%). The provo-cation tests were found to be non-specific inthat the Bernstein acid perfusion test waspositive in five patients without GOR andedrophonium reproduced symptoms in fourpatients without motility disorders. NCCP is acomplex problem and it may not be caused by asingle aetiological factor.

Intralesional treatment of idiopathic oeso-phageal ulcers in AIDS

J SMITHSON, B G GAZZARD, (INTRODUCED BY B GGAZZARD) (AIDS Unit, Westminster Hospital,London) Idiopathic oesophageal ulcers causingdysphagia and oesophadynia have been des-cribed in patients with AIDS. We report twocases which resolved symptomatically andendoscopically after intralesional steroidinjection.Two HIV positive patients with previous

AIDS diagnoses and complaining of dys-phagia, retrosternal pain, odynophagia, andweight loss were found at endoscopy to havelarge oesophageal ulcers. Histology from bothulcers showed non-specific acute and chronicinflammation with no evidence of viral inclu-sions, mycelia, or other pathogens on light orelectron microscopy and immunoflorescentstaining. After two weeks of (foscarnet) anti-CMV treatment with no endoscopic change,the patients were treated with intralesionalmethyl prednisolone acetate (120 mg in total atthree sites along the ulcer).There was a noticeable improvement in pain

in both patients within two hours and improve-ment in dysphagia and appetite over the next 24hours. Follow up endoscopies, at two weeks inboth cases, showed resolution of the ulcerationwith residual scarring only. Both ulcers recur-red at the same site within two months andagain responded to intralesional injections bothsymptomatically and endoscopically. Bothpatients are now maintained on intralesionalsteroids every six to eight weeks.

Prevalence of hiatal hernia and its influenceon gastro-oesophageal reflux and treatmentresponse in patients with reflux oesophagitis

H ZHU, F PACE, 0 SANGALETTI, G BIANCHI PORRO(Gastrointestinal Unit, L Sacco Hospital, Milan,Italy) It is still controversial whether thepresence of a sliding hiatal hernia (HH) mightadversely influence gastroesophageal reflux(GER) and treatment results of patients withGER. We submitted to oesophagoscopy andoesophageal pH monitoring 185 patients withtypical GER symptoms.

Eighty four patients proved to have neitheroesophagitis nor pathological GER (PhR), 37had pathological reflux but no oesophagitis(PR), and 64 had reflux oesophagitis (RE). HHwas found in 19 (29.3%), 11 (16-9%), and 35(53 8%) respectively. GER parameters in thethree groups were statistically the same.Patients with oesophagitis were treated for upto 24 weeks with H2 blockers, at normal ordouble doses: after treatment, no significantdifference was found in the proportion ofhealed patients with or without HH.We conclude that HH was more frequent in

reflux oesophagitis patients, that GER para-meters were similar overall in all groups with or

without HH, and that HH had no influence ontreatment results in oesophagitis.

Thoracoscopic enucleation of leiomyoma ofthe oesophagus

N J EVERITT, M GLINATSIS, M J MCMAHON(University Department ofSurgery, The GeneralInfirmary, Leeds) A 48 year old woman with asix month history of dysphagia was shown tohave the characteristic appearances of aleiomyoma of the mid-oesophagus on bariumswallow and on endoscopy.

Endoscopic enucleation was carried outunder general anaesthesia with the patient inthe left lateral position. The right lung wascollapsed and a video laparoscope was insertedthrough the fifth intercostal space. The lungwas retracted medially with two 5 mm diameterrod retractors. The azygos vein was dividedbetween catgut ligatures and locking poly-dioxanone clips (Absolok - Ethicon). Thethoracic oesophagus was mobilised and retrac-ted laterally with a sling. Rotation of theoesophagus enabled a longitudinal myotomyover the posteriorly placed lesion. Theencapsulated leiomyoma was enucleated intactwithout mucosal damage. The longitudinalmuscle was closed with catgut sutures. Thepatient made a rapid and uncomplicatedrecovery.Our experience suggests that thoracoscopic

surgery has the potential to provide advantagesin the treatment of oesophageal leiomyomasimilar to those that laparoscopic surgery hasbrought to the treatment of gall stones.

Nifedipine promotes gastro-oesophagealreflux

A J MEHTA, J S DE CAESTECKER, T C NORTHFIELD(Department of Medicine, St George's HospitalMedical School, London) Nifedipine decreaseslower oesophageal sphincter pressure (LOSP),and amplitude (A) and duration (D) of distaloesophageal peristalsis. This effect shouldpromote gastro-oesophageal reflux (GOR), butthis has not been studied.Our aim was to assess the effect on GOR of

nifedipine and atenolol, two drugs commonlyused in ischaemic heart disease (IHD). Patientswith endoscopically proved peptic oesophagitis(n=8) and healthy controls (n=8) underwent adouble blind placebo controlled cross overstudy, each on three separate days. One hourafter treatment (nifedipine 30 mg/atenolol 100mg/placebo po), oesophageal manometry wasperformed (rapid pull-through for LOSP, 10wet swallows for A and D). A standard acidreflux test (SART) was then performed afterloading the stomach with 300 ml 0-1 N HCI.

Nifedipine, as expected, decreased LOSP inpatients and controls v atenolol or placebo(p<000S). Nifedipine decreased A in patients(p<005). SART score was increased withnifedipine (mean increase in patients 4-3 vplacebo, 5-5 v atenolol (p<0005), in controls1-75 v both placebo and atenolol (p<0-01)).We conclude that nifedipine increases GOR

in patients with oesophagitis and normal sub-jects. This could be important in patients withIHD treated with nifedipine, as acid GORcould mimic or provoke angina.

Does gastro-oesophageal reflux cause anginain patients with coronary artery disease?

A J MEHTA, J S DE CAESTECKER, T C NORTHFIELD(Department of Medicine, St George's Hospital

Medical School, London) Oesophageal acid per-fusion may cause anginal pain in patients withcoronary artery disease (CAD). The suggestedmechanisms are acid provoked coronaryischaemia or confusion of heartburn with trueangina.To distinguish between these possibilities,

we studied 15 patients with angiographicallyproved CAD (14 men; mean (SD) age 59 (7)years). All had ambulatory 24 hour oeso-phageal pH and seven lead ambulatory ECGmonitoring (for ST segment analysis). Sixpatients had angina during the study, with amedian and range of 2 (1-7) episodes, and ninehad episodes of ST depression >1 mm, with amedian and range of 7 (2-29) episodes. Sevenhad abnormal acid gastro-oesophageal reflux(GOR) (% total time pH <4 exceeding 7%).There were no significant correlations of %time pH <4 or number of reflux episodes withnumber of ST segment shifts. Of a total of 80ST shifts, only 11 correlated with refluxepisodes. An association between anginal painand GOR was observed in three patients. Inthese three patients, six of a total of 10 episodesofangina correlated with reflux episodes, but inonly one episode in one patient did GOR, STsegment shift, and symptoms coincide.We conclude that in patients with CAD: acid

GOR and episodes of ischaemic ST depressionare uncommonly correlated; the association isnot increased in patients with abnormal GOR;in a minority of patients, pain from acid refluxcannot be distinguished from their anginalpain, and this is the most frequent explanationfor episodes of angina related to reflux.

Oesophageal acid clearance before and afterhealing of oesophagitis

P SINGH, A ADAMOPOULOS, R H TAYLOR, D GCOLIN-JONES (Royal Naval Hospital, Haslar,Gosport, Hants and Queen Alexandra Hospital,Portsmouth, Hants) We have previouslyreported lack of improvement in oesophagealmanometric and transit abnormalities afterhealing of oesophagitis. This study investigatesthe effect of healing of oesophagitis on oeso-phageal acid clearance.

Nineteen patients with endoscopic oesopha-gitis were studied. Eighteen of them under-went 24 hour oesophageal pH monitoring. Ofthese, 14 (78%) had abnormal pH profiles. Athree lumen oesophageal manometry catheterand an antimony pH probe were passed via thenasal route into the oesophagus and the distaltips of both were positioned 5 cm above theupper border of the previously mapped LOS.Some 15 ml of 0- 1 N HCI was instilled into theoesophagus using the proximal port of thecatheter so that it arrived 15 cm above the LOS.The subject was then asked to swallow every 30seconds. Acid clearance time (ACT) wasmeasured in seconds as the interval from thetime of instillation of HCI to the time the pHcame up to 5 and stayed at or above that levelfor 60 seconds. The test was done in sitting andsupine postures. The procedure was repeatedin all the patients after complete endoscopichealing of oesophagitis following a course ofomeprazole 40 mg/day for a median duration of12 weeks. Twenty two healthy volunteersserved as controls.

In both patients (P) and controls (C) medianACT was significantly longer in the supine thanin the sitting posture (P: 490 v 420 seconds;p=004 and C: 369 v 252; p=0 03). Patientshad significantly longer median ACT in bothsupine and sitting postures compared with thecontrols (490 v 369; p=0-013 and 420 v 252;

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p=0-026 respectively). There was no correla-tion between the age, sex, or the grade ofoesophagitis and ACT. There was no signifi-cant change in the median ACT in supine orsitting postures after healing of oesophagitis(490 v 640 and 420 v 371 respectively).

Results from this study suggest thatimpaired oesophageal acid clearance is anintegral component of gastro-oesophagealreflux disease and that it does not improve withhealing of oesophagitis.

Results of simultaneous two level oesopha-geal pH monitoring in patients with gastro-oesophageal reflux disease and controls

P SINGH, A ADAMOPOULOS, R H TAYLOR, D GCOLIN-JONES (Royal Naval Hospital, Haslar,Gosport, Hands and Queen Alexandra Hospital,Portsmouth, Hants) For 24 hour oesophagealpH monitoring, the pH probe is positioned5 cm above the lower oesophageal sphincter(LOS). This is simply by convention, and so farthere has been no reported attempt to find thebest level for the pH probe to achieve thehighest discrimination of acid reflux. We com-pared the results of simultaneous 24 hour pHmonitoring with two probes at different levelsin the oesophagus.

Thirty one healthy controls and 45 patientswith endoscopically documented oesophagitiswere studied. Two antimony pH probes werepassed nasally and positioned 5 (distal) and 10cm (proximal) above the upper border of theLOS and connected to two separate recordingdevices. The 90th centiles of the values fromcontrols were used as the cut off points. Total% time pH <4 gave the best discrimination atboth levels with the 90th centile 4-9% for distaland 3-9% for the proximal level. This gave anoverall specificity of 90.3% separately for bothlevels, but the sensitivity was slightly higher atthe distal level (77.7% v 71-1%). Combiningwith supine and/or upright values or the valuesfrom the two probes did not improve dis-crimination.

In controls at distal level, the median % timepH <4 was significantly higher in upright thanin supine position (2-2 v 0 3; p=0 005). In bothgroups, there was a strong correlation betweenthe two probes for all variables (p<0-001). Incontrols, the median total time % pH <4 wassimilar for the distal and proximal probes (1-6 v1-8; NS); but in patients, the figure was muchhigher at the distal level (10-7 v 7.7; p<0-001).There was a significant correlation between thegrade of oesophagitis and all pH variables atboth levels with the association being strongerat the proximal level (p<0-02 at distal and<0 0025 at proximal).Oesophageal pH monitoring with a probe at

10 cm above LOS gives almost the same level ofdiscrimination as the conventional position andis less likely to give spurious results from probedisplacement.

Comparison of photodynamic therapy andNd:YAG laser therapy for obstructing oeso-phageal and gastric cancer

M ABULAFI, J ALLARDICE, R DEAN, M GRAHN, N SWILLIAMS, C P SWAIN (The Surgical Unit andAcademic Department of Gastroenterology, TheRoyal London Hospital, London) We comparedphotodynamic therapy (PDT) (26 patients)with Nd:YAG laser treatment (NLT) (24

patients) in 50 consecutive patients withobstructing oesophageal or gastric cancer whohad either received or were unsuitable forsurgery or radiotherapy. PDT used ivhaematoporphyrin derivative 4 mg/kg, acopper vapour pumped dye laser delivering 630nm light through a guide wire placed endo-luminal light delivery system designed by us.Endoscopic Nd:YAG laser treatment wasdelivered by non-contact 50-60 W thermalmethod.PDT results were as follows. Quantitative

radiology showed a median lumen diameter(MLD) before treatment of 3-9 mm (range 2-2-5) and after treatment of 8-6mm (range 7-11-4)p<0 05). The median before treatment dys-phagia score of 3 rose to 5 after treatment(p<005). The mean number treatmentcourses was 1-2. Median survival was 12 weeks(range 1-60). NLT results showed a MLDbefore treatment of 2-1 mm (range 0-5.2) andafter treatment 8-0 (range 3-16) (p<0 05). Thebefore treatment dysphagia score of 2 rose to4 (p<005). The mean number of treatmentcourses was 4-3. Median survival was 18 weeksrange (8-40). The perforation rate was '1/26(4%) in PDT and 1/24 (4%) in NLT and bothwere guide wire related. Thirteen of 26 PDTpatients developed skin photosensitivity (sevenmild, five moderate, one severe).

Advantages of PDT included smokelessnon-thermal nature, ease of treating tightestpart requiring less endoscopic skill and tumourselectivity with less danger in treating junctionsbetween normal and malignant tissue. Advan-tages of Nd:YAG laser treatment includedsuperior laser reliability and lack of skin photo-sensitivity. PDT patients required significantlyfewer treatment sessions (p<0 05). Photo-dynamic therapy seems a promising alternativeto Nd:YAG laser treatment for patients withobstructing oesophageal and gastric cancer.

Oesophagitis is as important as oesophagealstricture diameter in determining dysphagia

M DAKKAK, J R BENNETr, S C MASLIN (Hull RoyalInfirmary, Kingston Upon Hull) It is a commonobservation that stricture patients with severedysphagia may have a wide lumen, while otherswith a narrow stricture have few swallowingcomplaints.

In 64 patients with benign oesophagealstricture the dysphagia score was comparedwith the diameter of the stricture. There wasa positive association, but the correlationcoefficient (r) was 0 544, suggesting that thediameter of the stricture is an important,though not the sole, determinant of dysphagia.Stricture diameter explains 29-6% (r2) of thevariation in dysphagia score.The patients were divided into three groups

according to the severity of oesophagitis (19patients had minimal, 22 moderate, and 23severe oesophagitis). Analysis showed themean dysphagia scores to be 83, 73, and 59 (outof a maximum possible 90) in each grouprespectively. The dysphagia score of eachgroup was significantly different from theothers (Kruskal Wallis test). Relating the dys-phagia score to stricture diameter for eachgroup gives correlation coefficients of r=0-379,r=0-651, and r=0-583. If both diameter andseverity of oesophagitis are included then66-0% of the variation in the dysphagia scorecan be explained.We conclude that the degree of oesophagitis

is as important as luminal diameter indetermining swallowing ability.

Chest x ray in the diagnosis of iatrogenicoesophageal perforation - an audit

R N M VAN SOMEREN, J JACOMB-HOOD, S MCGEE,D S RAMPTON, J MURFITT, C P SWAIN (Depart-ments of Gastroenterology and Radiology, TheRoyal London Hospital, London) We havereviewed the value of the chest x ray (CxR) inthe detection of perforation occurring during aseries of 408 consecutive endoscopic pro-cedures involving oesophageal dilatation from1989-91. Twelve iatrogenic perforationsoccurred (3%), all in patients with malignantstrictures (nine/366 dilatations, three/42prosthetic placements). In the 48 hours afterendoscopy, perforation was diagnosed byendoscopy (two/12), CxR (seven/12), watersoluble contrast (nine/12), plain abdominal xray (one/12), clinical findings (five/12). The 20day mortality was 10/12. In all patients, CxRwas performed within 24 hours of the pro-cedure. Eleven of 12 CxRs in patients withperforation were available for blind retrospec-tive review by two radiologists and an endo-scopist, these were interspersed with x raysfrom patients who had not perforated.Evidence of perforation was mediastinal gas(5), hydropneumothorax (1), pleural effusions(3), some CxRs had more than one abnor-mality. One of seven control CxRs was thoughtwrongly to show perforation. The endoscopistdiagnosed perforation in only four/ 1 patientsfrom the CxR.The post-procedure CxR may detect per-

foration after the treatment of malignantstrictures, particularly if reviewed by aradiologist. However, we now routinely under-take contrast studies immediately after dilata-tion or intubation of such strictures. Since nopatients with benign strictures incurred per-foration, CxR in this group seems redundant.

Prevalence of oesophagitis in subjects onlong term non-steroidal anti-inflammatorydrugs

J D ARNOLD, G L SWIFT, G T WILLIAMS, W EWILKINS, J S MORRIS, J RHODES (Departments ofGastroenterology and Pathology, UniversityHospital ofWales, Cardiff) Fifty patients (mean(SD) age 52 (14) years, 28 female) attending arheumatology clinic were investigated byupper gastrointestinal endoscopy and oesopha-geal biopsy. All had been taking indomethacinfor at least one year. Endoscopic and histo-logical findings were recorded and graded.

Oesophageal lesions were present in 10(20%). There were erythema in three, linearerosions in five, and deep ulcers in two. Gastricerosions were present in 13 and three hadgastric ulcers. Twelve patients had duodenalerythema and or erosions and one patient had aduodenal ulcer. Endoscopy was normal in 12subjects. Four with linear oesophageal erosionshad normal biopsy specimens on histology buteight others with normal oesophageal mucosaon endoscopy had inflammatory changes onhistological assessment. Four of the 10 subjectswith oesophageal lesions noted on endoscopyhad no gastric or oesophageal symptoms.Asymptomatic oesophageal disease is

common in patients receiving long term non-steroidal anti-inflammatory drugs.

Neuronal maturation in the myenteric plexusof human fetal and infant oesophagus

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R J I HITCHCOCK, A E BISHOP, J M POLAK(Department of Histochemistry, Royal Post-graduate Medical School, London) This studyprovides the first quantitative analysis of thematuration of neurons in the myenteric plexusof the human oesophagus. Oesophagealsamples (eight weeks gestational age to 28months of age (n=35)) were immunostainedfor general nerve, synaptic vesicle, glial andneuropeptide markers and histochemicallystained for NADH-diaphorase. Cell fre-quency, size, and the immunoreactivemyenteric fraction were computer quantified.

Neuronal size increased with gestational age

from 6 im at eight weeks to 20 im at term and21 ,tm at 28 weeks. The myenteric fraction andcell frequency peaked at 16-20 weeks and thenfell rapidly until the third trimester. The ratioof glial to nerve protein immunoreactivityincreased throughout. Immature neurons

expressed general nerve and synaptic vesicleprotein immunoreactivity by eight weeks.Neuropeptide immunoreactivity was not seen

until 13 weeks but an adult-like pattern was

complete by 15-5 weeks.Thus, we have shown that though neuronal

maturation continued during gestation, neuro-

peptide expression was complete and neuron

frequency maximal at the onset of fetalswallowing at 16 weeks. These findings formthe basis for an investigation of abnormalneuronal maturation in oesophageal atresia.

MOTILITY

Gastrointestinal transit, colonic capaci-tance, and possible mediators in carcinoiddiarrhoea

M CAMILLERI, G THOMFORDE, D MINSKE,M VASSALLO, S POWERS, L KVOLS (INTRODUCEDBY S PHILLIPS) (Mayo Clinic, GastroenterologyUnit, Rochester, MN 55905 USA) The patho-physiology ofcarcinoid diarrhoea (CD) remainsunclear. Our aims were to study gut motorfunction in CD and the effects of putativemediators on gastrointestinal transit in rats. Infour unoperated patients with severe carcinoiddiarrhoea and 10 healthy controls, we

measured gastric emptying (GE) and smallbowel transit (SBT) by ""Tc labelled 1 mmpellets in a meal, and colonic transit by "'Inlabelled pellets from a delayed release capsule.Capacitance of the combined ascending andtransverse regions (proximal colon, PC) was

calculated (Gut 1990; 31: 443-9). In anesthe-tised rats, we measured the dose relatedeffects on combined GE and SBT of 'n'Tcsaline by the putative mediators, scrotonin(5HT), and substance P (SP), motilin andsaline (controls), and plasma from one

patient (normal plasma SP and urinary5HIAA) and one healthy control. In separatestudies the effects of 5HT, motilin, andplasma on GE in the rat were assessed bydynamic scintigraphy.The results showed that: (1) In CD, PC

emptying and overall colonic transit were

considerably accelerated (p<005); SBTshowed a similar trend (p=0-.07); GE was

normal. (2) Mean (SEM) PC volume was

lower in CD (793 (63) ml) than in health (1324(162) ml; p=0.01). (3) In rats, intra-aortic5HT and patient plasma accelerated GE(p<005); motilin and control plasma did not.Motilin and patient plasma accelerated com-

bined GE and SBT (p<005); 5HT, SP andcontrol plasma were ineffective.

We conclude that in CD, small bowel andcolonic transit are considerably accelerated,and PC capacitance is reduced. Patientplasma accelerates GE and SBT in rats; therat bioassay is a promising method toelucidate the bioactive mediator(s) of CD.

Measurement of orocaccal transit time by anew ferromagnetic technique

R B OLIVEIRA, J R MIRANDA, 0 BAFFA,N M MATSUDA, L E A TRONCON (INTRODUCED BYD G THOMPSON) (Faculdade de Medicina deRibeirao Preto, Universidade de Sao Paulo,Ribeirao Preto, SP, Brazil) Current methodsfor measurement of oracaecal transit time(OCTT) have some limitations, such as failureto produce hydrogen (H2) after non-absorbedsugars have reached the colon or exposure toradiation. We therefore investigated thevalidity of a new non-invasive ferromagnetictechnique for measuring OCTT and to detectabnormally rapid OCTT in patients. Experi-ments were carried out in 21 healthy controlvolunteers and in a group of 11 patients withdiarrhoea caused by gastric or small boweldisorders. After an overnight fast, a standardtest meal containing 5 g ofmagnesium ferrite asa magnetic tracer and 18 g of lactulose wasingested. The arrival of the magnetic tracer tothe caecum was monitored with a magneticdetector probe externally applied to the rightiliac fossa and end expiratory breath sampleswere taken up to three hours after meal inges-tion for H2 measurements. Values obtainedwith the ferromagnetic technique were closelycorrelated with those observed with the H2breath test (R=0-74, p<0-001). In the group ofpatients with diarrhoea, OCTT values werefaster than in controls either when measuredwith the magnetic technique (median: range;45:10-125 minutes v 84:40-155 minutes,p<0-01) or with the H2 breath test (42.5:30-95minutes v 80:40-120 minutes, p=0.02).

In conclusion, this study suggests that theferromagnetic technique can reliably measureorocaecal transit time and is effective to detectabnormally rapid upper gastrointestinal transit.

Return of colonic motility after sigmoidcolectomy using an ambulatory technique

J P ROBERTS, M BENSON, W W WOODS,J R ROGERS, N S WILLIAMS (Surgical Unit, TheRoyal London Hospital, London) Colonic motoractivity in the postoperative period has beenpoorly investigated. To determine the effect ofcolonic resection on pressure activity, sixpatients undergoing sigmoid colectomy andprimary anastomosis were studied using a threechannel microtransducer probe (CTO-3,Gaeltec Ltd) positioned across the anastomosisand connected to a solid state recorder (Gaeltec7MPR). Anaesthetic agents and postoperativeanalgesia were standardised. Probe positionwas verified radiologically. Traces wereanalysed quantitatively, by automated com-puter analysis, and qualitatively.

Colonic pressure was measured continuouslyin each case for 85-108 hours. There wasabsence of activity > 10 cm H20 for a variableperiod (median 25, range 14-66 hours) aftersurgery. The motility index (MI=mean ampli-tudex% duration activity) increased signifi-cantly by the third postoperative day comparedwith the first (median 1-4 range 0-05-14-8, v0-38, 0-7.3, p<0-01*), but there was a persis-tent loss of normal diurnal variation. Motor

activity comprised complexes of 11-2+1minutes (mean+SEM) duration with a fre-quency of 3-4/minute, and amplitude mostly<60 cm H20. This uncoordinated activityoccurred with equal frequency in channelsproximal and distal to the anastomosis. Thereturn of bowel sounds was not associated withchange in activity. However, the first passageof flatus corresponded to the appearance ofaboral migrating complexes (3-2 cm/second) infive patients.

Colonic ileus after colectomy may persist for60-110 hours. The transanastomotic pressuregradient rarely exceeds 50 cm H20 during thistime. Passage of flatus corresponds to thereturn to propagating activity.

*Wilcoxon rank.

Measurement ofthe human gastric relaxationresponses to distension and to feeding

N K AHLUWALIA, D G THOMPSON, L TRONCON,J BARLOW, L HEGGIE (University Department ofMedicine, Hope Hospital, Salford) Althoughreceptive gastric relaxation to food is wellrecognised, methodological difficulties haveprecluded its accurate measurement in manand the factors modulating the response remainpoorly understood. We therefore developed acomputerised pressure/volume sensor deviceattached to a 1200 ml balloon sited in thefundus to measure compliance (pressure/volume) responses to graded gastric distensionduring fasting and after food.

After an overnight fast 15 healthy volunteersingested the assembly and the balloon waspositioned in the fundus. Intrafundal pressurewas recorded for 30 ml stepwise inflations ofthe balloon from 0 ml to the maximal toleratedvolume and compliance was measured by cal-culating the slope (x 10 ') of the log trans-formed pressure/volume relationship. Threeconsecutive inflations were performed duringfasting plus a further inflation after ingestion ofa 250 ml, 250 kcal standard liquid meal. Sevenindividuals repeated the study on a separateday to assess reproducibility of the method.Fasting studies showed that the slope of theinitial inflation curve was mean 114-6 (SEM)(10-0) mmHg/ml. On the second pre-mealdistension, the slope decreased to 83 0 (5.4)(p<0-01 v first) indicating distension inducedfundal relaxation. No further change in com-pliance occurred during subsequent pre-mealdistensions (slope: 79-8 (5.7); p>0 05 vsecond). Feeding further decreased the slope ofthe pressure/volume curve to 60-27 (7.7)mm Hg/mI (p<0 05 v pre-meal) indicating afurther increase in fundal compliance. Repeatstudies showed that the slopes of the threefasting compliance curves were similar to theinitial values (95.29 (16-3), 82-14 (18-4), 81-0(16-2), p>0 05; coefficient of variation= 14%).

In conclusion, increasing distension of thehuman fundus induces a progressive and repro-ducible relaxation response which is modulatedby distension itselfand by food, both serving toincrease gastric accommodation for a givennutrient load.

The response of the human migrating motorcomplex to fasting gas and secretion

D SMITH, B WALDRON, F C CAMPBELL (Depart-ment ofSurgery, Ninewells Hospital and MedicalSchool, Dundee) The interaction of the phasesof the migrating motor complex (MMC) andintraluminal gas and acaloric secretion is un-

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known. In this study small bowel perfused tubemanometry was carried out in 17 volunteersover four separate three hour intervals each:(i) in the baseline fasting state (BL); (ii) aftertotal gas and fluid evacuation (TGFE) from theentire upper gastrointestinal tract through aperforated orocaecal tube; (iii) after intagastricinstillation of gas (IIG) (350 ml air); (iv) afterintagastric instillation of fluid (IIF) (350 mlacaloric 0.5% methylcellulose solution).

All studies showed fasting motility patterns.TGFE decreased phase II duration (median(interquartile range) 37.9 (30 4 40) minutes(TGFE) v 54-7 (35-1-67-3) minutes (BL),p=0O03) and contraction amplitude (mean(SEM) 16-7 (0.4) mm Hg (TGFE) v 18-5 (0.4)mm Hg (BL), p<0-001). Phase III contractionfrequency was decreased (median (inter-quartile range) 7-72 (6-99-9 3) (TGFE) v 10-07(9-66-10-96), p<0 005). Conversely, IIG in-creased both the duration (median (inter-quartile range) 67-3 (604-71-8) minutes (IIG)v 54.7 (35-1-67-3) minutes (BL), p<0 02) andthe contraction amplitude during phase II(mean (SEM) (0.3) mm Hg (IIG) v 17.6 (0.3)mm Hg (BL), p<0-001). Phase I duration wasdecreased (median (interquartile range) 27-6(25A4-33 3) minutes (IIG) v 37-7 (26.9-56 7)minutes (BL), p<0O05). Phase III contractionfrequency was increased by IIG (median (inter-quartile range) 9-88 (9-16-10-67) v 9 3 (8-18-9 72) (BL), p<0O04). IIF increased phase IIcontraction amplitude (mean (SEM) 20-3 (0.3)mm Hg (IIF) v 17-6 (0.3) mm Hg (BL),p<0-001), but not duration (median (inter-quartile range) 58.6 (56-69 4) minutes (IIF) v54.7 (35- 1-67-3) minutes (BL), p=NS).The phases ofthe MMC appear responsive to

alteration in fasting gut content and may con-tribute to differential transit of gas and fluid inthe fasting state.

Development and validation of a micro-computer technique for analysis of gastricand small bowel manometry (fasting and fedstate)

D SMITH, B WALDRON, B E STOREY, M LOUDON,F C CAMPBELL (Departments of Surgery andPhysics, Ninezvells Hospital andMedical School,Dundee) Manual analysis of motility is toolaborious for routine clinical use. Previouscomputerised methods have lacked facilitiesfor artifact exclusion, pattern recognition forthe migrating motor complex (MCC), andvalidation. This study has developed a newmicrocomputer technique with these features,and validated it in 24 hour ambulatory studiesof gastric, duodenal, and jejunal motility in sixvolunteers, against two assessments by twoskilled observers.No significant differences* were found

between microcomputer (Comp) and observer(Obs) analysis in detection of cough artifact,gastric MMC, duodenal MMC, and MMCmigration velocity. Interobserver differencesin contraction detection during 3x 30 minuteintervals were found (p<005),* whereas nodifference was observed between microcom-puter (total contractions; n=470) and the meanofboth observers (total contractions; n=457).*There was no significant difference* in mean(SEM) contraction amplitude (Comp=36 (2)mm Hg; Obs 1=37 (2) mm Hg and Obs2=37-7 (2) mm Hg); contraction duration(Comp= 3-4 (0O1) secs; Obs 1=3.3 (0-1) secs,and Obs 2=2-8 (0- 1) secs) or contractionpropagation (Comp: n=41; Obs 1:n=39 andObs 2:n=39) were found.

This novel technique provides an accurate

automated method for measurement of gastricand small bowel motor physiology.*ANOVA, two way analysis of variance.

Comparison of a perfused catheter and astrain gauge assembly in pharyngo-oesopha-geal pressure measurement

J A WILSON, A PRYDE, C C A MACINTYRE,R C HEADING (Departments ofSurgery, Medicineand Medical Statistics Unit, University ofEdin-burgh) Finebore strain gauge assemblies (SGA)are now available for manometric investigationand are increasingly used for pressure measure-ment in the pharynx and upper oesophagealsphincter (UOS). Other centres continue to useconventional perfused catheters, and themeasurement differences between the twocatheter types are unknown. We studied 21patients, 9 males, 12 females, aged 25-81 years(mean=56) with cervical symptoms (globus,dysphagia, hoarseness) using multiple radiallyorientated sensors of both a 4-8 mm perfusedcatheter (Arndorfer) and a 2-8 mm SGA(Gaeltec) linked to a GR800 computer recorder(Aspen Medical).The results showed lower LOS RPT

(p<005) and oesophageal body pressures(p<002) with the SGA than the perfusedcatheter (Student's t test). UOS RPT and SPTpressures were also lower with the SGA by anaverage of 30mm Hg (both p<0-001), pharyn-geal pressures were considerably lower with theArndorfer (4+19 mm Hg) than the SGA(96±50mm Hg, p<0-001).

In conclusion, the recording of pressuresconsistently lower in the LOS and oesophagealbody with the SGA than the perfused catheteris probably due to the smaller stretch/tensionresponse induced by the narrower SGAdiameter (2-8 mm). This response seems to begreater in the striated muscle of the UOS. Incontrast, SGA recorded pharyngeal pressureswere significantly higher, confirming thegreater ability of strain gauges to capture thesteep upstroke (AP/At) pharyngeal waves.Laboratories which introduce an SGA mustestablish normal reference ranges appropriateto the catheter diameter and transducercharacteristics.

Proximal small bowel motility is preserved inthe postoperative ileus: fact or fiction?

M J BENSON, J ROBERTS, J ROGERS, W WOODS,N S WILLIAMS, D LWINGATE (GI Science ResearchUnit and Surgical Unit, The Royal LondonHospital Medical College, London) Electromyo-graphic data suggest that primate proximalsmall bowel (PSB) contractility is not abolishedin postoperative ileus (POI). Using prolongedintraluminal manometry, we wished to docu-ment local and propagated phasic pressurechanges in the PSB during POI after majorintra-abdominal surgery. We studied six sub-jects (three M/three F; age 49-77 years) under-going sigmoid colectomy. Premedication,anaesthetic, and postoperative opioid analgesiawere standardised. At operation, a three-sensornasojejunal manometric catheter was intro-duced to locate the transducers in the proximaland distal duodenum and jejunum; its positionwas checked radiologically at the beginningand end of the study. Recording continuedfrom 30 minute after wound closure until thepassage of flatus.The mean duration of recording was 97-6

hours (range: 84-108). Phase III activity was

present within three hours in all patients. Themigrating motor complex (MMC) interval wasmarkedly reduced for the first 24 hours (mean(SEM) 27-8 minutes (3 0)) but tended to nor-malise with time. Phase II activity returnedafter a mean of 49-4 hours (range: 35-60).Phase III mean amplitude was decreased (- 10mm Hg) or absent in distal duodenum andjejunum in five of six patients for 29-6 hours(range 16-54-2). There was no correlationbetween the return of bowel sounds andchanges in PSB motility patterns.The disparity between EMG and pressure

data suggests that the SB motor 'programme' ispreserved but ineffective during POI. The lowamplitude of the pressure changes at the distalsensors suggests that contractile forces may bedissipated by luminal distension.

Oral and intravenous erythromycin has noeffect on distal human colonic motility

J S JAMESON, J ROGERS, A H RAIMUNDO,M M HENRY, J J MISIEWICZ (Department ofGastroenterology and Nutrition, Central Middle-sex Hospital, London) Motilin receptors in thelower oesophageal sphincter, stomach, gallbladder, and small bowel are stimulated byerythromycin and motilin infused at physio-logical concentrations increases colonicpressure activity. Erythromycin decreasescolonic transit time in humans, but its effect oncolonic segmental pressure activity is un-known.

Eight male volunteers were studied on twooccasions, receiving either 125 mg iv or 500 mgoral erythromycin, or placebo in a single blindrandomised crossover design. Sigmoidpressures were recorded with a four lumenwater perfused assembly at 50, 45, 30, and15 cm from the anal verge. Pressures wereanalysed for activity index (Al, mm Hg/minute) for the 35 cm colonic study segment.No significant (MANOVA) difference wasfound in the Als after erythromycin (mean(SEM) 498 (43) mm Hg/minute v 765 (44),basal) and placebo (588 (39) v 641 (21) givenorally, or after erythromycin (846 (67) v 1091(116) and placebo (1135 (57) v 739 (18) givenintravenously. In a further experiment onesubject was given increasing doses of iverythromycin (125 mg, 250 mg, and 500 mg)without change in colonic Al. (125 mg: 646(297) v 722 (195), basal; 250 mg: 950 (205) v936 (243); 500 mg: 863 (154) v 660 (322)).

Despite using doses known to affect smallbowel and gall bladder motility, neither oral norintravenous erythromycin affected segmentalcolonic pressure in the unprepared sigmoidcolon. These data suggest that motilinreceptors are not stimulated by erythromycinin the human sigmoid colon and previouslyreported effects of erythromycin on colonictransit may be secondary to changes in smallintestinal or proximal colonic function.

Irritable bowel syndrome and affective dis-order: a family history

P A DEWSNAP, G W LIBBY, M J G FARTHING(Department of GastroenteroloV, St Bar-tholomew's Hospital, London) A random sampleof 33 outpatients with a clinical diagnosis ofirritable bowel syndrome (IBS) were evaluatedby questionnaire for gastrointestinal (GI)symptoms including the Manning criteria anddiscriminatory symptoms of affective disorderas defined by the Research Diagnostic Criteria

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(RDC). In addition, a detailed family history ofGI and affective symptoms among their 145first degree relatives was taken. Where possible,this family history was supplemented by in-formation obtained directly from the relativesby a similar questionnaire. Twenty five of the33 probands (75%) met RDC criteria foraffective disorder, mainly major depression(54%). There was evidence for a family historyof IBS in 45% of probands. However, IBSoccurred in 22 of the 145 relatives (15%),comparable with that in the general population.A family history of major depression was foundin 19 of the 33 probands (57%) with a preva-lence among relatives of 19%. This is greaterthan in the general population (approximately10% lifetime prevalence) and of similar magni-tude to that found in family studies onpsychiatric patient populations.The results show that (i) there is an apparent

tendency for IBS to run in families which isexplained by the high population prevalence ofIBS, (ii) the high prevalence of depression infamily members suggests that the affectivediagnoses in IBS probands are genuine cases ofaffective disorder rather than normal reactionsto physical symptoms, but, (iii) there is noevidence to indicate that IBS and affectivedisorder reflect a common familial predis-position.

THERAPEUTICS

Bismuth pharmacokinetics in healthy malesubjects after twice daily oral dosing for10 days with ranitidine bismuth citrate,tri-potassium di-citrato bismuthate (De-Noltab), or placebo

L F LACEY, N M FRAZER, 0 N KEENE, J T L SMITH(INTRODUCED BY J MILLS) (Division of ClinicalPharmacology and Department of MedicalStatistics, Glaxo Group Research Ltd, Greenford,Middlesex) Ranitidine bisriuth citrate (RBC) isa salt of ranitidine with a complex of bismuthand citric acid. A 10 day repeat dose random-ised double blind, parallel group, comparator,and placebo controlled study was conducted.There were four treatment groups, with 12subjects per group: RBC (500 mg bd), RCB(1000 mg bd), De-Noltab (240 mg bd), andplacebo. Blood and urine samples were

collected after the last (19th) dose. Plasma andurine bismuth concentrations were determinedusing a validated inductively coupled plasmamass spectrometry method.RBC was well tolerated and there were no

serious adverse events. After the last dose,geometric mean (range) bismuth Cn., for RBC(500 mg bd) was 5 (2-19) ng/g, for RBC (100mg bd) was 12 (4-42) ng/g, and for De-Noltab(240 mg bd) was 21 (7-247) ng/g. The corres-

ponding trough plasma concentrations were 2(1-5) ng/g, 4 (2-8) ng/g, and 4 (2-20) ng/g,respectively. The geometric mean AUC over adosing interval after the last dose were 34 (18-91) ng.h/g, 71 (27-192) ng.h/g, and 79 (33-436)ng.h/g, respectively. The correspondingbismuth urinary recoveries (AeT) over thedosing interval were 97 (62-208 ig, 227 (90-990) jig, and 309 (137-1614) itg, respectively.When normalised for dose, Cmax and AeT were

significantly higher (p<005) and Cmax dis-played a greater degree of intersubject vari-ability with De-Noltab than with RBC.

In conclusion, twice daily dosing with RBCfor 10 days was safe and well tolerated and

resulted in plasma bismuth concentrations thatwere below the 'alert' threshold of 50 ng/g.

Is high dose balsalazide better than sulpha-salazine in initial management of ulcerativecolitis?

J C MANSFIELD, M H GIAFFER, P A CANN, C DHOLDSWORTH, D M McKENNA, P C THORNTON(Royal Hallamshire, Sheffield, MiddlesbroughGeneral Hospital, Middlesbrough, and BiorexLaboratories Ltd, Enfield) We have comparedbalsalazide (BSZ) 6-75 g/day and sulphasala-zine (SASP) 3 g/day in a double blind random-ised trial in 37 patients with newly diagnosedulcerative colitis (UC). Patients were notallowed steroids and were reviewed at two,four, and eight weeks. Sigmoidoscopic appear-ances, rectal biopsy specimens, and symptomand stool diary records were used to assessresponse between entry and eight weeks. Thegroups were well matched for age and sexdistribution.

Intolerance to therapy, necessitating with-drawal, was seen in one of 20 patients on BSZ(rash) and in eight of 17 patients on SASP(three nausea, three severe headaches, onerash, one pancreatitis) (p=0-02 Fisher's exacttest). Clinical deterioration of the colitis led towithdrawal and treatment with steroids in twopatients on BSZ and three patients on SASP(NS). Assessment of the patients who com-pleted eight weeks' treatment (BSZ 17patients, SASP six patients) shows similarimprovements in stool frequency, percentagesof unformed and bloody stools, as well asimprovements in sigmoidoscopic and histo-logical appearances in both groups.

In conclusion, high dose BSZ is bettertolerated than SASP and thus more successfulin the initial management of UC.

Improved maintenance of remission in ulcer-ative colitis by balsalazide 4 g/day comparedwith 2 g/day

M H GIAFFER, C D HOLDSWORTH, J E LENNARD-JONES, C A RODRIGUES, P B McINTYRE, SMANJUNATHA, J H BARON, I G BARRISON, R JPOLSON, A M HOARE, G S R DAVIES, P C THORNTON(Royal Hallamshire, Sheffield, St Mark'sHospital, London, Queen Elizabeth II Hospital,Welwyn, St Mary's Hospital, London, WycombeGeneral Hospital, and Biorex Laboratories Ltd,Enfield) Maintenance ofremission in ulcerativecolitis by sulphasalazine is dose related, butdosage increase is limited by side effects.Balsalazide 2 g/day is as effective as sulphasala-zine at the same dose for remission mainten-ance treatment and this drug is usually welltolerated in high dosage. We therefore com-pared in 133 patients with ulcerative colitis inremission treated with balsalazide 2 g/day (n=65) and balsalazide 4 g/day (n=68) with regularreview over one year.

Relapse was significantly more common onthe 2 g dose (53%) than on the 4 g dose (36%)p<0 01. Six patients (9%) were withdrawnbecause of intolerance at 2 g/day (three dys-pepsia, two diarrhoea, one constipation) andnine (13%) at 4 g/day (four diarrhoea, twonausea, two flatulence, one epigastric pain).We conclude that balsalazide 4 g/day is

superior to 2 g/day for remission maintenancetreatment in ulcerative colitis, resulting in arelapse rate very similar to that in another studyusing 3 or 6 g/day but with adverse reactionsmore frequent in the present study.

High dose balsalazide compared withsulphasalazine in the treatment of acuterelapse in ulcerative colitis

J R B GREEN, C H J SWAN, A E ROWLINSON, J AGIBSON, P BROWN, G D KERR, P C THORNTON(City General Hospital, Stoke-on-Trent, StaffordGeneral Infirmary, Shrewsbury Hospital, TelfordHospital, Biorex Laboratories) Balsalazide(BSZ) is a sulphasalazine (SASP) analogue andhas been shown to be well tolerated in high dosefor 12 months (Green, et al 1990). It may bethat the delivery of a higher concentration of 5-ASA to the colonic mucosa in acutely relapsedulcerative colitis (UC) will increase the ease andrapidity of achievement of remission. In aprospective double blind trial, 40 patients witheither acute relapse or first presentation of UCwere randomised to receive either SASP 3g/day or BSZ 6 g/day. Severity of relapse wasstratified into mild (no steroid needed),moderate (topical steroid needed), or severe(systemic steroid needed) to ensure two com-parable patient groups. Patients underwentsigmoidoscopy at four, eight, and 12 weeks toassess progress.

Seventeen of 22 patients (77%) who receivedBSZ were in remission at 12 weeks comparedwith 11 of 18 (61%) on SASP (NS). Fivepatients (29%) on SASP were withdrawn fromthe study due to intolerance compared withnone on BSZ (p=0-021 Fisher's exact test).

This study shows that high dose balsalazideis not only an effective therapy for acutelyrelapsed UC, but is also better tolerated thansulphasalazine in these patients.

Review of non-steroidal anti-inflammatorydrugs in general practice

G L SWIFT, J RHODES (University Hospital ofWales, Cardiff) Patients, many of whom areelderly, may receive non-steroidal anti-inflammatory drugs (NSAIDs) for long periodsand in general practice 'repeated prescriptions'may be obtained without a consultation. In ageneral practice with 12 000 patients we haveidentified 315 patients with repeat prescriptioncards which listed at least one NSAID oraspirin in anti-inflammatory dosage. Onehundred and forty one of these also listed drugsfor conditions sometimes made worse byNSAIDs (eg heart failure, hypertension,asthma), and 15 listed drugs with which inter-actions with NSAIDs may occur (eg anti-coagulants, sulphonylureas, anti-convulsants).Thirty eight randomly selected patients (age27-81 years) with non-rheumatic conditions,taking long term NSAIDs (range three monthsto 17 years) agreed to try an alternativeanalgesic - paracetamol, codydramol,coproxamol, or cocodamol. After one month,22 had very satisfactory pain relief withoutNSAID; 16 had resumed therapy but four weretaking reduced dosage. After four months, 25of the 38 had stopped their NSAIDs (includingone after haemorrhage from a peptic ulcer) andtwo others were well on reduced dosage.

In conclusion, patients' requirements forNSAIDs should be reviewed regularly; thosewith non-rheumatoid conditions may findequivalent pain relief from safer, cheaper,alternative analgesics.

Role of 5-hydroxytryptamine (5-HT) type 3receptors in cholera toxin induced secretion

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J A DIAS, F H MOURAD, M J G FARTHING (Depart-ment of Gastroenterology, St Bartholomew'sHospital, London) Intestinal secretion inducedby cholera is classically attributed solely to theactivation of the adenyl cyclase complex andincrease in intracellular cAMP. However,accumulating evidence suggests that theintestinal secretagogue 5-HT may contribute tothe secretory process via its action on 5-HT2and 5-HT3 receptors.We have examined this hypothesis by study-

ing the effect of a highly selective 5-HT3receptor antagonist on intestinal water move-ment in cholera toxin (CT) induced secretion.Adult male Wistar rats were injected sc withthe 5-HT3 receptor antagonist (BRL43694/Granisetron) 30 or 300 jig/kg, two hours beforeinstillation of 75 jig CT for two hours inisolated small intestine. In situ jejunoilealperfusion was then performed with plasmaelectrolyte solution (Na 140, K 4, Cl 104,HCO3 40 mmol/l) to assess water and sodiumtransport.CT induced net water secretion (median,

-50.1 Rl/min/g (interquartile range -59.5 to-29.8)). Prior treatment with BRL43694 30tg/kg reduced the secretory state (-13-5(-43- 1 to - 8.7); p<0 03) while at 300 jig/kg itwas reversed to net absorption (21-8 (14-7 to21-2); p<0 02). Net sodium and chloridemovement followed water movement.BRL43694 300 ig/kg had no effect on basalnet water and sodium movement in normal ratsmall intestine.Our findings provide further evidence that 5-

HT is involved in CT mediated secretion andimply that inhibition at 5-HT3 receptors alonecan prevent CT induced secretion.

COLORECTAL

Ultrastructural appearances of the pelvicileal reservoir mucosa

D L BRUCE, B F WARREN, P DURDEY, M LUCKETT,N A SHEPHERD (Departments of Histopathologyand Surgery, Bristol Royal Infirmary and Depart-ment of Histopathology, Gloucestershire RoyalHospital) The pelvic ileal reservoir hasimproved the lifestyle of patients with ulcera-tive colitis and familial adenomatous polyposis.With time and in relation to episodes ofinflammation, pelvic ileal reservoirs mayundergo colonic metaplasia, changing fromvillous small bowel mucosa to flat pouchmucosa with a variable chronic inflammatorycell infiltrate. There have been no detailedelectron microscopical studies of the pelvic ilealreservoir mucosa. In this study, we haveexamined mucosa from a resected pouch andfive pouch biopsy specimens in individualswith and without pouchitis. The ultrastruc-tural changes seen include villous flatteningand the appearance of basal bodies adjacent tothe microvilli, both of these being features ofnormal colonic mucosa, and adding furtherweight to the concept of colonic metaplasia inpouch mucosa. In distinct contrast to pouchesshowing only chronic inflammation, thereservoirs with pouchitis have almost completeabsence of microvilli. This may well accountfor much of the symptomatology of this idio-pathic relapsing condition of the reservoir.Our studies provide further evidence that

pouch mucosa acquires some of the character-istics of colonic mucosa and that pouchitis hasmany clinicopathological similarities to ulcera-tive colitis.

Is radioimmunolocalisation a feasible tech-nique for the intraoperative detection ofintra-peritoneal deposits of colorectalcancer?

J W DAWSON, W WADDINGTON, F SAVAGE, W HU,C DEAN, P B BOULOS (Departments ofSurgery andNuclear Medicine, University College, Londonand Institute Cancer Research, Sutton, Surrey)Radioimmunolocalisation (RIL) has beenstrongly advocated as a method for the peri-operative detection of subclinical colorectalcancer. The monoclonal antibody (MAb)'B723' labelled with '25Iodine, is claimed tosupercede other radiolabelled MAbs because ofit's specificity for tumour and low backgroundradioactivity. Clinical and immunohisto-chemical studies were performed on 28 patientsundergoing resection for colorectal cancer todetermine whether sensitivity and specificity ofthe technique were altered by either the isotopeor MAb.

Patients were injected with the MAb 'ICR2'labelled with 100 MBq of either "'Indium or125Iodine and probed at laparotomy, three days( 1 'Indium) or 10 days (125Iodine) later. A ratioof counts from tumour:normal colon (T/NC)was obtained. Immunohistochemistry wasthen performed on each cancer, comparingB72-3 with ICR2. T/NC ratios did not differsignificantly ("'1Indium, median 1-66, range0.9-2.13:125Iodine, median 1-75, range 1 1-5.8). Immunohistochemical staining of allcancers using B72-3 was no more specific totumour than ICR2.We conclude that probing is not impaired by

using a high energy radionuclide; detection oftumour is determined by the specificity ofMAbfor tumour. Immunohistochemistry ofB72-3 isno more specific to colorectal cancer than ICR2and we remain sceptical of results achievedelsewhere.

Likelihood of recurrence after an acutecomplication of diverticular disease

S SARIN, P B BOULOS (Department of Surgery,University College and Middlesex School ofMedicine, The Rayne Institute, London) Becausethe risk of further complications after eitherconservative or surgical treatment of an acutecomplication of diverticular disease is notdocumented, it is difficult to advise appropri-ately on the subsequent management. There-fore, all patients admitted with diverticulitis,haemorrhage, or peritonitis between 1980 and1987 were reviewed and prospectively followedup for a median of 48 months (interquartilerange of 30-65). The main outcome measureswere hospital readmission with further compli-cations and survival.Some 72 of 86 patients (84%) with diverti-

culitis responded to antimicrobial drugs andintravenous therapy with a readmission rate of2% per patient year. With haemorrhage, 10 of37 (27%) required a median blood transfusionof 4 (IQR 2-6) with no mortality and there wasa readmission rate of 5% per patient year.Patients who required staged colonic resectionand anastomosis for peritonitis, obstruction, orfor diverticulitis which failed medical treat-ment had a total inpatient mortality of 12% andno further readmissions. The long termsurvival rates of those who had surgery andthose treated conservatively were the same.The indications for emergency surgery

therefore should be strictly defined as there is ahigh mortality, although the risk of further

complications is eliminated. Conservativetreatment is a safe option in most instances,with a low risk offurther complications, so thatwe do not recommend elective resection afterrecovery from an acute attack.

Anti-neutrophil cytoplasmic autoantibodiesdirected against cathepsin G in sera frompatients with inflammatory bowel disease

D REUMAUX, J F COLOMBEL, A CORTOT, L H NOEL,P LESAVRE, P DUTHILLEUL (Laboratoired'H4fmatologie-Immunologie, CH Valenciennes,Clinique des Maladies de l'Appareil Digestif,CHU Lille, INSERM U 90, and Departementde Nephrologie, Hopital Necker, Paris, France)Anti-neutrophil cytoplasmic autoantibodies(ANCA) are present in sera from patients withinflammatory bowel disease (IBD). Our pre-liminary results suggested that ANCA could bedirected against cathepsin G (a constituent ofneutrophil primary granules) in IBD. The aimof the study was to assess the specificity andsensitivity of ANCA and of ANCA directedagainst cathepsin G for ulcerative colitis (UC)among patients with IBD. Sixty healthy con-trols, 119 patients with Crohn's disease (CD)(52 men, 67 women, mean age 30 years (50 withactive and 69 quiescent disease)), 53 patientswith UC (24 men, 29 women, mean age 33years (34 with active and 19 quiescent disease;7 proctitis, 19 left sided, 14 pancolitis, and 13colectomised)) were studied. IgG ANCA wereinvestigated using an indirect immunofluore-scence technique on ethanol fixed leukocytes.The cytoplasmic (c-ANCA) and perinuclear(p-ANCA) patterns were determined. Thepresence of anti-cathepsin G antibodies wastested by ELISA (positive values: >4 SD abovethe mean for controls).Among patients with IBD, the presence of

p-ANCA and of ANCA directed againstcathepsin G was 93% and 91% specific and 43%and 47% sensitive for UC respectively.The UC associated p-ANCA has a high

degree of specificity. The presence of ANCAdirected against cathepsin G in 47% of patientswith UC suggests that cathepsin G is a majortarget antigen for ANCA in UC.

Tuberous sclerosis is a common cause ofmultiple rectal polyps

S R GOULD, J B STEWART, L N TEMPLE (EpsomGeneral Hospital, Epsom, Surrey) Tuberoussclerosis (TS) is associated with epilepsy,mental retardation, and a variety of otherstigmata but rarely with clinically recognisedgastrointestinal manifestations. Fifteenpatients with TS were examined to determinethe incidence of rectal polyposis. All under-went sigmoidoscopy; 10 patients were alsoexamined by colonoscopy. Eleven of 15patients (73%) had rectal polyps. The polypscould be detected by careful rectal examinationin five patients. These polyps were asympto-matic. They were small (3-4 mm), usuallysessile, and frequently multiple. They weretypically of maximal density just above theanorectal junction, often in clusters, and some-times confluent. Their appearance was fre-quently sufficiently distinctive to differentiatethem from other types of rectal polyp. In onepatient presenting with irritable bowel syn-drome the presence of these polyps pointed tothe diagnosis of unsuspected TS. Histology

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indicated that these polyps were micro-hamartomata; adenomatous or malignantchanges were not seen.

In the population studied, characteristicrectal polyps were common and may be apreviously unrecognised and useful marker ofTS.

Microscopic colitis: a diagnosis to consider

S HAMID, W JAFRI, T QASEEM, H SHEIKH, AHUSSAINY, H KHAN (INTRODUCED BY P I REED)(Depdrtments of Medicine and Pathology,The Aga Khan University Hospital, Karachi,Pakistan) Microscopic colitis is a clinicalsyndrome of chronic watery diarrhoea forwhich no cause can be identified other than thepresence of diffuse, chronic, mild inflamma-tion in the lamina propria seen on colonicbiopsy specimen. Endoscopically and radio-logically the colon looks normal. We retro-spectively studied case records of 215 patientspresenting to our institution over a three yearperiod with chronic diarrhoea. Twenty fivepatients were identified in whom the onlyabnormality found on extensive investigationswas chronic inflammation on colonic biopsyspecimens. Ofthese, 19 patients were includedin the study where two pathologists indepen-dently agreed on the presence of inflammation.All patients had watery diarrhoea withurgency, and 63% had considerable nocturnalsymptoms. Mean frequency of motions was 6per day. Investigations showed normal stoolexaminations on multiple occasions. Labora-tory indices were normal in all patients, as werebarium enemas and small bowel enemas.Colonoscopy was normal in all, but multiplecolonic biopsy specimens showed infiltration oflamina propria with chronic inflammatorycells. A variety ofdrugs were used to treat thesepatients - eg mebeverine, ispaghula, metro-nidazole, loperamide, etc - with little benefit.A significant improvement was noted in onepatient given salazopyrine.

In developing countries, chronic diarrhoea ismost often attributed to infection and treatedwith antibiotics. Microgcopic colitis should beconsidered in the diagnosis of such patients.

Epidermal growth factor stimulates rectalproliferation in familial adenomatouspolyposis

M G THOMAS, W J GULLICK, S TEBBUT, R C NWILLIAMSON (Department of Surgery, RoyalPostgraduate Medical School, HammersmithHospital, London) Enhanced expression of areceptor for epidermal growth factor (EGF) hasbeen shown in colorectal carcinoma cell lines.We have investigated the effect of EGF on theproliferation of premalignant rectal tissuemaintained in short term organ culture. Pairedrectal biopsy specimens were obtained from 22patients with familial adenomatous polyposis(FAP) and 18 normal control subjects todetermine the crypt cell production rate(CCPR), using vincristine induced metaphasearrest. In eight patients with FAP, tissue wascultured in the presence of EGF (10 ng/ml).The second biopsy specimen was examinedhistologically to exclude microadenomas andthen a rabbit polyclonal antibody to the EGF-RI domain was used to assess receptor expres-sion.CCPR in FAP was not significantly increased

over control values (mean (+SEM) 7-08 (1-37)v 4-92 (0 29) cell/crypt/hour). EGF doubled

CCPR from a control value (n=8) of 3-62 (0.59)to 7-33 (0 90) cells/crypt/hour (p<0.01). Thepresence of the EGF receptor was confirmedhistologically in each section. Hence, EGFincreases rectal epithelial proliferation in FAPand could help promote neoplastic change.

Vitamin D and its analogue MC-903 inhibitcell proliferation in human colorectal tissue

M G THOMAS, L BINDERUP, S TEBBUT, R C NWILLIAMSON (Departments of Surgery andBiology, Royal Postgraduate Medical School,Hammersmith Hospital, London and Departmentof Biology, Leo Pharmnaceuticals, Ballerup,Denmark) Like calcium, vitamin D mayprevent colonic cancer. We have investigatedthe action of vitamin D and its analogue MC-903 (which avoids hypercalcaemia) on the invitro proliferation of HT-29 cells and on rectalmucosa maintained in short term organculture. Paired sigmoidsosopic biopsy speci-mens were obtained from 17 control subjectsand five patients with familial adenomatouspolyposis (FAP). Explants were established inculture with or without the addition of vitaminD. Cell proliferation was assessed (1)stathmokinetically using metaphase arrest todetermine crypt cell production rate (CCPR)and (2) histochemically using the monoclonalantibody Ki-67. Vitamin D3 (1,25(0H)2D3) inconcentrations of 1 iM to 100 pM reducedCCPR (cells/crypt/hr) in control subjects from4-74 (control) to 2-15-2-67 (p<0001) and Ki-67 labelling index from 7-28 to 3.75 (p<00l).Likewise vitamin D2 (10) reduced CCPR from4-74 to 2-74 (p<0 05), and MC-903 (10-7 M)from 4.85 to 2-38 (p<0 05). In FAP patients,vitamin D3 (10OpM) halved CCPR from 8.75 to4-22. MC-903 inhibited the proliferation ofHT-29 cells by 99% at 10-5 and 10-6 M and92% at 10-7M (p<0O001).Thus vitamin D and its analogues inhibit

proliferation in normal and premalignant rectalepithelium and suppress growth in a colorectalcell line.

Assessment of functional hyposplenism ininflammatory bowel disease by pitted red cellcounts

A F MULLER, E CORNFORD, P J TOGHILL (Depart-ments of Medicine and Radiology, UniversityHospital, Nottingham) Functional hypo-splenism in inflammatory bowel disease is wellrecognised and may predispose patients toinfection or postoperative complications.Patients most at risk are those with a pancolitis.Phase interference microscopy has been usedto assess splenic function by measuring thenumber of pitted red cells, the pits represent-ing cellular debris normally removed by thespleen. Normal values are less than 2%. Thismethod is easier, quicker, and more convenientthan the traditional method of assessing spleenfunction by the clearance of isotopically label-led heated erythrocytes.The current study measured pitted red cell

counts (Zeiss) in 20 patients with ulcerativecolitis (15/20 with documented pancolitis) and15 patients with Crohn's disease. Ten normalcontrols and eight splenectomised patientswere also studied. Both spleen size (cm2,measured by ultrasound) and cell counts wereperformed double blind. Mean (SEM) pittedred cells in the volunteers was 0-6 (0.05)% andin the splenectomy group 39 (3)%. Threepatients with ulcerative colitis had pitted cell

counts greater than 2% (2-3, 4.5, 4.7%) andeach of these was studied in an acute relapse.All Crohn's disease patients had cell counts lessthan 2%. A relation was present between spleensize and pitted cell count for the patientswith inflammatory bowel disease (r= -0-73,p<O002).

This study confirms the presence offunctional hyposplenism in some patients withulcerative colitis. The measurement of pittedred cell counts using phase interference micro-scopy seems to reflect spleen volume.

Escherichia coli adhesion is not related toacute pouchitis

A J LOBO, P M SAGAR, J ROTHWELL, T RICHES, DJOHNSTON, A T R AXON (Gastroenterology Unitand University Department of Surgery, TheGeneral Infinnary, Leeds) Restorative procto-colectomy with pelvic ileal reservoir is a wellaccepted option for the surgical treatment ofulcerative colitis. Acute pouchitis is one of themost common complications of this procedureand bears a number of similarities to acuteulcerative colitis (UC). UC is associated withthe carriage of Escherichia coli with theproperty of adhesion to epithelial cells. Thehypothesis tested in this study is that acutepouchitis is associated with the carriage ofadhesive E coli.E coli isolated from stool samples from 24

patients (median age 34 years, range 16-64)who had undergone restorative proctocolec-tomy with pelvic ileal reservoir were examinedusing the buccal epithelial cell (BEC) adhesionassay. Patients were studied a median of 12months (7-21) after operation. Eight of 24patients had acute pouchitis at the time ofstudy. Adhesive E coli were detected in 9/24patients with an ileal reservoir compared with0/12 controls (p<005). The BEC adhesionindex was inversely related to the degree ofacute pouchitis (Rs=-0 46, P=0-024) and tothe functional outcome (Rs=-0 49, p=0.022). Carriage of adhesive E coli was notrelated to reservoir design.

In contrast to ulcerative colitis, acutepouchitis is not associated with the carriage ofadhesive E coli.

Colonic carbohydrate metabolism in familialadenomatous polyposis

D M BRADBURN, J C MATHERS, A GUNN, I D AJOHNSTON (Departments ofSurgery and Agricul-tural Biochemistry and Nutrition, MedicalSchool, University of Newcastle upon Tyne andAshington Hospital, Northumberland) Colorectalcancer is the second commonest cancer in thewestern world yet its aetiology is poorly under-stood. A high fibre diet is thought to beprotective, possibly through the production ofshort chain fatty acids (SCFA) from fermenta-tion of carbohydrates. Butyric acid, a SCFA, isanti-neoplastic in vitro, and lowered molarproportions have been found in faecal samplesfrom patients with colorectal cancer.

In order to test the hypothesis that dimin-ished production of butyric acid has a role inpolyp formation, the pattern of SCFA pro-duced by in vitro fermentation of stool sampleswith a variety of carbohydrates was tested.Samples were collected from controls, familialadenomatous polyposis (FAP) gene carrierswith no polyps, and FAP gene carriers withpolyps.Gene carriage had no effect on the SCFA

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pattern produced but the presence of polypscaused significantly less butyrate to be pro-duced (p<0-001) and significantly more acetate(p<0 001). The results suggest that the pre-viously observed changes in SCFA pattern aresecondary to neoplasia rather than a primarycause. Due to the interactions of carbohydrateand bile acid metabolism, the findings mayhave implications for the interpretation ofabnormal duodenal bile acid profiles incolorectal cancer patients and those with FAP.

Anastomotic cancer: do sutures matter?

J L McCUE, J P SHEFFIELD, C UFF, R K S PHILLIPS(StBartholomew's HospitalandICRF ColorectalUnit, St Mark's Hospital, London) Local recur-rence of colorectal cancer after resection maybe partially explained by enhanced anastomoticcarcinogenesis. This study employs a noveltechnique of 'sutureless' colonic anastomosisto explore the relative role of sutures andthe healing colonic wound in experimentalcolorectal carcinogenesis.One hundred and sixty six male F344 rats

received 12 consecutive weekly subcutaneousinjections of azoxymethane (AZM) (10 mg/kg!week). Either: (1) a sham procedure; or a 5 mmtransverse colotomy repaired with (2) fourinterrupted 5/0 sutures of either (a) silk,(b) polyglactin (Vicryl), or (c) stainless steel; or(3) a 'sutureless' technique were performed.Animals were killed 28 weeks after the firstdose of carcinogen.

Animals with anastomotic tumour werefound in 46% of the sham group, 41% of the'sutureless group', and 68% in the suturedgroup (p<005 cf sham, x2=44; p<0 02 cf'sutureless', X2 =635). The correspondingfigures for anastomotic cancer were 9%, 22%,and 38% (p<0 002 cf sham, Fisher's exacttest).No significant differences in tumour yield

were noted between silk, Vicryl and steel. Allsutures seem to enhance anastomotic tumourformation and we suggest that 'sutureless'anastomosis may diminish this risk.

Cellular proliferation at colonic anastomoses

J L McCURE, R K S PHILLIPS (St Bartholomew'sHospital, London) Enhanced anastomoticcarcinogenesis is well recognised experiment-ally and may be due to accelerated cellularproliferation. As cancer yield is enhanced bysuture materials, the influence of differentsutures in an anastomosis and also a suture-less closure on anastomotic crypt cell produc-tion rate (CCPR) were explored.

Eighty male F344 rats were used. A 5 mmtransverse colotomy was created which wasrepaired with (1) four interrupted 5/0 sutures ofsilk, stainless steel, or polyglactin 910 (Vicryl)or (2) a 'sutureless' closure. Five animals ineach group were killed after one week, onemonth, three months, or six months. CCPRwas assessed by the stathmokinetic technique.At each time interval the number of metaphasefigures in 20 crypts were counted and plottedagainst time. The CCPR was derived from theslope of the regression line.

In the sutured animals, anastomotic CCPRwas significantly greater than adjacentdescending colon CCPR for at least threemonths postoperatively. By contrast, there wasno significant elevation of the CCPR at thesutureless anastomosis compared with theadjacent colon at any time point.

We conclude, that sutures at an anastomosisenhance crypt cell production rate for at leastthree months. This may explain why moreexperimentally induced tumours are found atsutured compared to 'sutureless' colonicanastomoses.

GASTRODUODENAL

Value of 14C urea breath test and urease slidetest (CLO test) to diagnose Helicobacterpylon in uraemic patients

A M EL NUJUMI, P ROWE, C A DORRIAN, K E LMCCOLL (University Department ofMedicine andTherapeutics, Western Infirmary, Glasgow) Asthe diagnosis of Helicobacter pylori infectionis often based upon measurement of theorganism's metabolism of urea, we haveinvestigated the reliability of these tests in 16uraemic patients on maintenance dialysis treat-ment. Eight of them were confirmed to haveH pylon' infection on the basis of histologicalantral gastritis associated with H pylon' likeorganisms and positive serology and culture.The other eight patients had normal antralhistology and negative serology and culture.The mean (range) serum urea concentration inthe infected patients was 21 (12-31) mmol/lcompared with 23 (11-32) mmol/l in those notinfected. In each of the infected patients endo-scopic antral biopsy specimen was positiveusing the urease slide test (CLO test) at fivehours whereas it remained negative in each ofthe uninfected subjects at 24 hours. The 20minute values for the 14C urea breath test in theH pylon' positive patients ranged from 61-801(mean 204) kg percentage dose/mmol CO2 x100 and showed no overlap with the values fortheH pylori negative patients (01 1-8, mean 7)(p<0005).The breath test values in these uraemic

patients are similar to those in patients withnormal renal function in whom we take apositive test as greater than 40 and a negativetest as less than 20. This study indicates thaturaemia does not reduce the value of the ureaseslide test or 14C urea breath test in diagnosingH pylon infection.

Patient understanding of non-steroid anti-inflammatory drugs and ulcer complications:a need for improvement

G SALEEBY, C W HOWDEN, S HOLT (University ofSouth Carolina, Columbia, SC, USA) The linkbetween non-steroid anti-inflammatory drug(NSAID) use and complicated peptic ulcerdisease (CPUD) is known by doctors, butpatient understanding may be poor. We con-tacted 39 patients six to 12 months afterhospital discharge following CPUD related toNSAID use. All had been told to avoid furtheraspirin or NSAIDs but only 10 rememberedthe advice. Thirty five said they were not takingNSAIDs (three were); four said they were (twowere not). Recurrent problems were rarealthough one patient had had a furtherhaematemesis. Only 11 were taking any anti-ulcer medication. Nineteen were taking para-cetamol instead of NSAIDs; none had anyworsening of joint symptoms.Of 311 patients admitted with CPUD, 194

(62%) had been taking NSAIDs (comparedwith 19% of controls; p<0001). Of these 194,

85 (44%) obtained the NSAID over the counter(OTC). Some 16% of these were takingibuprofen and 84% were on various aspirinpreparations.There is much unnecessary NSAID pre-

scribing. Many patients can stop NSAIDswithout adversely affecting joint symptoms.Few have recurrent abdominal symptoms onceoff NSAIDs. Many patients with CPUD aretaking OTC aspirin or NSAIDs (often incombination). The contribution of these drugsto CPUD could be reduced by improvedpatient education.

Evidence for an interaction between alcoholand certain H2 receptor antagonists

S HOLT, M GURAM, C W HOWDEN (University ofSouth Carolina, Columbia, SC, USA) Some H2receptor antagonists (H2RA) have beenreported to inhibit gastric alcohol dehydro-genase (ADH) resulting in increased bloodalcohol concentrations (BAC) and ethanol bio-availability after ingestion of small doses ofethanol (0- 15 or 0 3 g/kg).To examine interactions between anti-

secretory medication and alcohol, six healthymale physicians (mean age 34 years) ingestedalcohol (0.75 g/kg) after a meal in the evening,on six separate occasions following pretreat-ment, in random order, with cimetidine (800mg OD), ranitidine (300 mg OD), or nizatidine(300 mg OD), famotidine (40 mg OD), oromeprazole (20 mg OD) for seven days beforeeach study. Pretreatment with cimetidine ornizatidine caused a significant increase in peakBAC compared with control (100±3 9,90.3+3.4, and 75-9+3-4 mg/dl, respectively,p<0 02). Cimetidine, nizatidine, andranitidine increased ethanol bioavailabilitycompared with control (UC at 120 minutes,8934+484, 8556+289, 7821+410, and7122±407, p<0 05, respectively).The enhancement of mean BAC by cimeti-

dine or nizatidine are of medicolegal import-ance, and increased ethanol bioavailability dueto certain H2RA may be undesirable. Thesefindings are relevant to the selection of anti-secretory drugs that are used frequently inpatients who drink alcohol.

Eradication of Helicobacter pylon - meta-analysis to determine optimal therapy

N CHIBA, J W RADEMAKER, B V RAO, R H HUNT(Division of Gastroenterology, McMasterUniversity, Hamilton, Canada) Multiple anti-biotic regimens are used to treat Helicobacterpylon infections, with varied success reported.Eradication of H pylori has been shown todecrease duodenal ulcer relapse and is recom-mended for refractory ulcers. We have there-fore performed a meta-analysis of publishedtrials to determine the optimal combinationtherapy.A computerised and fully recursive search of

published reports in English up to October1990 retrieved 167 articles and 74 abstracts. Atotal of 26 studies (11 papers and 15 abstracts)met all the predetermiend selection criteria andprovided extractable data. Heterogeneity anddifferences between groups were tested by x2

Pooled eradication rates for triple therapy(79%) were significantly (p<000005) betterthan both single (19%) and double (48%)therapy. No differences were found betweenbismuth and amoxicillin single therapies. Fordouble therapies bismuth+ metronidazole

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(55%) was significantly (p<0 05) better thanbismuth+amoxicillin (44%). Triple therapywith bismuth+ metronidazole+ tetracycline(93%) was significantly (p<0.0005) better thanbismuth+ metronidazole+amoxicillin (73%).We conclude that the combination of

bismuth+metronidazole+tetracycline is cur-rently the best regimen available and results inan eradication rate of 93%.

Immunomodulatory effects of histamine H2receptor antagonists in healthy volunteers

P H NICHOLS, G V MILLER, C W RAMSDEN, J NPRIMROSE (Department of Surgery, St J3ames'sUniversity Hospital, Leeds) The immunologicaleffects ofa week's therapy with three histamineH2 receptor antagonists were investigated in 11healthy male volunteers. The parametersmeasured included natural killer (NK) andlymphokine activated killer (LAK) cellfunction; T lymphocyte proliferative capacity,and interleukin 2 (IL 2) production; peripherallymphocyte subset analysis for markers CD3,CD4, CD8, CD16, and CD25.

Cimetidine (400 mg bd) enhanced both NKcell number and function after 24 hours(p<005 Wilcoxon test) and also increased thepercentage of peripheral CD8+ (cytotoxic/suppressor) cells (p<0 02), with a concomitantfall in the expression of the soluble IL 2receptor (p<0 02). These differences were notapparent at any other time during therapy.

Ranitidine (150 mg bd) had no effect uponNK cells, but caused a reduction in LAK cellfunction (p<0 02), a depression of the lympho-cyte in vitro blastogenic response to mitogenstimulation with concanavalin A (p<0005),and a decrease in the lymphocyte production ofIL 2 (p<0 01). These effects, together with anincrease in the percentage of CD4+ (helper/inducer) peripheral lymphocytes (p<001),were consistent throughout treatment beforereturning to baseline within a week of stop-ping. Famotidine (40 mg mane), the mostpotent H2 antagonist, had no significant effectupon any of the immunological parameters.

Therefore, histamine H2 receptor antago-nists have diverse immunological effects butthis activity is unlikely to be mediated viaspecific interaction at the H2 receptor.

Arthritic joint dysfunction as a predictor ofnon-steroidal anti-inflammatory drug pepticulceration

A S TAHA, C MORRAN, N HUDSON, C J HAWKEY,R D STURROCK, R I RUSSELL (Departments ofGastroenterology and Rheumatology, RoyalInfirmary, Glasgow and University Hospital,Nottingham) Patients with deformed or poorlyfunctioning joints could, in theory, be at agreater risk of developing non-steroidal anti-inflammatory drug (NSAID) related pepticdamage, as advanced arthritis might need moreaggressive therapy. To test this hypothesis, weassessed the extent of joint dysfunction and theendoscopic findings in a group of arthriticpatients receiving NSAIDs for a minimum offour weeks. The patients' functional assess-ment involved inquiring about their ability toperform various daily activities, and whetheraids or devices were needed. A standardisedhealth assessment questionnaire was used, andthe overall response was graded on a (0-3)scale: 0, fully independent; and 3, highlydependent person. Three main functionalgroups were then identified: I, scoring 0-1; II,

1 1-2; and III, 21-3. Patients underwentendoscopy within two hours of the functionalassessments, and the endoscopist was notaware of the functional scores.A total of 89 patients were studied: 23 males,

66 females, median age 55 years. Ulcers werefound in 36 patients (36/89, 40%); they weredistributed as follows: 15/22 (68%) in func-tional group III, compared with 9/28 (32%) ingroup I (X2=5-2, p<0 02), and 12/39 (31%) ingroup II (X2=7-24, p<0 01).

In conclusion patients with debilitatingarthritis seem to have a higher prevalence ofNSAID related peptic ulceration. This findingmay be relevant to the process of selectingpatients for prophylactic anti-ulcer therapy.

Gastric and duodenal mucosal blood flow inpatients receiving non-steroidal anti-inflammatory drugs - influence of age,smoking, ulceration and Helicobacter pylori

A S TAHA, W ANGERSON, H BtEKMAN, C MORRAN,N HUDSON, C J HAWKEY, R D STURROCK, R I

RUSSELL (Departments of Gastroenterology,Rheumatology and Surgery, Royal Infirmary,Glasgow and University Hospital, Nottingham)Animal studies have suggested that non-steroidal anti-inflammatory drugs (NSAIDs)can suppress gastric blood flow which in turnmight lead to ulceration. The situation is notclear in patients on long term NSAIDs whocould have other factors that might alter bloodflow. Also, little is known about duodenalblood flow in such patients. Using laserDoppler velocimetry, we measured gastric andduodenal mucosal blood flow in 70 arthriticpatients (23 males, 47 females, median age 54years), who took NSAIDs for longer than fourweeks, and studied the correlation with demo-graphic factors, ulceration, andH pylori. Bloodflow was measured in healthy looking mucosain the gastric antrum and first part of duo-denum. H pylori was detected by histology andbacteriology in antral biopsy specimens.The median duodenal mucosal blood flow

was 150 perfusion units in smokers (n=29)compared with 175 in non-smokers (p=0-024,Mann-Whitney U test), 123 units in patientswith duodenal ulcers (n= 12) compared with160 in those without duodenal ulcers (p=0.020), and 135 units in patients with H pylori(n=30) compared with 168 in patients withoutH pylori (p=0 033). There was no correlationwith age or sex. Gastric blood flow was notinfluenced by any of the above variables.

In conclusion, duodenal, but not gastric,mucosal blood flow is reduced in NSAIDpatients who smoke, or those with duodenalulcers or H pylori.

Gastrojet infusion of ranitidine and intraduo-denal nutrition: a more rational prophylaxisfor stress ulceration?

D G MORGAN, N j V BELL, C JAMES, R H HUNT

(Department of Gastroenterology, McMasterUniversity, Hamilton, Ontario, Canada) H2receptor antagonists, often prescribed forstress ulcer prophylaxis in the intensive careunit, cannot easily overcome meal stimulatedacid secretion. Furthermore, enteral nutritionalone may reduce stress ulceration. To assessthe effect of an intravenous infusion of raniti-dine on gastric pH while receiving intraduo-denal nutrition, we performed a randomisedcross over study in eight healthy volunteers.Each underwent two 24 hour studies.

Commercially available enteral feeds wereadministered through a fluoroscopicallypositioned nasoduodenal tube. Ranitidine orsaline was infused iv using the Gastrojet (MICAg, Solothurn) which incorporates a pH data-logger with a small volume peristaltic pump,allowing feedback control of intragastric pH byindividualised drug dose titration to maintaina predetermined pH which was set at 5 0.Ranitidine infusion maintained a median pH6-2 (range 5-6-6.7) compared with placebo pH1-3 (1-2-2-1) p<00001. Intragastric pH wasmaintained above pH 3 for 92% (75-98) of thetime with ranitidine and for 7% (1-33) withplacebo p<0 0001. Ranitidine maintainedintragastric acidity above pH 4 and pH 5 for89% (65-97) and 86% (58-96) of the total timerespectively. The median dose of ranitidineused was 207 mg (140-316).

Gastrojet infusion of ranitidine with intra-duodenal nutrition can maintain a raised intra-gastric pH suitable for stress ulcer prophylaxis.

Effect of non-steroidal anti-inflammatorydrug induced gastric mucosal injury on intra-gastric pH and gastrin profiles in healthyvolunteers

J W RADEMAKER, T J MCDONALD, N CHIBA, R H

HUNT (McMaster University, Hamilton,Ontario, Canada and University of WesternOntario, London, Ontario, Canada) Both non-steroidal anti-inflammatory drugs (NSAIDs)and Helicobacter pylon' cause gastropathy pre-dominantly affecting the antrum. H pylon'increases gastrin secretion by unknown mecha-nisms.The effect of antral gastric mucosal injury by

indomethacin (50 mg tid for seven days) on the24 hour pH and gastrin profiles was studied in10 H pylori negative healthy male volunteers.Endoscopy before and after treatment deter-mined H pylori status and gastric mucosalinjury. 24 hour pH was measured using con-tinuous ambulatory pH monitoring andmultiple blood samples (30) for plasma gastrinmeasured by radioimmunoassay.Median (range) gastric mucosal injury score

increased significantly from 0 to 3.5 (1-11) andpredominantly affected the antrum. No changeoccurred in mean 24 hour pH before 2-15(0.45) and after 2-42 (1-17) treatment. The 24hour and meal stimulated integrated gastrinprofiles (ng.h/l) were also unchanged; mean(SD) 24 hour and meal stimulated integratedgastrin secretion before and after treatmentwere 516 (168) and 86 (31), and 467 (188) and77 (40) respectively.We conclude, that in contrast to H pylori,

NSAID induced gastric mucosal injury doesnot alter acid or gastrin secretion. Mucosalinflammation and mediators other than prosta-glandins appear to alter the regulation ofgastrin secretion in H pylori.

SMALL INTESTINE

14C breath tests and problems of using anassumed carbon dioxide output

A DUNCAN, A CAMERON, M S STEWART, R CARTER,R I RUSSELL (Gastroenterology Unit, RespiratoryUnit, and Institute of Biochemistry, RoyalInfirmary, Alexandra Parade, Glasgow)In the calculation of 14C breath test results an

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assumed value of 9 mmol/kg/hour for carbondioxide output (CDO) is invariably used.To test the validity of this assumption wemeasured CDO in 55 fasting patients on whoma 14C triolein breath test was performed. CDOwas measured in triplicate or quadruplicatefollowing collection of breath into Douglasbags. The respiratory quotient (r) was alsomeasured to detect those patients with a high rwho hyperventilated. Nineteen patients (35%)had elevated r and four (8%) had low r valuesand so these results were excluded. In thepatients with high r values the intraindividualvariability ofCDO was high (CV= 14.7%) andthe CDO was significantly higher than thosewith normal r values (p<0-001).

In the 32 patients with normal r values theintraindividual variability of CDO results wasgood (CV=6.7%). There was no significantdifference between the 24 controls and eightmalabsorbers who made up this group. Themean CDO was 8-66 mmol/kg/hour whichagrees with previous studies, but the resultsshowed a large degree of variation (range5-12-4 mmol/kg/hour, interquartile range7.55-9 86). In extreme cases this could causeoverestimation of results by 80% and under-estimation by 27%.When an assumed value for CDO is used

to calculate results of 14C breath tests such as14C triolein, 14C xylose or 14C cholylglycinetests, a sizeable error may be introduced whichcould cause false positive and false negativeresults.

R J CORSON, S T O'DWYER, I S PATERSON, B

OPPENHEIM, N Y HABOUBI, R A LITTLE, C NMCCOLLUM (University Hospital of South Man-chester, North Western Injury Research Centre,University ofManchester) Multiple organ failureafter aortic surgery is poorly understood, butmay be due to gut damage. We investigated theeffects of hind limb ischaemia and reperfusionupon gut permeability and systemic endotoxinconcentration, using anaesthetised rats. Threegroups were studied: three hour bilateral hindlimb ischaemia followed by two hour reperfu-sion (n=6); three hour hind limb ischaemiawithout reperfusion (n=6), and controls anaes-thetised for five hours without ischaemia(n=6). Hydration was maintained with ivsaline, and body temperature was maintainedat 37 5°C. Horseradish peroxidase (HRP) wasinstilled into the isolated ileocaecal loop 15minutes before killing to measure transmucosalpermeability ofHRP beyond intercellular tightjunctions by electron microscopy. Endotoxinvalues were measured using the chromogenicLimulus amoebocyte lysate assay beforetourniquet application, tourniquet release, andtwo hours after reperfusion.One animal in the control group and

ischaemia alone group showed increasedpermeability, however reperfusion lead to allsix animals showing HRP permeability(Fisher's exact test p=0-015). No statisticaldifference in endotoxin values was notedbetween the three groups.These results show that hind limb ischaemia

and reperfusion damages the gut, but are notassociated with systemic endotoxaemia.

Coeliac disease is primarily associated withthe DQA1*0501 DQB1*0201 heterodimer

G CHIARIONI, C SCATTOLINI, F BONFANTE, E

BARDELLI M T BRENTEGANI, L BENINI, I VANTINI(Division of Gastroenterology at Valeggio sIM,University of Verona, COC Valeggio sIMVerona, Italy) Nifedipine has been showedto inhibit small bowel motility in animals,but human studies are lacking. This study wasa randomised, double blind, comparison ofthe effect of nifedipine (30 mg) and placeboon orocaecal transit time of a liquid meal innine healthy volunteers. After an overnightfast, each subject had a single oral dose ofnifedipine 30 mg (three capsules, 10 mg each)or placebo, and 30 minutes later ingested aliquid meal comprising 300 ml of an enteraldiet (Nutridrink 1.5 cal/ml, Nutricia) withlactulose 20 g. Blood samples were taken beforenifedipine administration and at 30 minuteintervals for determination of the nifedipineconcentration. End expiratory breath samplesfor H measurement were collected at 10 minuteintervals for 30 minutes fasting and after themeal. The orocoecal transit time was takenas the time for a sustained increase abovemean fasting levels of at least 10 ppmof H.

Nifedipine significantly increased the transittime compared with placebo (mean (SEM) 131(16) minutes v 104 (15) minutes; p<0 05,Wilcoxon's test for paired data). Nifedipineplasma concentrations expressed as the areaunder the curve showed a positive correlationwith orocaecal transit time (r=0.92, p<0 004,regression analysis).

In conclusion, nifedipine 30 mg prolongs themouth to caecum transit of a liquid caloric mealin normal subjects. This effect is correlated toplasma drug concentration.

M R TIGHE, M A HALL, E CARDI, K I WELSH,P J CICLITIRA (Rayne Institute, St Thomas'sHospital, Molecular Immunogenetics, UMDS,Guy's Hospital, and The Children's Hospital,Rome, Italy) In northern Europeans, coeliacdisease is associated with the DR3 DQw2(DQA1*0501 DQB1*0201) haplotype.Linkage disequilibrium does not allow identi-fication of the susceptible allele in DR3 indi-viduals. In southern Italy, there is a highincidence ofDR3 negative patients with coeliacdisease.

This study investigated 43 patients withcoeliac disease from Rome, Italy togetherwith 39 ethnically matched controls.DRB, DQA, and DQB alleles were identi-fied using the polymerase chain reactionand sequence specific oligonucleotideprobes.

At the DRB locus, 51% ofpatients were DR3(10% controls), 42% DR5 (26% controls), and77% DR7 (36% controls). No patients werehomozygous for DR7, but were heterozygousfor DR5/7 (42%), DR3/7 (39%), or DRw6/7(15%).At the DQ loci, 91% of patients possessed

the DQA1*0501 allele (51% controls) and98% the DQB1*0201 allele (41% controls).The combination DQAl*0501 DQB1*0201was found in 91% patients v 18% controls(p=0 00005, X2=32 16, RR=38-0, EF=88 7%).These results support the hypothesis that

coeliac disease is primarily associated with thepresence of DQA1*0501 DQB1*0201 in bothDR3 positive and negative populations.

Hind limb ischaemia-reperfusion damagesthe gut but is not associated with systemicendotoxaemia

A potential method of reducing graft versushost reactivity in small bowel transplantation

C L INGHAM CLARK, P W CRANE, P A LEAR, R F MWOOD (INTRODUCED BY R K S PHILLIPS) (Pro-fessorial Surgical Unit, St Bartholomew'sHospital, West Smithfield, London) There isextensive migration of graft cells to hostlymphoid tissues after small bowel transplanta-tion (SBT) with cyclosporin A (CsA) immuno-suppression. This study examines the effect ofdelaying the start of CsA treatment on subse-quent graft cell emigration. SBT was carriedout in rats from PVG donors to DA recipientsin three groups; no immunosuppression(n=5), CsA (15 mg/kg/d) from day 0 (n=6),and CsA (15 mg/kg/d) from day 4 (n=6) aftertransplantation. On day 7 tissues were har-vested and stained with strain specific mono-clonal antibodies (OX27 vv PVG, MN4 vv DA)using an immunohistochemical technique.

Histological changes of acute rejection wereseen in the group receiving no treatment butnot in either of the CsA treated groups. Hostcell migration to graft tissues was reduced inboth CsA treated groups. Graft cell migrationto host tissues was much greater in the groupreceiving CsA throughout than in the rejectinggroup or the group receiving delayed start CsA.

Delayed CsA treatment successfully pre-vents macroscopic graft rejection yet reducesthe coincidental survival of graft leukocyteswithin host lymphoid tissues. Such strategiesmay be of value in obviating GVHD after smallbowel transplantation.

Effect of nifedipine on orocaecal transit innormal subjects: correlation with plasmadrug concentration

Epidemiology of Crohn's disease andabdominal tuberculosis in Bangladeshis andEuropeans in Britain

C S J PROBERT, V JAYANTHI, K KING, H COCK,D POLLOCK, S I BAITHUN, C SHELDON, N BARNES,

J F MAYBERRY, D S RAMPTON (Leicester GeneralHospital, Leicester, London Chest Hospital andRoyal London Hospital, London) The incidenceof Crohn's disease (1972-89) and abdominaltuberculosis (1985-89) in a defined Bangladeshicommunity was studied in an East LondonBorough (population 164 000 with 28 000Bangladeshis). From a review of about 3000potential cases there were 99 of Crohn'sdisease, including five Bangladeshis resident inthe borough at diagnosis. The incidence inBangladeshis was 1 3/105/year in the 1970s and2.2/105/year in the 1980s compared with 34/105/year and 4.2/105/year in Europeans, and4 6/105/year and 54/105/year in West Indians,respectively: none of ethnic group differencesin incidence or the changes with time wassignificant. There were 13 cases of abdominaltuberculosis, ofwhom eight were Bangladeshi.The incidence in the Bangladeshi communitywas 7.7 cases/105/year, which was significantlyhigher than that in Europeans (0.32/105/year,Z=5-8, p<0.001, relative risk 34 950oCI 4-271), but was not significantly differentto that of Crohn's disease (X2 = 0. 5,NS).The similarity of incidence of Crohn's

disease in Bangladeshis and Europeans con-trasts with other findings in South Asians inBritain. The high incidence of intestinal tuber-culosis indicates that it whould be given at leastequal weighting with Crohn's disease whenreaching a diagnosis in Bangladeshis withabdominal symptoms.

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Opioid immunoreactivity in myentericneurons of the guinea pig small intestine

P A STEELE, M COSTA (INTRODUCED BY D LWINGATE) (Centre for Neuroscience, Departmentof Physiology, Flinders University of SouthAustralia, GPO Box 2100, Adelaide 5001,Australia) Exogenous opioid compounds haveprofound effects on intestinal motility and yetthe role of endogenous opioids in entericneurons is not known. The aim of the presentstudy was to identify functional classes ofopioid immunoreactive neurons in myentericganglia on the basis of their morphology,distribution, neurochemistry, and projections.Whole mount preparations of the myenteric

plexus were prepared from control tissue andfrom tissue where intrinsic and extrinsic neuralpathways had been interrupted. Tissue wasdouble labelled with antisera raised againstproenkephalin derived peptides or prodynor-phin derived peptides combined with antiseraraised against other neurochemicals known tolabel certain classes of myenteric neurons.These experiments showed that opioidimmunoreactivity in cell bodies of myentericneurons coexisted with immunoreactivity forcalretinin, neurofilament protein triplet,neuropeptide Y, substance P, or vasoactiveintestinal peptide. The projections of theseneurons was established by interrupting nervepathways and examining the consequentchange in fibre distribution in the targets.

Together these experiments indicated thatopioid immunoreactivity is found in severalfunctionally distinct classes of myentericneurons: inhibitory and excitatory motor-neurons to the circular muscle, orally andanally directed interneurons in the myentericplexus, interneurons to the submucousganglia, and motorneurons to the muscularismucosae.

Rate of spinal bone loss of patients withinflammatory bowel disease: four yearlongitudinal study

R J MOTLEY, D CLEMENTS, W D EVANS, E 0CRAWLEY, C EVANS, J RHODES, J E COMPSTON(Departments of Medicine, Medical Physics,Radiology and Pathology, University Hospital ofWales, Cardiff) The prevalence of oesteoporo-sis is increased in patients with inflammatorybowel disease (IBD) and vertebral fracturesoccur in some relatively young patients. In thisstudy we have made serial annual measure-ments of bone mass in the lumbar spine over afour year period in 70 patients with IBD (41women, aged 20-81 years). Bone mineraldensity was measured in the first three lumbarvertebrae using quantitative computed tomo-graphy. The combined in vivo/in vitroprecision of the technique is 2-3%.The mean percentage annual change in

spinal bone mineral density was -2-1% formen (range -8-1 to +3.8) and -2% for women(range -7- 1 to +3-1). The heterogeneity inrates of loss was statistically significant(p<0001). There was no significant correla-tion between rates of spinal bone loss andpatient age, height, weight, disease duration orduration of corticosteroid treatment. In men,however, there was a significant positive corre-lation between the amount of corticosteroidingested during the study and the rate of spinalbone loss (p<005). Rates of bone loss werecomparable in patients with Crohn's diseaseand those with ulcerative colitis.These results indicate that high rates of

spinal bone lce . are maintained over relatively

long periods oftime in some patients with IBD.Bone densitometry should be considered in allpatients with inflammatory bowel disease, par-ticularly those with high risk factors so thatprophylactic measures can be taken whereindicated.

Cortical bone loss in patients with inflamma-tory bowel disease: an eight year longitudinalstudy

D CLEMENTS, R M MOTLEY, W D EVANS, R JCOLES, A HARRIES, J RHODES, J E COMPSTON(Departments ofMedicine and Medical Physics,University Hospital of Wales, Cardiff) Theprevalence of osteoporosis is increased inpatients with inflammatory bowel disease(IBD), but there have been few longitudinalstudies of bone loss in these patients. In thisstudy we have measured bone mineral densityat the junction of the distal one third andproximal two thirds of the radius using singlephoton absorptiometry in 50 patients withIBD. Thirty three had Crohn's disease and 17ulcerative colitis; 25 were women. The meanage was 45 years (18-70). All the patients weretraced and the measurements repeated in 39,after a mean follow up period of 7 9 years(range 7-1 to 8.2).

In female patients the annual change inradial bone mineral density was -0 74% (range-3.44 to + 1-03) (p=0 022), the greatest boneloss occurring in postmenopausal women(mean 1-1%/year). In male patients the meanrate of bone loss was -0 07% (range - 1 10 to+ 1-63) (p, NS). Patients with abnormally lowvalues at the first measurement remainedosteopenic at the second measurement whilesome others with normal values initiallyshowed increased rates of bone loss and had asubnormal bone mineral density after thefollow up period.

These results indicate increased rates ofcortical bone loss in some patients with inflam-matory bowel disease and emphasise the needto monitor bone mass in these patients so thatprophylactic measures can be instituted.

Iron status modulates heme uptake by smallintestine

S K ROBERTS, G P YOUNG, R HENDERSON (INTRO-DUCED BY B COLLINS) (Department ofMedicine,University of Melbourne, The Royal MelbourneHospital, Vic 3050, Australia) Ingested heme isclaimed to be a significant source of iron, yetheme must be taken up intact for the iron to beavailable. The aims of this study were todetermine whether iron status modulatesintestinal uptake of heme.

['4C]Heme was prepared by incubating[14C]6-aminolevulinic acid with rat reticulo-cytes (activity 0.4 [tCi/[mol). Six Sprague-Dawley rats made iron deficient (ID) by dietarymeans and six controls were perfused with1 FimoWl ['4C]heme through cannulated 10 cmsegments of jejunum. Heme uptake wasderived from "4C-radioactivity in perfusate,infusate, and mucosa after correction forrecovery of the marker, [57Co]cyanocobalamin.ID rats had a microcytic anaemia: haemo-

globin 92 (8) v 160 (2) g/l in controls. Mucosaluptake of [14C]heme was significantly greaterin ID rats (19-3 (2.8)% v 108 (1 1)%,p=0-031,t test). Mucosal I4C:57Co ratios confirmed[14C]heme extraction from infusate in bothgroups (p<0-01); the mucosal to infusate'4C;57Co ratio significantly greater in ID rats

(6-3 (0.9) v 3-7 (0.6), p=0 04). Histology ofperfused gut was unremarkable.

In conclusion, iron status is a significantmodulator of intestinal uptake of radiolabelledheme. As heme iron is not chelatable by dietaryligands, this should augment iron availabilityin iron deficient states.

Effect of 5-Hydroxytryptamine (5-HT) type 3receptor antagonism on water absorptionduring intestinal anaphylaxis

F H MOURAD, J A DIAS, L J D O'DONNELL, M J GFARTHING (Department of Gastroenterology, StBartholomew's Hospital, West Smithfield,London) The intestinal secretagogue 5-HT,present in mast cells and enteric neurons, maybe a mediator ofwater and electrolyte secretionin intestinal anaphylaxis. We have studied theeffect of a highly selective 5-HT3 receptorantagonist on water absorption in sensitisedrats during rechallenge with a food allergen.Adult male Hooded-Lister rats (200-250 g)were inoculated ip with 10 ,ug ovalbumin (OA)and alum adjuvant. Fifteen days later ratsreceived either a 5-HT3 receptor blocker(BRL43694/granisetron) 300 jig/kg sc, orsaline and two hours later a 15 cm segment ofjejunum was perfused in situ with eitherplasma electrolyte solution (PES) or PES+OA(20 mg/l). Successful sensitisation was con-firmed by specific IgE titres of > 1 in 8.Net water absorption after exposure to OA

(median 25 (interquartile range 21-33) d/min/g; n=6) was significantly reduced com-pared with PES (72 (60-82); n= 10; p<0 05).Pretreatment of sensitised rats with BRL43694partially reversed the decreased water absorp-tion after PES+OA (46 (36-65); n=10;p<005), but remained less than in theuntreated control group (p<005). The profileof net chloride movement followed that ofwater. BRL43694 had no effect on basal trans-port in non-challenged controls.

Thus, decreased water absorption duringintestinal anaphylaxis is partly due to activationof neuronal 5HT3 receptors but their blockadeprior to antigen exposure does not entirelyprevent the intestinal transport changes,implying that other mechanisms are involved.

Differential effects of fasting and semistarva-tion on the kinetics of Na dependent glucoseuptake by rat jejunal brush border membranevesicles

E S DEBNAM (Department of Physiology, RoyalFree Hospital School of Medicine, London) Areduced food intake produces complex effectson intestinal glucose uptake and one complicat-ing factor in the interpretation of results usingintact epithelium is a reduced enterocytenumber. In order to study rmembrane adapta-tion per se, brush border membrane (BBM)vesicles have been prepared from jejunalmucosal scrapes using control, three day fasted(F, 18% weight loss), and eight day semi-starved (SS, 25% food intake/day, 16-5%weight loss) rats. Vesicles were incubated forfour seconds with 5-6-980 [iM [3H]-D-glucosein the presence of a 100 mM NaSCN gradientimplying a similar electrochemical drivingforce in the three preparations. Uptake wasexpressed as nmol/min/mg total membraneprotein.

Hofstee analysis revealed two transporters(TI: high affinity, low capacity, T2: lowaffinity, high capacity). Fasting induced a

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higher Vmax of TI (+98%, p<0-01) and T2(+52%, p<0-01) but no change in Kt. SSvesicles had a reduced Vmax of TI (-52%,p<0O005) and T2 (-26%, p<005) togetherwith a decreased Kt of TI (-65%, p<0-001)and T2 (-27%, p<0 05).One explanation of these differential effects

is that in F rats, the absence of food may spare

the BBM glucose carrier at the expense of othermembrane proteins. For SS rats however thepresence of luminal nutrient, albeit at a lowerlevel, will require the retention of a wide array

ofBBM proteins.

SMALL INTESTINAL DISEASE

Low plasma cystine is a sensitive indicator ofsmall bowel disease

W DICKEY, G ROBERTS, K G PORTER (INTRO-DUCED BY J S A COLLINS) (Department ofMedicine, Queen's University ofBelfast, BelfastCity Hospital and Department of ClinicalChemistry, Royal Victoria Hospital, Belfast)Although the small bowel is important inamino acid metabalism and transport, few havestudied plasma amino acid values in smallbowel disease. We measured fasting plasmaconcentrations of 19 amino acids in ninepatients with subtotal or total villous atrophy,nine patients with small bowel Crohn's disease,and 22 control subjects with normal jejunalbiopsy and small bowel radiology.Only plasma cystine was significantly related

to small bowel disease. Values (mean (SEM))were 26 (6.4) [tmol/l (range 9-31) for villousatrophy, 26 (7.9) [smol/1 (range 13-38) forCrohn's disease, and 47 (13-4) limol/l (range24-80) in controls. The difference betweenvalues in patients with small bowel disease andin controls was highly significant (p<0-001).Low plasma cystine (<35 [tmol/1) had a sensi-tivity for small bowel disease of 94% (17 of 18)and specificity of 86% (19 of 22). Five patientswith previous villous atrophy which hadresolved on a gluten free diet had mean plasmacystine of49 ,tmol/l (range 37-77).

Thus, low plasma cystine is a sensitiveindicator of small bowel disease and may aidmonitoring of response to therapy, although itsclinical significance is unclear.

Is the endomysial antibody the best screeningtest for coeliac disease

M FERREIRA, S LLOYD-DAVIES, M G BUTLER, M L

CLARK, P J KUMAR (St Bartholomew's Hospital,London) There is no reliable non-invasivescreening test for coeliac disease (CD). Endo-mysial antibody (EMA) is a recently describedantibody found on the basement membranearound smooth muscle fibres of monkeyoesophagus. We havecompared the sensitivitiesand specificities of the anti-gliadin antibody(AGA-IgA, AGA-IgG using ELISA), AGA,and anti-reticulin antibody (ARA-IgA) andEMA using immunofluorescence, and alsocorrelated the results with jejunal morphology.

Sera of patients with untreated CD (UCDn= 21), disease treated with a strict gluten freediet (GFD n=87), or a non-strict GFD (NS-GFD n= 19) were compared with a GI diseasecontrol group (Crohn's disease (21), ulcerativecolitis (10)), a non-GI group (rheumatoidarthritis (20), SLE (33)), and normal subjects

(47). EMA was positive in 100% of patientswith UCD, 1-2% GFD, and 47% NS-GFD; allother patient groups were negative. Other testswere positive in 76-92% of UCD, 9-28% on

GFD, and 39-75% on NS-GFD; false positiveswere also seen but not with the ARA-IgA test.The sensitivities and specificities were EMA(100%, 98 8%), AGA-IgA (90 5, 85 4), AGA-IgG (76-2, 89), and ARA-IgA (90.5, 98 7)respectively. Jejunal mucosa was obtainedfrom 18 UCD, 32 GFD, and 13 NS-GFD. AllUCD patients had subtotal villus atrophy(SVA) and positive EMA; all GFD patientswith normal mucosa were negative. The corre-

lation was not 100% with PVA or SVA in theNS-GFD/'GFD' groups.

In conclusion the new EMA is more specificand sensitive than other current antibody testsfor diagnosis ofCD.

Localisation of increased intestinal perme-

ability in coeliac and Crohn's diseases

K TEAHON, T SMITH, I BJARNASON (ClinicalResearch Centre, Harrow and King's CollegeSchool ofMedicine and Dentistry, London) Thedifferential urine excretion of orally adminis-tered test substances shows increased intestinalpermeability in patients with coeliac andCrohn's diseases. A technique has beendeveloped to localise precisely the site of thepermeability changes.

Subjects fast from midnight for 36 hours. At7 am an iv drip is set up followed by im vitaminB12. At 8 am subjects drink a 100 ml testsolution containing 3-o-M-D-glucose (2-5 g) as

a jejunal marker, 57Co vitamin B12 (5 ,tCi) as an

ileal marker, sulphasalazine (3 g) as a caecalmarker (s-sulphapyridine), and 51CrEDTA (1[tCi) as the permeability probe with subse-quent measurement of serum values for 24hours.

Analysis of serum appearances of the testprobes (peak or 50% of plateau value etc) showthat the jejunum is the main site of 5'CrEDTApermeation in normal subjects (n:5). Patientswith untreated coeliac disease (n:5) haveincreased jejunal permeability to 5 CrEDTA,while patients with ileocaecal Crohn's (n:5)had increased permeation of 5 1CrEDTAcorresponding to the appearance of the ilealand caecal markers.

In conclusion, a technique for the localisa-tion of increased intestinal permeability hasbeen validated in patients with coeliac andCrohn's diseases. With minor modification itcan be used to localise the site of absorption ofmost orally administered compounds.

Indomethacin induced small intestinaldamage in rats resembles NSAID inducedenteropathy of the human small intestine

M A TREVETHICK, N CLAYTON, P STRONG,

I HARMAN (INTRODUCED BY K T BUNCE) (Depart-ments of Gastrointestinal Pharmacology andPathology, Glaxo Group Research Ltd, Ware,Herts) Non-steroidal anti-inflammatory drug(NSAID) induced enteropathy of the humansmall intestine (SMI) is associated with inflam-matory cell infiltration and haemorrhage,which can be reduced by misoprostol andsulphasalazine. We now report that indo-methacin (Indo) induced damage to the ratSMI is also associated with inflammatory cellinfiltration and haemorrhage and can belimited by misoprostol and sulphasalazine.

Indomethacin (15 mg/kg po) was adminis-

tered to female random hooded rats and atvarious time points animals were killed and (i)the number of visible ulcers throughout theSMI counted, (ii) infiltration by inflammatorycells determined histologically (score: 0-=none,1=little, 2=mild, 3=moderate, 4=marked,5=severe), and (iii) haemorrhage (measured asperoxidase activity) into the small intestinalcontents assessed. The effect of misoprostoland sulphasalazine (administered 30 minutesbefore and six, 24, and 30 hours after indo-methacin) on ulceration was also investigated.

Indomethacin induced a time dependentincreased in (i) the number of visible ulcers (sixhours=5 (3); 24 hours= 103 (7); 48 hours = 141(15)), (ii) inflammatory cell infiltration score(six hours=1-0 (0.4); 24 hours=2-0 (0.7); 48hours=3-8 (1-3)), and (iii) peroxidase activity(six hours=1-9 (0.7); 24 hours=8.7 (1.2); 48hours=7.7 (1-4) EU/g) (results are mean(SEM), n=8). Misoprostol (ED50 0054 mg/kgpo) and sulphasalazine (ED50 42 mg/kg po)significantly reduced the number of visibleulcers.Thus, indomethacin-induced ulceration of

the rat small intestine has remarkable similarityto that found in man in terms of inflammatorycell infiltration, haemorrhage, and suscept-ibility to drugs.

Relevance of intestinal bacteria, prosta-glandins, and pro-drug administration tonon-steroidal anti-inflammatory drug(NSAID) induced increases in gutpermeability

G R DAVIES, D S RAMPTON (GastrointestinalScience Research Unit, The London HospitalMedical College, London) NSAID inducedincreases in gut permeability are thought toreflect altered mucosal function and precedethe NSAID enteropathy (intestinal blood andprotein loss, inflammation, and ileal dysfunc-tion) that affects 70% of longterm users.Permeability changes have been prevented inshort term open volunteer studies by high doseprostaglandin supplementation, and metro-nidazole has reduced NSAID inducedintestinal inflammation.To investigate these observations further we

used a randomised, placebo controlled, cross-over, double blind study design; healthyvolunteers underwent a combined 5`Cr-EDTA(2 MBq) and mannitol (5 g) oral permeabilitytest before and after one week's treatment withindomethacin (50 mg tds) and either (a) miso-prostol (200 [sg qds) or (b) metronidazole (400mg bd).The 24 hour 51Cr-EDTA permeability

increased after one week's indomethacin (1-2%(0-11) (mean (SEM)) before and 2.37 (0-18)after; n=15, p<0-001). Co-administration ofmetronidazole prevented this effect (1 07(0-15) before and 1-51 (0 21) after; n=8, NS)but misoprostol did not (1 37 (0.27) before and3 26 (0.40) after; n=7, p<0 005). No drugregimen altered mannitol permeability.

In conclusion (1) if related to its anti-bacterial activity, the results with metronida-zole suggest that anaerobes facilitateindomethacin induced increases in perme-ability. (2) In contrast to previous work, wefound that misoprostol did not reverse indo-methacin induced permeability changes;prostaglandins may either be unimportant inthe pathogenesis of this phenomenon, oralternatively, misoprostol in therapeuticdosage may fail to maintain mucosal prosta-glandin values in the face of one week'sexposure to indomethacin.

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Intravenous aprotinin protects agaisnt celiloss during reperfusion of ischemic smallintestine

L E A FILEZ, R KERREMANS, W STALMANS,K GEBOES, F PENNINCKX (Departments ofAbdominal Surgery, Biochemistry, andPathology, Catholic University of Leuven,Belgium) The present study aimed to delineatethe role of proteases in the pathogenesis ofreperfusion damage. The influence of intra-luminal proteases was evaluated by intra-luminal aprotinin - a protease inhibitor andstabiliser of proteoglycan polymers - and/or byintraluminal wash out, whereas the intra-cellular and serum proteases were inhibited byiv aprotinin. In four groups of cats the wholesmall intestine was isolated on its vascularpedicle. Then the superior mesenteric arterywas occluded for one hour, followed by reper-fusion for another two hours. At the moment ofreperfusion, the cats were subjected to: groupI: no treatment (control); group II: intra-luminal wash out with 11 physiological solutionat 37°C; group III: wash out with the samesolution containing aprotinin 110 U; groupIV: aprotinin 30 000 U/kg iv. Before occlusionand at one hour intervals several mucosalenzymic activities were determined, as well asthe ratio of mucosal/muscle protein and thehistologic aspect.Compared with the control group, the total

lactate dehydrogenase and maltase activities(expressed as a % of the prereperfusion activityin U/g muscle protein; means (SEM)) aresignificantly better preserved after one hour aswell as after two hours of reperfusion in groupIV only. Lactate dehydrogenase: one hour ofreperfusion: 78-8 (7.4)% in group IV v 28-7(2.3) in the control group; two hours of reper-fusion: 62-8 (5.3) v 45-8 (4.3). The otherenzymic activities (aldolase B, maltase, gluta-mate dehydrogenase) gave similar results.Microscopical analysis showed a significantlybetter mucosal preservation only in group IV aswell.

In conclusion (1) intraluminal proteaseelimination has no effect on the mucosal reper-fusion damage. (2) The mnechanical effect of thewash out seems to promote epithelial cellshedding. (3) Aprotinin iv at the moment ofreperfusion prevents mucosal cell loss, themajor phenomenon of reperfusion.

20-153). The incidence of abdominal tubercu-losis in South Asians decreased significantlyfrom 27 cases/105/year during the 1970s to 8-9cases/105/year in the 1980s (X2=42, p<0 001).The mean incidence during the study was 15-2/105/year in Hindus, 12.3/105/year in Sikhs, and5-81/105/year in Muslims. The relative risk toHindus and Sikhs is 2-1 greater than that forMuslims (2-6 and 2-1 respectively), a findingsimilar to that in pulmonary tuberculosis.Abdominal tuberculosis is still not an

uncommon diagnosis amongst migrants andclinicians should remain alert to the diagnosisin South Asians.

Natural history of cryptosporidiosis in HIVinfection

C BLANSHARD, S DAVIES, M NELSON, G MCONNOLLY, V McDONALD, D C SHANSON, A MJACKSON, N FRANCIS, B G GAZZARD (AIDS Unit,Westminster Hospital, London) Cryptosporidio-sis was always thought to produce severechronic diarrhoea in HIV infected patients butthis is not always so. We analysed the caserecords of 121 HIV seropositive patients withcryptosporidiosis.

Since 1985, cryptosporidiosis has been diag-nosed in 5% of all patients with HIV infectionand 21% of those with AIDS. In 19% of thepatients with persistant cryptosporidiosis itwas their first AIDS diagnosis. The incidencehas apparently increased each year since 1985,and seasonal variation occurs. Four patterns ofdisease were identified: transient (24%),chronic persistent (58%), fulminant (14%), andasymptomatic (4%). The course of disease wasunrelated to CD4 count, P24 antigenaemia,histology, or treatment although those withfulminant disease more commonly had lost >7kg and had other concomitant infections.

Treatment with AZT, macrolide antibiotics,diclazuril, and interleukin 2 did not affect themean survival which was 7 5 months fromdiagnosis in those with chronic diarrhoea, 15months in those with transient infection, and40 days in those with fulminant disease.

In conclusion cryptosporidiosis in HIVinfected individuals is a heterogeneous disease.

whom were symptomatic. Six of 12 EBVpositive patients developed reactivation withfourfold increase in titres but no clinicalsymptoms. Chronic persistent hepatitis (CPH)developed in two children with CMV and inthree with EBV infection. Eleven children hadcoinfection with both CMV and EBV. One ofthese developed CPH and two chronic activehepatitis progressing to chronic rejectionrequiring retransplantation in one child.

After Tx, CMV and EBV infections arecommon in childhood and may be associatedwith the development of chronic hepaticdisease.

Bacterial infections capable of causing diar-rhoea in HIV infected patients

M R NELSON, D C SHANSON, B G GAZZARD(INTRODUCED BY B G GAZZARD) (AIDS Unit,Westminster Hospital, London) This studyaimed to assess the incidence, clinical presenta-tion, and rate of relapse of shigella (Sh),salmonella (Sa), and campylobacter (C) infec-tions in HIV positive patients.

All HIV antibody positive patients who hadblood or stool cultures showing species ofShigella, Salmonella, or Campylobacter wereidentified from three separate sources.Between January 1985 and December 1990,

2048 patients were diagnosed as HIV antibodypositive at our unit. Five hundred and twentyfour were investigated for diarrhoea. In thisperiod seven patients had infections with Sh(33 septicaemias, one relapse), 32 Sa (12 septi-caemias, 10 relapse), and 28 C (three septi-caemias, four relapse).

In conclusion (1) the incidence of Sa and C isincreased when compared with the homosexualpopulation as a whole, but the incidence of Shis not. (2) Patients with Sa and C have lowerCD4 counts than those with Sh and are morelikely to have had a previous AIDS diagnosis.(3) Patients presenting with possible entericinfections should always have blood culturestaken, as difficulty may be found in isolatingthe organism from the stool. (4) Relapse iscommon in infections with Sa and life longprophylactic treatment may be needed.

Significance of cytomegalovirus and Epstein-Barr virus infection in children after livertransplantation

GUT INFECTION AND IMMUNODEFICIENCY

Abdominal tuberculosis in Indian migrantsand the indigenous population in Leicester

C S J PROBERT, V JAYANTHI, A C WICKS, D L CARR-

LOCKE, P GARNER, J F MAYBERRY (LeicesterGeneral Hospital, Leicester and Brigham andWomen's Hospital, Boston, USA) A retrospec-tive, epidemiological study of abdominaltuberculosis was performed from 1972 to 1989.Potential cases were identified from hospitaldepartments of medical records and endo-scopy, in addition to the county notificationregister. The city population includes over

75000 South Asians. There were 146 cases

in South Asians and six in Europeans, fourof whom were British. The incidence inEuropeans has risen to 0 16/105/year, but theyhave significantly less abdominal tuberculosisthan South Asians (Z= 14-5, p<0-001 andrelative risk=55.4, 95% confidence interval

O O ADEODU, M S MURPHY, N GREEN, J BUCKELS,D A KELLY (The Liver Unit and Department ofPathology, Children's Hospital, LadywoodMiddleway, Birmingham) The associationbetween cytomegalovirus (CMV) and Epstein-Barr Virus (EBV) infection and clinical out-come in 37 children (age range 0-3-15 years)after liver transplantation (Tx) has beenstudied. Microbiological methods includedserological evaluation at eight week intervals,viral cultures, and histological examinationannually or when clinically indicated. Ten of29CMV negative patients seroconverted betweenseven and 22 (median 4) weeks after transplan-tation. Nine of these children received a CMVpositive liver with acyclovir prophylaxis. Oneof eight CMV positive patients developedreactivation after Tx. Three patients developedfever, hepatitis, ascites, one of whomdeveloped pneumonitis which responded totreatment with DHPG (Gancyclovir) andCMVhyperimmune globulin. Eleven of 25 EBVnegative patients seroconverted between sevenand 78 (median 26) weeks after Tx, four of

An algorithm for the investigation ofdiarrhoea in HIV infection

C BLANSHARD, B G GAZZARD (AIDS Unit, West-minster Hospital, London) About 50% ofpatients with symptomatic HIV infectiondevelop diarrhoea, commonly due to infectionof the upper or lower gastrointestinal tract.Previous algorithms have not included routineinvestigation for microsporidia.

Since August 1990, all patients with AIDS orARC presenting with chronic diarrhoea havehad six stool specimens examined (includingmethods for ova, cysts, parasites, crypto-sporidia, blastocystis, and AFB) sigmoido-scopy with three rectal biopsies, endoscopywith microscopy of duodenal aspirate andexamination of six duodenal biopsies and aCrosby capsule jejunal biopsy by light andelectron microscopy.Of 71 patients, 49 (69%) had one to four

infections: 21 cryptosporidiosis, 13 giardiasis,12 microsporidiosis, 10 CMV, two salmonella,two campylobacter, one shigella, three MAI,one MTB, two spirochaetosis, one entamoebahistolytica, two blastocystis. The diagnosticyield of a single stool specimen was 26%, sixstools 40%, duodenal aspirate 4%, rectal biopsy

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17%, and duodenal or jejunal biopsy 41%. Allcases ofmicrosporidiosis were detected by lightmicroscopy. Examination of three stools gives38% of all diagnoses; duodenal biopsy increasesthe yield to 83%, rectal biopsy to 96%, andstaining three further stools for crypto-sporidium to 99%.

In conclusion, duodenal biopsy is essential inthe evaluation ofHIV related diarrhoea.

ENDOSCOPY

Smali bowel enteroscopy with waterinsufflation - the first 80 cases

A J MORRIS, L WASSON, R H R PARK, J F

MACKENZIE (Gastrointestinal Investigation Unit,Royal Infirinaty, Glasgow) Per nasal Sonde-type enteroscopy using water or saline insuffla-tion and preservation of peristalsis has beenperformed in 80 patients. The median distanceenteroscope insertion was 190 cm (range 90-250 cm). The caecum was entered in threepatients. The technique allows views of finemucosal detail and has shown newly describedmucosal 'red-spot' lesions,' ulceration, and, inone case, a mucosal diaphragm with appreci-able luminal narrowing, as described byBjarnason et aP' in patients on longterm NSAIDtreatment. Some 56% of these patients had oneor more mucosa abnormalities. A total of 37%with other obscure gastrointestinal blood losshad small bowel lesions, and 10% of all patientsreferred for enteroscopy were found to havelesions in oesophagus, stomach, and duo-denum to account for their blood loss.

Preservation of peristalsis during examina-tion allowed retrieval of lost ground duringwithdrawal. Small bowel perforation occurredin two patients. There were no significant nosebleeds. An estimated 20-30% of the smallintestine slips past the tip during examination -a steerable tip may help to reduce this percent-age ofunexamined bowel.

1 Morris AJ, etal. Lancet 1991; 337: 520.2 Bjarnason IT, et al. Gastroenterology 1988; 94:

1070-74.

Cholecystectomy - a rare occurrence afterendoscopic removal of common bile ductstones

M RHODES, M LAVELLE-JONES, G CARLSON,I LAVELE, CW VENABLES (Departments ofSurgeryand Radiology, Freeman Hospital, Newcastleupon Tyne) Endoscopic removal of commonbile duct (CBD) stones is safe and effective. Issubsequent cholecystectomy always necessary?We present the results of a 10 year prospectivestudy in 212 patients with common bile ductstones (mean age 76 years, range 25-96) treatedby endoscopic duct clearance withoutcholecystectomy.The CBD was successfully visualised in 210

patients (99%) and duct clearance achieved in173 (82%). Some 33 of these patients were lostto follow up. The remaining 140 patients withsuccessful CBD clearance were followed up fora median of 47 months (range 6-124). Twentyfive patients (17%) required cholecystectomyfor: biliary colic (n= 15), acute cholecystitis(n=7), empyema (n=l1), recurrent jaundice(n= 1), and ascending cholangitis (n= 1).Cholecystectomy was performed between 0

and 30 months after ERCP (median 2 months);14 had their chc -cystectomy within threemonths. There were no postoperative deaths.Most patients with common bile duct stones

can be safely and effectively managed by endo-scopic removal, and cholecystectomy will notbe required in the majority. Operation, whennecessary, is safe. We recommend thatcholecystectomy need not be routinely per-formed after endoscopic CBD clearance.

Why does endoscopic injection therapy forbleeding peptic ulcer sometimes fail?

C RAJGOPAL, K R PALMER (GI Annexe, WesternGeneral Hospital, Edinburgh) The prognosis ofpatients presenting with bleeding peptic ulceris improved by endoscopic injection therapy(EIT), but failures occur and delay of definitivesurgery caused by unsuccessful EIT couldadversely affect outcome.We have attempted to identify factors pre-

dicting failure ofEIT in 122 patients treated bya single endoscopist for serious peptic ulcerbleeding. All patients had either active bleed-ing (n=34) or stigmata of recent haemorrhageassociated with at least one other risk factorfrom: age over 60 years, Hb less than 100 g/l, orclinical shock. EIT comprised 4-10 ml of1:100000 adrenaline and 1-2 ml 5% ethanola-mine.Awkward access or torrential haemorrhage

prevented EIT in 10 patients (8%). Overallsuccess for control of active bleeding (30 of 34cases) and for prevention of rebleeding (99 of118 cases) was excellent. Uncontrolled bleed-ing in four patients and rebleeding in 19patients necessitated surgery, and bleeding wasinvariably due to erosion of a major artery.

Factors associated with failed EIT wereinaccessibility, torrential bleeding, and thecombination of spurting haemorrhage from avisible, protuberant vessel (p<005). Otherfactors were not significantly more frequent infailures. These included increasing age, shock,anaemia, NSAID usage, ulcer type (GU orDU), ulcer position, a protuberant non-bleeding vessel, and adherent blood clot orspots.

Clinical factors do not predict the success ofEIT but patients presenting with the combina-tion of active bleeding from a protuberantvessel should be considered for early surgery.

The shadow at the end of the tunnel:limitations of laser treatment for malignantdysphagia

E SHMUELI, M F MYSZOR, D BURKE, C 0 RECORD,K MATTHEWSON (Gastroenterology Unit, RoyalVictoria Infirmary, Newcastle upon Tyne) Eightysix patients (mean age 72-9 years) with malig-nant dysphagia that was considered inoperablewere treated by endoscopic Nd YAG lasertherapy. During therapy patients received amean of 2-6 laser sessions, and were in hospitala median of eight days. After therapy 58 (67%)patients could eat a normal diet and 10 (12%)could manage some solids. In eighteen (2 1%),treatment was unsuccessful, and in eight thiswas because of complications (two tracheo-oesophageal fistulae, three perforations, andthree pneumonia). Nine had an endoprosthesisinserted. Forty four of the 65 initially success-fully palliated had recurrent dysphagia after amean of 7-8 weeks. Nine were well palliatedwith further laser therapy alone and sixrequired an endoprosthesis. Twenty seven

required dilatation and laser therapy and ofthese, seven eventually required an endo-prosthesis. Overall, 22 patients (26%) requiredintubation. Endoprosthesis related mortalitywas two (11%), both related to perforationcompared with a laser related mortality rate of3.5%.

Endoscopic laser therapy can palliate amajority of patients with inoperable oesopha-geal malignancy, but is limited by the highdysphagia recurrence rate and need forrepeated therapy. Laser therapy and endo-prosthesis insertion should be used as comple-mentary techniques.

Controlied trial ofendoscopic injection treat-ment for bleeding from peptic ulcers withvisible vessels

R B G OXNER, N J SIMMONDS, D J GERTNER, J M D

NIGHTINGALE, W R BURNHAM (Department ofGastroenterology, Oldchurch Hospital, Romford,Essex) All patients with acute upper gastro-intestinal bleeding over 26 months were endo-scoped within 24 hours by an experiencedendoscopist (n=4). Of these, 79 patients had anulcer with a visible vessel (60 non-bleeding, 15oozing, four spurting) and were randomisedto injection or standard treatment alone.Injections of 1/10000 adrenaline (2 ml) wereplaced at three to four sites around the ulcer.Adrenaline and ethanolamine oleate 5% (1-2ml) were then injected directly into the vessel.The medical team managing the patient wasunaware of the endoscopic treatment.The two groups were similar for age (injected

65-5; control 70 4 years), initial haemoglobinconcentration (9-63 v 8-87 g/dl), shock (21 outof 41 zv 24 out of 38), and ulcer site. Majorrebleeding (7 v 18; p=0 008) and transfusionrequirement (5 v 8 units; p=0-011) weresignificantly reduced in treated patients. Thetreated group also had lower mortality (4 v 8),requirement for surgery (4 v 7) and reducedhospital stay (mean 7-1 v 9 5 days).

These preliminary results suggest that endo-scopic injection treatment in this high riskgroup significantly reduces rebleeding rate andtransfusion requirement and may have otherbenefits.

Experience with new percutaneous biliaryendoscopes in the gall bladder and bile duct

R H T LOKE, P I CRAIG, A R W HATFIELD, S P LAKE

(Department of Gastroenterology, MiddlesexHospital, London) We report our experiencewith two prototype biliary endoscopes(Olympus; 10 and 12FG) over the past 10months. Twenty five patients (19 females; sixmales), median age of 66 (range 28 to 88 years),underwent percutaneous cholecystoscopy (14)or choledochoscopy (11) under minimal seda-tion. Of the 14 gall bladder patients, two hadretained stones after conventional percu-taneous cholecystolithotripsy and 12 wereexamined after percutaneous rotary cholecy-stolithotripsy, six of whom had retained gallbladder stones. The gall bladder and cysticduct were cleared in all eight patients, two ofwhom needed direct contact lithotripsy (3 FGelectrohydraulic probe).

Eleven patients had choledochoscopy (eightT-tube, three transhepatic); of these, four hadstones above a stricture and five had previoussurgical or endoscopic duct drainage. Stoneswere successfully removed in 10 of the 11patients, four needing percutaneous biliary


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dilatation and electrohydraulic lithotripsy.The one failure needing later ERCP andsphincterotomy.

Patients tolerated the procedures extremelywell with no major morbidity or mortality.This offers an exciting new treatment optionfor retained stones after percutaneous gallbladder procedures and difficult bile ductstones, particularly those above strictures.

A study of microwaves for haemostasis andtumour destruction in gastroenterology

A KALABAKAS, A PORTER, M BIRCH, C P SWAIN

(Departments of Medical Physics and Gastro-enterology, The Royal London Hospital, London)We designed, built, and tested a prototypemicrowave generator and delivery system foruse in gastroenterology. Using a 650 W, 2450MHZ magnetron, 0-160W was generated via awaveguide from the tip of a 180 cm flexiblecoaxial cable. We studied non-contact, contact,and interstitial thermal effects of microwaveson necropsy liver and stomach. Using thermo-couples, temperature gradients were measuredat points distal to thermal contact. Microwavepower was monitored by radiofrequency powermeter and correlated with calorimetricmeasurements. Maximum temperatureachieved in the stomach was 60°C on serosa atoptimal haemostatic settings (160°C comparedwith Nd:YAG laser p<005). We establishedpredictable relations between energy andthermal injury using non-contact, contact, andinterstitial methods. Two methods ofachievinghaemostasis with microwaves were identifiedstudying standard bleeding canine ulcers. (1)Contact method: inserting coaxial needle coreinto tissues and heating slowly until bleedingstopped. (2) Non-contact method: microwaveinduced sparking (dielectric breakdown) - tipheld 1 mm from tissue - was more rapidlyeffective and caused less tissue damage. Micro-wave coagulation was significantly superior topolidocanol 1%+adrenaline 1:10000 injectionstopping. 20/20 v 0/20 standard bleeding ulcers(p<005) and 10/10 v 0/10 iesenteric andserosal vessels (p<0 05).Microwave field depth is better controlled

than radio frequency current and is less likelyto be obstructed by smoke, bubbles, and bloodthan endoscopic laser therapy. Microwavesystems should cost 10 times less than lasers.Microwaves look promising for haemostasisand tumour destruction at flexible endoscopy.

Role of endoscopic interstitial photodynamictherapy in gastrointestinal neoplasia

P T CHATLANI, H BARR, N KRASNER, S G BOWN

(National Medical Laser Centre, The RayneInstitute, UCL, London and Walton Hospital,Liverpool) Although we primarily treat patientsreferred for palliation of upper and lowergastrointestinal (GI) tumours with endoscopicNd:YAG laser therapy, 22 patients withtumours thus treated were also treated withphotodynamic therapy (PDT) with a view tolocal eradication of their tumours - five upperGI carcinomas, 12 lower GI carcinomas, andfive sessile rectal villous adenomas.

Sensitisation was with 2 5 mg HpD, intra-venously, 48 hours before tumour assessmentand PDT. Immediately before PDT, mucosaldimensions or length of segment of gutinvolved were measured endoscopically and,with colorectal carcinomas, when possible themaximum depth of tumour was measured

using endoluminal ultrasound. PDT wascarried out using (630 nm) light doses of 50J(100 mWx500 s) at each treatment site, withone treatment site for each cm2, up to amaximum of seven treatment sites (treatmenttime one hour). Light from an argon ionpumped dye laser was delivered using a planetip fibre inserted 1-2 mm into the tumour.Follow up was by endoscopy at one week andone month after PDT, and at one month,endoluminal ultrasound and biopsy were alsoperformed.

Local necrosis was achieved in 21 of 22patients. When maximum tumour depth wasmeasured, the mean depth of tumour removedwas 6 mm. Only tumours <2 cm in mucosalextent were eradicated - three carcinomas andthree adenomas - with local disease freeintervals ranging from nine to 40 months. Withrectal carcinomas, little change in symptomswas noted if much tumour remained. Healingwas by regeneration of normal mucosa iftumours were eradicated. Only two complica-tions occurred - a mild sunburn and a lower GIbleed requiring transfusion of 2 units of blood.We conclude that endoscopic interstitial

PDT is a safe therapeutic modality with thepotential for cure of small lesions <6 mm indepth and <2 cm in mucosal extent, in patientsin whom surgery is inappropriate or, perhaps,as primary treatment in patients with early orsuperficial tumours, particularly those locatedin strategically important areas, such assphincters.

PHARMACOLOGY AND THERAPEUTICS

Enalapril and sclerotherapy of oesophagealvarices

P SVOBODA J OCHMANN (INTRODUCED BY

R SHIELDS) (Institute for Research of SpecialSurgery 662 50 Brno, Czechoslovakia) Thehaemodynamic effects of longterm (threemonths) treatment with enalapril, a potentangiontensin converting enzyme inhibitor,were studied in 12 randomly selected patientswith portal hypertension and previous episodeof haemorrhage from oesophageal varices. Allpatients had injection sclerotherapy of varicesat weekly intervals. There was a control groupof 13 patients treated only with injectionsclerotherapy and placebo.

After three months, the wedged hepaticvenous pressure (25.5 (4.8) v 21-3 (4.8) mmHg) and the wedged free hepatic venous

pressure gradient (17-0 (6.0) v 12-6 (3.4) mmHg) were significantly lower than the basalvalues (p<0-01) in the group treatedwith enalapril. In the group treated withsclerotherapy+placebo this pressure reductionwas not observed. Systemic haemodynamicsand liver function tests did not change duringthe treatment.We conclude that enalapril lowers portal

pressure in patients with portal hypertension(although not in all of them) and may be usedwith good effect to manage patients with oeso-

phageal varices in combination with sclero-

therapy.

Ranitidine bismuth citrate, a novelcompound possessing gastric antisecretory,mucosal protective, anti-pepsin and anti-Helicobacter properties

A BAXTER, C J CAMPBELL, N M CLAYTON, J WCLITHEROW, A A MCCOLM, R STABLES (INTRO-DUCED BY K T BUNCE) (Glaxo Group ResearchLtd, Ware, Herts and Greenford, London) Thenovel compound, ranitidine bismuth citrate(RBC), was evaluated for gastric antisecretory,mucosal protective, anti-pepsin and anti-Helicobacter pylori properties. In Heidenhainpouch dogs RBC and ranitidine hydrochloridedosed orally at 0-1 and 0.3 mg ranitidine/kg,produced similar dose related inhibitions ofhistamine induced gastric acid secretion. Inrats dosed orally with 1 ml ethanol, RBCinhibited the resultant gastric mucosal damagewith an ED50 of 9-3 (3.2-27) mg/kg po,whereas ranitidine hydrochloride was inactiveat 100 mg/kg po. The activity of four humanpepsin isoenzymes, determined in vitro at pH1-7, was inhibited by RBC at a concentrationequivalent to 1 mM bismuth as follows: pepsin1 by 81 (5)%; pepsin 2 by 37 (8)%, pepsin 3 by18 (4)%, and pepsin 5 by 32 (2)%. Ranitidinebase had no significant activity at 1 mM. RBCinhibited Helicobacter pylori in vitro with anMIC (range) of 8 (4-32) [sg bismuthlml, butranitidine hydrochloride had negligibleactivity. Ferrets naturally infected with therelated bacterium H mustelae were dosed forfour weeks with vehicle or RBC at 24 mg/kg bdand their H mustelae status was assessed atintervals by gastric biopsy. All control animalsremained colonised withH mustelae at two andfour weeks, but in 60 ferrets treated with RBCapparent clearance ofH mustelae was producedin 42% at two weeks, and 69% at four weeks.Longer term eradication was seen in 10% of theanimals.

This profile of action suggests that ranitidinebismuth citrate should be evaluated in thetreatment of peptic ulcer disease in man.

A two week eradication regime formetronidazole resistant Helicobacter pylori

R P H LOGAN, P A GUMMETT, N Q KARIM, M M

WALKER, J H BARON, J J MISIEWICZ (ParksideHelicobacter Study Group, Central Middlesexand St Mary's Hospital, London) In the UK,20% of Helicobacter pylori strains are resistantto metronidazole (MR Hp). We have pre-viously shown that presence ofMR Hp causesthe failure of eradication by conventionaltherapies. At present there is no acceptedeffective treatment for MR Hp. This studydetermines the eradication rate with a new twoweek eradication regimen consisting ofomeprazole 40 mg mane and amoxycillin 500mg qds for 2 weeks (days 1-14), with De-noltablets 1 qds (days 1-7), and ciprofloxacin 750mg bd (days 7-14).

In 19 patients (11 men, median age 35 years,range 17-72) with DU (n= 15) or NUD (n=4)H pylori was detected by antral histology(H&E/Gimenez), culture (selective/non-selective media), and positive '3C-urea breathtest ('3C-UBT, positive result=excess6'3C02>5 ppm). All patients had failed a oneweek eradication regimen and were known tohave MR Hp by simple disk testing (5 [ig Mastsensitivity disks) before starting treatment.Clearance was determined by '3C-UBT at theend of treatment and eradication by '3C-UBTat one, three, and six months. To confirmeradication, endoscopy and biopsy were doneone month after the end of treatment.H pylori was cleared in 16 of 19 (84%)

patients at the end of treatment and success-fully eradicated one month after finishingtreatment in 14 of 19 (74%). Negative '3C-UBT's were maintained for a median follow up

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of 2-4 months (range 1 5-6 months). Thetreatment was well tolerated. The five patientsin whom MR Hp was not eradicated compliedwith the treatment. These results suggest thattwo week's treatment with this regimen canachieve a 74% eradication rate ofMR Hp.

SHT3 antagonists: a role in irritable bowelsyndrome and non-ulcer dyspepsia?

D G MAXTON, C G HAIGH, P J WHORWELL(University Hospital of South Manchester,Didsbury, Manchester and Glaxo GroupResearch, UK) 5HT3 antagonists affect gutmotility and visceral sensitivity and may be oftherapeutic benefit in irritable bowel syndrome(IBS). Ondansetron, a selective 5HT3 antago-nist, was therefore evaluated in IBS.

Fifty IBS patients (age: 22-65 years, 1 IM39F) were randomised into a double blind,placebo controlled crossover trial. A two weekbaseline was followed by two treatment periodsoffour weeks separated by a two week wash outphase. Active treatment was ondansetron 4 mgtds. Efficacy was assessed by recording changesin abdominal pain, distension, bowel habit,and a variety of 'non-colonic' features.

Stools became firmer in 21 patients onondansetron compared with only four onplacebo (p<0-001). The effect was primarily indiarrhoea predominant patients where stoolconsistency improved in 13 of 28 on activetreatment compared with two on placebo(p=0i002), with daily bowel actions alsodecreasing (2-9 (2-1) v 2-0 (1-4), mean (SD),p=0 04). Ondansetron did nqt adversely affectbowel habit in patients with constipation.Ondansetron led to a pronounced improve-ment in upper gastrointestinal symptoms suchas postprandial discomfort (p=0 008), flatu-lence (p=0 02), and heartburn (p=0(003).Abdominal pain, distension, nausea, tiredness,and back pain were unchanged.

In conclusion, ondansetron may improvebowel function in diarrhoea predominantIBS. The effects on upper gastrointestinalsymptoms also suggest a role in non-ulcerdyspepsia.

Inhibition of leukocyte adhesion moleculeexpression: a novel mechanism of action ofsulphasalazine

S M GREENFIELD, A S HAMBLIN, N A PUNCHARD,R P H THOMPSON (Gastrointestinal Laboratoryand Department of Immunology, St Thomas'sHospital, London) Sulphasalazine (SASP) mayreduce inflammation in inflammatory boweldisease (IBD) by inhibiting leukocyte recruit-ment into the bowel. Recruitment dependsupon leukocyte adhesion to vascular endo-thelium, a process in which the adhesionmolecules CD1 1/CD18 may play an importantrole. We have investigated the effects of SASPupon TNF-induced upregulation of leukocyteCD11/CD18.TNF (160 pg/ml) was incubated for 30

minutes with 0 5 ml heparinised blood from sixhealthy volunteers±SASP (10-5-10-3 M).Leukocyte suspensions were obtained and thebinding of monoclonal antibodies againstCD1la, CDl1b, CD11c, and CD18 was deter-mined by flow cytometry. The intensity ofantigen expression was measured as meanfluorescence intensity (MFT).TNF increased mean MFI (SEM) ofCD1 lb

and CD18 on granulocytes compared withcontrols (no TNF) from 100-4 (11-0) to 135

(15-7) and from 84-8 (6-1) to 141-2 (10-2),respectively (both p<0 05, Wilcoxon signedrank test). 10-3M SASP inhibited thisupregulation ofCD1 lb and CD18 by 66 (20)%(p<005) and 94 (8)% (p<0-01), and 10-4MSASP by 91 (15)% (p<0-01) and 95 (7)%(p<001), respectively. TNF increased meanMFI ofCD1 lb and CD18 on monocytes (1 14-4(25 5) to 202 (28 2) and 116-3 (11-3) to 279-2(31-0), respectively; both p<0-01). 10-3MSASP inhibited this upregulation by 65 (20)%(p<005) and 90 (18)% (p<0-01) respectively,while 10-4M SASP inhibited CD18 upregula-tion by 89 (28)% (p<0-01), but had no effect onCD1 lb data. 10-5M SASP did not affectCD1 1/CD18 expression.SASP at concentrations found in blood in

vivo appreciably inhibited cytokine inducedupregulation of CD1lb and CD18 moleculeson monocyte and granulocytes. Thus, SASPmay reduce cellular recruitment in IBD byinhibiting adhesion molecule expression.

Immunological effects of elemental diet ininflammatory bowel disease - a prospectivestudy

O MWANTEMBE, A FERGUSON (Gastro-IntestinalUnit, University of Edinburgh and WesternGeneral Hospital, Edinburgh) Elemental dietsare as effective as corticosteroid therapy ininducing remission in Crohn's disease but thebeneficial mechanism of these diets remains tobe elucidated. Patients were treated withelemental diet (eo28) for a period of at leastseven days and 15 remitted. Blood and salivawere collected in 22 patients and in seven casesintestinal secretions were collected before andafter treatment. Antibodies to B-lactoglobulin,ovalbumin, and gluten in the IgA, IgG, andIgM classes were measured in all specimens byELISA. In nine patients, the values of cell freeinterleukin 2 receptor in serum and lavagebefore and after treatment were also measured.There was no significant change after

elemental diet in titres of food antibodies in anyof the specimens before and after the diet andthere were no significant changes in the num-bers of antibody secreting cells (ELISPOT).Conversely, a dramatic fall in the levels of cellfree interleukin 2R in lavage was found in thepatients who improved.The striking reductions in cell free inter-

leukin 2R suggests that elemental diet maywork by down regulating T cell activity (IL-2Ris a marker of T cell activity). This is the firstevidence of a possible mode of action ofelemental diet in inflammatory bowel disease.

Octreotide inhibits the growth of liveradenocarcinoma in an animal model of livermetastases

N DAVIES, J YATES, B A TAYLOR, S A JENKINS(University Department ofSurgery, Royal Liver-pool Hospital, Liverpool) The treatment ofmetastatic liver cancer remains poor, themajority of patients dying within one year ofdiagnosis. Adenocarcinoma is the commonestcancer metastatic to the liver. Octreotide, along acting analogue of somatostatin alters liverblood flow, stimulates reticuloendothelialsystem activity, and inhibits a wide variety oftrophic hormones. We have investigated itseffects on the growth and development ofhepatic adenocarcinoma induced by intra-portal inoculation of tumour cells.

After intraportal injection of 1 x 107 K12/Tr

cells (an adenocarcinoma of colonic originsyngeneic to the BDIX rat), groups of 12 ratsreceived either octreotide 2 [tg bd or saline(control). At four weeks there was a significantreduction (Mann-Whitney U, p<0-001) in thenumber oftumour nodules in the treated group(median 3 (range 7-0) compared with controlsmedian 21 (range 33-24)). Furthermore notumour was present in four of 12 livers in thetreatment group.These results indicate that octreotide signifi-

cantly inhibits growth and development ofhepatic adenocarcinoma of colonic origin in therat and may be of benefit in the treatment ofhepatic metastases in man. Further studies arerequired to evaluate this hypothesis.

Gall stones and longterm treatment withoctreotide

J V ANDERSON S M CATNACH, P D FAIRCLOUGH,G M BESSER, J A H WASS (Departments of Endo-crinology and Gastroenterology, St Bartholomew'sHospital, London) Octreotide is used long termin the management of acromegaly, to suppressgrowth hormone secretion. Its use has beenassociated with an increased prevalence of gallstone formation, although the prevalence ofgall stones in untreated acromegalics isunknown. We have performed gall bladderultrasound scans on 39 acromegalic subjectsbefore octreotide therapy.

Six of these had gall stones, no more thanwould be expected in a normal population ofsimilar age and sex. We studied 25 of thesepatients after treatment with octreotide and 12further patients who had not had a pretreat-ment scan. Fifteen of these 37 patients had gallstones, significantly more than those on notreatment.The mean length of treatment with

octreotide in those with stones was 21-7 (4.8)months compared with 16-3 (2.7) months inthose who did not have stones (p<001). Thereseemed to be a linear relation between durationof treatment and incidence of stones. In 'stoneformers', the stone burden increased rapidlyonce stone formation had started.

In conclusion, octreotide therapy is associ-ated with gall stone formation in acromegalics,and the incidence of stones is related to theduration of treatment.

NUTRITION: APPETITE AND SATIETY

Fat induces small intestinal satiety at a lowercaloric threshold than carbohydrate orprotein

J G GEOGHEGAN, D C LAWSON, C A CHENG, T NPAPPAS (INTRODUCED BY P B COTTON) (DukeUniversity and Veterans Administration MedicalCenters, Durham, North Carolina, USA)Nutritive substances in the small intestinecause satiety signals that probably regulate theintermeal interval. This study investigates therelative potency of carbohydrate, fat, andprotein in induction of small intestinal satiety.

Six dogs were prepared with oesophagealand gastric fistulas. Isovolumetric nutrientinfusions were given over two hours throughduodenal catheters passed through the gastricfistula. Each nutrient was given over a range ofcaloric levels to identify its satiety threshold.Satiety was measured by sham feeding at the

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end of each infusion. Intraduodenal fatinfusion significantly suppressed sham feedingwith just 5% of the total 24 hour caloricrequirement. For carbohydrate and proteininfusions the thresholds for suppression ofsham feeding were 10% and 20% of total 24hour caloric requirement respectively.

In conclusion, (1) small intestinal satiety canbe produced by a small fraction of the 24 hourcaloric requirement. (2) The three classes ofmacronutrients have different caloric thres-holds for small intestinal satiety. (3) Fat has thelowest threshold, followed by carbohydrateand then protein. Small intestinal satiety maybe mediated by mucosal chemoreceptorssensitive to specific nutrients and not post-absorptive calorie dependent mechanisms.

Intragastric lipid administration dosedependently increases gastric complianceresponses to distension

L TRONCON, D G THOMPSON, N AHLUWALIA, JBARLOW, L HEGGIE (Department of Medicine,Hope Hospital, Salford) The proximal stomachresponds to distension by increasing its compli-ance, which allows volume accommodationwithout substantial rise in intragastricpressure. It has also been suggested that com-pliance may be increased by food, although thenutrient component responsible is uncertain.In the present study we assessed the effects oncompliance of a series of meals varying in lipidconcentration.

Thirteen healthy volunteers underwent 36experiments. After an overnight fast a 1200 mlballoon attached to a gastric tube and con-nected to pressure sensors was positioned in thegastric fundus. Gastric compliance wasassessed by measuring intragastric pressureduring stepwise balloon distension both fastingand after the test meal. Six isomolar meals (250ml) were given in random order. Meals were280 mOsm saline and 1-25, 2.5, 5.0, 10-0, and20% Intralipid diluted in saline. The resultswere expressed as slope values (x 10- 5) of logtransformed volume:pressure data.

Saline did not affect gastric compliance(fasting v fed, median: range 105: 80-118 v104: 43-185, p>0-10) not did the 1-25% (105:86-124 v 113: 66-122, p>005) or 2.5% (108:60-129 v 82: 30-125, p>0 05) fat emulsions.Increasing fat concentration to 5.0% (90: 59-203 v 32: 17-115, p<0 05), 10-0% (91:62-106v 43: 20-48, p<0 05) and to 20-0% (66: 46-96v 25: 15-57, p<0 05) resulted in significantincreases in gastric compliance. A positivecorrelation was found between lipid concentra-tion and the intensity of the gastric complianceeffect in the range of 1-25 and 5.0% fatconcentration (R=0-62, p<005).

In conclusion, these results indicate thatlipid ingestion enhances gastric compliancethrough a pathway sensitive to lipid concentra-tion which is likely to make a major contribu-tion to the gastric emptying delay known to beinduced by lipid meals.

Plasma cholecystokinin response to a verylow calorie diet

R J LIEVERSE, J B M J JANSEN, A P VAN SETERS, C B

H W LAMERS (Departments of Gastroenterology-Hepatology and Endocrinology, UniversityHospital, Leiden, The Netherlands) Very lowcalorie diets cause more extensive weight losswith less hunger feelings when compared with

conventional weight reducing diets. It has beensuggested that the release of cholecystokinin(CCK) may be involved in the induction ofsatiety after a meal. Therefore we have studiedthe release of CCK in response to a very lowcalorie diet (Modifast) and we have comparedthese results with those obtained with a normal410 kcal meal.

Seven otherwise healthy obese subjects (fiveF, two M; mean age 34 years, range 23-44)with a body mass index of 40 (range 32-50) kg/m participated in a 10 week study on the effectof 3 dd 80 kcal Modifast on weight reduction,CCK-release, and hunger scores. They all hadnormal total serum T4 values and respondedadequately to 1 mg ofdexamethasone given theprevious evening at 23.00 (morning cortisol<0-08 [smol/l). Hunger scores were measuredwith 10 point visual analogue scales duringthree consecutive days before every meal andbefore the night. The sum divided by 12 is thehunger score. CCK release was studied inresponse to a normal 410 kcal meal (protein 19E%, fat 59 E%, carbohydrate 22 E%), a 387kcal of commercial liquid food meal (13 E%protein, 31 E% fat, 55 E% carbohydrates) andan 80 kcal Modifast (55 E% protein; 2-6 E% fat,42-3 E% carbohydrates) meal. Plasma CCK(antibody T204) was measured by a sensitiveand specific radioimmunoassay at -10, 0, 10,20, 30, 40, 50, and 60 minutes after the meals.Differences were tested for significanceemploying the Wilcoxon signed rank test.

During the 10 week treatment course withModifast, mean body weight was reduced from122 (9) kg (mean (SEM)) to 99 (7) kg (p<002).Hunger scores decreased from 3 8 (0.7) to 0.9(0.3) (p<0 05). The integrated CCK responsefrom 0-60 minutes to a Modifast meal was 138(21) pM.h. (After 10 weeks of Modifast treat-ment 100-8 (19-1).) These results were notsignificantly different from the CCK-responseto the normal meal (86 (13) pM.h) or the liquidfood meal (93 (14) pM.h) containing about fivetimes more calories.

In conclusion, the relatively high release ofCCK in response to only 80 kcal of Modifastmay be involved in the satiety effects inducedby a very low calorie diet.

Bombesin reduces food intake in lean but notobese man

R J LIEVERSE, J B M J JANSEN, A VAN DE ZWAN,L SAMSON, A A M MASCLEE, C B H W LAMERS(Department of Gastroenterology-Hepatology,University Hospital, Leiden, The Netherlands)The mechanisms that induce satiety are notclear. Studies in a variety of species have shownthat both bombesin (BBS) and cholecystokinin(CCK) are able to induce satiety. Since BBS is apotent stimulus of CCK release, the effects ofBBS on food intake may be mediated by therelease of CCK. The availability of the potentand specific CCK receptor antagonistloxiglumide (LOX) has enabled investigationof the role of CCK in BBS induced satiety. Inthe present study we have examined the effectof BBS on food intake in lean and obese man.Nine healthy lean volunteers (four M, five F;

mean age 25 years (range 22-36)) with a medianbody mass index of 22 (range 20-25) kg/mi2 andnine otherwise healthy obese volunteers (nineF; mean age 40 years (range 30-59)) with amedian body mass index of 40 (33-49) kg/mr2were studied. In a double blind fashion theyreceived either saline iv or BBS (375 [sg/kg leanbody mass. 150 min iv). Sixty minutes after thestart of the infusions an identical meal waspresented and each subject was free to eat as

much as he or she wanted. In the lean volun-teers, the BBS experiment was repeated with abackground infusion of LOX (25 mg/kg. 150minutes). Feelings of hunger and fullness werescored on visual analogues scales.Bombesin significantly decreased food

intake in lean volunteers from 602 (68) (mean(SEM)) g to 482 (74) g (p<0 01). Loxiglumidedid not affect the reduction of food intakeinduced by BBS (365 (69) g). Hunger andfullness feelings were also significantly influ-enced by BBS (p<0 05), but not altered byLOX. In obese volunteers food intake duringsaline infusion (499 (88) g) was not significantlyreduced by BBS (431 (60) g). Hunger andfullness feelings in these obese volunteers werealso not significantly affected by BBS. In bothlean and obese volunteers BBS infusionresulted in comparable plasma BBS and CCKvalues.

In conclusion, these data indicate that BBSreduces food intake and hunger feelings andinduces fullness in healthy lean volunteers.Obese volunteers are less sensitive to thesatieting effects of BBS. The BBS inducedeffects are not mediated by CCK.

Vertical gastric stapling without a band formorbid obesity

D WILKINSON, H SUE-LING, D JOHNSTON(University Department of Surgery, The GeneralInfirmary, Leeds) Vertical banded gastroplastyis an effective operation for morbid obesity butthe band is associated with complications. Analternative procedure has been developed inwhich no band is used. A longer stomach tubeis fashioned, starting at the angle of His andemptying adjacent to the crow's foot into theantral mill. Is this operation effective?Twenty patients (four M, 16 F, mean age 37

years, range 26-55) have undergone this opera-tion. Mean preoperative weight was 147-9 kg(range 108-222) and mean body mass index(BMI=weight/height2) was 53-6 kg/M2 (range42-87). Eighteen patients have been followedup for a mean of 21 months (range 12-36), twopatients have been lost to follow up.Mean postoperative weight was 109 kg

(range 76-193) and mean BMI was 39-3 kg/M2(range 28-53), often this took over one year toachieve. Mean percentage weight reductionwas 26- 1% (range 10-39), 12 patients lost morethan 25% of their body weight. Fifteen patientsare pleased with the results of their surgery andthree are disappointed. Two patients havebegun to increase their weight, after an initialfall.

This method of vertical gastric stapling,without the use of a band, is an effectiveoperation for morbid obesity.

LIVER DISEASE: PREVENTION AND TREATMENT

Experience with a pre-S containingrecombinant HBV vaccine: safety andimmunogenicity studies

I YAP, R GUAN, S H CHAN (Departments ofMedicine and Microbiology, National Universityof Singapore, Singapore) The only means ofpreventing the spread and subsequent chronicsequalae of chronic HBV infection is by activeimmunisation. Recent studies suggest thatinclusion of all HBV envelope polypeptides (S

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and pre-S) may increase the vaccine immuno-genicity.We studied the safety and immunogenicity

of a novel recombinant HBV vaccine contain-ing the pre-S components. Healthy volunteerswith no previous HBV infection were random-ised to receive three intramuscular doses ofeither 5 [ig (48 subjects) or 10 ,ug (49 subjects)ofthe vaccines at month 0, 1, and 6. One monthafter the third injection, 100% of the vaccineesseroconverted; 92% of the 5 [sg group and100% ofl0 [tg group had anti-HBs titre greaterthan 10 iu/l and the seroconversion rate did notchange at one year after vaccination. Thegeometric mean titres (GMT) of anti-HBsvalues at months 7 and 12 were similar in thetwo groups; 2162, 2687 iu/l (month 7) 734, 970iu/l (month 12) in the 5 and 10 ,tg groupsrespectively. Some 96% of the 10 pg groupwere seroprotected (GMT 182 iu/l) before thethird injection, and nearly 70% of all vaccineeshad an anti-HBs value more than 1000 iu/l atmonth 7. No unwanted effects were observed.This vaccine seems to be safe and ratherimmunogenic.

Endoscopic intravascular oesophagealvariceal pressure measurements: response tometoclopramide

C CIJEVSCHI, M STAN, E SANDULESCU, G BALAN,M FRASIN (University ofMedicine and Pharmacy,IInd Medical Clinic Gastroenterology, 6600 Iasi,Romania) Pharmacotherapy with intravenousmetoclopramide (M) has been reported to beeffective in the control of acute variceal bleed.This study reports the effects of M on intra-vascular oesophageal variceal pressure (IEVP)in patients with alcoholic cirrhosis. There were12 patients (10 men, two women), aged 35-68years with oesophageal varices caused byalcoholic cirrhosis. Six patients had recentlybled from their varices. The IEVP wasmeasured by endoscopicajly guided fine needlepuncture of the variceal columns 5 cm abovethe cardia. The needle was continuously per-fused with sterile saline (0.9%) and attached toa Statham gauge and the pressure values wererecorded on a Beckman writer. IEVP wascalculated taking the pressure in the oesopha-geal lumen as zero reference. IEVP wasmeasured before and after 10 mg intravenousM.

Metoclopramide caused a reduction in IEVPin 10 of 12 patients; overall, there was a fall inIEVP from 21-4 (3.5) mm Hg to 14-6 (2A4) mmHg (p<005). There were no complicationsrelated to the variceal puncture.

In conclusion, intravenous M, whichincreases lower oesophageal sphincterpressure, significantly decreases IEVP incirrhotic patients. However, to prove that M isa useful agent for the control of acute varicealbleeding, further studies are warranted.

Modifications of serum TNF and peripheralblood lymphocyte (PBL) subpopulationsduring recombinant a interferon treatment

F DE LAZZARI, G DE SILVESTRO, P FABRIS,M BORTOLAMI, A FLOREANI, C VECCHIATO,C VENTURI, M CHIARAMONTE (Department ofGastroenterology and Blood Bank, University ofPadova, Italy) Recombinant a interferon(ctINF) is an effective treatment for chronicviral infections, but up to now the specificinvolvement of T and B cell responses in viral

clearance has not been clarified. Ten patients(eight M, two F) enrolled in a clinical trial withrecombinant aIFN (raIFN) for chronic viralhepatitis (eight HCV related and two HBVrelated) were studied. Blood samples weretaken immediately before, and at six and 24hours and 15 and 30 days after parenteralinjections of raIFN (3 MU, three times aweek). aTNF was assayed by ELISA (Q-E-TNF, Nuclear Laser Medicine); peripherallymphocyte phenotypes (CD2, CD3, CD4,CD8, DR, CD20, T-DR, CD16, CD45RA,CD29) were tested by specific fluorescentmono-clonals (Ortho, Coulter) and then measuredwith a flow cytometric fluorescence technique(Ortho-Cytoron).The mean baseline value of serum aTNF

was 23-9 (5.5) pg/ml, which was not statistic-ally different from that observed after six and24 hours and 15 and 30 days of raIFN treat-ment. No differences were observed in anyPBL subpopulations except for NK (CD16+cells) with regard to the percentage and theabsolute number, comparing baseline values(12-1 (7.6)% and 319-8 (188)) with those at 30days (8-2 (8.2)% and 201-8 (189)), p<0 009.No correlation was found between aTNFserum values and PBL subpopulations.

In conclusion, these data suggest that raIFNcan induce an early viral challenge with subse-quent mobilisation of NK population fromperipheral blood to the liver where they prob-ably play a role in the cytolitic response.

Interstitial laser hyperthermia: a percutane-ous therapy for inoperable liver metastases

A MASTERS, A C STEGER, W R LEES, K MWALMSLEY, S G BOWN (Departments of Surgeryand Radiology, University College andMiddlesexSchool ofMedicine, London) There is a need fora simple and safe palliative treatment forinoperable discrete hepatic metastases.Interstitial laser hyperthermia (ILH) is a newtechnique, simple in concept. A thin flexiblelaser fibre tip is inserted percutaneously into asolid organ tumour with absorption of emittedlaser light as heat producing an area of tumournecrosis which subsequently heals byregeneration/fibrosis. Experimental studies innormal liver have shown ILH to be effectiveand safe. In a pilot clinical study, the feasibilityand safety of this technique for inducingnecrosis in hepatic metastases was studied.Ten patients (aged 46-78 years) with a total

of 18 metastases (diameter 2-0-6.5 cm) and noextrahepatic disease were treated on 31occasions using a Nd:YAG laser. Some 70% ofmetastases had arisen from the colon/rectum.Under intravenous sedation, three to fourhollow 19 G needles were inserted per-cutaneously in juxtaposition into a selectedmetastasis under ultrasound control (US). A200 i laser fibre was inserted down each fibreso the tip lay within the tumour, which wasirradiated using a power of 1-5 to 2-0 wattsapplied for 500 seconds. There were no com-plications and all patients were dischargedwithin 24 hours of treatment. Real time USmonitoring during treatment showed conver-sion of the metastases from a predominantlymixed echogenic appearance to a hyper-echogenic pattern. Follow up computedtomography at six to eight weeks showedradiological evidence of at least partial necrosisin 10 of the 18 metastases. Of smaller meta-stases (diameter -3-0 cm, n=9), seven showedthe largest percentage necrosis by volume (30-100%) with biochemical and radiological

evidence ofarrested growth on longer follow up(median=6 months) in five.ILH is a safe and simple technique produc-

ing radiological evidence of necrosis in smallmetastases and is worthy of further evaluation.

Does a interferon priming enhance theefficacy ofsubsequent a interferon therapy inchronic hepatitis B virus infection?

A P CATTERALL, R KING, J Y N LAU, H M DANIELS,G J M ALEXANDER, I M MURRAY-LYON, ROGERWILLIAMS (Institute of Liver Studies, King'sCollege School of Medicine and Dentistry,London and Department of Gastroenterology,Charing Cross Hospital, London) a Interferon(aIFN) is an established treatment for chronicHBV infection but only 30-50% of the patientsrespond successfully in terms of e-seroconver-sion and sustained loss of serum HBV DNA.To determine whether a priming course ofaIFN enhances the efficacy of subsequenttherapy, we conducted a randomised trial tocompare aIFN priming (aIFN for one month,no treatment for one month) followed bystandard aIFN therapy (aIFN for threemonths) with standard aIFN therapy (aIFNfor three months) with standard aIFN therapyalone (lymphoblastoid aIFN 10 MU thriceweekly).Some 35 patients seropositive for HBsAg

(>12 months), HBeAg and HBV DNA, andwith histological evidence of active liver inflam-mation, were recruited. They were all sero-negative for markers of HDV but seven wereseropositive for HIV. Twenty nine patientsattended at least eight months' follow up; 16received aIFN priming and therapy and 13received aIFN therapy alone. Side effects(pyrexia, fatigue) were mild and well toleratedand were the same in both groups.These data suggest that a short priming

course of aIFN may augment the developmentof anti-HBe achieved with the standard threemonth course of aIFN therapy.

Ursodeoxycholic acid treatment in activecirrhosis with or without hepatitis C virusantibodies

F LIRUSSI, A BECCARELLO, L OKOLICSANYI(Institute of Internal Medicine, University ofPadua, Italy) Ursodeoxycholic acid (UDCA)improves liver function tests (LFTs) in chole-static disorders. However, little is known aboutits effect in patients with established cirrhosisof different aetiology. We therefore gaveUDCA (600 mg/day) to 17 anti-HCV positive(+ve) and 12 (eight with previous HBV infec-tion, four alcoholics) anti-HCV-ve patientswith Child's A cirrhosis plus chronic activehepatitis for 13-3±0-7 months (range 8-20)and 10-2±1-3 months (range 6-18) respect-ively. Treatment efficacy and safety wereassessed by six monthly changes in routineLFTs, galactose elimination capacity (GEC),and antipyrine clearance (APCL) as comparedwith pretreatment values.

In anti-HCV-ve cirrhosis, ALT decreasedfrom mean (SEM) 138 ull (32) to 79 (12)(-43%), AST from 97 u/l (16) to 63 (8)(-35%), and y-GT from 111 u/l (27) to 63 (16)(-43%). In the anti-HCV+ve group serumtransaminase values were slightly reduced (12-14%), whereas y-GT values dropped from 135u/1 (34) to 57 (14) (p<0 05). Mean serumalkaline phosphatase and total bilirubin values,which were normal before therapy, changed

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little after UDCA treatment. Similarly, GECand APCL, which were considerably impairedat entry, showed only modest changes through-out the treatment period.

In conclusion, in patients with anti-HCV-ve active cirrhosis, UDCA was welltolerated and improved some indices of liverinjury. By contrast, the 'activity' of chronicliver disease associated with HCV infection wasnot influenced by UDCA treatment, thoughy-GT values returned, on average, to normalvalues.

Aprotinin improves renal function incirrhosis with ascites

A J MACGILCHRIST, A CUMMING, K CRAIG, I A DBOUCHIER, P C HAYES (University Department ofMedicine and Gastrointestinal/Liver Service,Royal Infirmary, Edinburgh) Several vaso-dilators have been found in increased amountsin cirrhosis and have therefore been implicatedin the arterial vasodilatation which may triggersodium retention in these patients. However,none has proved causal due to a lack of studiesemploying appropriate antagonists. We havepreviously shown that the plasma kallikrein-kinin system is activated in cirrhosis (Gut 1989;30: A1505). This potent vasodilator system canbe inhibited by aprotinin ('Trasylol').We measured renal function (including

clearance of inulin and para-amino hippurate)and systemic haemodynamics (includingcardiac output by thermodilution) in eightcirrhotics with ascites before and during anintravenous infusion of aprotinin. Patientswere on no diuretics and 40 mmol of sodium/day. Renal blood flow increased from mean(SEM) 454 (54) to 663 (65) ml/minute, p<0 05and glomerular filtration rate increased from 72(10) to 121 (19) ml/minute, p<0 05. Renalsodium excretion increased in seven patients bya mean of 15 1%, and plasma renin fell in allpatients from 10.0 (2.9) to 5.9 (1.9) (bothp>0 05). Aprotinin increased systemicvascular resistance and lowered cardiac outputin five of the six patients with low baselinevalues.

Thus, aprotinin improves renal function incirrhosis with ascites, associated in most caseswith a reduction in systemic vasodilatation.This study supports the arterial vasodilatationtheory of ascites and implicates the plasmakallikrein-kinin system in its pathogenesis.

Treatment of active cirrhosis B with hy-droxychloroquine: longterm follow up of anopen study

E A KOUROUMALIS (Academic Departmentof Gastroenterology, University Hospital,Heraklion, Crete, Greece) Treatment of activecirrhosis in HBsAG +ve anti-HBe +vepatients is controversial. Interferon does notseem to be indicated. Hydroxychloroquine, alysosomotropic agent, was found to be effectivein reducing spontaneous cytotoxicity in anvitro system, in a dose dependent manner.Twenty patients, all with active anti-HBecirrhosis, entered an open study receiving 200mg hydroxychloroquine tid for three monthswith regular monitoring of liver function tests.They have been followed up for 3-6 years(median 4.5 years). Five patients with ascites atthe time of presentation were also included.

All 20 patients responded after one month oftreatment with reduction of aminotransferasesand improvement of prothrombin time. In 17

of 20 aminotransferases became normal. Allfive patients with ascites showed no response.Fifteen of 20 relapsed after a mean of threemonths. All responded to a second three monthcourse and are maintained so far with furthercourses upon reactivation. Five of 20 had apermanent biochemical response, all with lowanti-e titres. Two patients died from varicealbleeding at two and four years. No occular sideeffects were noted. Liver biopsy at one year inseven of 20 showed inactive cirrhosis.

In conclusion, (1) hydroxychloroquine is asafe, very cheap, and effective drug for activecirrhosis. Relapses of disease respond equallywell. (2) Piecemeal necrosis disappears duringremission. (3) Patients with high titres of anti-etend to relapse. The drug is not active inpatients with ascites.

PAEDIATRIC SECTION

Aztreonam prevents necrotising enterocolitisin premature neonates

P M MACKAY, M R MILLAR, M I LEVENE,V LANGDALE, N WILD, j W L PUNTIS (Departmentof Paediatrics and Child Health, Leeds GeneralInfirmary, Leeds) Previous work has implicatedbowel colonisation with enterobacteriaceae in

the pathogenesis of necrotising enterocolitis(NEC), a major cause of morbidity andmortality in the premature newborn. We have,therefore, examined the effect of aztreonam,an antibiotic with selective activity for entero-bacteriaceae, on bowel flora and the incidenceof NEC. Infants <32 weeks gestation were

randomised to receive treatment with intra-venous aztreonam and vancomycin (group A,n=72), or gentamicin and vancomycin (groupB, n=7 1) in the event of suspected infection ata postnatal age >7 days. Stool samples were

collected prospectively from birth. Forty seven

(65%) of group A and 52 (73%) of group Bsubsequently received antibiotics. Entero-bacteriaceae disappeared from the bowelwithin four days of treatment with aztreonambut were not affected by gentamicin. Group Ahad a lower incidence of bowel colonisation byenterobacteriaceae than group B at all ages >7days. There was no difference between groupsin colonisation with yeasts, anaerobes, or

enterococci. Eight infants in group Bdeveloped NEC, while none in group A were

similarly affected. Enterobacteriaceae were

present in the stools of all the six patients withNEC from whom stool samples were collectedin the 48 hours before diagnosis.

These findings suggest that aztreonam pre-vented the development of NEC in prematureinfants by suppressing bowel colonisation withenterobacteriaceae.

Therapeutic use of epidermal growth factorin necrotising enteritis

P B SULLIVAN, M J BRUETON, Z B TABAR, R A

GOODLAD, C Y LEE, N A WRIGHT (WestminsterChildren's Hospital and Imperial CancerResearch Fund, London) Epidermal GrowthFactor (EGF) stimulates epithelial cell pro-liferation in the intestinal mucosa, althoughthese properties have not found any notableapplication in enteric disease. Intravenoushuman recombinant EGF (100 ng/kg/hourinfused for six days) was used in a girl aged 8

months with necrotising enteritis in whichthere was dilatation and discolouration of thewhole bowel together with extensive mucosalsloughing. The response was assessed byjejunal mucosal morphology and estimation ofcrypt cell kinetics before EGF infusion (day 0)and days 2, 4, and 7 thereafter. Total villusatrophy and crypt destruction (day 0) werefollowed by crypt hyperplasia on day 2although villus atrophy persisted. By day 4,however, villus height had increased in associa-tion with a significant (p<0-01) increase incrypt mitotic activity. On day 7 the mucosalooked normal. Histological repair was accom-panied by gradual clinical improvement andthe patient made an uneventful recovery.These results show a significant increase in

crypt cell proliferative activity in associationwith noticeable recovery of the surfaceepithelium during EGF infusion and it isprobable that the rate of recovery exceeded thatwhich would be expected during normalmucosal regeneration after injury. Furtherstudies should be undertaken to establish thevalue of stimulated crypt regeneration inacquired enteropathies.

Transient precocious sucrase activity inrotavirus infected neonatal rats

M SHAHRIER, M W SMITH, M J G FARTHING,

j A WALKER-SMITH (The Medical College of StBartholomew's Hospital, London and Institute ofAnimal Physiology and Genetics Research,AFRC, Cambridge) It has been proposed thatneojnatal rotavirus infection results in morerapid maturation of small intestinal epithe-lium. To study this we infected 6 day oldneonatal rats with group B rotavirus andmeasured sucrase and maltase activity by bio-chemical, histochemical, and microdensito-metric techniques at 6, 12, 24, 120, 265, and360 hours post-infection (HPI).There was no measurable sucrase or maltase

activity in infected and control animals up to 24HPI. At 120HPI there was increased sucraseactivity (median 26.5, interquartile range 0-59pmol/min/g) in rotavirus infected rats com-pared with controls (2 5, 0-6 5; p<0 05).Sucrase activity was then undetectable ininfected and control rats at 264HPI (17 daysold) but reappeared at 360HPI (21 days old)rats at similar levels. Maltase activity wasincreased in rotavirus infected rats at 120HPI(200, 151-242 v 72, 47-122; p<0-01) andremained at this level up to 264HPI. Histo-chemical and microdensitometric assessmentsparalleled the biochemical assays.The precocious increase in sucrase and

maltase activity confirms the earlier maturationof intestinal epithelium during rotavirus infec-tion but the subsequent discordance betweenthese activities indicate differential effects ofrotavirus on enzyme expression.

Seroepidemiology of Helicobacter pyloriinfection in early childhood

J-E THOMAS, R B DOWNES, P G LUNN, C ANORTHROP-CLEWES, L T WEAVER (MRC DunnNutrition Unit, Keneba, The Gambia and Cam-bridge, UK) Helicobacter pylori infection iscommon in West Africa. Longitudinal studiesin Europe suggest that spontaneous resolutionof established infection is rare, but is notknown whether acute infection in early child-hood inevitably causes chronic disease.A total of 134 children (aged 1-15 months),

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from three Gambian villages were studied overtwo years. Specific IgG and IgM antibodies toH pylon (Hp-IgG, Hp-IgM) were measuredmonthly, using a previously validated ELISAtechnique.Twelve (9%) had high Hp-IgG values at one

month, which then declined. Forty four (33%)subsequently had diagnostically raised Hp-IgG, and 21 (15%) also showed a briefHp-IgMresponse. In 33 children (24%), raised Hp-IgGvalues returned to normal, although manybecame reinfected later. Only 21 (15%) hadestablished chronic infection by the end of thestudy. There were no nutritional differencesbetween cases and controls at seroconversion.

In a separate study in the same community,13C urea breath tests showed that 46 of 50(92%) 3-5 year olds were strongly positive forH pylori.

In conclusion, H pyloii infection is commonin The Gambia from an early age. Mostchildren can eradicate their first infection, butestablished infection is normal by 5 years.Clearing infection does not protect fromfurther disease, and undernutrition does notpredispose to H pyloni infection.

Vitamin E deficiency, lipid peroxidation, andsmall intestinal function in the Wistar rat

K J LINDLEY, M A GOSS SAMPSON, D P R MULLER,P J MILLA (Medical and Membrane BiochemistryUnits, Institute of Child Health, London)Increased concentrations of free radicals havebeen implicated in the cycle of malnutritionmalabsorption and infection leading to pro-tracted diarrhoea of infancy. Infection canproduce an oxidising stress in malnourishedchildren with low antioxidant defences.Vitamin E is the most important chain break-ing antioxidant in biological membranes.Unstripped jejuna from fasted 12 month oldvitamin E deficient and sufficient male Wistarrats were studied in an Ussing chamber. Basalshort circuit current (Isc) was higher indeficient animals (deficient 91 pA/cm2 (95% CI80-101) v control 73 gA/cm2 (67-79), n=40,p<005). Tissue resistances were comparable(72 Q/cm2 (67-78) v 77 Q1cm2 (68-86)). 10mMmucosal and serosal aminophylline producedgreater responses in deficient rats (56 ItA/cm2(40-72) v 34 pA/cm2 (25-43), n= 14, p<0 05),as did mucosal Escherichia coli heat stable toxin(STa), 60 mU/ml (55 pA/cm2 v 31 iA/cm2,n= 10, p<0-01). Serosal bethanecol (1 mM)produced similar changes in both groups (34pA/cm2 (26-44) v 32 pA/cm2 (23-41)).Thiobarbituric acid reactive substances(TBARS) an index of lipid peroxidation, werehigher in mucosal scrapings from deficientjejuna (1-93 (1-38-2-48) v 1-01 (094-1 09)nmol/mg protein, n=6, p<0-01). A positivecorrelation was found between TBARS and Isc(r=0.803, p<0 005).

Lipid peroxidation in vitamin E deficientrats correlated with increased basal and cyclicnucleotide mediated secretion. This may be ofrelevance of the pathogenesis of protracteddiarrhoeal disease in malnourished popula-tions.

ENDOSCOPY

neoplasia in the first degree relatives ofpatients with colorectal cancer

B M STEPHENSON, V A MURDAY, D T BISHOP, P JFINAN (INTRODUCED BY D JOHNSTON) (ImperialCancer Research Fund, Genetic EpidemiologyLaboratory, University ofLeeds and the Depart-ment of Surgery, Leeds General Infirmary) Firstdegree relatives (FDRs) of patients presentingwith sporadic colorectal cancer are at increasedrisk of developing colorectal neoplasia.Although screening of FDRs has been pro-posed, the methods used remain debatable. Wereport the results of a screening study usingfaecal occult blood tests and endoscopy in onesurgical practice.The endoscopic technique depended on the

empiric risk value for developing colorectalcancer based upon family histories - FDRswith risk <1:10; flexible sigmoidoscopy andrisk > 1: 10; colonoscopy. Screening wasoffered to FDRs with risk <1:10 aged 50-75years and risk >1:10, from 10 years youngerthan their affected relative.One hundred and thirty three FDRs of 151

patients were contacted. Compliance for FDRswas 69%, compared with 46% for spousecontrol group (p<0-001). Sixteen of 92 (17%)FDRs had adenomatous polyps (mean size: 1cm, range: 0-5-2- 1 cm) compared with three of28 spouses (11%). Median age of FDRs withpolyps was 54 years compared with 66 years inspouses. Faecal occult blood tests were unhelp-ful in detecting polyps. Although no cancerswere detected, two are known to have occurredsince the study started (one in a non-compliantFDR and one in a FDR >75 years).These results suggest that FDRs provide a

high risk group who are more compliant andaccept more invasive screening techniques.

Improved assessment of small bowel Crohn'sdisease using Sonde enteroscopy

A J MORRIS, L WASSON, R H R PARK, J FMACKENZIE (Gastrointestinal Investigation Unit,Royal Infirnary, Glasgow) Eight patients withsuspected active small bowel Crohn's diseasewere examined using the new technique ofsmall bowel enteroscopy. The patients (fourM: four F) with median age 32 years (range 28-64) all had a normal upper gastrointestinalendoscopy. Seven patients had previous smallbowel resections for Crohn's disease and priorto enteroscopy had no evidence of activedisease on small bowel radiology (SB enemafour patients; barium meal and follow throughthree patients). The indication for enteroscopywas undiagnosed significant blood or proteinloss in four patients, suspected recurrent smallbowel Crohn's disease in three patients, andPVO in one patient. In four patients, smallbowel enteroscopy identified active diseasewhich had not been identified radiologically. Inthese four cases, information obtained byenteroscopy led to changes in patient manage-ment and subsequent clinical improvement.We suggest that significant additional

clinical data can be obtained enteroscopically insome patients with Crohn's disease.

Placement of biliary stents above thesphincter of Oddi prolongs stent patency indogs

J G GEOGHEGAN, M S BRANCH, J W COSTERTON,T N PAPPAS, P B COTTON (Duke UniversityMedical Center, Durham, North Carolina, USA

and University of Calgary, Alberta, Canada)Conventionally, endoscopic biliary stents areplaced with the tip in the duodenum. This maypromote accumulation of biological materialleading to stent occlusion. This study investi-gates whether stent placement completelyabove, rather than across the sphincter of Oddi(SO) reduces the occlusion rate.Twelve dogs were randomised to receive a

7 FG biliary stent either across or above the SO.Stents were placed at laparotomy through aduodenotomy, and fixed with a tape ligaturearound the common bile duct (CBD). Thestents were removed one month later. Stentweight, patency, and serological and macro-scopical indicators of biliary obstruction wereassessed.

Five of six stents placed across the sphincteroccluded; all six placed above the sphincterremained patent (p<0 05). Stent weight, CBDdiameter, bilirubin, and alkaline phosphatasewere all significantly increased when stentswere placed across rather than above the SO.

In conclusion, biliary stents occlude earlierin dogs if the distal tip is in the duodenum. Thismay be due to reflux of duodenal contents intothe stent. Human studies comparing standardplacement of biliary stents with placementabove the SO are indicated.

An endoscopy simulator for teachingcolonscopy

C B WILLIAMS, D F GILLIES, A HARITSIS (StMark's Hospital, London and Department ofComputing, Imperial College, London) Accuratemanipulation of endoscope controls, logicalhand-eye coordination while tracking throughbends, and empiric responses in controllingshaft loops are all fundamental to insertion of acolonoscope, but slow to learn and difficult toteach.We have developed a graphics program for a

standard PC microcomputer (with graphicsand voice synthesis boards) interacting with adummy video endoscope and an electronic'patient' box. It produces a screen image whichresponds realistically to steering, twisting, orpush-pull movements as well as to inflation/deflation and lens washing and also allowscoagulation of polyps in the simulated colon.Screen help messages or audible instructionsguide the beginner, and overinsufflation orclumsy manoeuvres result in patient protests,as well as recording an appropriate score.

Preliminary results suggest that handskillsand basic confidence in colonoscopy are rapidlyacquired, with little involvement of teacher andnone of patient. Simulators could makepracticable the widespread teaching ofsophisticated flexible endoscopy to medical ornurse practitioners, with the added possibilityof objective assessment of an individual'sability.

Needle knife spincterotomy: an ill deservedreputation?

P CURLEY, M J MCMAHON (University Departmentof Surgery, General Infirmary, Leeds) Needleknife sphincterotomy (NKS) is a techniqueused to gain access to the bile duct at ERCP inthe 10% of patients in whom cannulation of theampulla proves difficult. It has, however, beenassociated with a high incidence of complica-tions.Over a two year period, NKS was used to

gain access to the bile duct in 37 cases, whichEndoscopic screening for colorectal

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represents 12% of ERCP examinationsperformed. Five out of 37 cases had diagnos-tic ERCP performed, while endoscopicsphincterotomy and stone clearance waspossible in 26 cases and placement of a biliarystent achieved in two cases. Five patientshad unsuccessful therapeutic manoeuvresattempted after NKS giving an overall successrate of89%. The mean age was 67-64 years witha range of 46-91 years. Despite high reportedcomplication rates, there were no deaths in thisseries and no case of haemorrhage after NKS.A single patient had a recurrence of acutepancreatitis after NKS and ES. One reason forthis lower complication rate may be the use ofa50% lower diathermy current than previouslyreported.We believe that this technique compliments

use of the Classen-Demling sphincterotomeand enables safe and efficient diagnostic andtherapeutic examinations in technicallydifficult cases.

computer graphics simulation of lower gastro-intestinal endoscopy to test the hypothesis thatendoscope handling skills can be learned with-out using patients. Our simulator consists ofthree elements: (1) a desk top microcomputer(IBM-386 clone running at 33 MHz) boostedby a graphics processor, (2) a novel computerprogramme, which creates a 3-D representa-tion of the colon using a polygon mappingtechnique, and (3) a 'dummy' endoscope, ahighly modified Olympus duodenoscope whichconverts mechanical input into electricalsignals that drive the simulation. The 'dummy'endoscope is advanced and withdrawn througha sensing device that provides variable resis-tance to simulate wall collisions and looping.The simulation provides both verbal andwritten feedback. Speed and sound synthesisallow the computer to 'talk' to the trainee, anda record is maintained of each 'procedure'performed. A multicentre prospective, ran-domised trial of computer simulation versusstandard training in flexible sigmoidoscopy isbeing undertaken in the United States in 1991.

Guidewires in gastroenterology

J H JACOMB-HOOD, R N M VAN SOMEREN, M J

BENSON, C P SWAIN (Departments of Radiologyand Gastroenterology, The Royal LondonHospital, London) Gastroenterology units,unlike other hospital departments, re-use

guidewires. Kinks in guidewires may increaserisk of perforation. The expense of an admis-sion for a perforation would buy a lot ofguidewires. We analysed guidewire re-usage in15 London hospitals, examined the frequencyof kinks in guidewires in our own departmentand studied the manoeuvres required to cause

perforation in necropsy gastrointestinal tissue.Fifteen of 15 endoscopy units contacted in theLondon area re-used guidewires but most,including our own, said that kinked guidewireswere discarded. We examined 30 reused guide-wires in our unit. Only two of 30 reusedguidewires had no kinks. Some 106 kinks werefound in 28 of 30 guidewires, most frequentlyin the first 10 cm. In 160 studies of transendo-scopic guidewires, penetration/perforationusing new and re-used guidewires andnecropsy tissue we showed: (1) It was difficultto perforate normal necropsy gastrointestinaltissue with unkinked guidewires. (2) Tipkinked guidewires penetrated mucosa deeperand split tissue more than unkinked wires. (3)Mucosal penetration is easier than muscularispropria: unexpectedly serosa offered greatestresistance to perforation (except small bowel).(4) Some patient specimens proved resistant to

perforation. (5) Perforation only occurred withendoscope held against bowel. (6) Perforationoccurred easily using the wrong end of theguidewire. (7) Perforation of the bowel alwayscaused kinking of the guidewires.We recommend careful inspection of re-used

guidewires and support a trend towards dispos-able use.

Computer graphics simulation as a trainingtool for flexible sigmoidoscopy and colono-scopy

J BAILLIE, P JOWELL, H EVANGELOU, W BICKEL,P B COTTON (Duke University Medical Center,Durham, North Carolina, USA) Basic endo-scopy training requires the acquisition of hand-eye coordination skills. Until now these havebeen developed by performing procedures on

patients; these procedures are often prolongedand uncomfortable. We have developed a

Do clinical and biochemical features ofcholestasis predict choledocholithiasis inpatients with gail bladder stones? A prospec-tive ERCP study including the effects ofsphincterotomy on natural history

J P M ELLUL, M L WILKINSON, I MCCOLL, R H

DOWLING (Gastroenterology Unit and Depart-ment ofSurgery, Guy's Campus, United MedicalandDental Schools, London) Although commonduct stones (CDS) cause more problems thangall bladder stones (GBS), the prevalence ofCDS is too low to justify ERCP in all GBSpatients. Therefore, we need to define a sub-group of GBS patients in whom routine ERCPis justified.We hypothesised that: (i) in patients with

GBS, clinical and biochemical markers ofcholestasis predict the presence ofCDS and (ii)in those with CDS, sphincterotomy plus stoneextraction improve the natural history.

Selection criteria were as follows: sympto-matic GBS plus: (i) history of cholestasis, (ii)back pain, and/or (iii) raised serum alkalinephosphatase, bilirubin, and GT.When CDS were found, sphincterotomy and

stone extraction were performed and symp-toms were reassessed within four weeks and atthree month intervals.Of 96 patients with symptomatic GBS, 23

(24%) fulfilled the selection criteria and under-went ERCP. Of these, CDS were confirmed insix (25%) and suspected (ragged/patulouspapillae) in two (total 35%). In these six,predictive factors were: history of dark urine(sensitivity 83%, specificity 29%), jaundice(67%, 33%), back pain (67%, 27%), and raisedserum alkaline phosphatase (17%, 13%). Aftersphincterotomy, four of the six (67%) hadpersistent symptoms and underwent chole-cystectomy; the other two remain well after 8-0(4.2) months.

In conclusion, clinical and biochemicalfeatures of cholestasis predict CDS in upto 35% of GBS patients and justify ERCP.Sphincterotomy and stone extraction preventcontinuing symptoms only in a minority.

PAEDIATRICS

Extraceliular matrix components, tenascin

and fibronectin in Hirschsprung's disease: animmunohistochemical study

D H PARIKH, P K H TAM, D VANVELZEN, D EDGAR(INTRODUCED BY A KINGSNORTH) (Department ofChild Health, University of Liverpool, RoyalLiverpool Children's Hospital, AlderHey, Liver-pool) Previous in vitro studies have suggestedthat successful neural crest cell migration couldbe influenced by the composition of the extra-cellular matrix components, tenascin andfibronectin in the developing gut. We aimto gain insight into the pathogenesis ofHirschsprung's disease (HD) by studying thedistribution of tenascin and fibronectin inbowel specimens of patients with HD.

Immunohistochemical examination wascarried out in specimens from 10 HD patients(eight aganglionic, five transitional, and 10normoganglionic zones) and 18 age and sitematched controls from other gastrointestinalsurgery.The distribution of tenascin was restricted to

the basement membranes of smooth muscle,vasculature, around neuronal ganglia, andalong nerve fibres in all the controls and 10proximal normoganglionic HD specimens.More intense tenascin immunofluorescencewas observed in the smooth muscle basementmembranes of the muscularis externa of eightaganglionic and five transitional zones of HD.Widespread distribution of fibronectin wasfound in all the basement membranes as well asin the lamina propria and submucosa of allcontrol and 10 normoganglionic HD sections.More intense immunofluorescence with fibro-nectin was observed in all the layers of eightaganglionic and five transitional zones of HDspecimens.Our findings suggest that the extracellular

matrix constitution is inappropriate in theaffected bowel and may be responsible for thepathogenesis of HD.

Measurement of gastric emptying in infantsusing applied potential tomography

S NOUR, Y MANGNALL, A G JOHNSON, J A SDICKSON (Subdepartment of Paediatric Surgery,The Children's Hospital, Sheffield and Depart-ment of Surgery, The Royal HallamshireHospital, Sheffield) Applied potential tomo-graphy (APT) is a non-invasive, non-radiological method used to measure gastricemptying by creating tomographic images oftissue resistivity which has been used success-fully in adults.APT was validated by gastric aspiration and

used to measure gastric emptying in infantsunder 3 months old (30 term, 53 preterm, 49infantile hypertrophic pyloric stenosis (IHPS),and 12 with vomiting).

In term infants, milk emptied more slowlythan Dioralyte (T½/2: mean (SEM) 41-33 (3.09)v 22-0 (1-84), p<0-001) and preterm infantshad similar results (44.45 (3.08) v 21-78(2-31)). Gestation, postnatal age, birthweight,investigation weight, volume, mode, and typeof milk feed had no detectable influence ongastric emptying. The IHPS infants had littleor no emptying before surgery but postopera-tive studies at day two, four, and seven showedgradual return to normal at seven days.Statistical significance was noted between pre-operative and all postoperative studies. Ten ofthe 12 vomiting infants had normal findings, aresult significantly different from the preopera-tive investigations of the IHPS infants.APT is a safe and simple method which can

be used to study gastric emptying of infants atthe bedside.

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Gastro-oesophageal reflux disease in cysticfibrosis: evaluation with combined oesopha-geal and gastric pH monitoring

C A MCGIBNEY, P J BYRNE, P LAWLOR, B DENHAM,T P J HENNESSY (National Children's Hospital,Dublin and University Department ofSurgery, StJfames's Hospital, Dublin, Ireland) Prevalencerates for gastro-oesophageal reflux disease(GORD) in cystic fibrosis (CF) vary accordingto selection criteria and diagnostic techniquesemployed. To evaluate the true prevalence ofthe disease and its possible aetiology, 24 hourdual channel (oesophageal and gastric) pHmonitoring was carried out in an unselectedgroup of children with CF: n=20; median age10, range=4-15 years.

Seventeen of 20 children had abnormaloesophageal acid profiles - only two of whomwere symptomatic. Greater oesophageal acidexposure times, including % time oesophagealpH <4 and duration of reflux episodes, par-ticularly in the supine position, were associatedsignificantly with those who had severebronchospasm (SB) and those with poorgrowth profiles (PGP); p<0-01, p<0.01respectively. Intragastric pH, assessed for thesupine period and at all pH intervals, wassignificantly greater at the pH < 1 level, in thetwo subgroups.

In conclusion, GORD is underestimated incystic fibrosis. With dual channel pH monitor-ing, diagnosis of GORD can be made, riskgroups for GORD (those with severe broncho-spasm or poor growth profiles) and exacerbat-ing factors such as suppine position can beideptified. A combined aetiology - pooroesophageal clearance and gastric hypersecre-tion - is also suggested.

COLORECTAL

Sexual dysfunction among women withCrohn's disease: a hidden problem

G MOODY, C S J PROBERT, E SRIVASTAVA,

J RHODES, J F M MAYBERRY (Leicester GeneralHospital, Leicester and University Hospital ofWales, Cardiff) The sexual problems of 50women with Crohn's disease were investigatedby structured interview and compared with agematched controls (mean ages 34-7 and 33-6years respectively, t=0-92 NS). The patientshad been married significantly longer thancontrols (t=2 1 p<0.005) and the divorce ratewas similar (Fisher's p=0 09 NS). Patients hadsignificantly more sexual problems. The fre-quency of intercourse was less in patients thancontrols (mean 1-9 and 2-3 respectively t=4 1p<0-001). Indeed there was a significantlylarger proportion (24%) of patients who had nointercourse at all (X2=8.3 p<0 005). Thereasons for this included abdominal pain(24%), diarrhoea (20%), and fear of incontin-ence (14%). Dyspareunia was more common in

patients (X2=6-5 p<0-01), this was irrespectiveof the site of Crohn's disease (small bowel v

controls X2-=63 p<0-01, large bowel v con-

trols X2=9.4 p<0-005 and large v small bowelX2=0.85 NS). Vaginal candidiasis was morecommon in patients ('2=58 p<0 02).Women with Crohn's disease experience

considerably more sexual problems than con-

trols. They need sympathetic investigation andmanagement.

COLORECTAL

Site of platelet activating factor action on

colonic mucosa

S P L TRAVIS, B CROTTY, D P JEWELL (Gastro-enterology Unit, The Radcliffe Infirmary,Oxford) Serosal platelet activating factor (PAF)decreases transepithelial resistance (R,) andstimulates anion transport in the distal rabbitcolon. The site of action within the mucosa hasbeen investigated using mucosal segments ofrabbit descending colon mounted in Ussingchambers. Two human colonic epithelial celllines (T-84 and HT-29) were also used to assess

whether PAF has a direct action on epithelialcells.

Serosal PAF (5OnM) decreased R, by mean

(SEM) 23 (3)% in mucosal segments (n= 11

pairs, p<0-001), with a twofold increase inmucosal:serosal 14C-mannitol flux (n=6 pairs,p=0-013) relative to paired controls. This isconsistent with an increase in paracellularconductance. Net ion transport was monitoredby changes in short circuit current (dSCC, FA/cm2, mean (SEM)). The two phases of the SCCresponse to PAF were completely inhibited byindomethacin (10-6 M, serosal): dSCCcontrol=30 (3) (phase 1) and 11 (5) (phase 2),compared with 0 (1) (p=0-001) and -6 (3) (p=0.047) with indomethacin (n=4 pairs), respect-ively. Tetrodotoxin (10-7 M, serosal), whichinhibits neurally mediated changes in iontransport, had no effect on the SCC response toPAF (n= 8 pairs).

Monolayers of T-84 cells mounted in Ussingchambers showed no change in SCC or Rt after5 or 50OnM PAF, whether added to the serosalor mucosal surface (n=2-5 pairs). Chloridesecretion in the T-84 monolayers could beshown by a rise in SCC after ionomycin (10-5M, n=5 pairs), which was inhibited by serosalfrusemide (10-4 M, p<0-01), or ouabain (10-4M, p<001). Receptors for PAF, investigatedby binding studies with 3H-PAF, could not bedetected on T-84 or HT-29 cells.The results are consistent with an indirect

action of PAF on the colonic epithelium,probably through release of eicosanoids. Therole of enteric nerves in the response of rabbitcolon to PAF needs further investigation.

Regional differences in colonic permeability

S P L TRAVIS, D P JEWELL (Gastroenterology Unit,The Radcliffe Infirmary, Oxford) Segmentalheterogeneity in electrolyte transport, motility,and response to some secretagogues has beenshown in mammalian colon, but regionaldifferences in colonic permeability are poorlydefined.

Transepithelial resistance (R,) and 14C-mannitol flux were used to assess colonicpermeability in mucosal segments of rabbitcaecum and distal colon, mounted in Ussingchambers. Basal R, (ohm.cm2, mean (SEM))was 124 (6) (n=30) in caecum and 403 (25) indistal colon (n=30, p<0-001). This was con-

sistent with a greater mucosal:serosal mannitolflux (pmol/cm2/hour) in the caecum (27-0 (2.7),n=20) than in the distal colon (5.4 (0.6), n=14), p<0-001). Regional responses to a calciumionophore and a lipid inflammatory mediatorwere then examined. Ionomycin (10-5 Mserosal, n=4-5 pairs) caused a greater decreasein Rt relative to paired controls in distal colon

(60% (6.7)) than in the caecum (17% (2.8),p<0-001). Platelet activating factor (PAF, 50nM serosal, n=7-11 pairs) decreased Rt indistal colon (27% (3.3), p<0-001) and caecum(14% (4), p=0-007), and the differencebetween the segments was significant (p=0.026). Mannitol flux increased from 5-2 to 7-3pmol/cm2/hour in distal colon after 50 nmMPAF and decreased from 5.2 to 3-4 in six pairedcontrols (p=0-013). In caecum, mannitol fluxincreased from 30.5 to 40.4 pmol/cm2/hourafter 5 nM PAF, and from 23-6 to 26-0 in 10paired controls (p=0-021). Both ionomycinand PAF stimulated anion secretion in distalcolon, but not in caecum.

In conclusion, the basal permeability of therabbit caecum is greater than the distal colon,but the distal colon may be more susceptible toagents that increase mucosal permeability.

Total mesorectal excision and local recur-rence: a study of tumour spread in themesorectum distal to rectal cancer

N SCOTT, P JACKSON, P J FINAN (INTRODUCED BYM F DIXON) (Department of Pathology andSurgery, University of Leeds, Leeds) Localrecurrence is a common cause of morbidity andmortality after 'curative' surgery for cancerof the rectum. Very low rates of recurrenceare reported by Heald who practises totalmesorectal excision (TME), suggesting thatincomplete excision of carcinoma in the distalmesorectum is an important source of recur-rent tumour.We have examined the mesorectum distal to

20 rectal cancers removed by AP or anteriorresection combined with TME. The fixedmesorectum from each case was sliced at 1 cmintervals and inspected for tumour depositsand lymph nodes. Alternate slices were pro-cessed whole for microscopic examination.We found distal spread of carcinoma in 20%

of cases, extending between 1 and 3 cm fromthe luminal tumour. Spread was via mesorectallymphatics in three cases and by direct exten-sion in three.We conclude that local tumour spread

involving the distal mesorectum is not anuncommon event in rectal cancer, and that inorder to minimise local recurrence at least 3-5cm of mesorectum should be excised distal tothe luminal cancer.

Serum cholesterol is increased in patientswith colorectal adenomas

G I MANTZARIS, E PANAGOU, A HATZIS, GGEORGIOU, P KONTOGIANNIS, N RAPTIS, GTRIANTAGHILLOU (Gastroenterology Clinic A,Evagelismos Hospital, Athens, Greece) Patientswith hypercholesterolaemia may be atincreased risk for developing colorectaladenomas and carcinomas. The aim of thisprospective study was to correlate fastingserum cholesterol concentrations and colono-scopic findings in 196 patients undergoing firstcolonoscopy. Patients with colorectal cancer,inflammatory bowel disease, polyposissyndromes, and colorectal cancer in 1stdegree relatives were excluded. A total of 101adenomas were found in 66 patients (42 men,24 women, mean age 63-6 years) whereas noadenomas were found in 130 patients (87 men,43 women, mean age 65-1 years). Some 44adenomas were found in the rectum, 36 in thesigmoid, 12 in the right colon, and nine in othersites of the colon. Twenty seven of 101 (26.7%)

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had a villous component. A significant differ-ence was found between cholesterol values inthe adenoma and the control groups (mean(SEM) 253.3 (6.0) mg/dl v 220 (4.8) mg/dlrespectively, p<0 05). Considering cholesterolvalues :200 mg/dl as normal, significantlymore patients with adenomas than controls hadserum cholesterol concentrations above uppernormal (55 of 66 (83%) v 81 of 130 (62%),p<0-Ol).These results support the hypothesis that

hypercholesteroaemia is a risk factor fordeveloping colorectal adenoma, a known pre-cursor for colorectal carcinoma.

Effects of selenium and vitamin E supple-mentation on colonic celi proliferation inpatients with adenomatous polyps

R J CAHILL, K R O'SULLIVAN, P M MATHIAS,B CORRIDAN, S BEATTI, C O'MORAIN (Sir PatrickDun Research Laboratories, Trinity CollegeMedical School, St_James's Hospital, Dublin 8,Ireland) Cell kinetic studies have shownthat patients with adenomatous polyps haveincreased colonic crypt cell proliferation com-pared with patients with no colonic disease.Recent studies suggest that dietary seleniumand vitamin E, as antioxidants, may be protec-tive against colorectal cancer.

This study assessed the effect of oralselenium and oral vitamin E supplementationon colonic crypt cell proliferation in patientswith a history of adenomatous polyps. Nine-teen patients were recruited, 10 received 200[ig of selenium daily and nine received 160 mgof vitamin E daily. Supplementation continuedfor one month. Patients were colonoscoped andbiopsy specimens were taken before and aftertreatment. In vitro labelling for S phase coloniccrypt cells was performed using the mono-clonal antibody to bromodeoxyuridineimmunohistochemical technique. The meannumber of proliferating cells as a ratio percentto total cells per crypt was analysed as thelabelling index percent (LI%). In this shortterm study vitamin E supplementation did notdecrease the LI% whereas selenium supple-mentation did so significantly (p<0.0001).These results show that supplementation

with 200 Fg of selenium daily for one monthdecreases colonic crypt cell proliferation inpatients with adenomatous polyps.

The surgical management of desmoiddisease in familial adenomatous polyposis

K C R FARMER, R K S PHILLIPS (St Mark'sHospital, London and Professorial Surgical Unit,St Bartholomew's Hospital, London) Manyintra-abdominal desmoids are inoperable at thetime of diagnosis because of vascular encroach-ment in the small bowel mesentery.We have examined the results of surgical

management of extra-abdominal desmoids infamilial adenomatous polyposis (FAP) toestablish whether aggressive surgery leads tolow recurrence rates.Of 24 desmoids completely excised, 18

(75%) are free of recurrence (mean follow up13-8 years, range: 2-40 years) although fourpatients required two excisions and onerequired three. Of the six patients with residualrecurrent disease, four are static, one died froman intra-abdominal desmoid, and the other hasinsufficient follow up.

Prosthetic repair of the abdominal wall was

necessary in three cases. This was not associ-ated with recurrence.The mean size of non-recurrent desmoids

and recurrent desmoids were 7-2 cm and 12-2cm respectively (0O2>p>0 1, Mann-WhitneyU test).

Extra-abdominal desmoids can be success-fully treated surgically in the majority of cases.Recurrences often remain static. Smallerdesmoids may be associated with lower recur-rence rates. These findings suggest that aggres-sive surgery can be curative in desmoid diseasein FAP. Earlier diagnosis with intra-abdominaldesmoid disease before vascular encroachmentis advanced may similarly permit curativesurgery.

Palliative surgery for intra-abdominaldesmoid disease in familial adenomatouspolyposis

K C R FARMER, R K S PHILLIPS (St Mark'sHospital, London and Professorial Surgical Unit,St Bartholomew's Hospital, London) Visceraland vascular encroachment of advanced intra-abdominal desmoid tumours have lead to thecurrent policy ofreserving surgery for the reliefof severe symptoms or complications.We have examined the course of 12 patients

(five males, seven females) with advanceddisease underoing 13 procedures for palliationto determine whether this type of surgery isworthwhile.

Small bowel obstruction, perforation, orfistula were indications for surgery in ninepatients. Ten attempted palliative proceduresincluded partial excision (n=7) and/or seg-mental small bowel resection (n= 3) and/orenteric bypass (n=4). There were three intra-operative deaths from exsanguinating haemor-rage. Median duration of symptom relief insurvivors was 2 years (range 2 months-13years). No patient experienced acceleratedgrowth of desmoid tissue.Three patients with ureteric obstruction had

uretero-ureterostomies. Obstruction has notreccurred with follow up of 3-8 years; twopatients experienced desmoid regression afterpostoperative medical treatment with sulindac.

Palliative operations for desmoid disease inFAP may be associated with a satisfactoryperiod of relief of symptoms but surgery formajor intestinal involvement carries a 30%mortality.

Is anterior resection without a defunctioningcolostomy safe?

K MEALY, P BURKE, J HYLAND (Department ofSurgery, St Vincent's Hospital, Dublin, Ireland)The need to defunction the anastomosis atanterior resection remains controversial. Asour policy has been not to perform a defunc-tioning colostomy during anterior resections,we examined the outcome of our last 100consecutive anterior resections, all without acovering colostomy. During this period, 20abdominoperineal resections (15%), fiveHartman's procedures (4%), and two resec-tions with coloanal anastomosis (2%) were alsoperformed. Sixty two patients were men andthe mean age was 62-5 (36-93). Thirty eight ofthe resections were high and 62 low, defined ascompletely above or below the peritonealreflection. Clinical anastomotic dehiscenceoccurred in six patients - all in the low anteriorresection group (6% of total group or 9-8% ofthe low anterior resection group). All of these

patients had a further laparotomy and endcolostomies fashioned. Among the last 52patients, three radiological leaks have alsooccurred, none of which required any furthersurgical management. Perioperative mortalitywas 4% within the anterior resection group;one death was attributable to anastomoticdehiscence and sepsis whereas the other threedeaths were due to unassociated medical pro-blems. Our results show similar leakage andmortality rates to published studies whereanterior resection is frequently performed witha defunctioning colostomy.These results indicate that the routine use of

a defunctioning colostomy at anterior resectionis not warranted.

High rectal pressure waves in rectal prolapseare associated with internal sphincterinhibition

R FAROUK, G S DUTHIE, A PRYDE, D C C BARTOLO,R MILLER (Departments of Surgery and Gastro-intestinal Liver Service, Royal Infirmary ofEdinburgh and Bristol Royal Infirmary)Recovery of continence frequently accom-panies rectopexy for prolapse. We propose thatthe prolapse causes reversible rectoanalinhibition resulting in faecal incontinence.To investigate this, 12 patients (10 female;

age median (IQ) 72 (56-77) years) with com-plete rectal prolapse (CRP), 15 patients (11female; age 68 (46-72) years) with neurogenicfaecal incontinence (FI), and 11 normal con-trols (five female; age 36 (25-71) years) under-went computerised ambulatory anorectalmanometry.The median resting anal pressure was CRP=

26 cm.H20 ((9-60); p<0 002; Mann-WhitneyU test v normals*), FI=42 cm.H20 ((26-66);p<0-01*) and normals=90 cm.H20 (60-130).Median resting rectal pressures were CRP= 15cm.H20 ((6-31); p>0.1*), FI=18 cm.H20((10-26); p>0-01*) and normals= 10 cm.H20(5-16). The median number of anorectalsampling events per hour were CRP=7 ((6-9);p<0.002*), FI=7 ((5-8); p<0.002*) andnormals= 5 (4-6). High pressure rectal waves(median=110 cm.H20 (82-134); p<0-001Rank Wilcoxon test) associated with sphincterinhibition, lasting 20-30 seconds were seen in11 patients with CRP. The remaining patient inthis group was continent. These were not seenin normals or FI.We suggest these high pressure rectal waves

represent the prolapse entering the rectumresulting in rectoanal inhibition.

Faecal proteinase activity; raised values inpatients with ulcerative colitis

H J SAMSON, A ALLEN, J P PEARSON, W JCUNLIFFE, M RHODES, J RHODES (Department ofPhysiological Sciences, Medical School, New-castle upon Tyne and Department of Gastro-enterology, University Hospital of Wales,Cardiff) Faeces contain substantial amounts ofproteinase activity which data suggest is raisedin inflammatory bowel disease. Here we reporta detailed study on the proteinase activity offaecal extracts in healthy controls and patientswith ulcerative colitis.

Proteinase activity was measured by freeamino group formation with succinyl albuminsubstrate, in supernatants prepared from faecalslurries (1:10 dilution of faeces in pH 7*5phosphate buffer). Proteinase activitymeasured in weekly samples over 10 weeks in

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healthy volunteers (expressed as mean (SEM)units of mmol N terminals/min/g dry weight)was 3-51 (1.5) units (n=7) in menstruatingwomen. This was significantly higher than thatin postmenopausal women (0-71 (0-19) units,n=4 p<0 05) but not significantly higherthan that in men (2.72 (1-36) units, n=5).Proteinase activity for ulcerative colitis patients(8-15 (1-18) units, n=69) was threefold greaterthan that for the mean of all healthy volunteers(2-61 (0 80) units, n= 16 p<0 005).These studies show (i) wide variation in

faecal proteinase activity from different sub-jects; (ii) faecal proteinase activity in men-struating women is significantly higher thanthat of postmenopausal women; (iii) faecalproteinase activity is significantly higher inpatients with ulcerative colitis than healthysubjects. Faecal proteinase activity has beenshown to degrade the colonic mucus barrierand its elevation may be significant in thepathophysiology of ulcerative colitis.

Anal transition zone and the distribution ofneuroendocrine cells in the anorectum

G CHATTOPADY, M NEWBOLD, D KUMAR

(Department of Surgery, The Queen ElizabethHospital, Birmingham) The presence of neuro-endocrine cells (NEC) in the anorectum is welldocumented. However, the density of theendocrine cells in different regions of the analcanal has not been determined. The aim of thisstudy was to determine the distribution of theNECs in different regions of anal canalepithelium.We have studied anal canal epithelium in 14

blocks in seven specimens from patients under-going abdominoperineal resection. Sectionswere stained with haematoxylin and eosin andalso by argyrophil technique. NECs werecounted in the epithelium and glandular cryptsin every 2 mm of visual field at an imagemagnification of 125. Anal transition zone(ATZ) was only present in three of sevenspecimens studied. None of the 14 blocksexhibited NECs in the squamous lined analcanal. However, melanocytes could be identi-fied in this region. ATZ, when present, con-tained a relatively small number ofNECs. Thedensity of NECs showed a gradual increasefrom the squamocolumnar junction upwardsfor approximately 10 mm.These data show that the ATZ is absent in

about 50-60% of subjects. Also, NECs are onlypresent in columnar lined anal canal. This maybe important in operations on the anorectum asonly columnar lined anal canal is likely to beaffected by peptidergic modulation.

Cause of deteriorating continence afterpostanal repair

J ORTIZ, M OYA, T BACELAR, G CHATrAPADY,B PANAGAMURA, M R B KEIGHLEY (Departmentof Surgery, Queen Elizabeth Hospital,Birmingham) Twenty patients who initiallyimproved after postanal repair for neuropathicfaecal incontinence were interviewed andassessed by anal physiology measurements. Innine patients (group A) the quality of con-tinence deteriorated with follow up resulting inincontinence to solids: in the remaining 11patients the postoperative continence wasmaintained (group B). The groups were similarfor age (53 years and 59 years), but duration ofincontinence was longer in group A: 36 monthsv 24 months (NS). Preoperative anal pressures

were higher in group A (maximum restingpressure 90 v 55 cm H20; maximum squeezepressure 110 v 95 cm H20 (NS)). Rectalsensation was comparable in both groups.Preoperative anal canal length, anorectal angle,pelvic floor position, and perineal position asassessed by dynamic videoproctography atrest, during maximum pelvic floor contraction,and attempted defaecation did not differbetween the groups. However, patients whodid not deteriorate were shown to have asignificant increase in anal canal length, areduced anorectal and less pelvic floor descentafter operation. Those whose quality of con-tinence deteriorated with time had increasingperineal descent after operation suggesting thatthey continued to strain.These data suggest that persistent perineal

descent and straining is associated withdeterioration after postanal repair.

GASTRODUODENAL

Inhibition of nocturnal gastric secretion isunnecessary for ulcer healing: further con-

firmation

M LAZZARONI, F PARENTE, G BIANCHI PORRO

(Gastrointestinal Unit, L Sacco Hospital, Milan,Italy) Current ulcer treatment with H2receptors is based on the inhibition ofnocturnal gastric secretion. However, recentreports have shown similar rates of healing ofduodenal ulcer (DU) regardless of whether theH2 receptor antagonists were administered inthe morning or at night. The experience is,

however, very limited. The aim of this studywas to compare the DU healing and analgesiceffects of morning v single bedtime doses offamotidine. Two hundred patients with activeDU were randomly assigned to a double blindtherapy with famotidine at 08.30 am (F om)and 10 pm (F on) for up to eight weeks.The therapeutic efficacy parameters were

endoscopic healing and antacid consumption.The patients were matched for age, sex,

smoking, and drinking habits, previous com-

plications, duration ofdispeptic symptoms andHelicobacter pylori antral infection. Onehundred and ninety six patients (98 in eachgroup) completed the study. At four weeks,ulcers had healed in 60/98 (60%) in the F om

group and 64/99 (64%) in the F on group (p=0-72, odds ratio 0-863, 0-464-1-604). At eightweeks the corresponding healing rates were 81and 87% respectively (p=0-30, odds ratio0-602, 0-24-1-45). The weekly consumption ofantacids was similar in both groups.The equivalent efficacy of the morning and

bedtime famotidine administration raisesfurther doubts as to the predominance ofnocturnal gastric acidity in the pathogenesis ofDU.

Effect of circulating gastrin on antral andfundic somatostatin concentrations in rats

F J VAN DE BRUG, J B M J JANSEN, I J KUIJPERS,C B HW LAMERS (Department ofGastroenterology-Hepatology, University Hospital, Leiden, TheNetherlands) It has been suggested thatsomatostatin (SST) acts as a paracrine inhibitorof gastrin release. In return, gastrin itself has

been demonstrated to be a weak stimulant ofSST secretion in rats. In this study the role ofcirculating gastrin on fundus and antrum SSTconcentrations during peptone stimulation wasstudied with and without immunoneutralisa-tion of circulating gastrin with a specific gastrinantiserum.Twenty six conscious male wistar rats (mean

body weight 291±2 g) equipped with gastricfistulas and jugular and portal vein cannulas,were studied. Rabbit anti-gastrin serum (60jl) or normal rabbit serum (60 il) wereinjected into the jugular vein 30 minutes beforea 30 minute intragastric peptone stimulationperiod. At the end of the study period portalserum and fundic and antral tissue werecollected for determination of free gastrinbinding sites or serum gastrin concentrations inserum and tissue SST concentrations respect-ively. Differences were tested for statisticalsignificance by Mann-Whitney U test forunpaired results.

Peptone stimulated portal gastrin valuesfrom 384±59 to 572±62 pg/ml (n= 18;p<005), antrum and fundus SST concentra-tions were respectively 892±136 ng/g and737±113 ng/g. After gastrin antiseruminjection serum gastrin values were no longerdetectable while antrum and fundus SST con-centrations were significantly (n=8; p<0.05)higher than during control experiments(1688±192 ng/g and 1181±249 ng/g,respectively).

In conclusion, immunoneutralisation ofcirculating gastrin resulted in increases inantral and fundus SST concentrations duringpeptone stimulation. These data suggest thatpeptone stimulates directly or indirectly theproduction of SST in both antrum and fundusand indicate that circulating gastrin mayinhibit the production of SST in antrum andfundus.

Durations of complete focal mucosalischaemia required to produce gastric ulcera-tion at low acidity

C PIASECKI, C THRASIVOULOU (INTRODUCTIONBY R POUNDER) (Department ofAnatomy, RoyalFree Hospital School of Medicine, London) Werecently showed that most mucosal arteries inthe guinea pig are end arteries. Here we used asnare to temporarily occlude single mucosalarteries repeatedly. Each vessels's end arterystatus was ascertained by noting the reductionin mucosal perfusion after occlusion. (Apreliminary study, showed that 92 to 97%reduction indicated non-viability, whilst 50to 86% meant survival n=14; p=0-001.)Occlusions of increasing severity showed thatafter four, five minute occlusions repeated atfive minute intervals, circulation began not tore-establish itself due to coagulation at the siteof occlusion (p=0 025 between one and 10minute occlusions, n=20). Full thicknessnecrosis in underlying mucosa was seen atsacrifice three hours later, but no necrosis insurrounding areas with undisturbed circula-tion. pH of secretions during experiment was5.8 to 6 6. This acid will have caused necrosisin areas rendered ischaemic.

It is known that contraction of musclelayers can completely obstruct perforatingarteries. Thus, repeated obstructions of endarteries, each lasting only five minutes arelikely to initiate ulceration via endothelialcoagulation mechanisms. Obstruction couldoccur from vasospasm or spasm of muscularismucosae.

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Changes to mucus glycoproteins in gastriccancer

R L SIDEBOTHAM, N K DHIR, L HOUGH, (LATE) JSCHRAGER (INTRODUCED BY J H BARON) (Depart-ment of Surgery, Royal Postgraduate MedicalSchool, London and Department of Chemistry,Kings College, London) Immunochemical andlectin studies show that carbohydrate bio-synthesis of mucus glycoproteins is altered ingastric carcinogenesis. To extend these obser-vations we have compared the content anddistribution of carbohydrate in mucus glyco-polypeptides (MG) from non-malignantmucosa (16 specimens; individuals with benignpeptic ulcer, or disease free necropsies), andfrom uninvolved mucosa in patients withstomach cancer (14 surgical specimens). Thenumber of carbohydrate residues associatedwith representative core segments of equallength decreased by 12% (p=0 02) inMG fromuninvolved mucosa. Also, carbohydrate wasdistributed differently in MG from uninvolvedmucosa. Numbers of carbohydrate chains (0-elimination analyses) declined from a mean of448 to 332 chains per 1000 amino acid residues(p<0001), with significant decreases ofserine and threonine in the polypeptide core.Structural units per carbohydrate chainincreased from a mean of 5.7 to 6-9 (p=0 005),with significant increases in ratios of N-acetylglucosamine or galactose to N-acetylgalactosamine.

Comparative analyses of(1) MG from diseasefree antrum and duodenum (necropsies) and(2) MG from non-malignant antrum before andafter structural modification by partial 1B-elimination suggested that the above changesare attributable to biosynthesis of intestinalmucus glycoproteins within metaplasticmucosa, or decreased biosynthesis of neutralrelative to sulphated mucus glycoproteins bygastric mucus cells.

Mucosal tissue-type plasminogen activatoractivity in peptic ulcer disease

M A WODZINSKI, K D BARDHAN, P COOPER,J T REILLY, F E PRESTON (Northern GeneralHospital, Sheffield, District General Hospital,Rotherham, and Royal Hallamshire Hospital,Sheffield) Impaired fibrinolytic activity (FA)may lead to occlusion of the rich vasculature ofthe gastroduodenal mucosa causing tissuenecrosis and ulcer formation. To examine this,FA was studied in patients with benign gastriculcer (GU) (n=6), active duodenal ulcer (DU)(n=9), healed DU (n=6), and normal controls(n= 11). Multiple biopsy specimens were takenat gastroscopy from the stomach and duo-denum, and in GU and DU cases from ulceredge or scar (DU) and opposite wall. Tissuetype plasminogen activator (tPA) activity wasassayed spectrophotometrically in biopsyspecimen homogenates and expressed as mIU/mg protein. The mean (range) tPA in controlswas: stomach 2970 (2030-3840) and duodenum4320 (3120-6260). In GU, tPA at ulcer edgewas 1220 (220-2820) and opposite wall 2210(1310-4440). In active DU, tPA at ulcer edgewas 2170 (730-5130) and opposite wall 3170(1760- 5120), while in healed DU, tPA at thescar was 3200 (1760-5180) and opposite wall3810(1390-6090).These results show control duodenal mucosa

has higher tPA than gastric mucosa (p<001).Compared with controls, in GU tPA is notice-ably reduced at the ulcer edge (p<0.01) andopposite wall (p<005); in active DU tPA is

reduced at the ulcer edge (p<001) andopposite wall (p<0 05), and at the scar ofhealed DU (p<0 05).

This reduction in mucosal tPA may pre-dispose patients to ulcer disease and suggests avascular involvement in ulcer pathogenesis.

Early gastric carcinoma: correlation ofDNAploidy, tumour types and prognosis

M J BRITO, M I FILIPE, J ROSA, G WILLIAMS,H THOMPSON, G ORMEROD, J TETLEY, R MORRIS(Departments ofHistopathology, Guy's Hospital,UMDS, London; IPO Lisbon; University ofWales; Central Hospital, Birmingham; ICR,Sutton; and Public Health, Guy's Hospital,UMDS, London) DNA ploidy and S-phasefraction of 92 early gastric carcinomas werestudied by flow cytometry using formalinfixed, paraffin embedded material. Thetumours were classified according to Kodama:36 small mucosal (Mucosa (M)-26; submucosal(SM)-10); 33 super mucosal (M-15; SM-18);8 Pen A and 15 Pen B.

Fifty seven tumours were diploid (62%) and35 aneuploid (38%). No significant differencein ploidy was found between mucosal andsubmucosal tumours or between those withand without lymph node metastases. However,the majority (63%) of the Pen A tumours,considered as carrying a worse prognosis, wereaneuploid.DNA ploidy was significantly different

between small mucosal (M,SM) and super-mucosal (M,SM) types (p=0-01). Signet ringtumours (n=20) were predominantly diploid(88.5%) compared with 55 8% in the tubulartype (n= 52) (p=0 002).

Preliminary data of follow up (between threemonths and eight years) in 81 patients showthree local recurrences and four related deaths,all in cases belonging to super or Pen Asubtypes.

In conclusion, aneuploidy was more oftenseen in tumours known to be associated withworse prognosis (tubular, Pen A and supertypes). Thus DNA ploidy may play a role inpreoperative assessment of tumour behaviour.

Mutant p53 expression in gastric carcinomasis a prognostic indicator

M I FILIPE, M H MARTIN, D P LANE (Department ofHistopathology, UMDS Guy's Hospital, Londonand Cancer Research Campaign, The University,Dundee) Abnormalities of the p53 gene havebeen identified in many malignancies withreports of aberration in over half of colorectal,lung, breast, and hepatocellular carcinomas.The normal gene acts as a recessive oncogenewhile mutations change the apparent functionto that of a dominant oncogene.

In this investigation a three layered immuno-peroxidase technique was applied to routinelyfixed and paraffin embedded tissue sectionsfrom 125 gastric carcinomas, using a polyclonalanti-p53 antibody.

It was found that 57% of these carcinomasexpressed the mutant p53 protein (positivenuclear staining). Survival table analysisshowed a strong association between p53 statusof the tumour and patient survival time afterdiagnosis (p<0 02-Mantel-Cox test). The fiveyear survival of patients with mutant express-ing tumours was 24%, compared to 56% withnon-mutant expressing tumours (the mediansurvival times were 13, and 102 monthsrespectively).

These results confirm the idea that altera-tions in the p53 gene affect tumour behaviour.

Transforming growth factor (a expression innormal gastric epithelium, intestinal meta-plasia, dysplasia, and gastric carcinoma

M M NASIM, D M THOMAS, M R ALISON, M I FILIPE(Departments of Histopathology, Hammersmithand Guy's Hospital, London) Transforminggrowth factor ax (TGFa) is a mitogenic andmorphogenic polypeptide structurally relatedto epidermal growth factor (EGF) and sharingthe same cell surface receptor. There isevidence that over expression ofTGFa may bedirectly involved in the series of pathologicalevents leading to malignancy. Using a mono-clonal antibody (GF10; Oncogene Science) andimmunohistochemistry on formalin fixed,paraffin embedded tissue sections we haveassessed the expression of TGFa in normalgastric mucosa, in precancerous gastric lesions,and in cancer of the human stomach. TGFaimmunoreactivity was predominantly cyto-plasmic with occasional membrane staining.Expression was observed within the differen-tiated compartment of the normal mucosa (n=20) (that is, in surface epithelium and in cellsdeep in the gastric gland, particularly parietalcells). Overexpression of TGFu was seen in70% of mucosal samples exhibiting intestinalmetaplasia (n= 38); in 60% of dysplasticepithelium (n= 10) and in 60% of gastriccarcinomas (n=24). Interestingly, while 93%of intestinal type carcinomas showed strongimmunoreactivity, only 30% of diffuse typecarcinomas were similarly stained.We suggest that TGFa may be involved in

the pathogenesis of gastrointestinal metaplasiaand neoplasia as well as in the maintenance ofthe integrity of the normal gastric mucosa.

Effect of acid suppression and gender ongastric emptying using applied potentialtomography

J W WRIGHT, D F EVANS (Department ofSurgery,Queen's Medical Centre, Nottingham and GIScience Research Unit, The Royal LondonHospital Medical College, London) Gastricemptying (GE) can be measured using appliedpotential tomography (APT), an impedanceimaging technique, but acid secretion isthought to alter the resistivity of the stomachand modify the results obtained. Acid inhibi-tion is therefore recommended.We have used APT to measure GE of 500 ml

Oxo and 500 ml porridge in 16 volunteers (10male, six female) without acid suppression andafter 400 mg cimetidine and 40 mg omeprazole.

Interpretable results were obtained withoutacid suppression and there was no difference inliquid emptying between different treatmentsor between men and women. In the femaleporridge group GE was significantly acceler-ated after omeprazole compared with controls(83 mean (SEM) (8.6) minutes (50% emptying)v 148 (14.6) minutes, p=0 001). There was nodifference in solid emptying in men.The men emptied significantly faster than

women in both the control (100 3 (8.4) minutesv 148 (11.9) minutes, p=0.01) and the cimeti-dine groups (74.7 (7.2) minutes v 130 (18.3)minutes, p=0 03). The omeprazole group didnot reach significance.

In conclusion, acid suppression acceleratedGE of solids in women. Acid suppression isunnecessary when using APT to measure

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gastric emptying. A gender difference in solidgastric emptying has been shown.

CELL BIOLOGY

Proliferative assessment by computer aidedimage analysis - a new technique forobjective quantification of gastrointestinalproliferation

M R GRAY, J A HUNT, R W IRLAM, D F WILLIAMS,A N KINGSNORTH (Departments of Surgeryand Bioengineering, University of Liverpool)Immunocytochemistry can selectively stainproliferating cells using monoclonal anti-bodies. PC10 is a monoclonal antibody specificfor proliferating cell nuclear antigen. Objectivequantification of immunostaining, whichreflects proliferative rate, is difficult as stainingintensity varies between sections, largenumbers of cells need to be counted, andcomplete blinding of observers is impossiblebecause the histology is coincidentallyapparent.We have used a technique coupling PCIO

immunostaining with computer aided imageanalysis. Staining of conventionally fixedtissues was carried out with PC10 using a DABchromogen without counterstain. Slides were

read at x200 magnification by a Hitatchi solidstate CCD camera and fed to an image analysissystem of a Joyce-loebl mini-magiscan. Imageswere manipulated using Genius software toadjust for staining intensity, subtract back-ground, and artifact and separate overlappingcells. Twenty 1mm2 fields were scanned foreach data point.

Repeated scanning of the same field ofPCNA stained gastric body absolutely repro-duced nuclear counts without variation.Multiple counts on the saime section compiledfrom 20 observations showed a standarddeviation of 2-7%. This represents an unprece-dented degree of reproducibility which can beapplied to assess objectively the proliferatingfraction in histological sections.

Colonic ion transport and platelet activatingfactor

S P L TRAVIS, D P JEWELL (Gastroenterology Unit,The Radcliffe Infirmary, Oxford) Distal colonicion transport exhibits a biphasic response toplatelet activating factor (PAF), a lipidmediator derived from membrane phospho-lipid. The ionic basis of the increase in shortcircuit current (SCC) has been investigated inisolated mucosal segments ofrabbit descendingcolon, mounted in Ussing chambers, andbathed in Ringer's solution containing 0-25%albumin. Serosal PAF (50 nM) stimulated an

initial rise in SCC (mean (SEM) [tA/cm2 of 28(3) (phase 1, maximal at 2-3 minutes), thenremained 12 (6) above baseline SCC (phase 2,maximal at 15-30 minutes), compared withchanges in controls of 0 (1) and -5 (2) respec-tively (n= 11 pairs, p=0-012). The PAF meta-bolite, Iyso-PAF, had no effect and bothphases were inhibited by a PAF analogueinhibitor. Restimulation with PAF 30 minutesafter initial exposure did not alter the SCC.Mucosal amiloride (10-4 M, n=7 pairs)abolished baseline SCC, but did not alter eitherphase of the response to PAF. Serosalfrusemide (1.0-4 M, n=6 pairs) partially

inhibited phase 1 (by 36%, p=0-014) andcompletely inhibited phase 2 (p=0.005). Thechloride channel blocker diphenylaminecarboxylic acid (2x 10-4 M, mucosal, n=5pairs), had a similar effect (phase 1 p=0-016;phase 2 p=0-012). No phase 2 response wasapparent with bilateral chloride free Ringer's(n=8 pairs), although there was no change inthe ,hase 1 response. Serosal DIDS (10` and10- M, n=4 pairs), an anion exchangeinhibitor, increased baseline SCC, but did notconsistently alter either phase of the responseto PAF.

In conclusion, PAF has a specific effect onion transport in the colonic mucosa, whichbecomes desensitised after initial exposure.Stimulation of chloride secretion by PAFseems to explain partially phase 1 of the SCCresponse and to be totally responsible forphase 2.

Vertical and longitudinal gradients of trans-forming growth factor a expression indicateselective differentiation programmes in therat colon

D J AHNEN, G ELIA, N A WRIGHT (Imperial CancerResearch Fund Histopathology Unit, London andDenver Department of Veterans Affairs MedicalCenter, Denver, Colorado, USA) All the neces-sary components oftransforming growth factora (TGFa) mediated autocrine or paracrinegrowth regulation are present in the colon(TGFa and its receptor are synthesised bycolonocytes, colonocyte proliferation is stimu-lated by TGFa). We have used immunoperoxi-dase immunohistochemistry to examine theexpression of TGFa in normal, preneoplastic,and neoplastic rat colonic mucosa. Appreciablevertical (maximal expression in upper crypt,none at the crypt base) and longitudinal(maximal expression in the caecum; a progres-sive decrease distally) gradients of TGFctimmunoreactivity are present in the colon.Refeeding of 48 hour fasted animals resulted inincreased proliferation in all colonic segmentsand decreased TGFa immunoreactivity in thedistal colon (no change seen in the proximal).Dimethylhydrazine treatment (25 mg/kgweekly for up to 16 weeks) resulted in increasedproliferation but no apparent alteration inTGFa immunoreactivity in the non-neoplasticmucosa (at 10, 15, or 20 weeks). DHM inducedtumours consistently had lessTGFa expressionthan the adjacent mucosa.These observations show that TGFa expres-

sion is regulated both during differentiationand regionally within the colon; they suggestthat in the distal colon TGFa is secreted inresponse to (and thus could mediate) a physio-logic stimulus to proliferation (refeeding); thatTGFa expression is decreased in neoplasticmucosa; and that the altered proliferation ofpreneoplastic colonic mucosa may not bemediated by major alterations in TGFaexpression.

Localisation and quantification of gastricbody proliferative compartment in omepra-zole treated rats using computer aided imageanalysis

M R GRAY, J A HUNT, R W IRLAM, D F WILLIAMS,A N KINGSNORTH (Departments of Surgery, Bio-engineering, and Physiology, University ofLiver-pool) The proliferative compartment of theoxyntic mucosa is confined to the mucous neckcells. Expression of proliferation associated

antigens is uncommon in foveolar, surface andgland cells.

Using proliferating cell nuclear antigen(PCNA) as a marker of cellular proliferation weused a computer aided image analysis system toquantify objectively gastric body immuno-staining. Two groups of 10 male Wistar ratswere treated with omeprazole 400 ltmol/kg/day for 30 days. Controls received vehicle. Alldata are expressed as median (range) andcompared by Mann-Whitney U test.Mean serum gastrin in omeprazole treated

rats rose 10 fold from 75 fmol/ml (19-170 fmol/ml) to 750 fmol/ml (450-850 fmol/ml)(p<0-001). Oxyntic mucosal thickness wasincreased 15% from 4-9 mm (4-42-5- 11 mm) to5.69 mm (54-7 05 mm) (p<0-001). Mucousneck cell labelling increased 33% from 500/mm2 (200-600/mm2) to 670/mm2 (488-820/mm2) (p<0*001). Gland cell labelling increased300% from 62/mm2 (36-88/mm2) to 200/mm2(144-377/mm2) (p<0 001).The number of cells expressing PCNA is

appreciably increased in the mucosa of thehypergastrinaemic rat. Increased expression ofproliferation associated antigens is morenoticeable in the oxyntic gland compartmentthan in the mucous neck cells.

SV40 T antigen allows resumption of celidivision in the small intestinal vUllus oftransgenic mice

R A GOODLAD, C Y LEE, G SCHMIDT, S HARRIS, E SREES, S HAUFT, J GORDON, D J AHNEN, N AWRIGHT (Imperial Cancer Research Fund Histo-pathology Unit, London; Department ofGenetics,Glaxo, Greenford, Middlesex; and WashingtonUniversity School of Medicine, St Louis,Missouri, USA) An unique pattern of prolifera-tion is reported from the intestine of a strain oftransgenic mice. The SV40 large T antigen waslinked to an intestinal fatty acid bindingprotein (IFABP) promoter and the antigen wasexpressed in the villi of the more proximalregions of the small intestine. Mice wereinjected with tritiated thymidine andvincristine. While the pattern of proliferationin the crypts was conventional, proliferatingcells were observed on the villi, especially in theduodenum, where the labelling index (LI) forthe villus was 11-6±0-26%. The LI of thecrypts was 33-4+4-3%. The density of label-ling (grain count) however, was significantly(p=0O007) less (28-3±1-7 v 52 5±4.55). Fewlabelled cells were seen in the basal part of thevilli or in the top fifth, most activity was in themid zones of the villus. Cell division was alsoshown by positive proliferating cell nuclearantigen (PCNA) immunostaining, and by thepresence of mitotic figures.Thus, the IFABP linked expression of the

large T antigen produced unique patterns ofintestinal epithelial cell proliferation; in whichcells on the villus recommenced proliferation.These mice offer a powerful model system forassessing the effects of proliferation onepithelial cell differentiation programs that arenormally expressed during translocation alongthe crypt to villus axis.

Calretinin and calbindin-D28k immuno-reactivity in human gastrointestinal nervesand endocrine cells

J R F WALTERS, A E BISHOP, P FACER, D E M

LAWSON, J H ROGERS, J M POLAK (Departments ofMedicine and Histochemistry, Royal Post-

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graduateMedical School, London; Department ofBiochemistry, King Saud University, Riyadh,Saudi Arabia; and the Physiology Laboratory,Cambridge) Calretinin and calbindin-D28k aretwo high affinity Ca2' binding proteins having58% sequence homology. They have beenlocalised to the cytoplasm of different specificcentral neurones including those involved inneurodegenerative disorders. We have studiedthe immunocytochemical distribution of thesetwo proteins in the human gastrointestinaltract.

Unlike calretinin, calbindin immuno-reactivity was found in some endocrinecells including gastric enterochromaffin likeand D cells, and small intestinal S cells.In both the submucosal and myenteric ganglia,a proportion of nerve cell bodies wereimmunoreactive for calbindin (in duodenum,13% in submucosal and 37% in myenteric)or calretinin (24% and 23% respectively), orboth proteins (8% and 4%). In nerve pro-cesses, calretinin was generally more abundantthan calbindin, particularly around bloodvessels. Calretinin was localised to submucosalganglion cells which were also immunoreactivefor vasoactive intestinal peptide, neuropeptideY, galanin, or substance P and to myentericcells with substance P immunoreactivity.Calbindin was colocalised with fewer pep-tides, being found with vasoactive intestinalpeptide or galanin in submucosal cells. Dis-crete neuronal localisation for both proteinswas found by eight weeks of fetal develop-ment.

Both calretinin and calbindin may proveuseful in determining Ca2+ mediated actions inthe enteric neuroendocrine system in normaland diseased states.

Induction of adhesion molecultes bycytokines (interferon y, interleukin I, tumournecrosis factor a, interleukin 6) on thesurface ofHT 29 and i407 cells

S L BLOOM, D P JEWELL (INTRODUCED BY D PJEWELL) (Gastroenterotogy Unit, The RadcliffeInfinnary, Oxford) In view of evidence suggest-ing a role for adhesion molecule ligand pairs inimmune recognition and cellular cytotoxicity,we examined basal and cytokine inducedexpression of eight adhesion molecules onintestinal epithelial cells using a panel of eightmonoclonal antibodies.

Cells from a colonic (HT 29) and anembryonic small intestinal cell line (i407) wereexposed to cytokines at various doses, stainedat times from seven hours to seven days laterwith monoclonal antibodies, and then analysedby FACscan.

Results showed: (1) A high constitutiveexpression of class 1 antigen with somefurther induction by interferon y (IFNy) butnot by interleukin I (ILI), tumour necrosisfactor a (TNFa) or interleukin 6. (2) Consti-tutive expression of ICAM 1 varied from 5 to30% with a trend to higher expression on HT29 cells than i407 cells. (3) ICAM 1 is inducedon both cell lines by IFNy and TNFa butnot by IL6 or ILl, unlike other tissues.(4) CD66, a member of the CEA family, isexpressed on HT 29 cells but not i407 cellsand is not induced by cytokines. (5) Otheradhesion molecules (ELAM, VCAM) were notexpressed.These results support the hypothesis that

inducable ICAM 1 expression may play a rolein leukocyte-epithelial cell interaction in thegut.

A method for the isolation of viable epithelialcells from human colonic biopsy specimens

J MEENAN, C O'FARRELLY, P W N KEELING,C FEIGHERY, D G WEIR (Departments of ClinicalMedicine and Immunology, Trinity College,Dublin) Attempts to isolate human colonicepithelial cells from endoscopic biopsy speci-mens have been hampered by low yields,lamina propria contamination, and the toxicityof mucolytic agents. We describe a method forthe isolation of large numbers of epithelial cellswith high viability and long survival.

Four biopsy specimens were taken at 30 cmfrom each of 14 normal colons. Specimens wereput directly into 1 mM Dithiothreitol in Ca21/MG21 free Hank's buffered salt solution (CMFHBSS) supplemented with 0 3% bovine serumalbumin (BSA), penicillin, and streptomycin.After four hours at room temperature thebiopsy specimens were transferred into 1 mMEDTA with CMF HBSS/0-3% BSA and in-cubated for one hour at 37°C on an inclinedrotating table. The supernatant was washed inCMF HBSS at 75 g for 10 minutes. Assessmentof cell numbers and viability were performedusing ethidium bromide/acrodine orange label-ling in a haemocytometer. Cell identificationwas by FACscan analysis using the monoclonalantibodies DAKO-Ber-EP4, CD3, and CD19.Median cell count was 2-1 million (1(0-

8.35). Mean viability 85% (70-100). FACscananalysis showed 94% epithelial cells with 6%intraepithelial lymphocytes. Samples with lowviabilities were incubated in a nylon woolcolumn. This procedure increased cell viabilitycounts by 6-14%. After 72 hours in RPMI(10% fetal calf serum) at 4°C mean viable countwas 1-64 million.

In summary, this method allows for theharvesting of large numbers of viable cells fromhuman colonic biopsy specimens. It introducesa novel method for increasing the percentageviability of cell suspensions and broadens theuse of the FACscan.

Effects of recombinant cytokines on EGF-induced hepatocyte DNA synthesis

A C WOODMAN, H J F HODGSON (GastroenterologyUnit, Royal Postgraduate Medical School,London) The coordinated control of liverregeneration requires both growth stimulationand inhibition. We have shown that condi-tioned medium from hepatic non-parenchymalcells (NPC) after 70% partial hepatectomyinhibits epidermal growth factor (EGF)induced hepatocyte proliferation in vitro. Toinvestigate the potential role of Kupffer andendothelial cell derived factors, we haveassessed the effects of recombinant interleukinI a (ILla) IL1fi, TNF, and TGFO, on EGFinduced DNA synthesis, assessed by [3H]-thymidine incorporation into primary adult rathepatocyte cultures.

IL1P (0.001-1 ng/ml) and TGFI31 (0-001-1 ng/ml) considerably reduced the response to10 ng/ml EGF (15644 (991) dpm/20000hepatocytes for ILIB, 7531 (311) for TGFP1,cf 38 758 (2943) for EGF alone; mean (SEM),n=8), whereas TNF (0.01-1 ng/ml) and ILla(0-01-10 ng/ml) had no effect. The specificityof the IL1 P and TGFf31 effects were confirmedby abrogation of inhibition by the respectivespecific neutralising antibodies (anti-ILIl,2 [ig/ml; anti-TGFf3i, 250 ng/ml).

Neither antibody however inhibited theeffect ofNPC conditioned medium on hepato-cyte DNA synthesis induced by EGF, indicat-

ing the existence of other cytokines capable ofmodifying growth responses after partialhepatectomy.

NEOPLASIA

An autocrine role for gastin/cholecystokininpeptides in pancreatic tumour cell growth

M BLACKMORE, B H HIRST (Department ofPhysio-logical Sciences, Medical School, Newcastle uponTyne) A role for gastrin as a growth factor ingastric and colonic tumour cells has beenproposed. We have examined the effectsof gastrin/cholecystokinin (CCK) receptorantagonists on the growth of the AR4-2J ratpancreatic tumour cell line. The antagonistsproglumide (IC50=1 3x 10-3 M), benzotript(IC50=4x 10-4 M), CR1409 (IC50=1 5x10-5M), and CR1505 (IC50=2.5x10-5 M) com-peted with '25IhG17-1 for binding to gastrinreceptors on AR4-2J cells and inhibited AR4-2J proliferation over a four day period (asassessed by the MTT and neutral red assays) atsimilar concentrations. The inhibition ofAR4-2J proliferation by these gastrin/CCK receptorantagonists could be partially reversed byaddition of 5 x 10 ` M gastrin two hours beforethe antagonists. Anti-gastrin immunoglobulinsalso inhibited AR4-2J proliferation when com-pared with a control immunoglobulin prepara-tion.These results are consistent with an autocrine

growth factor role for gastrin in AR4-2J ratpancreatic tumour cells and imply that gastrin/CCK antagonists may be useful in therapyagainst gastrin receptor positive tumours. Incontrast to the other gastrin/CCK antagonistsinvestigated, much greater concentrations ofL365,260 were required to inhibit AR4-2J cellproliferation (IC50=6-5 x 10-5 M) as comparedwith its ability to compete with '25IhG17-1binding (IC50=2x 10-8 M). The anti-tumouractivity of L365,260 is, therefore, unlikely tobe mediated by gastrin receptors.

Oestrogen and progesterone receptors incolorectal cancer tissue and five colon cancercell lines

C W HENDRICKSE, C E JONES, I A DONOVAN,J P NEOPTOLEMOS, P R BAKER (Department ofSurgery, Clinical Research Block, Universityof Birmingham and Dudley Road Hospital,Birmingham) The finding of oestrogen receptor(ER) mRNA in colonic tumour and normalmucosa is consistent with a role for sex steroidsin colorectal cancer. Using EIA we quantifiedER and progesterone receptors (PgR) in 17carcinomas (11 F; 6 M) with paired normalmucosa in 10 and in five colon cancer cell lines.ER and PgR (fmol/mg) were detected in 15 and17 cancers respectively: median (range) ER 1-3(0-113), PgR 3.9 (0-3-10-2). Values in pairedcancer and mucosa tissue were not significantlydifferent but ER correlated with PgR in cancertissue (tau=0 551, p<0005) and ER inmucosa (tau=0-533, p<005). These relationsexhibited significant linear log correlations (r=0-678, p<0 003; r=0-669, p<0 03 respect-ively). Mucosal PgR did not correlate withcancer PgR nor ER in mucosa. ER 3-5 (1-2-11-8) and PgR 24-3 (9 1-63.2) were detected inall cell lines (HT-29, LS-174T, SW-620,LOVO, Colo-320). In all cell lines PgR was

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greater than ER; oestradiol (10 nM) did notseem to down regulate ER or induce PgR.

This study indicates that oestrogen receptorsare a feature of colonic mucosa and that incarcinomas they seem to regulate PgR suggest-ing oestrogen responsiveness.

Secretion of pancreatic secretory trypsininhibitor by Capan 1 pancreatic tumour cellline is not influenced by cholecystokinin orgastrin

R J PLAYFORD, P H DEPREZ, J WOODBURN,J CALAM (Department of Medicine, Rayal Post-graduate Medical School, London) Secretion ofpancreatic secretory trypsin inhibitor (PSTI)by normal pancreatic acinar cells is increasedby cholecystokinin (CCK) or gastrin. PSTI hasalso been shown to be a growth factor for the ratpancreatic AR4-2J tumour cell line. We deter-mined if the human pancreatic tumours Capan1, MiaPaCa-2, and PANC-1 secreted PSTI andif this secretion was under the influence ofCCKor gastrin.About 5 x104 cells of the various cell lines

were incubated in 10 ml of normal growthmedium (RPMI 1640), containing 10% fetalcalf serum, for 72 hours. In addition to thesesamples, the various cell lines were incubatedunder identical conditions but with theaddition of CCK or gastrin in the medium at afinal concentration of 10-6 to 10-12 M. At theend of the 72 hours the medium was collectedand assayed for PSTI by radioimmunoassayusing antiserum T4.Medium from Capan 1 cells which had not

had CCK or gastrin added contained 170 nglmlof PSTI-like immunoreactivity. Similar con-centrations of PSTI-LI (140-190 ng/ml) werealso found in the medium from Capan 1 cellswhich also contained CCK or gastrin. NoPSTI-LI was found in the media fromMiaPaCa2 and PANC-1 cell lines±CCK orgastrin.

In conclusion, Capan 1 cell lines secrete largeamounts ofPSTI, but unlike normal pancreaticacinar cells, the secretion is autonomous andnot influenced by CCK or gastrin.

Increased secondary faecal bile acids in anew hamster model of colorectal cancer

C H E IMRAY, T MINOURA, A DAVIS, S RADLEY,K M NEWBOLD, M LAVELLE-JONES, A M LAWSON,P R BAKER, J P NEOPTOLEMOS (Departments ofSurgery, University of Birmingham and DudleyRoad Hospital, Birmingham, and ClinicalResearch Centre, Middlesex) We argued that thehamster would be a more suitable model forstudying faecal bile acids (FBA) and colorectalcancer (CRC) since its hepatic metabolism ismuch closer to humans than that of otherrodents.Four groups of 12 hamsters had twice weekly

intrarectal instillation of a locally actingcarcinogen, MNNG at doses of 1, 4, and 8 mgKg- 1 or vehicle (DMSO) alone for four weeks.Sacrifice at 15-40 weeks showed CRC in allanimals at the higher MNNG doses and oneadenoma at the lowest. FBA analysis wasperformed by gas chromatography massspectrometry and showed 9 FBA in the con-trols (no tumours) which were remarkablysimilar to the FBA profile of 10 healthyhumans. The median (range) FBA ([tmols.g-'faeces) of cancer bearing animals (0.52, 0 46-0 84) was lower than controls (1-08, 0-95-1-65,p=0-008; two tailed Mann-Whitney U) or non-

tumour bearing MNNG-treated hamsters(1-18, 0.641-42, p=0 003). These differenceswere largely accounted for by a reduction ofcholic acid derivatives (3a, 12a-, 3a, 70i, 120-,and 12-oxo, 3a-hydroxy-5¶ cholanoic acids;p<001 at least).The metabolic abnormalities of FBA in

tumour bearing animals supports a previoussuggestion that human tumours absorb moredeoxycholic acid and may partly explain incon-sistent findings of FBA in case control studiesof CRC. This is therefore a suitable model toinvestigate this further.

Bile and DNA damage in an animal model

A D SPIGELMAN, D K SCATES, S VENITT, R K SPHILLIPS (St Mark's Hospital, Royal MarsdenHospital and StMary's Hospital, London) Manycarcinogens react with individual DNA basesto form DNA adducts. Adduct values aregreater in the duodenum of patients withfamilial adenomatous polyposis (FAP) than inthe duodenum of controls, and are greater inthe duodenum than in the stomach of FAPpatients. This pattern of adducts mirrors thedistribution of foregut tumours in FAPpatients. Possible explanations includedelivery of carcinogens to mucosa by bile ordefective DNA repair mechanisms.We collected gall bladder bile at surgery

from FAP and control patients and gave it bygavage to Fischer rats (FAP bile, 6 rats, controlbile, 7; dose: 0.5 ml bile/100 g body weight,thrice weekly for nine weeks). Adduct valueswere measured in small bowel DNA by 32p-postlabelling/chromatography.DNA adduct values (adducts/109 nucleo-

tides) were significantly higher in rats treatedwith FAP bile than in rats treated with controlbile (FAP bile: median 23-5, range 12-40;control bile: median 10 range 2-27; p=0 004).

These results suggest that the distribution ofadducts found in the FAP foregut is a result ofcarcinogens in bile rather than of defectiveDNA repair. This is consistent with the ideathat bile is important in foregut tumourdevelopment in patients with FAP.

Lipiodol as a vehicle for targeted internalradiotherapy in liver metastases

R E HIND, S PERRING, J FLEMMING, V BATrY,S BIRCH, I TAYLOR (University Department ofSurgery and Departments of Nuclear Medicineand Radiology, Southampton General Hospital,Southampton) Lipiodol, an iodinated derivativeof poppy seed oil, has been shown to beselectively retained within primary livertumours. We have studied the biodistributionof lipiodol in patients with colorectal hepaticmetastases after hepatic arterial injection, andassessed dosimetry for possible treatment using13II labelled lipiodol.

Fifteen patients underwent selective angio-graphy before treatment for colorectal hepaticmetastases, when 3 ml radiolabelled (2 MBq131-I) lipiodol were injected. At subsequentlaparotomy biopsy specimens of tumour andnormal liver were taken and subjected to wellcounting, allowing tumour:liver ratios to beevaluated. Two patients had low ratios in large(> 10 cm) metastases. Of the remainder, at 24hours the median ratio was 1-5 (1 1-2.5; n=6),at three to nine days (n=8) the ratio was 2 75(1-64).Ten patients have undergone whole body

counting and SPECT imaging on at least two

occasions after injection of 3-5 ml radiolabelled(40 MBq 131-I) lipiodol, with CT overlayimages to confirm site and size of metastases.Significant activity was detected only in theliver and lungs.The beneficial tumour:liver ratios suggest

that a potentially tumouricidal dose of targetedradiotherapy may be safely administeredto selected patients with colorectal livermetastases.

Survival after surgery for colorectal cancer isas good in district general hospital practice asin teaching hospital practice

R D KINGSTON, S WALSH, J JEACOCK (INTRO-DUCED BY R D KINGSTON) (Department ofClinicalStudies, Trafford General Hospital, Manchester)We aimed to analyse the short and long termresults of treating patients with colorectalcancer admitted to teaching and non-teachinghospitals.A total of 567 patients admitted to district

and teaching hospitals in the north west wereentered to the study. Altogether 295 patientswere treated in a teaching hospital and 272patients in a district hospital. Demographic,pre and postoperative details and pathologicaldata were entered onto a computer compatibleform and input to a mainframe computer.Patients were followed up annually for a mini-mum of five years and patients' status and anyevidence of recurrence were recorded on afollow up form. The data were analysed usingSPSSX and survival analysis performed on thefollow up data using program PIL on BMDPpackage.There was no significant difference in the

number ofoperative mortalities. The incidenceof postoperative complications was similar.Patients' hospital stay was slightly longer innon-teaching hospitals and there was a greaterproportion of more elderly patients. There wasno difference in the survival rates.

In conclusion, complication rates, operativedeaths, and five year survival rates in the twostudy groups were similar.

Perioperative heparin - a successful adjuvantto surgery in colorectal cancer

R D KINGSTON, J W L FIELDING, M PALMER(INTRODUCED BY R D KINGSTON) (Department ofClinical Studies, Trafford General Hospital,Manchester) We aimed to evaluate the effect onsurvival of perioperative subcutaneous heparinwhen given as an adjuvant to surgery.

Extensive data were collected from a pro-spective study of 601 patients with colorectalcancer undergoing curative surgery. Patientswere followed up every three months untildeath, or for five years. Time to recurrence andduration of survival was calculated from date ofresection.

Factors influencing survival were identifiedby multiple regression analysis using Cox'smethod. Survival and event free curves werecalculated using the Kaplan-Meier method.

Results suggest a small but significantimprovement in survival at five years or equiva-lently a reduction in the risk of death. Thiseffect as apparent is not explained by demons-trable differences between heparin and non-heparin patients in the distribution of knownprognostic factors. Adjustment of these factorsslightly increased the apparent magnitude ofthe beneficial effect.The magnitude of survival and event free

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survival is similar to that reported by Moertelafter one year of adjuvant cytotoxic therapy.

In conclusion, perioperative subcutaneousheparin has a small but significant effect on fiveyear survival.

Do smokers and drinkers have an increasedrisk of colorectal adenomas?

R F A LOGAN, J LITTLE, I D TURNER, J DHARDCASTLE (University Departments of PublicHealth and Epidemiology, and Surgery,University Hospital, Nottingham) Recentstudies have suggested that smoking andalcohol intake are important and possibly inter-active risk factors for developing colorectaladenomas (Kikendall et al, Gastroenterology1989, Cope et al, Gut 1991). We have enquiredabout these factors in subjects participating in alarge trial of faecal occult blood (FOB) screen-ing for colorectal neoplasia. FOB +ve adenomacases (n= 147), FOB -ve age and sex matchedcontrols (n= 153) and FOB +ve patients with-out adenomas (n= 176) were interviewed athome two years after investigation. Uncon-ditional logistic regression has been used toestimate relative risks (RR) and 95% con-fidence intervals (CI) adjusted for age, sex, andsocial class.The RR ofcolonic adenoma for ever smokers

and those smoking 15+/day respectively (neversmokers RR=1) were 0-78 (0-5-1-3) and 0-82(0-3-2-1) for FOB -ve controls and 0-87 (0 5-1-5) and 1.1 (04-2 8) for FOB +ve controlswith no association evident between total packyears of smoking and risk of adenoma. Basedon current consumption there was a weakassociation between adenomas and total alcoholintake: using FOB -ve controls the RR ofadenoma was 1-3 (0 7-2.5), 1-4 (0.7-2.8), and1-7 (0 8-3.6) for increasing tertiles of alcoholintake compared to non-drinkers (RR= 1)(Trend X2=2- 1) and using FOB +ve controlsthe RR being 1-2 (06-2.2), 1-6 (0 8-3.2), and1-8 (0.9-3.8) (Trend X2=3.2). Adenoma pre-valence was not related to the type of alcoholconsumed.

For both exposures, relations did not varysignificantly when analysed by adenoma size,site or histological type. These results indicatethat alcohol intake, but not smoking, is weaklyassociated with the prevalence ofasymptomaticcolorectal adenomas. These results are consist-ent with recent metaanalyses of smoking andalcohol in colorectal cancer which show only aweak relation between cancer and alcoholintake and no relation with smoking.

Do alterations in renal haemodynamicspredict the presence of hepatic micro-metastases?

D M NOTT, J YATES, J S GRIME, S A JENKINS(University Department ofSurgery, Royal Liver-pool Hospital, Liverpool) We have previouslyshown that the increase in the hepatic perfusionindex (HPI) in the presence of overt tumour inthe rat is accompanied by a significant decreasein renal blood flow. Since there is little informa-tion on the temporal relation between altera-tions in renal blood flow and the growth anddevelopment of hepatic tumour, we haveundertaken such a study in the rat. Male Fisherrats received an intraportal injection of1 6x107 Walker cells. Control animals weredosed with the same number of dead cells.Renal and hepatic blood flow were measured bythe microsphere method and by dynamic

scintigraphy. The rats were studied at 2, 4, 6,and 21 days after intraportal administration ofviable or dead Walker cells.

Micrometastases were present histologicallyfour days after inoculation. The hepatic perfu-sion index (HPI) at four days (51-8+±168) wassignificantly greater (p<0-0001 Mann-Whitney U test) than in controls (33-78+± 1-77).The increase in the HPI four days after inocula-tion was accompanied by a significant increasein the mean renal transit time (3-95± 118seconds) compared with controls (2-28±0-48seconds). Conversely, the renal blood flow wassignificantly reduced in animals with micro-metastases (7-32±2-81 ml/minute) comparedwith controls (14-02±3-42 ml/minute). Thesechanges in HPI, renal transit time, and renalblood flow were maintained at six and 21 daysafter inoculations.These results suggest that renal blood flow is

reduced during the early stages of growth anddevelopment of hepatic tumour. Furthermore,since renograms with a flow phase are techni-cally easier to perform in man than estimationsof the HPI, determination of renal blood flowmay be of value in the detection of occult livermetastases.

Urgent admission and subsequent surgeryfor colorectal cancer has a poor prognosis?

R D KINGSTON, J JEACOCK, S WALSH (INTRO-DUCED BY R D KINGSTON) (Department ofClinicalStudies, Trafford General Hospital, Manchester)We aimed to analyse the short and long termresults of treating patients with colorectalcancer admitted as emergencies.A total of 733 patients admitted to one

district general hospital for colorectal cancerwere included in this study. Three main groupswere identified, patients admitted electively,patients admitted as emergencies and operatedon within 24 hours ('urgent'), and otheremergency patients as defined by admittingsurgeon. Demographic, pre- and postoperativedetails were recorded on a standard form forcomputer input and analysed on a mainframeusing a standard statistical package (SPSSX).Data included symptoms, surgical and patho-logical data, complications, and follow upinformation. Survival analyses on the follow updata was performed using program P1L of theBMDP package.

Patients admitted as emergencies had asignificantly poorer performance status. Theoperative mortality in the urgent group wasmore comparable with the elective group; 11%and 9% respectively. The other emergencygroup showed an operative mortality rate of21%. Five year survival for the elective patientswas 31% compared with 18% for bothemergency groups.

In conclusion urgent surgery for emergencycases does not necessarily result in a higheroperative mortality or wound infection rate,but has a lower probability of curative resec-tion. Five year survival for all emergencypatients was worse than for elective patients.

Fatty acids in the phospholipid and neutrallipid fractions in colorectal cancer

C W HENDRIKSE, S RADLEY, A DAVIS, I DONOVAN,P BAKER, M KEIGHLEY, J P NEOPTOLEMOS(Department ofSurgery, Clinical Research Block,University of Birmingham and Dudley RoadHospital, Birmingham) Previous experimentalstudies in the rat and man have suggested

increased arachidonate (20:4, n-6) anddocosahexaenoate 22:6, n-3) values incolorectal cancer but is controversial. There-fore, we assessed fatty acid profiles in bothphospholipid and neutral lipid fractionsseparated by column chromatography in thecancer tissue, transition zone mucosa, (3 cmfrom the cancer), and normal mucosa in 10patients with colorectal cancer. Analysis was bycapillary gas liquid chromatography (pmolsensitivity).The results were as follows: (1) Total mean

(SD) mg/g wet wt fatty acids in cancer tissue,5-96 (0.56) was significantly increased com-pared with both transition zone mucosa, 4-76(1-15) and mucosa, 4-32 (0.97) (both p<0 05,AOVO). (2) Total fatty acids in the neutrallipid fraction were reduced in cancer tissue,1-68 (0.6) compared with transition zonemucosa, 4.7 (3.7) and normal mucosa, 3-87(2 09) (both p<0 05). (3) In the phospholipidfraction of cancer tissue, 20:4, n-6 was 0.57(0-18) and 22:6, n-3 was 0-13 (0.06), bothhigher than in normal mucosa, 0.44 (0- 16) and0.07 (0.04) respectively (both p<0 05); valuesin the transition zone were intermediate for20:4, n-6, 0-51 (0-14) and for 22:6, n-3, 0.09(0.05) (NS).

In conclusion: (1) This study supports pre-vious findings of increased 20:4, n-6 and 22:6,n-3 in colorectal cancer. (2) The increase wasmost noticeable in the phospholipid fractionand is of relevance since this fraction is meta-bolically labile, indicating active roles for 20:4,n-6, the precursor of putative tumour promot-ing prostaglandins and 22:6, n-3 suggestive ofreduced lipid peroxidation implicated in cancergrowth.

NUTRITION

Zinc sulphate supplementation modifies thelong chain fatty acid metabolism in patientswith Crohn's disease

A BELLUZZI, C BRIGNOLA, M CAMPIERI, LPIRONI, P GIONCHETTI, F RIZZELLO, P IANNONE,M MIGLIOLI, L BARBARA (INTRODUCED BY C JHAWKEY) (Clinica Medica e Gastroenterologia,Farmacologia Clinica e Terapia Medica,Policlinico S Orsola, University of Bologna,Italy) Patients suffering from Crohn's disease(CD) can develop a zinc deficient status. Sincezinc is involved in long chain fatty acid (FA)metabolism, we used gas chromatography toinvestigate the FA profile of red blood cellphospholipid (RBC-P) before and after supple-mentation with zinc sulphate (ZnSO4) (200 mgdaily for six weeks) in 15 patients with CD inclinical remission.RBC-P FA profile was measured since it is

less susceptive than the plasma P FA profile,to short term, meal related changes. Weinvestigated the same FA profile in 15 healthycontrols (HC) without any alteration of zincmetabolism.The plasma zinc values were 72 (8) [tg%

before the treatment and increased to 114 (10)[tg% afterwards (arith.mean (SEM)). Beforesupplementation the two main saturated FAs,palmitic and stearic (16:0, 18:0) and oleic(18:1) were significantly increased (p<0-001)while linoleic (18:2), arachidonic (20:4), andw3 (20:5, 22:5, 22:6) FAs were reduced(p<0-001) in CD patients compared with HC.Treatment with ZnSO4 abolished these differ-

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ences so that there were no significant differ-ences between CD patients and HC at the endof the treatment.

In conclusion, patients with CD have zincdeficiency which affects FA metabolism andmembrane composition.

Role of felbinac gel in the prophylaxis ofperipheral parenteral nutrition relatedthrombophlebitis

J S PAYNE-JAMES, S KAPADIA, M J BRAY, S RANA,D MCSWIGGAN, D B A SILK (Department ofGastro-enterology and Nutrition, Central MiddlesexHospital, London) The aetiology of peripheralvein thrombophlebitis (PVT) associated withperipheral parenteral nutrition (PPN) is multi-factorial. This study determined whetherlocal application of a non-steroidal anti-inflammatory gel (felbinac 3% - Traxam,Lederle Laboratories, UK) could reduce theincidence or delay onset of thrombophlebitis.

Fifty healthy volunteers had a peripheralvein cannula (Vasculon 2, Viggo AB, Sweden)inserted in each forearm for five days. Bothforearms were randomised to receive either (a)twice daily application of 1 g of active gel (A),or (b) 1 g of inactive placebo gel (I) on skinoverlying the cannula. Twelve hourly observa-tions of cannula sites were made recording thedevelopment of (a) redness, (b) swelling, (c)hardness (each measured as <2 cm or >2 cm inlength), and (d) presence or absence of pain.Three sites were examined: (i) site of insertionof cannula, (ii) mid-point of cannula, (iii)cannula tip. Cannulas were removed ifany signwas >2 cm in length at any site or if pain wasexcessive.

(A) had significantly fewer episodes of painat the insertion site (p<005). (A) had signifi-cantly fewer cannulas with signs >2 cm at eachtime point. For (A) and (I) respectively at eachtime point these values were (% cannulas); 12hours, 0 v 2; 24 hours, 4 v 10; 36 hours, 6 v 10;48 hours, 10 v 20; 60 hours, 12 v 22; 72 hours,15 v 28; 84 hours, 17 v 30; 96 hours, 20 v 34;108 hours, 22 v 45 (p<0 05).We conclude that topical felbinac gel may

have a significant role in reducing the incidenceand delaying onset of the changes of PVT, andthus may be appropriate for the prophylaxis ofthrombophlebitis in patients receiving PPN.

Fine bore silastic and polyurethane cathetersfor the peripheral venous delivery of intra-venous nutrition: a randomised study

N J EVERIIT, M MADAN, D J ALEXANDER, M JMcMAHON (University Department of Surgery,The General Infirmary, Leeds) A randomisedprospective study compared the efficacy ofsilastic (23 g Epicutaneo Cava Katheter -Vygon), and polyurethane (22 g SecalonHydrocath - Viggo) fine bore catheters forthe delivery of intravenous nutrition via aperipheral vein. Fifty patients were fed for amedian duration of nine days with a 2-5 l feed(osmolality 1250 mOsm/l, 13 g nitrogen, 1800kcal). Twenty five patients received a silasticcatheter and 25 a polyurethane catheter.The rate of thrombophlebitis was similar in

each group (silastic 0-018 episodes/patient dayv polyurethane 0-015 episodes/patient day).Silastic catheters had a shorter median lifespan(silastic 172 hours v polyurethane 201 hours,p=003 Mann-Whitney). Silastic catheterswere more prone to occlusion without thedevelopment of thrombophlebitis (silastic 9 v

polyurethane 2). Some 84% of patients neededonly one silastic catheter for the duration oftheir feed, and 90% needed only one poly-urethane catheter.

This study confirms the value of fine borecatheters for the delivery of full intravenousnutrition via a peripheral vein. The poly-urethane catheter used was shown to have asuperior lifespan compared with the silasticone.

Comparison of radiological and endoscopicmethods for percutaneous gastrostomy andjejunostomy

N SATHANANTHAN, J MURFITT, H FAWCETT,N VAN SOMEREN, J POWELL-TUCK, P SWAIN(Departments ofRadiology, Gastroenterology andClinical Nutrition, The Royal London Hospital,London) We compared radiological (R)with endoscopic (E) methods of placing per-cutaneous gastrostomy (PG) and jejunostomy(PJ) in 24 patients requiring long term enteralfeeding unable to tolerate nasogastric tubes.Twelve patients had radiologically placedgastrostomies/jejunostomies (Fresenius PGn=2, Cook: Carey-Alzate-Coons PJ n= 10) and14 patients had attempted endoscopicgastrostomies/jejunostomies (Fresenius n=6,Abbott n=2, Caluso n=2, Bard n=2) PG n=10, PJ n=2). (R) PG/PJ were placed in 12 of 12.(E) PG/PJ were placed in 12 of 14. Poortransillumination prevented endoscopic place-ment in two which were subsequently placedby a combined radiological and endoscopicmethod. Radiological PG/J diagnoses: CVA(6), head/neck/oesophageal cancer (4) shortbowel (1), scleroderma (1); endoscopic PG/Jdiagnoses: CVA (9), motor neurone disease (3).No major complications occurred with either

technique. Mean duration of percutaneousfeeding was (R) 7/12 (2-17), (E) 5/12 (0-13).Minor complications were initially observedmore commonly (p<0t05) with radiologicalmethods: mild peristomal infection 5 (R),2 (E), late tube migration 4 (R), 0 (E), but werereduced by antibiotics and earlier tube change.Diarrhoea was commoner with PJ than PG,3 (R), 1 (E) (NS).We conclude that radiological placement is

effective and safe and allows long term enteralfeeding in patients with head/neck/oesophagealcancer in whom peroral endoscopic gastro-stomy placement was not possible and wastechnically superior to endoscopic methods forplacing jejunal tubes. Combined radiologicaland endoscopy allowed placement in patientswhere endoscopy alone failed to indicate safeapposition of stomach and abdominal wall.Radiological methods extend the usefulness ofless invasive percutaneous feeding techniques.

Oral salt supplements to compensate forjejunostomy losses: comparison of sodiumchloride capsules, glucose electrolytesolution, and glucose polymer electrolytesolution

J M D NIGHTINGALE, J E LENNARD-JONES, E RWALKER, M J G FARTHING (St Mark's Hospital,London) Six patients with jejunostomies andresidual jejunal lengths of 105 to 250 cm tookthe same food and water each day for eightstudy days. In random order, three methods ofsalt replacement were tested, each over 48hours, against a period without added salt.During the three test periods the patients took120 mmol of sodium chloride daily, as salt in

gelatine capsules, as an isotonic glucose electro-lyte (280 mOsm/kg, 30 kcal) solution and as aglucose polymer (Maxijul) solution (280mOsm/kg, 200 kcal). The daily stomal outputremained constant for each patient during thefour test periods but varied between patientsfrom 0U60 to 2-84 kg (daily intestinal fluidbalance 074-2-61 kg). Without a salt supple-ment, three of the patients lost more sodiumfrom the stoma than they took in by mouth(-25, -94, -101 mmol/day) and the meansodium balance for all six subjects was - 16mmol (range -101 to 79) daily. Extra salt wasabsorbed with each form of supplement(p<005); no patient was in negative balancewith the glucose electrolyte solution (mean 96,range 0 to 226 mmol), one patient with theglucose polymer solution (mean 96, range -25to 164 mmol) and two with the salt capsules(mean 66, range - 8 to 145 mmol). Twopatients vomited with the salt capsules. Therewas only a small increase in energy absorption(mean 115 kcal) with the glucose polymersolution as compared with the glucose-electrolyte solution.A sipped glucose electrolyte solution seems

to be the optimal mode of sodium replacementin patients with a high output jejunostomy.

Ultrafine bore catheters for intravenousnutrition - peripheral venous nutrition with-out thrombophlebitis?

M MADAN, D j ALEXANDER, M j MCMAHON(University Department of Surgery, GeneralInfirmary, Leeds) Intravenous nutrition (IVN)can be administered via a peripheral vein butthe high incidence of thrombophlebitis limitsthe osmolality of the feed. Osmolality can bereduced by limiting the amino acid or glucosecontent but this also reduces the nutritionalvalue of the feed. In this study a feed providing1800 kcal per day (800 kcal as glucose), with anosmolality of 1250 mmol/kg was administeredthrough a peripheral vein via a standard 20 GTeflon cannula or a fine bore (23 G) siliconecatheter.

Patients in both groups were fed for a medianof five days. The incidence of thrombophlebitiswas significantly higher in the Teflon group,2-04 episodes v 0.07 episodes per patient. Themedian life span of a silicone cannula wassignificantly higher than that of a Tefloncannula, 128 v 36 hours.These results suggest that a low incidence of

thrombophlebitis can be obtained by the use offine bore silicone catheters thus avoiding theneed for central venous access in most patientswho require IVN.

Effects of osmolality and heparin with hydro-cortisone on thrombophlebitis in peripheralintravenous nutrition

M MADAN, D J ALEXANDER, M J MCMAHON(University Department of Surgery, GeneralInfirmary, Leeds) Intravenous nutrition,administered via the central route, incurs boththe risks of catheter insertion and catheterrelated sepsis. Peripheral intravenous nutritionis associated with a high risk of thrombo-phlebitis. We investigated the incidence ofthrombophlebitis caused by the infusion of (a)a ready to use mixture with an osmolality of1130 mOsm/kg, (b) this mixture plus heparinand hydrocortisone, and (c) a feed, with anosmolality of 700 mOsm/kg, with heparin andhydrocortisone to investigate the effects of the

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addition of heparin and hydrocortisone and theeffect of osmolality on the incidence ofthrombophlebitis.The addition of heparin (500 U/1) and hydro-

cortisone (5 mg/l) to feed (a) significantlyreduced the daily risk of thrombophlebitisfrom 0 43 to 0-11 episodes per patient, p<0 05.A reduction in the osmolality resulted in a

further fall in the incidence of thrombo-phlebitis to 0.04 episodes per patient with a

significant increase in the median life span ofthe cannula from 26 hours to 86 hours, p<0 02.

These results show that a low incidence ofthrombophlebitis can be achieved by the use ofa low osmolality feed with heparin and hydro-cortisone thus the peripheral route is ideal forshort term intravenous nutritional support.

PANCREAS

Effect of pancreastatin on insulin release andsecretin stimulated exocrine pancreaticsecretion

J V SCHONFELD, M K MULLER, M RUNZI, H

GOEBELL (INTRODUCED BY D WINGATE) (Depart-ment ofGastroenterology, Medical Clinic, Essen,Germany) Pancreastatin, a 49-amino-acidC-terminal amidated peptide, was isolatedfrom porcine pancreas in 1986. It has sincebeen shown to inhibit insulin release andcholecystokinin (CCK) stimulated exocrinepancreatic secretion in vivo. There are, how-ever, very few studies on pancreastatin andsecretin stimulated exocrine pancreatic secre-

tion, and these have rendered contradictoryresults.The arterially perfused isolated pancreas of

male Wistar rats was used. The exocrinepancreas was stimulated submaximally bysecretin (100 pg/ml), insulin release was stimu-lated by glucose (16-8 mM). The pancreaticduct was cannulated by a polyethylene tube.The volume of and amylase content in 10minute samples of pancreatic juice and insulinconcentration in 60 second samples of theeffluent were measured. Then 20 pM and 200pM pancreastatin were tested in two subse-quent 10 minute intervals (n=8; p<O 05).

Insulin output was significantly reduced bypancreastatin (first 10 minute interval and 20pM pancreastatin: 6170±610 v 2919±550 [tU/10 minutes; second 10 minute interval and 200pM pancreastatin: 7040±790 v 3210± 500 [tU/10 minutes). Secretin stimulated volume andamylase output (10±2 ,ul/10 minutes and 35 ± 8U/10 minutes, respectively) were not affectedby 20 pM pancreastatin (9±1 1i/10 minutesand 35±7 U/10 minutes respectively) or 200pM pancreastatin (7±1 [tI/10 minutes and30±7 U/10 minutes, respectively).

In conclusion, pancreastatin inhibits insulinrelease, but does not affect secretin stimulatedexocrine pancreatic secretion in vitro. Pancrea-statin does not seem to affect pancreatic acinarcells directly, or to inhibit exocrine pancreaticsecretion indirectly via the islet-acinar axis.

Impact of endoscopic retrograde cholangio-pancreatography (ERCP) on the incidence ofacute pancreatitis in west London

P C RUTTER, R HITTINGER, M ALDRIDGE,G GLAZER (St Mary's Hospital, Queen Elizabeththe Queen Mother Wing, Paddington, London)

The incidence and aetiology of acute pan-creatitis (AP) has been examined in a mixedurban and suburban population of 1.5 millionserved by eight hospitals in the North WestThames Health Region over a period of 38months. The criteria for AP were amylase>1200 iu/l with abdominal pain and signs ofperitoneal irritation, or computed tomogram,laparotomy, or necropsy evidence ofpancreatitis. Some 487 cases have beendocumented, giving an overall incidence ofAP of 103 per million population peryear.

In 376 cases (77%) an aetiology was found.Alcohol and gall stones (155 (32%) and 140(29%) respectively) accounted for most of thecases. Iatrogenic causes accounted for 9%(ERCP (20); postoperative (18), and drugs (6)).Other causes included trauma (3), viral (2), andtumour (2). Indications for ERCP were; biliarystones (12), pancreatic investigation (5), andnon-stone causes of obstructive jaundice (3). Infive patients the pancreatobiliary system wasnever visualised and a further five patients haddiagnostic imaging alone. Only 10 had atherapeutic procedure performed, which wassuccessful in seven.AP following ERCP had a significant

morbidity in that median hospital stay was 11days (range 4-101).

Natural and unnatural course of chronicpancreatitis based on a long term follow up ofa medical surgical series

I VANTINI, G CAVALLINI, G ANGELINI, B VAONA,G TALAMINI, M FILIPPINI, G CATAUDELLA, A

FIORETTA, G CASTELLANI, P BOVO, M GUIOTTO(Ist Clinica Medica e Div Gastroenterologiain Valeggio sIM Universita di Verona, Italy)During 1970-89, 637 patients with chronicpancreatitis (CP) (549 M; 88 F) were observed.The data were submitted to statistical analysis(also for censored data). In 81-7% the aetiologywas alcoholic (M>F, p<0-001), in 2-2%familial, in 5-7% idiopathic (F>M, p<0-001)and in 6-3% there were other causes. Some 542CP patients were followed for 11±6-5 years.Cumulative survival was 76% at 15 years.Causes of death (known in 91 of 119) wereextrapancreatic tumours, cirrhosis, cardio-vascular disease, digestive haemorrhage (28,11, 10, and 9 cases respectively), pancreatitis(11), diabetes (8), pancreatic cancer (9), andother causes (5). A total of 341 CP patientswere operated upon for complications (25.5%)and/or pain (71-5%). About 50% of operationswere carried out within the third year ofillness, but no more than 3-6% of CPpatients were operated on per year from theseventh year. Risk of surgery was associatedwith the number of painful relapses in thefirst year (p<0-0001), cysts (p<0-0001),smoking (p<0.001), and alcohol intake atclinical onset (p<0005). Surgery was followedby rapid and lasting decrease in pain(p<00001). In non-operated CP patientsthe median value of relapses per year de-creased in time; from year eight, 50% werevirtually pain free. Alcohol intake droppedover time and the frequency of relapses washigher in drinkers than in abstainers (ratioabout 2: 1).

In conclusion, CP is mainly alcoholic,alcohol and smoking-related diseases areimportant causes of death. Though surgeryis followed by pain relief, pain subsides intime in a substantial number of non-operatedpatients.

Reversal of transforming growth factor astimulated pancreatic cancer growth in vivoby somatostatin analogue RC-160

P KAPUR, N M DAVIES, J GILLESPIE, A V SCHALLY,P J GUILLOU, G J POSTON (Academic SurgicalUnit, St Mary's Hospital, London; DepartmentofMedicine, Tulane University and VA MedicalCenter, New Orleans, USA) Transforminggrowth factor a (TGFa) is an autocrine growthfactor for pancreatic cancer in vitro and istrophic to these tumours when administered invivo. The purpose of this study was to examinethe effect of the somatostatin analogue RC-160on TGFa stimulated pancreatic cancer growthin vivo.Some 24 male Syrian golden hamsters were

inoculated in both cheek pouches with H2Thamster ductal pancreatic cancer cells and thenequally randomised to four equal groups:saline; RC-160 (100 pg/kg); TGFa (10 pg/kg),and RC-160+TGFa each at the same dosage asthe other regimens. Treatment was given threetimes a day for seven weeks by intraperitonealinjection. Tumours were measured weekly; atsacrifice tumours were weighed and analysedfor DNA content.From week four until sacrifice TGFa signifi-

cantly promoted tumour growth, while RC-160, alone and in combination with TGFa,significantly inhibited tumours (p<0-01 by twoway ANOVA). At sacrifice, tumour weightsfollowed this trend, as did tumour DNA con-tents which were significantly different.

In conclusion, RC-160 abolishes the growthstimulatory effect of TGFFa on pancreaticcancer in vivo, in addition to having a directtumour inhibitory role. These findings supportthe therapeutic use of somatostatin analoguesin the treatment of patients with pancreaticcancer.

Photodynamic therapy on the pancreas andadjacent normal tissues in the hamster

P J 0 NUUTINEN, P T CHATLANI, J BEDWELL, A J

MACROBERT, S G BOWN (National Medical LaserCentre, The Rayne Institute, University College,London) Photodynamic therapy (PDT) is basedon the interaction of light with a previouslyadministered photosensitiser to give localnecrosis and has the potential to destroy smalltumours in situ. Previous results in hamstersshowed that pancreatic cancers are more sensi-tive to PDT than normal pancreas, but for safeclinical use, it is essential that adjacent normaltissues are not damaged. We studied PDT onthe pancreas and adjacent organs in normalhamsters. The extent of necrosis depends onthe concentration and microscopic localisationof photosensitiser. We studied the distributionof the sensitiser disulphonated aluminiumphthalocyanine (AlS2Pc) by both alkali extrac-tion and fluorescence microscopy. Tissuesamples were removed at necropsy 1, 3, 48, or168 hours after sensitisation using 5 jimol/kgAlS2Pc. Fluorescence microscopy was carriedout using a CCD (charge coupled device)camera. The effect of light was assessed inseparate experiments. Forty eight hours aftersensitisation with 1 or 5 [smolUkg AlS2Pc, 50Jof light at 50 mW was delivered via a 200 ,umfibre just touching the surface of the targettissue. The animals were allowed to recoverand killed up to two weeks later to assess theresults. Chemical extraction showed the high-est concentration of AlS2Pc in the duodenum48 hours after sensitisation, with values muchhigher than in stomach or pancreas. The CCD

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results showed highest fluorescence values induodenal submucosa and bile duct wall at 48hours after photosensitisation, falling onlyslightly by 168 hours. Pancreatic ducts, duo-denal mucosa, and gastric mucosa and sub-mucosa exhibited intermediate values withrelatively weak fluorescence in pancreaticacinar tissue and the muscle layer of thestomach. As expected from the distributionstudies, the duodenum and bile duct were thetissues most vulnerable to PDT. With 5 ,imol/kg AIS2Pc, duodenal perforations, gastriculcers, and transudation of bile occurred, butthe bile duct and stomach healed by two weekswithout perforation or obstruction. There waslittle effect on the pancreas or major bloodvessels.

In conclusion, with treatment parametersshown previously to necrose pancreatic cancersin the hamster, there is little damage to thenormal pancreas. The only tissue vulnerable toserious, irreversible damage is the duodenum.If the duodenum is protected, PDT may be ofvalue in treating small volumes of residualtumour in the pancreas, particularly if the mainbulk can be removed by conventional tech-niques such as surgery.

Somatostatin suppresses raised pancreaticenzyme synthesis and secretion but results instagnant pooling of enzyme stores in shortbowel syndrome patients with secretorydiarrhoea

S J D O'KEEFE, W M BENNET, M W HAYMOND(INTRODUCED BY S F PHILLIPS) (Mayo Clinic,Rochester, Minnesota, USA) Studies haveshown that the somatostatin analogue,octreotide (SMS), can be useful in controllingsecretory diarrhoea. Using a recently validatedmodel for measurement of human pancreaticenzyme synthesis (SYN), enzyme pool (that is,zymogen stores) turnover (PTO), and secretion(SEC) based on a primed/continuous infusionof 14C leucine with cholecystokinin (CCK) (40nglkg/hour) and measurement of isotopicincorporation into secreted enzymes, we haveexamined pancreatic function in 10 HPNpatients with severe SBS before and after sevendays of SMS (100 ig tds)The results (mean (SEM)) showed that in

comparison with 10 matched healthy sub-jects, trypsin, amylase, and lipase SEC washigher (355 (55) Eq/hour v 190 (21) p<0 05),SYN was faster (45 (15) v 71 (15) minutes), butPTO was similar (43 (20) v 36 (10)%/hour)in SBS patients. After treatment, SYN andSEC returned to normal, but PTO was reducedto 23 (5)%/hour indicating an increase inenzyme pool size to 1022 (260) Eq (normal528 (48)).The results suggest that high stomal losses

are associated with adaptational pancreatichyperplasia and that SMS therapy results instagnation of the large intracellular enzymepool. Our results support the use of SMSin suppressing pancreatic secretory losses,but raise concern over its use in acute pan-creatitis where intracellular enzyme activation(for example, crinophagia) of the enlargedpool of enzymes may exacerbate diseaseactivity.

Influence of growth factors on growth ofpancreatic cancer in vitro

G V MILLER, J N PRIMROSE (Department ofSurgery, St3James's University Hospital, Leeds)Antiproliferative effects of somatostatin havebeen attributed to direct receptor activation orindirect interference at growth factorreceptors. The aim of this study was to evaluatethe effects of epidermal growth factor (EGF),transforming growth factor a (TGFct), and thesomatostatin analogue RC- 160 on growth of thehuman pancreatic carcinoma cell line,MIAPaCa2. Cells were synchronised by culturein the absence of fetal calf serum for 24 hours,then cultured in complete medium with dailyaddition of growth factors alone (0-5-100 ng/ml), RC-160 alone (10- 12 M-10-6 M), and RC-160 in the presence of EGF or TGFa. Resultswere expressed as mean (SEM) incorporationof 75-Selenomethionine (as percent of vehicletreated controls).

Both EGF and TGFa elicited a trophicresponse in MIA PaCa2, maximal at 100 ng/mlTGFa (201-8 (12-5)%) and at 50 ng/ml EGF(181-0 (16-3)%). RC-160 alone produced noinhibition of cellular proliferation. In thepresence of EGF or TGFa, the trophicresponse to these agents was not inhibitedby RC-160 over the concentration rangetested.

In conclusion, EGF and TGFt are trophic tothe human pancreatic carcinoma cell line, MIAPaCa2. This effect is not prevented by thesomatostatin analogue RC- 160 and no directeffects of RC-160 on unstimulated cell growthwere observed. These data suggest that in vivoantiproliferative effects of somatostatin and itsanalogues are not mediated by direct somato-statin receptor activation or by interference atthe EGF receptor level.

Is there a cephalic phase for pancreaticenzyme secretion in humans?

A H RAIMUNDO, J ROGERS, P FIELDEN, N SEBIRE,M AKMAL, J J MISIEWICZ, D B A SILK (Departmentof Gastroenterology and Nutrition, CentralMiddlesex Hospital, London) Previous studieshave shown a cephalic phase ofgastric secretionand intestinal flows in response to a fooddiscussion (FD) stimulus. To investigate theeffect of cephalic stimulation on pancreaticexocrine function in the presence and absenceof gastric acid, the (FD) stimulus was appliedto six normal volunteers (mean age: 26- 1 yearsrange: 24-29). Subjects were pretreated withranitidine 1200 mg (in four divided doses) oridentical placebo, in random order, 24 hoursbefore study. Subjects were intubated with amultilumen tube, and duodenal contents wereaspirated continuously with aliquots collectedat 15 minute intervals for three hours beforeand three hours after FD. There was nosignificant difference in pancreatic enzymesecretion between the 30 minute FD periodand the preceding 30 minute basal period in theplacebo study: trypsin 63-9 (18-6) IU/1 v 88-4(19-3); chymotrypsin 569 (166) IU/1 v 772(259); amylase 94458 (37645) IU/1 v 116375(38437); lipase 10535 (2971) IU/1 v 23195(13 498) or in the ranitidine study: trypsin 704(271) v 300 (110); chymotrypsin 2746 (746) v1330(242); amylase 505916(109 459) v 444 791(112 249); lipase 77 444 (22 762) v 29 979 (8026)(values mean (SEM)).These data show that there is no cephalic

phase of pancreatic enzyme secretion either inthe presence or in the absence of gastric acid,and do not confirm the previous findings inhumans, which used sham feeding as thestimulus.

AUDIT

Oesophageal function testing: is it costeffective?

W J OWEN, A ANGGIANSAH, N F BRIGHT (Depart-ment of Surgery, Guy's Hospital, London)Between 1983 and 1990 the oesophageal labora-tory performed studies on 1300 patients refer-red by consultant physicians and surgeons. Allhad been investigated with endoscopy orbarium studies, or both. They underwentoesophageal manometry with a solid statemicrotransducer catheter (Gaeltec). Most alsohad a modified Bernstein test, edrophoniumprovocation test, and 24 hour pH monitoring.Referral diagnoses and final laboratorydiagnoses, for each patient, were enteredprospectively on a database. Diagnoses weregrouped into none, normal, gastro-oesophagealreflux (GOR), achalasia, and inotility disorders(OMD). Data from 1015 studies on people withno previous oesophageal surgery were available.Referral diagnosis was compared with thelaboratory diagnosis to determine how oftenoesophageal function testing caused a signifi-cant change in the diagnosis and a probablechange in treatment.

Overall the diagnosis was changed in 476patients (46 8%). At a cost of £200/study eachchange in diagnosis costs £427.

Are cholecystectomy patients satisfied?

M W SCRIVEN, N A BURGESS, A EDWARDS, N JBUNDRED, M H LEWIS (East Glamorgan GeneralHospital, Mid Glamorgan) Recent studies havesuggested that up to halfofpatients are dissatis-fied with the outcome of cholecystectomy. Wehave investigated the views of patients aftercholecystectomy.

Seventy five patients undergoing electivecholecystectomy under one consultant in adistrict general hospital filled in a questionnaireabout their symptoms, preoperatively and oneyear afterwards.The most common preoperative symptoms

were colic (89%), fat intolerance (80%), andnausea (73%). Eleven patients (15%) hadjaundice. Postoperatively abdominal discom-fort (39%) and bloating (37%) were the mostcommon symptoms. One third of the patientsdeveloped at least one new symptom.The symptoms best cured by the operation

were jaundice (100%), colic (73%), and fatintolerance (72%). Overall, 66% graded theirresidual symptoms as none or mild, and 77%said they were either completely or well satis-fied.

In summary, therefore, at least threequarters of patients were satisfied with chole-cystectomy. Postoperative symptoms wereusually mild and often arose de novo postopera-tively. We thus conclude that despite thesesymptoms a high degree of satisfaction can beachieved.

Financial consequences of failing to diagnoselaxative induced diarrhoea

A DUNCAN, A CAMERON, A J MORRIS, M SSTEWART, W G BRYDON, R I RUSSELL (Gastro-enterology Unit and Institute of Biochemistry,Royal Infirmary, Glasgow and GI Laboratory,Western General Hospital, Edinburgh) Laxative

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induced diarrhoea (LID) is a well documentedcause of diarrhoea which is readily diagnosedby urine analysis. We introduced such a serviceto biochemists and gastroenterologists in theWest and Central belt of Scotland. The preval-ence of LID was measured in two populationsand found to be present in 2 of 49 (4%) newpatients referred to gastroenterology with diar-rhoea, and in 2 of 10 (20%) patients who werealready being investigated for diarrhoea ofunknown origin. Of seven patients with LIDthe diagnosis was suspected in five (71%). Thisfinding and the low rate of requests made of thelaxative analysis service (eight per annum)suggest that clinical awareness of this diagnosisis low. We have calculated the cost of failing tomake the diagnosis in eight LID patientsdiagnosed in Glasgow and Edinburgh GI units,in whom laxative ingestion was eitherunsuspected or only considered late in thepatient's investigation. An average of £2807(range=£60-£10709) was spent on investiga-tions which would have been avoidable had anearly laxative test been performed. In compari-son, each laxative test costs £24 and so the costof screening all GI patients presenting withdiarrhoea was estimated at £600 for eachlaxative abuser diagnosed (assuming a preval-ence rate of 4%).

It may be financially worthwhile to perform alaxative test on all new GI referrals presentingwith diarrhoea.

A prospective audit of investigations in out-patients with iron deficiency anaemia

A S MCINTYRE, R G LONG (Medical ResearchUnit, City Hospital, Nottingham) A gastro-intestinal source of bleeding is a frequent causeof anaemia. Previous reports have suggestedthat up to 20% ofpatients may have dual upperand lower gastrointestinal pathology. We pro-spectively audited the results of investigationsin 114 patients referred to outpatients over 17months (6% ofnew referrals).Some 111 patients (mean age 63 years, range

20-86; 68 F) had anaemia confirmed, 64 ofwhom were on ir'on therapy. Sixty three hadproved iron deficiency (TIBC >72, ferritin<20), 43 probable iron deficiency, and four noevidence of iron deficiency. Thirty fourpatients had received NSAIDs. Some 120causes for anaemia were found in 99 patients,and no cause was found in 12. Upper gastro-intestinal lesions were found at endoscopy in 39cases and strongly suspected in 24. Lesionscausing anaemia were no more likely in patientstaking NSAIDs than those not taking NSAIDs(11 v 14, p>O-1). Duodenal biopsies in 50patients revealed coeliac disease (3), giardia (1),and alactasia (1). Large bowel pathology (bybarium enema, colonoscopy, and sigmoido-scopy) accounted for 20 cases. Other causesincluded other small intestinal disease (3),menstrual loss (8), haematological abnormali-ties (6), malignancies (5), and dietarydeficiency (3). In searching for dual gastro-intestinal pathology a colonic cause for anaemiawas found in only one patient with a gastriculcer (polyp) and two with oesophagitis (polyp(1), known colitis (1)) in the 92 patients whohad upper and lower tract investigations. Thusa cause for anaemia was identified or stronglysuspected in 90% of cases.We conclude that unsuspected dual path-

ology in the gastrointestinal tract was rare(2%). Colonic investigations have a lowdiagnostic yield if patients have no colonicsymptoms and have a significant upperintestinal cause for anaemia.

GASTRIC DISEASE

F237Study of 24 hour gastric pH profiles inpatients with major upper gastrointestinalbleeding from peptic ulcers

A KALABAKAS, R N M VAN SOMEREN, M J BENSON,G R DAVIES, D F EVANS, C P SWAIN (AcademicDepartment of Gastroenterology, The RoyalLondon Hospital, London) Gastric acidity mightbe important in the pathogenesis of furtherbleeding from peptic ulcers. Drugs suppress-ing gastric acidity appear to have failed to alteroutcome following peptic ulcer bleeding. Itremains probable that available antisecretorydrugs incompletely suppress gastric acid inpatients with bleeding peptic ulcer betweenadmission and further bleeding. We measured24 hour gastric pH in 13 patients with majorpeptic ulcer bleeding (two had further bleed-ing, one died).

Twenty-four hour recordings were com-pleted in 11 (one operated at 11 hours, onerecording stopped at 13 hours). Patients weregiven ranitidine (RAN) 300 mg bd or omepra-zole (OM) 40 mg od orally at the time ofurgentendoscopy within 12 hours of admission andplacement of pH probe. Gastric acidity was

measured as % of time below threshold pHvalues 5 4 and 6.4. At pH 5 4, all clottingfunctions (PT, PTT, KPTT, and plateletaggregation) are zero and at pH 6-4, PT, PTT,KPTT are fourfold prolonged and plateletaggregation 23%. In this study, gastric pH was<5*4 for 76% OM, and 84% RAN and <pH 6-4for 98-8% OM and 96.7% RAN. pH neverreached 7-4. RAN significantly reduced pHafter one hour, oral OM after six hours (2 of 12had further bleeding within six hours). Withcontinued/recurrent bleeding (n=2), the pHrose (median pH=6). Patients who were fedhad effective buffering ofpH for two hours.

It remains difficult to achieve and maintainpH values that could normalise clottingfunction in patients with bleeding peptic ulcerwith currently available antisecretory drugs.The hypothesis that rebleeding from pepticulcers might be reduced by neutralisation ofintragastric pH to values normalising clottingfunction has yet to be tested.

Regional variation in the generation ofgastricmucosal potential difference

B J NG, F SEOW, M C NGU (INTRODUCED BY D BJoNES) (Gastroenterology Unit, RepatriationGeneral Hospital, Concord, NSW 2139,Australia) This study characterises ion trans-port mechanisms responsible for the genera-tion of transmucosal potential difference (pd)in gastric mucosa.Measured in vitro (Ussing chambers), fundic

and antral gastric mucosa of the rat showed pdof 31-7±0-5 mV (n=129) and 28.9±0 5 mV(n= 53), respectively. In the antrum, part ofthepd was dependent on apical sodium channels asshown by a fall in pd when 10-5 M amiloridewas present. This concentration of amiloridehad no effect when added to the basolateralside. However, at 10-3 M, amiloride causeda marked fall in pd, suggesting the presenceof Na+/H+ antiport on the basolateralmembrane. The chloride channel blocker,diphenylamine-2-carboxylate (10-4 M), whenadded to either the apical or basolateral side,also reduced pd, indicating the presence of

chloride channels on both sides. In addition,the basolateral membrane appears to contain aNa/Cl- symport sensitive to bumetanide(l0-4 M). Like the antrum, the fundic pd wasalso shown to be dependent on apical sodiumchannels and basal Na+/H+ exchangers.However, diphenylamine-2-carboxylate andbumetanide had no effect on pd when added toeither mucosal or serosal side.Our findings indicate distinct regional differ-

ences in ionic transport processes responsiblefor mucosal pd in the rat stomach.

Peptic ulcer disease: the north/south divide?1983-1985

J D O'BRIEN, J ASHLEY, M J S LANGMAN (Depart-ment ofMedicine, Queen Elizabeth Hospital andThe Office ofPopulation, Censuses and Surveys,London) Examination of hospital admissiondata in the past has suggested that peptic ulcerdisease has greater impact in the north than inthe south of the United Kingdom. This preval-ence pattern has not been assessed since a risingfrequency in ulcer perforation and mortalityhas been observed in women, nor since data onbleeding and perforated ulcer have been avail-able.We have now examined hospital admission

rates for bleeding and perforated gastric andduodenal ulcers from 1983 to 1985, which is thelatest period available according to hospitalregion, using Hospital Inpatient Enquiry(HIPE) samples of discharges and deaths.

Duodenal ulcer perforation rates in menwere over 70% higher in four northerly healthregions (North West, Northern, Mersey, andYorkshire) than in the four Thames healthregions, and gastric ulcer perforation rateswere 32% higher. Less pronounced changeswere observed for bleeding duodenal ulcer(+24%) and the bleeding gastric ulcer rate was,if anything, rather less in the north than thesouth (-14%). By contrast, there were nosubstantial differences in gastric or duodenalulcer bleeding or perforation rates in women.The results suggest that there are factors

affecting men, but not women, in the norththat predispose particularly to ulcer perfora-tion.

Low dose aspirin: an unrecognised cause ofgastric mucosal damage

N HUDSON, A T COLE, F E MURRAY, P HYMAN-TAYLOR, L KURLAK, B FILIPOWICZ, C j HAWKEY(Department of Therapeutics, UniversityHospital, Nottingham) Regular low dose aspirinused in cardiovascular prophylaxis is associatedwith increased risk ofmelaena. Doses as low as75 mg daily are often used. It is not knownwhether these doses are less harmful to thegastric mucosa than standard therapy. The aimof this study was to evaluate gastric damagecaused by low dose plain aspirin and comparethis with enteric coated (EC) aspirin 300 mg asNuseals.Twelve volunteers each received five days'

treatment with: placebo, aspirin 300 mg daily,aspirin 75 mg daily or EC aspirin 300 mg daily,in a double blind, crossover trial. Endoscopywas performed on days 0, 1, and 5 for eachtreatment, and gastric erosions were counted.Results were expressed as median (IQR)number of erosions at endoscopy.

Aspirin 300 mg caused significantly moremucosal injury after multiple doses 18 (2-26)than EC aspirin (p<0-001) and placebo

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(p<0-001). Aspirin 75 mg caused less mucosalinjury 1.5 (0-7) than aspirin 300 mg (p<0 6)but more than EC aspirin 0 (0-1) (p=0-15) or

placebo 0 (0-2) (p=0- 16). There was no differ-ence between damage caused by EC aspirinand placebo (p=0.98).

In conclusion, aspirin 75 mg causes lessgastric mucosal injury than aspirin 300 mg butmore damage than (EC) aspirin 300 mg. Injurycaused by EC aspirin is at placebo levels.Enteric coating of aspirin may offer more

gastric mucosal protection than lowering thedose.

Barrier properties of the adherent gastricmucus gel to pepsin

V K HOSEIN, D THAKKER, A ALLEN, J P PEARSON(Department of Physiological Sciences, MedicalSchool, Newcastle upon Tyne) Pepsin erosion ofadherent gastric mucus is balanced by new

mucus secretion thus maintaining a protectivegel mucosal layer that excludes pepsin fromthe mucosal surface. We have tested thishypothesis in vitro.A layer of fresh pig gastric mucus gel (2 mm

thickx 2.3 mm diameter), separating two com-partments, was exposed on one side to pepsin(2 mg.ml- , pH 2) and on the other citratebuffer (pH 2). Soluble degraded mucin andpepsin were measured in both compartments atintervals over four hours incubation at 37°C.The rate of pepsin mucolysis of the mucus

gel was 4-54 mg (0.47) (mean (SEM), n=3)degraded mucin over the four hours, equiva-lent to a decrease in mucus thickness ofapproximately 25 im.hr-1. With acid (pH 2)alone, pepsin plus polyacrylate carbomer (1mg.ml- ) or sucralfate (0-63 mg.ml- 1, 0 57 mg(0-1) (n=6) of degraded mucin was released.Diffusion of pepsin (2 mg.ml-l, pH 2) or

myoglobin (15 mg.ml-l, pH 7) through themucus layer over four hours was less than0-25%.hr-'.These studies show: (i) pepsin mucolysis

would cause discontinuities in the mucus layerin vivo if not balanced by new mucus secretion;(ii) the adherent mucus layer is a protectivepermeability barrier against luminal pepsin;(iii) mucosal protective agents, carbomer andsucralfate, inhibit pepsin mucolysis of theadherent mucus gel.

Focal spasm of gastric muscularis mucosae

can induce focal ischaemia and ulceration

C PIASECKI, C THRASIVOULOU (INTRODUCED BY

R POUNDER) (Department of Anatomy, RoyalFree Hospital School of Medicine, London)While transilluminating guinea pig gastricwall, we noticed foci of partial and completecompression of submucosal vessels by trans-verse bands. Mucosal blood perfusion beneathfoci, measured by 02 electrode, was 2 to 5% ofnormal. The area involved was shrunk by 27%,with resulting tortuosity of vessels. Weattribute this to compression of vessels byspasm of muscularis mucosa, because thesevessels are embedded in this muscle (externalmuscle was removed). Arteries and veinsreturned to normal with normal mucosal perfu-sion, either spontaneously within five minutesor immediately following gentle mucosalstimulation. However in five of 15 animals'spasm' remained for one to three hours, andthere was full thickness necrosis of the underly-ing mucosa. Surrounding areas without spasmshowed no necrosis. pH during the experimentwas 5.2 to 6-8. Acid is probably necessary for

necrosis - in this case it attacked foci of mucosarendered ischaemic by spasm of muscularismucosa.

This hitherto unseen phenomenon suggeststhat stress (anaesthesia and surgery) can induceischaemia mediated by spasm of muscularismucosa. In the absence of mucosal stimulation(hypomotility), the effect can be prolongedsufficiently to cause ulceration.

Follow up of patients with type III intestinalmetaplasia and increased detection of earlygastric carcinoma

M I FILIPE, T ROKKAS, G E SLADEN (Department ofHistopathology and Gastroenterology Unit,UMDS Guy's Hospital, London) Early gastriccancer (EGC) is associated with a much betterprognosis than advanced stage disease and istherefore a valuable diagnosis. Incomplete sul-phomucin secreting intestinal metaplasia (typeIII IM) has been related to gastric carcinoma(GCa) but its malignant potential and value insurveillance have not been tested in prospectivestudies with patient follow up. Here we presentand compare data on the incidence and fre-quency of EGC detection in two periods: (A)1976-81 retrospective, no patient follow up;(B) 1982-87, prospective - patients with typeIII IM on initial biopsy underwent biopsy againat six to 12 month intervals. During 1976-87,718 gastrectomies for GCa were performed; 24were EGC, and six (1-5%) and 18 (6.4%) weredetected in periods A and B respectively(p 0.01). During 1982-87, 2286 biopsy speci-mens were examined, of which 4% were typeIII IM from 80 patients. Of these, 22 patientsshowed coexisting GCA (of which five wereEGC), four had peptic ulcer, and 11 are undersurveillance. The remaining patients were lostto follow up or not yet recalled. The diagnosis ofEGC arose from the initial gastroscopy in all sixcases of period A compared with period B inwhich most cases 61% (11 of 18) were diag-nosed as a direct result of regular follow up. Forthese 11 patients, the medium time betweenfirst endoscopy and diagnosis of EGC was 25months (range 12-30 months).We conclude that EGC can be diagnosed

with increasing frequency if patients with typeIII IM are closely followed up with biopsy.

Double blind comparative study ofmisoprostol with placebo in acute uppergastrointestinal bleeding

G C BIRNIE, G C FENN, M J SHIELD, G C ROBINSON(Department of Gastroenterology, WesternInfirmary, Glasgow and Medical Department,G D Searle & Co Ltd, High Wycome, Bucks)The effect of misoprostol (M) or placebo (P) onrebleeding was assessed in 150 patients withacute upper gastrointestinal haemorrhage con-firmed endoscopically within 24 hours ofadmission. Admission criteria required con-firmation of a significant gastrointestinalhaemorrhage (indicated by haematemesis,melaena, or hypovolaemic shock) or thepresence of stigmata of recent haemorrhage(SRH).

In this single centre study patients receivedM 300 [tg qds (n=75) or P (n=75). Endoscopyor surgery was used to confirm suspectedrebleeding during the study period of up to 10days. Presence of SRH was associated with anincreased risk of rebleeding or surgery: withSRH=27/98 (28%); without SRH=3/52 (6%).Rebleeding was less common in patientstreated with M (15%) than in patients treated

with P (25%), p=0-22. The transfusionrequirements were higher in the P treatedgroup (median units transfused: P=3 units,M=2 units, p=0.02). In patients receiving M,4% required surgery compared with 15% in Ppatients (p=0.05).Among the 17 patientswho received NSAIDs

in the two weeks prior to entry there were sixrebleeds (35%) and three required surgery(18%); this compared with 18% rebleeds and8% requiring surgery in non-users ofNSAIDs.There were three withdrawals (1 M, 2 P)because of abdominal pain. Two patients (3%)receiving M had diarrhoea, one of whomwithdrew. The five other withdrawals (all inthe M group), were for non-compliance (2),rash, congestive cardiac failure and non-Hodgkins lymphoma. One patient in the Mgroup was excluded from analysis owing toprevious major gastric surgery. There were nodeaths in either group.

In conclusion, M significantly reduced theneed for surgery and for transfusion in patientswith a recent upper gastrointestinal haemor-rhage. Rebleeding was reduced in the M groupbut this did not reach statistical significance.

Reduction in angiogenesis in non-steroidalanti-inflammatory drug associated gastriculcers

N HUDSON, M BALSITIS, C J HAWKEY (Depart-ments of Therapeutics and Pathology, UniversityHospital, Nottingham) Non-steroidal anti-inflammatory drugs (NSAIDs) are associatedwith peptic ulceration. The pathogenesis ofthis action remains unclear. One mechanismmay be impaired ulcer healing. Angiogenesis isa prerequisite for the repair of deep mucosalulceration in the stomach. The aim of thisstudy was to investigate whether NSAIDtherapy inhibits angiogenesis in gastric ulcers.

Endoscopic biopsy specimens were takenfrom the edge of gastric ulcers in five patientson longstanding NSAID therapy and sevencontrol patients and fixed in formalin. Allulcers were greater than 5 mm in diameter andat least 2 mm in depth. Sections (5 [) werestained immunocytochemically for CD31, aspecific vascular endothelial cell marker.Vascularity was determined in three separatezones: (1) superficial margin of the ulcer withgranulation tissue present, (2) deep marginwith granulation tissue present, (3) theadjacent superficial area with glandular tissue.The parameters of vascularity assessed were:number of vascular buds, number of hollowvessels and maximum vessel diameter.The edge ofNSAID ulcers in the presence of

granulation tissue was significantly lessvascular than controls; number of hollowvessels mean 11-8 (95% confidence limits: 7-7-18-1) v 23-1 (15-7-33-9) per high power field(p<0-01 Student's t test) and vessel maximumdiameter 16-7 (13-9-20-5) v 29-9 (18-2-49-3)(p<0.03). The number of vascular buds wasalso lower in the NSAID patients 9-4 (5 3-16-5) v 16-6 (8-7-31-9) (p=0-11). Vascularityin adjacent normal mucosa was not signifi-cantly affected by NSAID treatment; hollowvessels 7-4 (1.5-36) v 6-4 (4-8-15 5), vesselmaximum diameter 152 (3-1-37-5) v 14-9(3 8-58 5) and vascular buds 2 7 (0 0-23.4) v2-6 (0-0-19-3).

In conclusion, NSAID associated gastriculcers have reduced vascularity compared withcontrol ulcers and this may inhibit repairmechanisms. This may explain the high pre-valence of peptic ulcer complications associ-ated with their use.

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PANCREAS

Effect of soybean lectin on pancreaticsecretion and plasma cholecystokinin

P H DEPREZ, R J PLAYFORD, J CALAM (Gastro-enterology Unit, Royal Postgraduate MedicalSchool, Hammersmith Hospital, London) Rawsoya strongly stimulates pancreatic secretionand growth, and promotes pancreatic neoplasiain the rat. Soya's trypsin inhibitors are thoughtresponsible, but we found in a pilot study thatthese had little effect on secretion comparedwith raw soya flour (RSF). Soya also contains a

potent lectin (SL) which has been reported tostimulate pancreatic growth. We tested itseffect on pancreatic secretion.

Jugular, pancreatic, and duodenal catheterswere inserted into anaesthetised, atropinisedrats (n=6 per group). Biliopancreatic juice wasdiverted and protein measured in 15 minutecollections. Blood samples (0-6 ml), takenbefore and 15 minutes after intraduodenalinjection of RSF (30 mg) or SL (1-8 mg;

equivalent to the RSF by hemagglutinationtest), were assayed for cholecystokinin (CCK)by radioimmunoassay using antiserum A2.

Pancreatic protein output increased rapidly(within 15 minutes) from mean (SEM) 33 (6)[sg/min to 116 (23) (p<0*01) after SL and to 97(27) after RSF (p<0*05). Plasma CCK rose

only slightly after SL from 10 (3) to 15 (4)pmol/l (NSD).

In conclusion, pure soybean lectin stronglystimulates pancreatic secretion and may be a

major factor in the harmful effects of soya on

the pancreas. The rise in CCK release appearedinsufficient to account for the massive pan-

creatic response.

Pancreatic adaptation to massive enterec-tomy is abolished by the cholecystokininantagonist CR-1409

P WATANAPA, M EGAN, P H DEPREZ, M R ALISON,J CALAM, R C N WILLIAMSON (Departments ofSurgery, Medicine, and Histopathology, RoyalPostgraduate Medical School, HammersmithHospital, London) Since pancreatic adaptationto massive proximal small bowel resection(PSBR) may be modulated through chole-cystokinin (CCK) secretion, we tested theeffect of the CCK antagonist CR-1409 on thisresponse.Male Wistar rats (n=72) weighing 200-225 g

were randomised to receive either PSBR or

transection/resuture followed by saline or CR-1409 (10 mg/kg daily sc). Rats were killed one,two, or three weeks postoperatively, whenblood was obtained for CCK assay and thepancreatic cell proliferation was assessed bythree parameters: nucleic acid and proteincontent, bromodeoxyuridine (BUDR) label-ling index, and proliferating cell nuclearantigen (PCNA) expression. PSBR increasedplasma CCK concentration by 83-102% at oneto three weeks, irrespective of CR- 1409 treat-ment. Total pancreatic DNA content increasedby 37% at two weeks (p<0 05) and by 93% atthree weeks (p<0005), while RNA contentincreased by 67% and 180% (p<0-001) andprotein content by 15% and 88% (p<0 05).PSBR increased BUDR labelling index andPCNA positive staining. CR-1409 completelyabolished this proliferative response and also

prevented the rise in nucleic acid and proteincontents.The results confirm the tropic role of CCK

after PSBR, and show that CR-1409 preventsthis adaptive growth.

relative risk ofC in smokers v non-smokers was1-21. At 17 years 277 smokers (69%) with CPdeveloped C compared with only 93 non-

smokers (55%).In conclusion, in our CP patients only

smokers have an increased risk ofdeveloping C(21%).

Immediate prognostic assessment of acutepancreatitis using assays to quantify pan-creatic zymogen activation

A M GUDGEON, D I HEATH, A JEHANLI, G PATEL,C W IMRIE, J HERMON-TAYLOR (Departments ofSurgery, St George's Hospital, London and TheRoyal Infirmary, Glasgow) While prognosticcriteria for acute pancreatitis are available 48hours after admission, there is no simple,reliable, non-invasive test which can be used onadmission. We have developed sensitiveimmunoassays specific for trypsinogen andhuman prophospholipase A2 activation pep-

tides (TAP and PLAP) using C-terminallydirected antibodies which enable a directmeasurement of pathological zymogen activa-tion. In 53 patients with acute pancreatitis themedian on-admission urine PLAP concentra-tion for those with mild disease (uncomplicatedpancreatitis) was 1-51 nmol/l (range 0-4.95nmol/l) and for severe disease (those develop-ing one or more major local or systemic compli-cation) 4-12 nmol/1 (range 0-2-70 nmoL/l)(p<0.005 Mann-Whitney U test). Similarly,there was a significant (p<0.0001) medianurine TAP increase in severe pancreatitis(mild: 0 nmol/l, severe: 3-21 nmol/l). Aspecificity of 100% and sensitivity of 60% forpredicting severe disease was obtained using acut off level of 8 nmol/l for combined urineTAP and PLAP concentrations.The results indicate that assays quantifying

zymogen activation provide a simple non-

invasive on-admission prognostic assessmentof patients with acute pancreatitis which may

influence management.

Is smoking associated with the risk ofdeveloping pancreatic calcification inpatients with chronic pancreatitis?

G CAVALLINI, G TALAMINI, B VAONA, P BOVO,M FILIPPINI, I VANTINI, A RIELA, L FRULLONI,V DI FRANCESCO, M P BRUNORI, E TASINI,P PEDERZOLI (Clinica Medica and ClinicaChirurgica, Policlinico B.go Roma, University ofVerona, Italy) It is unknown whether there is anassociation between cigarette smoking (S) andcalcification (C) in chronic pancreatitis (CP).We determined if there was an associationbetween C, S, and other variables includingalcohol intake in CP. Some 637 consecutive CPpatients diagnosed over the period 1973-89were reviewed (mean follow up 11 ±6-5 years).Only patients who had ultrasound or ERCP, or

both, and computed tomogram and plain film ofthe abdomen every three years were included inthe study. Onset of C was considered the endpoint of the follow up. The patients were

divided in two groups: non-smokers andmedium to heavy smokers (. 10 cigarettes/day).Of637 patients only 570 fulfilled our criteria. Atotal of 376 (66%) developed calcifications(CCP), while 64 (17%) had C at the time ofdiagnosis. C were detected in 266 (71%) ofCCPpatients at five years and in 365 (97%) at 17years. Smoking was correlated with thepresence of development ofC (Mantel-Cox testp<0004, likelihood test p<0 0009). The meantime fordevelopingC in smokers was eight yearscompared with 12 years in non-smokers. The

GUT MOTILITY

Defining the physiological responses of thehuman oesophagus to distension

D WILLIAMS, D G THOMPSON, L HEGGIE, JBARLOW, J BANCEWICZ (Departments ofMedicineand Surgery, Hope Hospital, Salford) The aim ofthe study was to provide a precise definition ofthe neurophysiological responses of the normalhuman oesophagus to distension in vivo. Six-teen healthy volunteers underwent multiple(30 second duration) intraoesophageal disten-sions at five sites varying from six to 18 cmabove the lower sphincter using a novel doubleballoon technique capable of simultaneouslymeasuring manometric and propulsiveresponses both above and below the site ofdistension.At all sites, inflation of either balloon beyond

a threshold of 7 (3-10) ml (median, range)induced both a distension dependent increasein proximal contractile activity (125 (40-190)mm Hg/30 sec at 10 ml inflation) and propul-sive force (60 (45-72) gm at 10 ml inflation).Inflation of the lower and upper balloontogether induced a potentiation of the motorresponse proximal to the upper balloon, 350(280-520) mm Hg/30 sec (p<0 01 v upperballoon alone), indicating ascending excitation.In contrast, inflation of the upper balloonreduced the propulsive response induced byinflating the lower balloon to 10 ml from 60(45-72) gm to 12 (8-20) gm (p<0 01) indicat-ing descending inhibition. Patterns of responseto inflation showed regional differences incharacter, with induction of peristaltic contrac-tions in the upper, but non-peristaltic contrac-tions in the lower, oesophagus. The magnitudeof the proximal response also varied regionallyto similar degrees of distension, from 110 (70-165) mm Hg to 10 ml at 6 cm, v 75 (35-120)mm Hg to 10 ml at 15 cm, above the loweroesophageal sphincter (p<0O01).

In conclusion, oesophageal distensioninduces both an ascending excitatory and adescending inhibitory neural response whichtogether result in an aboral propulsion forcewhose magnitude is directly related to degree,length, and site of oesophagus distended.

Nutrient propulsion through the small bowelis modulated via a fi adrenoreceptor pathway

N K AHLUWALIA, D G THOMPSON, D WILLIAMS,J BARLOW, L HEGGIE (University Department ofMedicine, Hope Hospital, Salford) While P1adrenergic blockade is known to acceleratehuman upper intestinal nutrient transit andmay produce diarrhoea, the motor eventsresponsible remain unexplored. We devised acombined intraluminal manometric and forcetransduction catheter to study both propulsiveforce and propagation of intestinal motilitywith and without atenolol 100 mg to induce P3adrenoreceptor blockade.Ten volunteers participated in the study

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after an overnight fast. The catheter assemblywas positioned in the proximal small intestine,and propulsive and manometric activity were

measured simultaneously for 90 minutes beforeand 30 minutes after ingestion of a standardmeal (360 ml; 200 kcal). The study was

repeated on a separate day 60 minutes afteringestion of 100 mg atenolol.

Control study results are as follows. Duringfasting (phase II) motility, (mean (SEM) 2-7(0 3)) propulsive events/minute were observed(86% of total motility) generating 24 (4) gmforce/minute, in addlftion 0.4 (0-1) non-

propulsive events/minute were noted. Afterfood a similar number of propulsive events/minute were observed (3.0 (0.5), p>0 05 v

fasting (74% of total motility)), generating 17(3) gm force/minute (p>0 05 v fasting), butnon-propulsive activity was significantlyincreased (1-0 (0-2)/minute, p<0 05 v fasting).Atenolol study results are as follows. Fastingpropulsive activity was unaffected by 0blockade 2-0 (0.4) events/minute generating 21(8) gm/minute (p>0.5 v control). After foodboth propulsive and non-propulsive activitywere similar in frequency to control study(propulsive 2-6 (0.6) events/minute, non-propulsive 1-4 (0-3)/minute, p>0 5) but con-

sistently stronger forces were generated 30 (6)gm/minute (p<003 v control).

In conclusion, atenolol uncovers a tonicallyactive 0i adrenoreceptor mediated inhibition ofintestinal propulsive force in man whichappears to modulate normal intraluminal trans-port by preventing precipitate nutrient passagethrough the upper gut.

Strategy for an inexpensive, non-invasive,sensitive test for identification of colonicmotility disorders in clinical practice

M CAMILLERI, A R ZINSMEISTER (INTRODUCEDBY S F PHILLIPS) (Mayo Clinic, GastroenterologyUnit, Rochester, MN 55905, USA) Althoughwidely used in the assessment of delayedcolonic transit, the radiopaque marker methodwith a single abdominal radiograph on thefourth day appears to be less sensitive fordetection of accelerated colonic transit. Ouraim was to develop a relatively inexpensive,non-invasive, accurate test of fast or slowcolonic transit utilising selected scans takenduring the first 24 hours after the ingestion of apH sensitive, methacrylate coated capsule con-

taining 1 l 1In resin pellets.We analysed regional colonic transit data

from three groups: 22 healthy controls;10 patients with functional and four withcarcinoid diarrhoea (D); and seven patientswith idiopathic constipation (C). A logisticdiscriminant analysis compared sensitivity andspecificity ofcomplex and simple summaries oftransit.The results showed that among complex

summaries, proximal colon emptying rate(PCER) (p<0-01 for D only) and geometriccentre of colonic isotope at four hours(p<0005 for C and D) and 24 hours (p<0O005for C only) showed significant differences fromhealthy controls. Simpler transit summariesalso had significant discriminant value; theseincluded ascending (AC), transverse (TC), anddescending (DC) colon counts at four hours(p<0-01 for all); and AC, TC, and stool countsat 24 hours (p<005). Receiver operatingcharacteristic curves showed that at 90% sensi-tivity, specificity of TC counts at four hourswas identical (79%) to that of PCER.

In conclusion, quantitation of isotope incolonic regions at four and 24 hours provides a

clinically applicable, accurate means of detect-ing accelerated or delayed transit in patientswith suspected colonic motility disorders.

Impact ofa late meal on rapid eye movement/non-rapid eye movement sleep activity

D KUMAR, G TSANG, R JAMES (Department ofSurgery, The Queen Elizabeth Hospital,Birmingham, Janssen Research Foundation,Grove, Wantage, Oxon) Sleep has previouslybeen shown to suppress postprandial activity.To determine the effect of a late meal on thesleep rapid eye movement/non-rapid eye move-ment (REM/non-REM) cycle, we haverecorded sleep activity after an early and a latemeal in eight healthy volunteers. Sleep wasrecorded using the standard electrodes and aportable sleep recorder with eight channels(Oxford Medical Systems, Oxon UK). Thesubjects were required to ingest a standard 600kcal meal at 6 pm on night 1 and 15 minutesbefore going to bed on night 2. The two nightswere studied in a random order in all subjects.The total sleep times between the two nightswere similar (454 v 460 minutes (mean)). Thepercentage of total sleep time occupied byREM sleep was also similar for the two nights(mean (SEM) 19-83 (3 32) v 21-2 (2.46), NS).However, REM latency after a late meal wassignificantly shorter (mean (SEM) 81-4 (12-43)v 159-17 (56 59) minutes, p<0.01). Stages 2and 3/4 did not differ significantly between thetwo nights (stage 3/4 31-03 (6-81) v 28-43(3.86), stages 2 45-17 (3.95) v 46 0 (3-19),NS).A late meal followed by sleep seems to reduce

REM latency without changing the overallproportion of the REM/non-REM sleep cycle.These data lend further support to the conceptof gut-brain axis and may explain why post-prandial activity after a late meal immediatelybefore sleep is significantly shorter.

Colonic circular smooth muscle relaxation byleukocyte derived nitric oxide

S J MIDDLETON, J 0 HUNTER (Department ofGastroenterology, Addenbrooke's Hospital,Cambridge) We have previously shown that ratdistal colonic circular smooth muscle(DCCSM) is extremely sensitive to nitric oxide(NO). Reduced tone of colonic smooth muscleis a feature of ulcerative colitis but its patho-genesis is unknown. DCCSM from non-fastedmale Wistar rats was attached to isotonictransducers (Harvard T3) in 2 ml organ bathsand perfused with oxygenated Krebs Henseliteat 37°C. Human neutrophils (N) and mono-nuclear cells (M) relaxed acetycholine precon-tracted DCCSM (21+19-4%, p<0-01 and18-5±21%, p=0-018). N-G-monomethyl-L-arginine (L-NMMA) competitively inhibitsNO synthase and this, but not D-NMMA,reduced relaxation by both N from53-2+35-1% to 1-8+10% (p=0-01) and Mfrom 33+42% to 7*7+30% (p=0 041), aneffect reversed by the addition of the substratefor NO production L-arginine (3 mM/l).Haemoglobin 200 nM/1, which binds NO,decreased relaxation by N by 70.4% and M by76 5%.NO is released by human leukocytes and

may be an important pathogenetic factor inulcerative colitis where inhibitors of NOsynthesase may have a therapeuticrole.

Anorectal physiology: the effect of acutestress

A PRIOR, L A HOUGHTON, P J WHORWELL(University Hospital of South Manchester, WestDidsbury, Manchester) Visceral hypersensitivityoccurs in many patients with irritable bowelsyndrome (IBS). However, it is more commonin those with high anxiety levels, raising thepossibility that it is merely a reflection ofunderlying anxiety. To investigate factorsinfluencing visceral sensitivity, the effect ofacute stress on anorectal responses to balloondistension was assessed in 14 healthy volun-teers (three male, 11 female; age 24-52). Eachsubject was studied on three occasions and wasexposed to cold pain, mental stress or controlstudy in random order.Both subjective and objective measures of

stress increased significantly during both stressstudies (mean (SEM) anxiety level; control 23(2.9), cold 56 (5.4), mental 61 (6.5), p<002;pulse rate; control 71 (0.5), cold 82 (0.9),mental 84 (1-2), p<005). However, there wereno changes in rectal sensitivity (volume todiscomfort (ml); control 190 (14-5), cold 198(16-9), mental 180 (14-9)), rectal compliance(ml/cmH2O; control 6-4 (0.6), cold 7 3 (0.9),mental 6 3 (0.7)), or distension inducedmotility (motility index; control 1405 (376),cold 1389 (387), mental 1021 (289)).

In conclusion, acute stress does not affectanorectal responses to balloon distension innormal volunteers, suggesting that the abnor-malities in visceral sensitivity noted in IBS arenot solely due to anxiety.

Small intestinal motility in diarrhoea pre-dominant irritable bowel syndrome

D A GORARD, G W LIBBY, M J G FARTHING(Department of Gastroenterology, St Bartholo-mew's Hospital, London) Abnormalities of smallbowel motility have been reported in irrit-able bowel syndrome (IBS). We have studiedsmall bowel motility using a transnasal catheterincorporating six strain gauges spanning 95 cmin six patients with diarrhoea predominant IBS(median age 28.5 years, range 24-53) and sixcontrol (C) subjects (25.5, 19-32). Ambulatoryrecordings began in the afternoon, continuingtill the following morning, during which timeonly small amounts of clear fluids wereallowed.

Ninety nine hours of recording in IBSpatients and 98 hours in C subjects wereanalysed. The IBS patients exhibited circadianvariation in migrating motor complexperiodicity at the proximal jejunum; diurnalperiodicity mean (SEM) 106 (24) minutes,nocturnal periodicity 63 (6) (p<005). In C,periodicity was 86 (9) diurnally and 73 (9)nocturnally. There were no differences inoverall, nocturnal, or diurnal periodicitiesbetween IBS and C. The mean duration ofphase III complexes at each recording siteincreased aborally in IBS and C subjectsrespectively: from 5.4 minutes and 5.9 minutesin proximal jejunum, 7-6 and 6 8 minutes inmid-jejunum to 8 4 and 10.2 minutes in ileum.The durations were not different between IBSand C. There were no differences in velocity orextent of propagation of phase III complexes.The number of phase III motor complexesstarting distally was similar in both groups.Clustered contractions occupied 10-5 (2.4)%(C) and 12-2 (4.4)% (IBS) of total recordingtime. Orocaecal transit time (OCTT),measured by lactulose hydrogen breath test,

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was 52 (10) minutes in the IBS group and 77 (6)in 10 control subjects (p<0 05).Thus, although OCTT is faster, we have

been unable to show any small intestinal intra-luminal pressure abnormalities in these diar-rhoea predominant IBS patients.

Selective affective biasing in recognitionmemory in irritable bowel syndrome

J E GOMBORONE, P A DEWSNAP, GW LIBBY, M J GFARTHING (Department of Gastroenterology, StBartholomew's Hospital, London) In depres-sion, emotionally negative sensory inputsestablish stronger memory traces than neutralor positive inputs. That is to say, there is amood-congruent bias in information process-ing. This bias is now recognised as funda-mental to the nature of affective disorder. Wehave explored the relation between IBS andaffective disorder from the novel perspective ofinformation processing.We constructed a word recognition memory

task which contained 24 emotionally loadedstimulus words (eight negative, eight positive,and eight neutral) which subjects wererequired to remember, and later select from aword list. We tested randomly selected IBSpatients (n=30) and compared results withdepressed patients (n=28), patients withorganic gastrointestinal disease (n=28), andnormal controls (n= 30), all of comparable ageand sex. A similar bias to emotionally negativestimuli in word recognition responses occurredin IBS (93% negative words recalled) anddepressed patients (87%) which was morecommon than in normal controls (67%;p<005) and patients with organic disease(73%; p<0 05). The IBS and depressedpatients differed, however, in that the IBSgroup incorrectly over-identified emotionallynegative words that were not test stimuli(p<O-01).

This implies that the IBS patients were farmore receptive to negative sensory input. Thismay well have clinical relevance in terms of theIBS patients negative interpretation of theirown abdominal proprioceptive stimuli.

Incidence and disappearance of functionalgastrointestinal disorders

N J TALLEY, A WEAVER, A R ZINSMEISTER, L JMELTON (Mayo Clinic, Rochester, Minnesota,USA) Accurate data on the natural history offunctional gastrointestinal disorders in thegeneral population are lacking. Using a highlyreliable and valid questionnaire, we estimatedthe incidence and chronicity of specific func-tional disorders. An age and sex stratifiedrandom sample of 1021 residents of OlmstedCounty, Minnesota, aged 30-64 years, was sentthe questionnaire; 82% responded (n=835). Ina follow up questionnaire sent to responders 12to 18 months later, 83% responded again (n=690). Based on standard symptom criteria, theage and sex adjusted prevalences per 100 (95%confidence intervals) for irritable bowelsyndrome (IBS, using the Manning criteria),chronic constipation, chronic diarrhoea, anddyspepsia (frequent upper abdominal pain)were 17-0 (14-4, 19-6), 17-3 (14-8, 20.0), 6-0(4 4, 7.7), and 15-7 (13-2, 18-2), respectively,on the first mailing. The estimated prevalencerates on the second mailing were not signifi-cantly different. Fifty two cases of IBS (9%)developed in 582 subjects free of IBS on thefirst survey, while 41 of 108 who had IBS

initially had a loss of their symptoms subse-quently (38%). Similar incidence and resolu-tion rates were observed for the other symptomgroupings. Adjusting for differences betweenresponders and non-responders and for theestablished precision of the questionnaire didnot significantly alter the results.While symptoms codipatible with functional

gastrointestinal disorders are common inmiddle aged people and overall prevalence isrelatively stable, there is substantial variationwithin individual subjects from year to year.

LIVER

Different pattern of genomic DNA loss incolorectal liver metastasis and hepatocellularcarcinoma

SHI-FA DING, N A HABIB, J J DOOLEY, C WOOD,L BOWLES, J DELHANTY (Department ofSurgery,Hammersmith Hospital, London, Departments ofSurgery and Medicine, Royal Free HospitalSchool ofMedicine, London, and Department ofGenetics and Biometry, University CollegeLondon) A candidate tumour suppressor gene(TSG) on chromosome 5 for colorectalcarcinomas (CRC) has been cloned (Kinzler,et al, Science 1991; 251: 1366). We previouslyreported allele loss on chromosome 5 inhepatitis B virus (HBV) negative hepato-cellular carcinomas (HCC), which mightsuggest a TSG loss for HCC (Ding, et al, Gut1990; 31: A1211). In order to investigatewhether the same gene deletion on chromo-some 5 occurs in both CRC and HCC, wecompared allele loss in 11 patients withcolorectal-liver metastasis (CLM) with that insix patients with HBV negative HCC.DNA was prepared'from paired tumour and

non-tumour materials, and Southern analysisperformed with two probes assigned todifferent regions ofchromosome 5 (YN5.48 for5q21-22, the locus of candidate CRC gene andkMS8 for 5q35-qter). Allele loss in four out offive informativeCLM cases was shown with theprobe YN5.48 and three out of seven withkMS8. In comparison, HBV negative HCCshowed allele loss in four out of four informa-tive cases with the probe MS8 but no allele losswith the probe YN5.48.

In conclusion, these data show differentpatterns ofallele loss on chromosome 5 inCLMand HCC. It seems that the proposed TSGlocus for HCC on chromosome 5 appears to bedistinct from the CRC gene.

Cyclosporin A increases the tight junctionalpermeability in rat liver

D MARTINES, L LORA, M PLEBANI, A R FLOREANI,M SALVAGNINI, R NACCARATO (Department ofGastroenterology and Department of ClinicalBiochemistry, University of Padua, Italy) Toevaluate changes in junctional permeabilityduring exposure of the liver to cyclosporin A(CsA), we studied the paracellular transport ofhorseradish peroxidase (HRP) from perfusateto bile in the in situ perfused rat liver.

Sixteen male Sprague Dawley rats (rbw275 g) were used for the study. The perfusionmedium was Krebs - Ringer bicarbonatebuffer (albumin 1%, amino acid mixture andred cells 20%). CsA, dissolved in miglyol or thevehicle alone or nothing (in control rats) was

added to the perfusate reservoir (1200 ng/mlconcentration of CsA). After an initial 30minutes of continuous perfusion, livers wereconverted to single pass condition and HRP (25mg) was given as a one minute pulse. After sixminutes, the single pass perfusion was con-verted back to recirculating perfusion. Five, 2minute and 10, five minute bile samples werecollected during the perfusion.

In miglyol and in CsA perfused rats, bile flowrates were lower than in control rats but thedifference was not significant. The first biliaryHRP peak (paracellular pathway) occurred atseven minutes. In CsA rats, it was higher thanin miglyol and control rats (44- 1 ± 14- 1,9 5±3 3, 5-9±2-1 ng/minutes, respectively;p<003 ANOVA test). Conversely, the secondHRP peak (transcellular pathway) observed at20 minutes, was similar in the three groups ofrats (14-1+±34, 19-3±3-2, 14-9±5-0, respect-ively).

In conclusion, CsA increases tight liverjunction permeability. This suggests thathepatic junctions may be involved in CsAinduced cholestasis.

Autonomic function tests in cirrhosis

J F DILLON, J N PLEVRIS, D J EWING, I A DBOUCHIER, P C HAYES (Department ofMedicine,Royal Infirmary, Edinburgh) Abnormal cardio-vascular reflex tests have been reported incirrhosis, but their interpretation is unclear.We studied 22 patients (16 male: six femaleaged mean (SD) 62-3 (14- 1) years) withcirrhosis (15 alcoholic). Patients were groupedas Child's A (16) and Child's B and C (6). Weused a standard battery of cardiovascular reflextests (as described by Ewing and Clarke) as wellas RR interval variability for 24 hour ECGtapes, and pupil cycle time (PCT). PCTinvolves shining a slit of light on the edge of thepupil and timing the cycles of constriction andrelaxation. Prolonged cycle lengths over 1150ms are abnormal. Failure to cycle may repre-sent abnormality, although 20% of normalsubjects do not cycle. The battery of cardio-vascular reflex tests was graded as normal,early, or definite/severe involvement.

In Child's A 6 (38%) were normal, 6 (38%)had early, and 4 (25%) definite involvement. InChild's B and C, 1 (17%) was normal, 2 (33%)had early, and 3 (50%) had definite abnormali-ties. Five of 11 (45%) Child's A patients hadabnormal R-R variability. Of the 22 patients,three (14%) had normal PCT, three (14%) hadprolonged, and 18 (73%) did not cycle. Nodifferences were detected between alcoholicand non-alcoholic patients.These results provide further evidence of

autonomic dysfunction in cirrhosis.

Survival and use of a prognostic model inprimary sclerosing cholangitis

J M FARRANT, K HAYLLAR, S K LO, R W CHAPMAN,R WILLIAMS (Institute of Liver Studies, King'sCollege Hospital, London and Department ofGastroenterology, John Radcliffe Hospital,Oxford) In a study of survival in primarysclerosing cholangitis in a tertiary referralcentre for liver disease (centre A), 46 (37%) of126 patients died of liver disease or underwentliver transplantation and the estimated mediansurvival was 12 years. In the present study,survival in 42 patients from a centre specialis-ing in inflammatory bowel disease (centre B)was investigated. Patients in centre B tended to

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be older at first presentation that those in centreA (mean ages: 47 years (B) v 38 years (A),p<0 005). According to the multivariate prog-nostic factors identified in the previous study,the patients in centre B had significantly lesssevere disease at first presentation: hepato-megaly (62% (A) v 29% (B), p<0 001);splenomegaly (32% (A) v 5% (B), p<0 001);serum alkaline phosphatase (means: 689 IU/1(A) v 340 IU/1 (B), p<0 001) and histologicalstage 3/4 (49% (A) v 33% (B), p<0 05). Aspredicted, survival among the patients incentre B was considerably better than in centreA (p<0-0001).

During a median follow up of 6-4 years(range 0 1-15 8 years), only 5 (12%) of the 42patients in centre B developed end stage liverdisease causing death (4) or leading to livertransplantation (1). With so few end points,formal validation of the prognostic modeldeveloped in centre A was not possible.However, when applied retrospectively to thepatients in centre B, the model had a specificityof 100% and a sensitivity of 25%. The lattershould be improved with the development of adynamic prognostic model.

Surveillance for cytomegalovirus infectionusing culture techniques in liver transplantrecipients

M SMITH, D R PILLAY, D CHARMAN, P DGRIFFITHS, K ROLLES, A K BURROUGHS (Hepato-biliary and Liver Transplantation Unit andDepartment ofVirology, Royal Free Hospital andSchool of Medicine, London) Cytomegalovirus(CMV) infection is a major cause of morbidityand mortality after liver transplantation, butprophylaxis against CMV is not routinely used.Serological surveillance is complicated bymodified antibody responses due to immuno-suppression, so that strategies for prophylaxisrequire prospective surveillance using culturetechniques. Surveillance was evaluated weeklyin 46 consecutive liver transplant recipientsusing a rapid culture technique (detection earlyantigenic fluorescent foci - DEAFF), conven-tional cell culture, and liver immunocyto-chemistry. CMV infection was found in 17(37%) ofwhich 11 (24%) including the only twoseronegative recipients had CMV disease(pyrexia with viraemia or hepatitis orpneumonitis) which caused four deaths withinone year of transplantation.Three independent risk factors for CMV

infection were: (1) recipient seropositivityprior to transplant, in whom donor sero-positivity conferred increased risk compared todonor seronegativity; (2) increased transfusionof whole blood and fresh frozen plasma; (3)increased use of immunosuppressive drugs.Positive CMV cultures from whole blood and/or liver biopsy specimens, but not from urineor throat swabs were significantly associatedwith CMV disease.

This surveillance programme suggests thatblood cultures are the most important tosample routinely and that CMV prophylaxisshould be used in the groups at risk. Controlledtrials should be set up to confirm the value ofCMV prophylaxis.

Significance of serum IgM anti-hepatitis Cvirus (HCV) in chronic HCV infection

S BRILLANTI, C MASCI, P RICCI, M MIGLIOLI,L BARBARA (Instituto Di Clinica Medica eGastroenterologia, University of Bologna, Italy)

During a 12 month study period, serum speci-mens were taken from 10 anti-HCV positivesubjects with normal ALT values, 14 untreatedpatients with chronic HCV, and 26 patientswith chronic HCV treated with 6 MU ofrecombinant interferon a-2a thrice weekly forsix months. Each serum specimen was testedfor IgM antibody to C100-3 antigen (IgM anti-HCV) by ELISA. All 10 subjects with normalALT tested negative for IgM anti-HCV.

Eighty two per cent of patients with chronichepatitis C had detectable IgM anti-HCV andshowed mean ALT values significantly higherthan IgM anti-HCV negative patients. Apositive correlation was found between theheight of ALT value and the IgM anti-HCVvalue. No significant changes in IgM anti-HCVvalues were observed in untreated patients, intreated patients who did not respond tointerferon treatment, and in responders whorelapsed after termination of interferon treat-ment. Disappearance of IgM anti-HCV occur-red in 8 of 9 patients with sustained response tointerferon therapy.

In conclusion, positivity for serum IgM anti-C100-3 correlates with active hepatitis C. Intreated patients, disappearance of IgM anti-HCV seems to predict a sustained response tointerferon treatment.

Safety of major surgery in acute hepaticporphyria

S R DOVER, L PLENDERLEITH, M R MOORE, K E LMCCOLL (University Department ofMedicine andTherapeutics and Department of Anaesthetics,Western Infirmary, Glasgow) Patients with acutehepatic porphyria are often denied surgery forco-existing diseases because of fear that theanaesthetic or stress of surgery will precipitatea life threatening porphyric crisis. We havereviewed the outcome of 31 major surgicalprocedures under general anaesthetic in 20patients with acute hepatic porphyria. Theprocedures included cholecystectomy (6),renal transplant (3), cardiac surgery (2),hysterectomy (3), laparotomy (3), mastectomy,hip replacement, and nephrectomy (1 each).Seventeen of the patients were known to haveporphyria preoperatively, and they onlyreceived anaesthetic agents believed to be safein porphyria. These 17 patients had uneventfulrecoveries with none developing porphyriccrisis. In six of these patients the urinaryexcretion of the porphyrin precursors delta-aminolaevulinic acid and porphobilinogen wasmonitored and none showed a postoperativerise. Two of the three patients not known tohave acute porphyria preoperatively, and whotherefore received standard anaesthetics, diedin porphyric crisis in the postoperative period.

This study indicates that patients with acutehepatic porphyria can be subjected to majorsurgery provided appropriate anaesthetics areused. The risk is for undiagnosed cases.

Endotoxaemia during orthotopic liver trans-plantation: a clinically important problem?

M LARVIN, S A PERRY, C W RAMSDEN, M IALDOORI, S A SADEK, G R GILES (UniversityDepartment of Surgery, St James's UniversityHospital, Leeds) Endotoxaemia occurs duringorthotopic liver transplantation (OLT), but itsclinical relevance is uncertain. Endotoxicshock is mediated by cytokines secreted bymononuclear phagocytes on binding endo-toxin. The present study investigated whether

endotoxaemia is associated with cytokinerelease during OLT.Twelve consecutive OLT recipients were

studied, aged 19-63 (median 48.5) years(6 males, 6 females). Blood samples werecollected preoperatively, during anhepatic andreperfusion phases, 12 and 72 hours post-operatively, into endotoxin free heparinisedtubes. Endotoxaemia was quantitated bychromogenic substrate/limulus bioassay(normal < 100 pg/ml). Plasma tumour necrosisfactor (TNF), interleukin 1 (ILl) and inter-leukin 6 (IL6) were determined by enzymelinked immunosorption (sensitivity 10 pg/ml).

Plasma endotoxin rose significantly frompreoperative values (median 79-8 pg/ml)during the anhepatic phase (median 96 0 pg/ml, p<0005 Wilcoxon), declining signifi-cantly 12 hours postoperatively (median 72 0pg/ml, p<0-001). Six subjects developedanhepatic or reperfusion endotoxaemia > 100pg/ml.

Although detectable TNF was discoveredin five patients (20-100 pg/ml), ILl in one (13pg/ml), and IL6 in four (80-1000 pg/ml);endotoxaemia and plasma cytokines were notsignificantly correlated, nor did any parameterpredict graft function, rejection, or outcome.The results suggest that endotoxaemia duringOLT does not stimulate cytokine release, andmay not be of clinical importance.

Intracerebroventricular neuropeptide Ystimulates bile secretion in the rat via a vagalmechanism

M FAROUK, J G GEOGHEGAN, W C MEYERS(INTRODUCED BY P B COTTON) (Duke University,Durham, North Carolina, USA) The cholereticresponse to feeding is known to be abolished byvagotomy. The central mediators responsiblefor this choleresis have not been identified. Inrats, intracerebroventricular (ICV) administra-tion of neuropeptide Y (NPY) potentlystimulates feeding. In this study, the effect ofICV NPY on bile flow was investigated innormal and vagotomised rats.Common bile duct and femoral vein

catheters were placed in urethane anaesthetisedrats. Local stimulation of bile flow by gastricacid was avoided by pyloric ligation and gastricdiversion. An intravenous infusion of 1-2 FtM/kg/minute of sodium taurocholate was com-menced and bile flow allowed to stabilise fortwo hours. A bolus of InM NPY or carrier ascontrol (0-1% albumin in 0.9% saline) wasinjected stereotaxically into the lateralventricle. Bile was collected in 15 minutesamples. Four groups were studied (six rats pergroup). Vagotomy was performed at thecervical level.Mean bile output, observed 30-120 minutes

after injection: control group=mean (SEM)1-36 (007), control and vagotomy=1-31(0-18), NPY=-154 (0-1l)*, NPY andvagotomy=1-32 (0.13) (units: ml of bile/90minutes,* p<0 05 by ANOVA).

This study shows that ICV NPY causes asignificant choleretic effect which is abolishedby vagotomy and the choleretic response tofeeding may be initiated by the release ofcentral NPY.

Indirect utilisation of glucose for thesynthesis of hepatic glycogen in man

R F G J KING, K IBRAHIM, M MADAN, M JMCMAHON, D JOHNSTON (University Department

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of Surgery, The General Infirmary, Leeds)Hepatic glycogen is synthesised from intra-cellular glucose 6-phosphate. It is oftenassumed to involve exclusive utilisation ofglucose without rearrangement of the carbonring (direct pathway) but it is now believed 3Cfragments may be used preferentially forsynthesis (indirect pathway). We haveaddressed the hypothesis that 3 carbon inter-mediates (such as lactate) are used in theindirect pathway in fasted individuals follow-ing a glucose load. Fifteen patients were givenan infusion of 20% glucose (79-90 mllhour)before elective abdominal operation. Allreceived a 2-5 g bolus of 1110 kBq of D-[6-3H]or D-[3-3H] glucose and D-[U-J4C] glucosebefore removal of a 1 g biopsy specimen ofliver. 3H and 14C were determined in purifiedglycogen as well as in glucose and lactate fromsamples of peripheral blood. In each case boththe ratio and specific activity of 3H and 14C inglycogen were found to be significantly lowerthan those in administered glucose. By calcula-tion 50-90% of glycogen repletion occurred byindirect pathways and not all of this was fromglucose supplied.

It is concluded that the operation of a directpathway in man is not exclusive and thatsignificant fluxes for repletion of hepaticglycogen occur by an indirect route.

Ursodeoxycholic acid in late primary biliarycirrhosis: long term follow up

E A KOUROUMALIS (Academic Departmentof Gastroenterology, University Hospital,Heraklion, Crete, Greece) Fifteen patients, allwomen with stage III (9) and stage IV (6)primary biliary cirrhosis (PBC), have beenfollowed up for at least two years (24-36months) on ursodeoxycholic acid (UDCA).Initially, a dosage of 10 mg/kg/BW was used forthree months and then 15 mg/kg/BW wereadministered. Routine liver biochemistry andimmunology were done at regular intervals. Atone year 7 of 15 had a second liver biopsy.The initial dosage was ineffective. Bio-

chemical improvement started after 30-45 dayson the higher dosage. Normalisation of ALT-AST occurred in 12 of 15 patients and a meandrop of 30% in alkaline phosphatase and yglutamyl transferase was noticed, withoutimmunological response.

Remission was permanent in only 2 of 15.Reactivation under UDCA occurred in 12 of 15after a mean period of 13 months. An increaseto 20 mg/kg/BW resulted in 7 of 12 having apartial response. Three of 12 (all stage IV)deteriorated. Histology at one year showedprogression to stage IV in 2 of 5 with stage III.

In conclusion, despite good initial bio-chemical response, only 13% of late PBCpatients maintain biochemical remission, whilerelapses respond only partially on dosageincrease and histology does not improve.UDCA treatment does not seem to be helpful inlate PBC.

Osteopenia and liver cirrhosis

P BRAMLEY, B OLDROYD, S STEWART, A

HORSMAN, M SIMPSON, M LOSOWSKY (Depart-ment of Medicine, St Jfames's UniversityHospital, MRC Bone Mineralisation Unit,University of Leeds, Leeds) In order to deter-mine the degree of osteopenia in consecutiveunselected patients with established livercirrhosis, a cross sectional survey using dual

energy x ray absorptiometry of the lumbarspine (L2-L4) and femoral neck was per-formed (precision <1%). Bone mineral density(BMD) was measured in 150 patients (M:F,57:93) - 121 with cirrhosis and 29 after livertransplantation (OLT). Local controls wereused to construct regression equations to deter-mine age and sex matched normal values. Thedegree of osteopenia was measured by theBMD difference from expected values.

Patients with primary biliary cirrhosis (n=30) exhibited noticeable osteopenia (mean=-0-115, 95% CI -0-190 to -0040 g/cm2;p<0 005) and 18 patients with cryptogeniccirrhosis had similar reduction in BMD(-0- 111, -0-161 to -0-060 g/cm2; p<0 005).Patients with alcoholic cirrhosis (n=34)showed no significant decrease in spinal BMD.Patients post-OLT had the most severeosteopenia with spinal BMD difference(-0-158, -0-218 to -0 099 g/cm2,p<0-0001) and femoral neck BMD difference(-0 095, -0-14 to -0 05 g/cm2, p<0-0001).No other cirrhotic group showed significantreduction in femoral neck BMD.These data show that spinal osteopenia is

common in cholestatic and non-cholestaticcirrhosis, and that patients following OLT areat an increased risk for the development ofsevere osteopenia.

Effects of octreotide on liver regeneration inthe rat

N DAVIES, J YATES, B A TAYLOR, S A JENKINS(University Department of Surgery, RoyalLiverpool Hospital, Liverpool) The liver has a

remarkable capacity to regenerate after traumaor resectioii. Since octreotide inhibits therelease of a number of hepatotrophic factorsand reduces portal flow we have investigated itseffect on liver regeneration in the rat.Male Wistar rats underwent a 67% hepatec-

tomy, followed by treatment with octreotide (2sg bd) or saline (control). Liver regeneration,portal pressure, and hepatic haemodynamics(microsphere method) were determined at 48hours and one and two weeks after the start oftreatment in both groups (n= 15). There was nosignificant difference in the regeneration indexat 48 hours. However at one week and twoweeks there was a significant reduction (Mann-Whitney U test p<005) in the regenerationindex in the octreotide group (one week 1-02(0-9-1-1), two weeks 1-23 (0.99-1.36)) com-

pared with controls (one week 1-16 (1-0-1-37),two weeks 1-36 (1-05-1-67)). Portal pressure(mm Hg) was significantly reduced in theoctreotide group (48 hours 7 5 (3-10), one

week 6 (4.5-9), two weeks 4.9 (3.5-8)) com-

pared with controls (48 hours 10-8 (9-12.5),one week 9 (9.5-8.2), and 2 weeks (5.8(3.5-9)). There was no significant reduction inhepatic arterial flow and portal venous flow inflow between the two groups.The results of this study suggest that

octreotide inhibits liver regeneration in the rat,but further studies are required to establish itsmechanism of action and its effects on thegrowth of liver tumour after hepatectomy.

Hepatic processing of a novel agent forimaging and assessing hepatobiliary function

W AHMED, A I MORRIS, I T GILMORE, P MALTBY,D BILLINGTON (Gastroenterology Department,Royal Liverpool Hospital and Liverpool Poly-technic, Liverpool) Galactosyl neoglycoalbumin

(NGA) is a synthetic ligand for the asialoglyco-protein receptor. Uptake of99ITc-NGA allowsa functional assessment of receptor concentra-tion and 99mTc labelling gives simultaneoushepatic imaging. We have assessed the hepaticprocessing of 99mTc-NGA using the isolatedperfused rat liver.

Forty per cent of a pulse (150 pmol) of99mTc-NGA was taken up first pass. Of this,only 7% was released at the sinusoidal pole,41% was excreted in bile, and 51% remained inthe liver. Fractionation on Sephadex G25showed that >85% of biliary 99mTc comprisedthree small MW metabolites and <15% wasintact NGA. Pretreatment with leupeptin, alysomomal protease inhibitor, abolished out-put of the small MW metabolites, but not ofintact NGA. Thus biliary output of small MWmetabolites of 99mTc-NGA is by the lysosomalpathway.

This contrasts with 125I labelled NGA wheremost radioactivity is released as small MWmetabolites at the sinusoidal pole because of adifferent chemical attachment of the label tothe ligand. For 99mTc labelled NGA this arte-factual anomaly can be used to advantage as animaging agent as most of it is confined withinthe hepatobiliary system.

BILIARY TRACT

Plasma fatty acids change after cholecystec-tomy

M W SCRIVEN, J C M STEWART, D F HORROBIN,M C A PUNTIS (Department ofSurgery, Universityof Wales College of Medicine, Cardiff andEfamol Research Institute, Nova Scotia,Canada) Surgical trauma causes changes inimmune function and thrombotic tendency.These changes also occur with abnormalities intissue polyunsaturated fatty acids (PUFA). Wethus investigated PUFA perioperatively.The fatty acids in plasma phospholipid were

measured in 20 patients undergoing chole-cystectomy (mean age 56, 6 M: 14 F): preopera-tively and for the first two days postoperatively.Analysis concentrated on the 20 carbon PUFA(c20-PUFA): arachidonate (AA), dihommo-gammalinolenate (DGLA) and eicosapentae-noate (EPA). These are metabolised toeicosanoids, which include prostaglandins andleukotrienes.There were no significant changes in total

c20-PUFA. There were, however, changesin individual c20-PUFA. AA rose at day 1(p<005) and this change persisted to day 2(p<005). EPA and DGLA each fell, at day1 (p<005) and day 2 (p<001) respectively.The ratios DGLA:AA and EPA:AA showedsignificant depression, on both days (p<0.01).These results show that tissue PUFA, as

reflected by plasma values, change after chole-cystectomy. There is a shift towards AA whichis metabolised to prothrombotic and immuno-suppressive eicosanoids. There is also a fall inEPA and DGLA, which have antithromboticproducts. These changes may explain some ofthe responses to surgical trauma.

Laparoscopic cholecystectomy - a compari-son with open cholecystectomy

K S WYNNE, C M S ROYSTON (Hull RoyalInfirmary, Hull) One hundred laparoscopic

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cholecystectomies are compared with 100 opencholecystectomies. Complications occurred in12 patients undergoing laparoscopic cholecy-stectomy, three major (two bile peritonitis, onelaparoscopic injury causing bleeding), the restminor. There were 20 complications from opencholecystectomy, including one death fromcomplications following acute pancreatitis andsubphrenic abscess. There were two furthermajor complications, the rest were minor. Themean hospital stay following laparoscopiccholecystectomy was 1-77 days. Ninety percent of patients were discharged within 48hours. The mean hospital stay following opencholecystectomy was 7-3 days. Eighty per centwere discharged within the first week. Operat-ing time for laparoscopic cholecystectomyvaried between 20 minutes and two hours witha mean over all operating time of 49 minutes.The average time to return to normal activitiesfor patients following laparoscopic cholecystec-tomy was 4-5 days. Forty one per cent of thoseworking returned to work within one week.Following laparoscopic cholecystectomy 31%of patients did not require any analgesics; 91%did not require narcotic analgesics.The main advantages of laparoscopic chole-

cystectomy are reduced hospital stay, lack ofpain from the procedure, early return tonormal activities and work, and minimal scar-ring.

How to minimise failure during exchange ofendoscopic biliary stents

D F MARTIN (Department of Radiology, Gastro-enterology Unit, Withington Hospital, UniversityHospital ofSouth Manchester) When endoscopicbiliary stents become blocked they arenormally removed by snaring the stent, remov-ing it along with the endoscope and then re-cannulating the papilla and tumour to insert anew stent. Occasionally re-cannulation failsand further endoscopic or percutaneous pro-cedures are required for stent replacement. Tomaintain access across the tumour, a guide wireis inserted through the blocked stent, which isthen withdrawn through a large channel duo-denoscope by a biliary dilatation balloon(Olbert: 180 cm long 6 Fr catheter, 2.5 cmlong, 4mm diameter balloon) which is insertedover the guide wire into the stent lumen andinflated with water. After withdrawal of the oldstent, a new stent is inserted over the guidewire.

This technique has been used in 35 patientsto date with success in 31. Three of the fourfailures occurred early in the series when aninappropriately long 4 cm balloon was used.There has been no complication. Ten or 11-5Fr stents can be removed via a 4-2 mm channelduodenoscope and although the anchoringflange of the stent above the tumour evertsduring removal, this does not obstruct with-drawal.While the balloon catheter is relatively

expensive, its use avoids the costs associatedwith further endoscopic and radiological pro-cedures, which are a consequence of failedstent re-insertion.

Laser laparoscopic cholecystectomy - ourfirst 150 patients

M J HERSHMAN, R D ROSIN (St Mary's Hospital,London) Laparoscopically performed opera-tions cause less postoperative pain and reducedhospital stay, compared with 'open' opera-

tions. Use of a laser enables a clean, relativelybloodless dissection with minimal tissuedamage. We report our experience of laserlaparoscopic cholecystectomy (LLC).One hundred and fifty consecutive patients

underwent LLC. In five other patients LLCwas attempted but abandoned due to denseadhesions (3), cholangiocarcinoma (1), andabsent gall bladder (1). There were 121 womenand 29 men, with a mean age of 49 years and amean weight of 67 kg. Eighteen patients hadpostoperative jaundice, eight had ERCP withfour CBD stone extractions. A NdYAG laserwas used for dissection. The mean operatingtime was 29 minutes (range 29-300 minutes)and the mean laser time was 10 minutes (range4-35 minutes). Operative cholangiography wasperformed in 89 patients, not attempted in 41,and cannulation failed in 20. All patients hadgall stones. The mean hospital stay was 3-4days. All had drains inserted, the mean drain-age was 40 ml (3 had 0 ml). The mean omnoponrequirement was 0 33 mg/kg.There were seven complications (5%), three

patients requiring immediate laparotomy(haemorrhage (2) and gall bladder rupture (1)),and four requiring subsequent laparotomy(slipped cystic duct clip, common bile ductdamage, duodenal perforation, leaking acces-sory hepatic duct). Ofthe 150 patients who haduneventful LLCs, all reported an excellentcosmetic result and 63% reported excellentpain control, one had poor control. The meantime to resume normal activity was 9-6 daysand to return to work was 13-5 days.These data show that postoperative recovery

is excellent after LLC and certainly better thanafter 'open cholecystectomy'.

Effect of jaundice on N-6 fatty acid inducedmonocyte tumour necrosis factor production

W G JIANG, M C A PUNTIS (Department ofSurgery,University of Wales, College of Medicine,Cardiff) Polyunsaturated fatty acids (PUFA)are involved in immune regulation and in thisstudy we investigated the effect of n-6 fattyacids on peripheral blood monocyte tumournecrosis factor (TNF) production. From non-jaundiced and patients with obstructivejaundice, cells were cultured with y linolenicacid (yLA) dissolved in ethanol (final concen-tration of ethanol less than 0-01%). After 24hours, culture media were changed and thecells stimulated by lipopolysaccharide (LPS)(10-0 ,ug/ml) for a further 24 hours. TNFvalues (U/ml) in the supernatants weremeasured by the L929 cell line bioassay. yLAat 10 mM and at 50mM significantly increasedcontrol monocyte TNF production from 20-7U/ml (medium only) to 32-0 U/ml and 56-1U/ml (p<005 by Wilcoxon signed rank test).However, monocytes from jaundiced patientsshowed no response to any concentration ofyLA tested.

These data show that the n-6 PUFA yLA canpotentiate LPS stimulation of monocyte TNFproduction; however this sensitisation is lost injaundice. The serum fatty acids are known tobe altered in jaundice and we suggest that thePBM membrane fatty acids are similarlychanged thus modifying the cells response toyLA.

Relation between gall stones, cholecystec-tomy, and colorectal cancer: a necropsystudy

P MERCER, M HARRISON, F REID, T BATES (TheWilliam Harvey Hospital, Ashford, Kent) Thereports of 8563 necropsies were reviewed forevidence of an association between gall stonesor cholecystectomy and the subsequentdevelopment of colorectal cancer (CRC). The219 subjects with a previous cholecystectomy(CT) were age and sex matched with 219control cases with unoperated gall stones (GS)and with 219 cases with a normal gall bladder(NGB). There were 80 men and 139 women,and only seven subjects were less than 50 years.Seven of the 219 CT subjects had developedCRC compared with 8 of 219 (GS) and 7 of219(NGB) controls. The relative risk ofCRC in thecholecystectomy subjects compared with thegall stone controls was 0-87 (95% CI 0-31-2.44). Right sided CRC has been reported inexcess in women after CT but neither of thesefactors showed a positive trend.

Conversely the 192 subjects with CRC werecompared with 192 age and sex matched con-trols without CRC. Seven v 10 (3.6% v 5.2%)had had CT, 45 v 45 had GD, and 140 v 137 hadNGB.

This study does not support an associationbetween cholecystectomy or gall stones andcolorectal cancer. However, a preliminarymeta-analysis of the available publishedreports does show positive trends and thepresent findings may represent a false-negativestudy of a population with a low cholecystec-tomy rate or a publication bias in favour ofpositive findings.

Photodynamic therapy for malignanttumours of the ampulla of Vater

A M ABULAFI, J T ALLARDICE, R DEAN, N VANSOMEREN, C P SWAIN, N S WILLIAMS, C AINLEY(The Surgical Unit and Academic Department ofGastroenterology, The Royal London Hospital,London) Ten patients (55-78 years) withperiampullary carcinoma who were unsuitablefor resection were treated with photodynamictherapy (PDT), an experimental anticancertreatment which is potentially curative forsmall, light accessible lesions. Four tumourswere confined to the ampulla, three hadlocalised duodenal spread and three causedduodenal stenosis. Haematoporphyrin deriva-tive (4 mg kg-') was given intravenously andactivated within tumour at 48 hours by 630 nmlaser light via a duodenoscope (flat tipped fibre50 J/site/cylindrical diffuser 200 J cm- ', inter-stitially, three to four applications), to causeselective oxidative necrosis. One to five treat-ments were given over a period of two to 16months, and were well tolerated. Medianhospital stay was 4 days (range 4-10).

In four with tumours confined to ampulla,the macroscopic appearances returned tonormal at six weeks. Biopsy specimensfrom two patients, brush cytology from oneon anticoagulants taken three to 16 monthsafter initial treatment showed no residualtumour but one with a positive biopsy speci-men developed recurrence at six months.Four with duodenal spread had noticeableendoscopic improvement with reduced tumourmass. Two patients with duodenal stenosis hadno significant improvement. Three patientsdeveloped moderate skin photosensitivityreaction but there were no othercomplications.PDT produces safe and highly effective

tumour destruction in most patients withampullary malignancy and in small tumoursit may be curative.

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Biliary ultrasound in the elderly - howappropriate?

M MACMAHON, T N WALSH, P BRENNAN,H OSBORNE, M G COURTNEY (INTRODUCED BY J SDOYLE) (Departments of Gastroenterology,Surgery and Radiology, Beaumont Hospital,Dublin, Ireland and The Royal College ofSurgeons in Ireland) Pancreatobiliary diseaseposes a diagnostic challenge in all ages butparticularly in high risk elderly patients whereultrasound (US) is the initial and often onlyimaging technique used to investigate thisproblem, thus avoiding invasive tests. Toexamine the accuracy of US in an elderlypopulation, 50 patients (age range 65-94 years)were studied prospectively, comparing USfindings with endoscopic retrograde cholangio-pancreatography (ERCP) and liver blood tests.

Indications for ERCP were abdominal pain(30), jaundice (19), cholangitis (5), andretained stones (1). The procedure was success-ful in 46 (92%) of patients, and showed abnor-malities in 34 (74%): common bile duct stones(22), carcinoma of pancreas (3), cholangiocar-cinoma (3), ampullary carcinoma (1), pancreasdivisum (1), haematobilia (1), mucocoele (1),and gall bladder stones (2).US agreed with ERCP findings in only 21 of

46 (45%) cases. US correlated in only 12 of 34abnormal (sensitivity 35%) and in nine of 12normal ERCPs (specificity 75%). In patientswith ductal obstruction, US agreed with ERCPin 10 of 30 (33%) cases while liver biochemistryshowed an obstructive pattern in all 30 (100%).Using ERCP, surgery was avoided in 22 (48%).There were no complications of ERCP.Thus, US was misleading and inaccurate in

25 (54%), while ERCP, despite it's risk poten-tial, was safe and appropriate. Because of thelimitations of US in this age group, it isrecommended that ERCP is a necessaryadjunct to that examination in the investigationof pancreatobiliary disease in the elderly.

Impaired renal function in elderly patientswith extrahepatic biliary obstruction

A J MACGILCHRIST, A D CUMMING, K CRAIG, I A DBOUCHIER, K R PALMER (Department ofMedicine, Edinburgh Royal Infirmary andGastro-Intestinal Unit, Western GeneralHospital, Edinburgh) It is well known thatdehydrated patients undergoing surgery forrelief of obstructive jaundice are at particularrisk of developing acute renal failure but thepathogenesis of this potentially fatal complica-tion is unclear.

Renal function was assessed in 16 jaundicedpatients with malignant extrahepatic biliaryobstruction. In nine of these it was reassessedafter successful endoscopic stenting. All sub-jects took 150 mmol Na daily and centralvenous pressures were normalised. Meanbilirubin concentration was 365±45 pmol/l atpresentation and 21±7 [tmol/1 after stenting.In six patients aged less than 65 years renalfunction was normal at presentation; renalblood flow (RBF) 543±61 ml/minute,glomerular filtration rate (GFR) 132±26 ml!minute, and fractional Na excretion (FENa)1.22+0.31%. No changes occurred after stent-ing. In the 10 patients older than 65 years (69-82 years) mean RBF was appreciably reducedat presentation, 189±18 ml/minute. In stentedpatients (n=5) RBF improved from 177 to269±59 ml/minute. Mean GFR was modestlyreduced, 63±6 ml/minute, and did not changeafter stenting. Mean FENa was increased at

1-98±0-28% despite the reduced RBF suggest-ing renal tubular dysfunction in this elderlyjaundiced group.Serum concentrations of catecholamines,

renin, angiotensin, aldosterone, kallikrein, andPGE were normal throughout in all subjects,suggesting that the renal abnormalities werenot due to neurohumoral imbalance.

In elderly jaundiced patients renal bloodflow is reversibly decreased and tubularfunction is depressed; this predisposes to thedevelopment of renal failure.

AIDS related sclerosing cholangitis: naturalhistory and influence on overall prognosis

G M CONNOLLY, A FORBES, C BLANSHARD, I MMURRAY-LYON, M G ANDERSON, B G GAZZARD(AIDS Unit, Westminster Hospital, London)Right upper quadrant pain, obstructive liverfunction tests, variable biliary ultrasoundabnormalities, and an ERCP indistinguishablefrom primary sclerosing cholangitis lead, in theHIV infected, to a diagnosis of AIDS relatedsclerosing cholangitis (ARSC). Its naturalhistory and effect on overall prognosis have notbeen recorded.

Nineteen consecutive patients with ARSC(positive HIV serology, two characteristiclesions at ERCP, without ulcerative colitis orgall stones) were therefore studied. Median ageat diagnosis was 34 years (range 27-50). HIVserology had been positive for 35 months (2-72). All had abdominal pain; 10 had diarrhoea.Alkaline phosphatase (ALP) was >2X normalin 12; bilirubin was raised in two. The medianCD4 was 58 (7-341). Cryptosporidiosis waspresent in 10, active cytomegalovirus (CMV) infive. No gastrointestinal pathogen was identi-fied in seven.Symptoms attributable to ARSC were con-

trolled within eight weeks in surviving subjectsby symptomatic measures (includingmorphine); evidence that CMV therapy influ-enced response is inconclusive. Seven are alivewithout ARSC symptoms but with persistentlyraised ALP at 10 months (2-28). Twelve havedied at median 5 (1-13) months. The initialCD4 was <120 in those dying within sixmonths of the ARSC diagnosis. It is likely thatARSC has itself a good prognosis, and is notan independent influence on the outcome ofAIDS.

Effect of indomethacin on human gailbladder mucin glycoprotein synthesis andsecretion

F E MURRAY, B FILIPOWICZ, C J HAWKEY (Depart-ment of Therapeutics, University Hospital,Nottingham) Gall bladder mucin glycoproteinsecretion is essential for gall stone formation,acting to promote cholesterol monohydratecrystal nucleation. Prostaglandins may controlgall bladder mucin secretion, and non-steroidalanti-inflammatory drugs (NSAIDs) preventgall stone recurrence in man. The aim of thisstudy was to evaluate the effect of indo-methacin on gall bladder mucin synthesis andsecretion in man.

Gall bladder mucosal explants (n=6 pergroup) were prepared from patients under-going routine cholecystectomy for gall stones.Mucin secretion in organ culture was measuredas incorporated 3H-glucosamine after precipi-tation with TCA/PTA. Results are expressed asmean (SEM).

Indomethacin caused a dose-dependent

inhibition of mucin glycoprotein synthesis andsecretion over the range 10-5_10-3 M:synthesis: control: 35 157 (2270) dpmlmgprotein; 10-5 M: 24 418 (1991); 10-4 M: 24 406(1460); 10-3 M: 9308 (332); secretion: control:21 920 (22802 dpni/mg protein; 10-5 M: 12 335(1053); 10` M: 12375 (845); 10-3 M: 7152(340); p<0 01. Sepharose 4B-columnchromatography confirmed that secretion ofthe higher molecular weight glycoproteinswere specifically reduced in a dose-dependentmanner by indomethacin.

In conclusion, indomethacin inhibits bothmucin glycoprotein synthesis and secretion byhuman gall bladder.

Estimation of phospholipid in human gailbladder bile by 'H nuclear magneticresonance spectroscopy

J P M ELLUL, H HUSSAINI, R Z SLAPA, H PARKES,G M MURPHY, R H DOWLING (GastroenterologyUnit, Guy's Campus, UMDS, London andNMR Unit, Department of Chemistry, BirkbeckCollege, University ofLondon, London) Conven-tional analytical techniques disrupt the dis-tribution of biliary lipids between the vesicularand mixed micellar phases. We and othersshowed that in model bile, 'H nuclear magneticresonance (NMR) differentiates non-invasivelybetween cholesterol (chol) and phospholipid(PL) in these two phases, although the changesmay be temperature dependent. As a first stepwe quantitated total phospholipid in native bileby NMR.

Gall bladder bile was obtained peropera-tively (n=6). Total bile acid (TBA), PL, andchol concentrations were determined enzy-matically. 'H NMR spectra of unaltered bilewere obtained at 500 MHz, 11-75 Tesla usingD20 and a reference standard (TSP) in anexternal tube at 37°C. The assigned resonancefor the PL choline group at 3 25 ppm and theTSP resonance were integrated. Vesicular andmicellar phases of bile were separated bysucrose density gradient ultracentrifugation(DGU; n=3) and % PL, chol, and TBA in eachphase were determined.

Correlation between NMR and enzymatictotal PL was 0-887 (p<0 002). Mean PL byNMR was 28-8±11-8 and enzymatically PLwas 23-6±8-42. By DGU the vesicular phaseconstituted 82-8, 39-6, and 22-6% of the totalPL respectively.

In conclusion, total PL can be detected andaccurately quantitated in both the micellar andvesicular phases ofhuman bile.

Prediction of common bile duct stones: theimportance of ultrasonic duct visualisation

R J C STEELE, K PARK, F GILBERT (Departments ofSurgery and Radiology, University of Aberdeenand Department of Surgery, University ofNottingham) One hundred and forty patientsadmitted for cholecystectomy for uncompli-cated gall stones underwent specific commonbile duct ultrasound scanning during the 24hours before surgery. In addition, blood valuesof bilirubin, aminotransferase, alkaline phos-phatase, y glutamyl transferase, and amylasewere determined within the same time period.At operation, operative cholangiogram wasperformed routinely, and 22 patients werefound to have common duct stones.Of 10 patients in whom common duct stones

had been seen on ultrasound, all were found tohave such stones, and of 35 other patients in

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whom an entire empty duct had been visual-ised, none were found to have stones. Thus ifstones or the whole length of the common ductwere imaged, ultrasound attained 100%efficiency.

In the remaining 95 patients, however, a

dilated duct was not very useful having a

positive predictive value of only 42%. Like-wise, alkaline phosphatase, the best bio-chemical predictor, had a positive predictivevalue of 45%. A combination of these twoparameters was better, but only achieved a

positive predictive value of 71%. Attempts atimproving non-invasive preoperative predic-tion of common duct stones should focus on

improved ultrasonic visualisation of the wholelength of the duct.

Diarrhoea after cholecystectomy: an under-estimated problem?

D PARKER, K W HEATON (University Departmentof Medicine, Bristol Royal Infirmary, Bristol)Diarrhoea after cholecystectomy, caused bytype 3 bile acid malabsorption, is generallythought to be rare but bowel function aftercholecystectomy has not been systematicallystudied. We have assessed bowel function in 48of the 51 cholecystectomised subjects in a

random population sample (27% men) and, as

controls, 85 ofthe 92 people with ultrasonicallydiscovered gall stones in the same sample (46%men, ages similar). Time elapsed since chole-cystectomy was 3 months to 26 years (mean7 years). Nearly all the newly discovered gallstones were asymptomatic. Subjects recordedthree defecations on a special form, includingstool type on a validated six point scale. Symp-toms and bowel frequency were assessed bystandard questionnaire.Unformed stools (types 5 and 6) and liquid

stools (type 6) were significantly commoner inthe cholecystectomy group (unformed 27-5%of all stools v 12-4% in the gall stone group,p<O-001; liquid 11-7% v 6-4%, p<005).Urgency as a frequent complaint (>1 in 4defecations) was much more prevalent in thecholecystectomy group (35 9% v 5.7%,p<0.001). These differences were present inboth sexes (but small numbers precludedsignificance in men). No cholecystectomy sub-ject habitually defecated more than twice dailyand in only 5% were all three recorded stoolsliquid.

In conclusion, unformed stools and urgencyof defecation are commoner after cholecystec-tomy but continuous diarrhoea is rare.

COLORECTAL

Histological predictors of poor outcome inDukes's B colorectal cancer

H MULCAHY, M TONER, L DALY, S PATCHETr, D P

O'DONOGHUE (Departments of Gastroenterology,Pathology and Epidemiology, St VincentsHospital, Dublin, Ireland) Dukes's classifica-tion is a widely used histological prognosticindicator of colorectal cancer (CRC). However,long term survival of patients with early lesionsas staged by this system is by no means assured.Some 70% of patients undergoing surgery forDukes's B CRC can expect to be alive at fiveyears. Identification of the 30% of individuals

destined to die of recurrent disease would helptarget these patients for adjuvant therapy.The histological specimens of 123 patients

with newly diagnosed Dukes's B CRC admit-ted between 1983 and 1988 were subjected todetailed analysis by a single histopathologist.Histological variables studied included theoverall grade and extent of tumour, type oftumour front, presence or absence of inflam-mation, mucin, vascular invasion, neuralinvasion, necrosis, stromal reaction, Crohn'sreaction, peritonitis, the presence of a papillarypattern to the tumour, signet ring pattern, andthe number of negative lymph nodes in thespecimen. Follow up was between 19 and 87months. The end point was taken as totalmortality.

Using a stepwise Cox regression model, bothneural invasion and necrosis were found to beindependent variables related to survival.Patients with neural invasion had an increasedrelative risk of 3-02 (p<0-01) while thosewhose tissues displayed necrosis had anincreased relative risk of 2-5 (p<0-01). Noother parameter added to these could predictan unfavourable outcome. Neither age nor sexwere significant variables.

In conclusion, the finding of neural invasionor tissue necrosis in patients with Dukes's BCRC heralds a poor prognosis and such indi-viduals should be considered for adjuvanttherapy.

This abstract was also published in the Manchesterprogramme, April 1991, but not presented.

Embolisation of superior haemorrhoidalartery for severe rectal bleeding

J K DERODRA, J F REIDY, M H JORDAN (INTRO-DUCED BY R C MASON) (Departments ofRadiologyand Surgery, Guy's Hospital, London) Angio-graphy is invaluable in localising the site ofgastrointestinal bleeding, but its role in con-trolling such bleeding remains unproved. Wedescribe two cases of severe rectal bleedingsuccessfully treated by embolisation ofsuperior haemorrhoidal artery. Case 1 hadbleeding from a solitary rectal ulcer and case 2after local excision of rectal villous adenoma. Inboth cases, conventional surgical procedureshad failed to control this bleeding.

Using coaxial catheter techniques and a 3FTeflon catheter, the superior haemorrhoidalartery was selectively catheterised and thenembolised using Gelfoam particles. Thisarrested bleeding in both cases, with noevidence of bowel ischaemia. In case 1 emboli-sation was used as the sole treatment due to thepatient's poor medical condition. Case 2 had anA-P resection of the rectum once his generalcondition improved, after embolisation andcessation of bleeding.

Embolisation of superior haemorrhoidalartery in controlling rectal bleeding has notbeen described before and this is a relativelyeasy solution to what can be a formidableproblem, especially in poor risk patients.

Smoking and pouchitis

M N MERRETT, N MORTENSEN, M G WKETTLEWELL, D P JEWELL (GastroenterologyUnit, The Radcliffe Infirmaty, Oxford) Retro-spective assessment of smoking habits hasshown a reduced risk of ulcerative colitis (UC)in current smokers. One case control studyfound overall relative risks of4 and 3-6 for male

and female non-smokers compared withcurrent smokers. Conversely Crohn's disease(CD) is positively associated with smoking.The aetiology of pouchitis in patients with

UC who have had a restorative proctocolec-tomy is unknown. It may represent recurrentinflammation similar to the original UC in ilealmucosa that has undergone colonic metaplasia.Therefore, it seemed plausible that pouchitismay be related to smoking habit.

Patients having a functioning pouch for 1year were assessed. Smoking data were collatedvia questionnaire or direct interview. Non-smokers included ex-smokers who had ceasedprior to pouch formation. Patients wereexcluded if (i) original indication was not UC(n=4), (ii) the excised pouch revealed histo-logical appearances diagnostic of CD (n=2), or(iii) data was inadequate (n= 10). Smokers(8 M: 3 F) had a mean follow up of 3-9 years(total=43 years). Average cigarette consump-tion was 10 5/day. Non-smokers (32 M: 18 F)had a mean follow up of 3-4 years (total= 170years). Pouch type was similar in the twogroups being 5 J, 5 W, 1 S, and 20 J, 19 W,11 S respectively.One smoker has had one episode of

pouchitis. Conversely 14 non-smokers havehad 34 episodes (mean=2-1, SD=11) ofpouchitis. The difference in number ofepisodes was significant (X2 with Yates correc-tion p<0 02). Pouch 'function' at 12 months(number of bowel actions in 24 hours) wassimilar in the two groups being mean=4-1,SD=1-6 in smokers, and mean=5-1, SD= 16in non-smokers.

This study suggests that smoking mav beprotective against pouchitis. Further largerstudies are indicated.

Colonic type mucin occurs in the ileal pouchand small intestinal Crohn's strictures, butnot in coeliac disease

M N MERRETT, H J DE SILVA, J M RHODES, J DMILTON, A CAMPBELL, C PRINCE, D P JEWELL(Gastroenterology Unit, The Radcliffe Infirmary,Oxford) Colonic metaplasia (adaptation) is welldescribed in the ileal pouch. This has beenattributed to stasis and possibly bacterial over-growth. However, the mechanism is unknown.The aims of this study were to assess adaptationof pouch mucin and to determine whether thechanges are specific to the ileal pouch.

Paraffin sections of ileal pouch (9), proximalend of resected small intestinal Crohn'sstrictures (11), active coeliac disease (7),ileostomy (1), normal ileum (2), and rectum (4)were assessed. Villous height was assessed onhaematoxylin and eosin stained sections andthe degree of inflammation scored (0-3) forboth acute and chronic changes. Mucin histo-chemistry was performed using high iondiamine-alcian blue (HID-AB) graded 1 =sialomucin, 2= mixed, and 3=sulphomucin, aswell as with a monoclonal antibody (MMM-17)against 8-0 acetyl sialomucin (colonic mucin)also graded 1-3.The pouch biopsy specimens showed mixed

staining, with a mean grade of 2-0 (HID-AB)and 2-2 (MMM-17). In Crohn's strictures thegrades were 2-2 and 2-6, coeliac disease 1-0 and1-0, ileostomy 1-0 and 1-0, ileum controls 1-0and 1-0, and rectum controls 3.0 and 3.0respectively. In pouch mucosa villous atrophy,but not inflammation, seemed to correlate withthe presence of colonic mucin.

In the ileal pouch and proximal to smallintestinal Crohn's strictures, there is a partialswitch to colonic mucin. No such change was

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seen in active coeliac disease or in mucosa froman ileostomy. This suggests that stasis, and notvillous atrophy or inflammation, is related tothe mucin changes.

Lifetable survival analysis of patients withintra-abdominal desmoid disease in familialadenomatous polyposis

K C R FARMER, R K S PHILLIPS (St Mark'sHospital, London and Professorial Surgical Unit,St Bartholomew's Hospital, London) Intra-abdominal desmoid tumours encase thesuperior mesenteric artery making resectionhazardous. Surgery is usually undertaken lateto alleviate intestinal and urinary obstruction.We have performed a lifetable analysis ofsurvival of34 patients (15 male, 19 female) withfamilial adenomatous polyposis (FAP) andintra-abdominal desmoids to establish theirclinical significance.Ten deaths (3 male, 7 female) were related to

desmoid disease. Five deaths were due to directeffects of visceral infiltration. There were fourperioperative deaths in advanced disease. Onepatient died during chemotherapy. Mean age atdeath was 30.3 years and median survival afterdiagnosis was two years. The age at diagnosis inthose who died (25-0 years) was significantlylower than that of survivors (34.7 years)(p<005, Mann-Whitney U test). Lifetableanalysis showed a five year probability ofsurvival of 0-68. All but one death occurredwithin seven years of diagnosis.There seem to be two types of intra-

abdominal desmoid disease: a more aggressiveform occurring in younger patients with earlydeaths, and a more benign form seen in olderpatients. The diagnosis of intra-abdominaldisease does not carry a universally dismalprognosis.

Results of restorative proctocolectomy inpatients over the age of 50 years

W LEWIS, P J HOLDSWORTH, P SAGAR, DJOHNSTON (University Department of Surgery,The General Infirmary, Leeds) Restorativeproctocolectomy (RP) is the operative pro-cedure of choice for 'young' patients withulcerative colitis (UC). However, a report fromthe Mayo Clinic that mean bowel frequencywas 11 in 24 hours after RP with J pouch inpatients over 50, compared with 7 in 24 hoursin patients under 50, has - together with con-siderations of risk to life - tended to limit theuse ofRP to younger patients.Between 1986 and 1991, 18 patients aged 50

to 66 years (median, 55 years: 9 male) under-went RP with ileoanal anastomosis, end to endwithout mucosal stripping (11 W, 5 J, 2 no,pelvic reservoirs). The results were comparedwith those of 18 matched patients (same sex,reservoir, operative technique, follow up) agedunder 50 (median 34 years).

Function of the anal sphincters was wellpreserved in the older patients after RP withoutmucosal stripping. The functional outcomewas slightly, but not significantly, inferior tothe outcome in younger patients. Hence,'fitter' patients over the age of 50 need notbe denied the benefits of restorativeprotocolectomy.

Delormes procedure for rectal prolapse - aconsecutive unselected series

M R THOMPSON, P W LEOPOLD, S JACKSON (StMary's Hospital, Portsmouth) Since October1983, Delormes has been the procedure ofchoice to treat full thickness rectal prolapse onan 'all comers, no exclusion' basis. Fifty sixpatients underwent 60 procedures includingfour repeat Delormes. Six patients hadpreviously undergone six different proceduresto treat their rectal prolapses with limitedsuccess. None of these procedures precludedDelormes. Mean age was 73 years (range 27-83 years) with 44 patients (78%) over the age of70 (51 female and 5 male). Prolapse historyranged from 1 month to 20 years. Anaesthesiaused included 53 general, 4 local, and 3 spinalanaesthetics. Length of mucosal strippingranged from 4 cm to 36 cm, and 11 patients hadsimultaneous posterior internal sphinctero-plasty performed. All patients tolerated theprocedure well, with one perioperative andthree late deaths. Of six recurrences, four havebeen successfully repeated, one awaits and onerefuses further surgery. Subjective assessmentof functional results was good with both con-stipation and frank faecal incontinenceimproved. The postoperative deaths reflect thevery frail 'no-exclusions' population with nopatient too sick to undergo Delormes. Therewas also a definite recurrence rate.

Despite this we feel Delormes is a very welltolerated procedure which can be repeated,with excellent functional results.

Qualitative analysis of bile in patients withcolorectal cancer

A TOCCHI, L BASSO, G COSTA, L LEPRE, G LIOTTA,G MAZZONI (INTRODUCED BY C O'MORAIN)(Ist Department ofSurgery, University ofRome,'La Sapienza', Italy) In order to assess thehypothesis of an altered bile composition inpatients with colorectal cancer, we prospec-tively studied 72 subjects. Thirty six of thesepatients had colorectal cancer (group A), whilethe remaining 36 required a laparotomy fornon-gastrointestinal illnesses (group B, controlpopulation). Bile samples were always takendirectly from gall bladder at operation. Wefound, for each biliary salt, the following meanpercentile values: cholate 36-7% in group A v40.7% in group B, chenodeoxycholate 37 9% ingroup A v 41-1% in group B, deoxycholate20-9% in group A v 13.4% in group B, litho-cholate 3.5% in group A v 4.9% in group B. Atstatistical analysis of the standard error of thedifferences between the above reported means,only deoxycholate proved to be significantlyhigher in the colorectal cancer group comparedwith the controls.

This study suggests that colorectal cancerpatients are carriers of an altered bile only withregard to deoxycholate, which, alone, shouldtherefore be considered as one of the possiblepromoters of colorectal cancer.

Acetylator status: a link between hepaticmetabolism and colorectal cancer

K C R FARMER, S E OLIVER, A D SPIGELMAN, P NBENNETT, R K S PHILLIPS (St Mark's Hospital,London and Professonral Surgical Unit, StBartholomew's Hospital, London) Bileinfluences gastrointestinal neoplasia, perhapsby hepatic metabolism of environmentalcarcinogens. The enzyme N-acetyltransferasedetoxifies gastrointestinal carcinogens and itsactivity (fast or slow) is inherited. Slow acety-

lators may therefore excrete more carcinogen inbile than fast acetylators.We determined acetylator status in familial

adenomatous polyposis (FAP) patients (n=41), sporadic colorectal cancer (CRC) patients(n= 11), and normal healthy controls (n=232).

After ingestion of 300 mg of caffeine and aneight hour urine collection, urinary metaboliteswere measured by liquid chromatography andmetabolic ratios used to determine acetylatorstatus. The x2 test was used for statisticalanalysis.

There were significantly more slow acety-lators in FAP (75%) and sporadic CRCpatients (91%) compared with controls (52%)(p<O0OOS).These findings support the hypothesis that

liver metabolism plays a role in colorectalcarcinogenesis.

Existence of colonic neuropathy in slowtransit constipation: evidence from a histo-logical survey

D KUMAR, M J BENSON, J ROBERTS, J E MARTIN, MSWASH, D L WINGATE, N S WILLIAMS (SurgicalUnit, GI Science Research Unit and Departmentof Pathology, Royal London Hospital, TheLondon Hospital Medical College, London)From the results of functional studies, it hasbeen suggested that a colonic neuropathy maybe responsible for the delay in colonic transit inslow transit constipation (STC). However, todate there is little histological support for thishypothesis.

Tissue was obtained from 12 female patients(age: 30-57 years) with STC (defecationx 1/7-14 days, prolonged marker retention(>80 at 5 days) and "4In-DTPA (showingtransverse/splenic flexure delay) transitstudies), who underwent therapeutic subtotalcolectomy for this condition and 12 controlspecimens removed for neoplastic disease.Samples were taken from both resectionmargins and at 5-10 cm intervals. Histo-chemical stains and immunochemistry forneurofilament, S-100, and neuron specificenolase (NSE) antigens were performed. Everyregion sampled in all specimens from STCsubjects showed an increase in small nervefibres of the muscularis propria: this was notseen in any of the controls. No other neural ormyocyte abnormalities were detected. Therewas no correlation between distribution ofhistological changes and regional delay incolonic transit as detected on "I'In-DTPA.These changes are not similar to those

reported in other gastrointestinal neuropathicconditions. Although definite abnormalities ofinnervation occur in the colon in STC, it is notpossible to say whether these represent aprimary defect or an adaptive response to thefunctional abnormality.

Measurement of segmental colonic transitin idiopathic constipation using orallyadministered isotope in enteric coatedcapsules

B PANAGAMUA, N TULLEY, A NOTGHI, M OYA, L K

HARDING, D KUMAR (Department of Surgery,Queen Elizabeth Hospital, Birmingham andDepartment of Nuclear Medicine, Dudley RoadHospital, Birmingham) We measured segmentalcolonic transit using a methacrylate coatedcapsule filled with 2 MBq of" 'In impregnatedresin in four healthy volunteers and sevenpatients with chronic idiopathic constipation

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(CIC). Half to three hourly images of the colonwere obtained during a three day period. Timezero was when all activity was seen in thecaecum. The colon was divided into fourregions of interest (ROI) - caecum to hepaticflexure, transverse colon, splenic flexure, restof the colon and rectum respectively. Visualanalysis of images indicated patients witheither right sided (group 1) or left sided (group2) delay in transit. Percentage activity in eachROI at 6, 24, 32, 48, and 56 hours wasmeasured and mean values in the two groupswere compared with those in the controlsubjects.Group 1 had mean (SEM) 59-2 (4.9)%

activity retained in ROI 1 compared with 15-8(8.5) in controls (p=0002). Correspondingly,this group had significantly less activity inROI 3 (p=0-01) and ROI 4 (p=003) whencompared with controls. Similarly, group 2 hadgreater activity (32-7 (9 1) v 10-4 (2.0),p<0-01) in ROI 4. At the end of 48 hours,the controls and patients in groups 1 and 2had evacuated 50%, 5%, and 0% activityrespectively.These data show segmental transit delays in

CIC. This technique allows quantification ofcolonic transit and may be useful in the man-agement of patients with CIC.

Levamisole and other reticuloendothelialsystem stimulators: implications for adjuvanttreatment?

N DAVIES, J YATES, B A TAYLOR, S A JENKINS(University Department ofSurgery, Royal Liver-pool Hospital, Liverpool) Adjuvant therapy withfluorouracil and levamisole has been shown toincrease survival significantly in patients withDukes's C colorectal cancer. We have com-pared the effect of levamisole on the hepaticand splenic reticuloendothelial system (RES)with other known RES stimulants. Groups of10 Wistar rats received saline (control), glucan,zymosan, chlormethiazole, octreotide (somato-statin analogue), or levamisole. RES wasassessed by the hepatic and splenic uptake of99Tc sulphur colloid (SC), 20 minutes after anintravenous injection of 2-5 MBq of colloid.All agents significantly (Mann-Whitney Up<0.001) increased hepatic uptake: (mean(SEM)) controls, 6-1 (1-3) glucan, zymosan16-3 (3- 1), chlormethiazole 23-1 (17),octreotide 34-2 (2-1), and levamisole 22-0 (3.9).Splenic uptake, was significantly increasedexcept in the levamisole group. Octreotideincreased uptake of sulphur colloid signific-antly more than levamisole in both liver andspleen (p<0.005).The results of this study suggest that

octreotide is a more potent stimulator of RESfunction than levamisole and may be of benefitin the adjuvant treatment of colorectal cancer.

Mucosal alkaline phosphatase as an indicatorof disease activity in ulcerative colitis

C DO AMARAL-CORFIELD, A P CORFIELD, M HALL,B F WARREN, H S RIGBY, R A MOUNTFORD, J RCLAMP (Departments of Medicine and Histo-pathology, Bnrstol Royal Infirmary, Bristol) Wehave investigated the measurement of mucosalalkaline phosphatase activities as an improvedindicator of ulcerative colitis activity.

Rectal biopsy specimens were taken from 24patients with known ulcerative colitis and froma control group of 29 with non-specific symp-toms. One specimen was processed for routine

histology. Colitis was graded as active orinactive. The other was homogenised in bufferand assayed for alkaline phosphatase activityand related to the DNA content of the biopsyhomogenate.A highly significant difference in alkaline

phosphatase activity was found between thecontrol (0.53+0.2 U/mg DNA) and ulcerativecolitis (1-31+0-58 U/mg DNA) groups (p=0-001). The active ulcerative colitis group(n= 9) had higher alkaline phosphatase activity(1 63+0-56 U/mg DNA) relative to the inactivegroup (n=15, 1.I2+0.52 U/mg DNA). Thisdifference was significant (p<005).The measurement of mucosal alkaline phos-

phatase values may represent an objective andreliable assessment of disease activity.

Does the rectum contract duringdefecation?

A MACDONALD, P J PATERSON, J N BAXTER, I GFINLAY (Departments of Surgery and Urology,Royal Infirmary, Glasgow) During normaldefecation the intrarectal pressure is observedto rise. In the absence of a reference catheter inthe pelvis, the contribution of abdominalstraining and rectal contraction to the intra-rectal pressure rise is unclear. The aim of thisstudy was to examine the mechanism of intra-rectal pressure elevation using the emptybladder to measure intrapelvic pressure.Ten consecutive women with no gastro-

intestinal symptoms undergoing urodynamicswere studied. A double lumen catheter wasplaced in the rectum to measure pressuresduring the filling and evacuation of a waterfilled rectal balloon. Intrapelvic pressure wasrecorded via second intravesical catheter.

Prior to rectal filling, abdominal straining(Valsalva's maneouvre) produced identicalrises in intrarectal and intravesical pressure.The mean (SD) instilled volume required for

a call to stool was 96 (28) ml. During filling therectal pressure increased from 2 (0.5) to 18 (4)cm H20. The intravesical (pelvic) pressureremained unchanged at 2 (1) cm H20. Evacua-tion of the rectal balloon produced an increasein intrarectal pressure from 18 (4) cm H20 (endfilling pressure) to 68 (15) cm H,O. Theintravesical pressure increased from 2 (1) to 51(18) cm H20. The true intrarectal pressure(intrarectal minus intrapelvic) did not riseduring defecation.These data suggest that the rise in intrarectal

pressure during rectal evacuation can beexplained by increased intrapelvic pressurealone. These observations suggest that rectalcontraction is not important in defecation andalso support the hypothesis that posteriorpelvic floor contraction is important for normaldefecation.

GASTRODUODENAL

Gastric mucosal leukotriene B4 synthesis andhistological gastritis in patients on non-steroidal anti-inflammatory drugs

N HUDSON, M BALSITIS, C J HAWKEY (Depart-ments of Therapeutics and Pathology, UniversityHospital, Nottingham) Non-steroidal anti-inflammatory drugs (NSAIDs) are associatedwith gastric mucosal damage. This is widelyattributed to inhibition of prostaglandin

synthesis. We have previously shown thatlongstanding NSAID therapy is associatedwith increased gastric mucosal leukotriene B4(LTB4) synthesis. LTB4 may promote gastritisby neutrophil recruitment, lysosomal enzymerelease, and changes in vascular permeability.The aim of this study was to examine therelation between gastric mucosal LTB4synthesis and mucosal inflammation assessedhistologically.

Fifty eight patients on longstanding NSAIDtherapy underwent endoscopy. Two ex vivoantral gastric biopsy specimens were stimu-lated by vortex mixing and supernatantmeasurements of LTB4 determined by radio-immunoassay, two further biopsy specimenswere processed for histological assessment.Microscopy was classified as normal mucosa,chemical gastritis (foveolar hyperplasia,smooth muscle extention, vascular ectasia), oractive chronic gastritis (inflammatory cellinfiltrate+ architectural distortion).The results showed that there was a signifi-

cant increase in median gastric mucosal LTB4synthesis in NSAID patients with chemicalgastritis 2.2 pg/mg (IQR.0.4-2.9) comparedwith patients with normal mucosa 0-2 pg/mg(0 0-08) (p<0-01). Patients with activechronic gastritis also had higher LTB4 09 pg/mg (04-3.2) but this did not reach significance(p<O 1).

In conclusion, gastric mucosal LTB4synthesis is strongly correlated with thepresence of chemical gastritis, which is a wellrecognised histological finding in NSAIDusers. Since neutrophils are not increased inchemical gastritis it is likely that LTB4 isderived from other mucosal cells and may be animportant mediator of NSAID gastritis.

Interobserver variability in assessment ofgastric lesions by video endoscopy

N HUDSON, S J EVERITT, C J HAWKEY (Departmentof Therapeutics, University Hospital, Notting-ham) Non-steroidal anti-inflammatory drugs(NSAIDs) are associated with significantgastrointestinal morbidity and mortalitv.Endoscopic studies report the incidence ofpeptic ulceration in NSAID users as between9-25%. It is likely that many of these lesions aretrivial and benign and differences in reportedulcer prevalence may reflect interobservervariability.

Endoscopic video recordings of 84 gastriclesions in patients taking NSAIDs and of nineulcers detected concurrently in non-NSAIDusers were shown to six experienced endo-scopists. Lesions were categorised as: intra-mucosal haemorrhage, haemorrhagic andnon-haemorrhagic erosions, and deep or super-ficial ulcers.

Eight of the nine non-NSAID ulcers (88%)were classified as deep ulcers compared with 16of 44 (36%) of those associated with NSAIDs.Other NSAID lesions were non-haemorrhagicerosions (n=29), haemorrhagic erosions (4),and intramucosal haemorrhage (8). Eightveight per cent of the video observer's choiceconcurred with the original diagnosis for non-NSAID ulcers compared with 51% for NSAIDulcers (X2: p<0-001). Forty five per cent ofdeep NSAID ulcers were misclassified assuperficial ulcers and 40% of superficialNSAID ulcers were misclassified as non-haemorrhagic erosions. Conversely, 17% ofNSAID erosions were misclassified as ulcers.We conclude that observers concur about

the diagnosis of non-NSAID ulcers. NSAIDulcers, however, are more superficial and often

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difficult to distinguish from erosions. NSAIDulcers look different from non-NSAID ulcersand may have a more benign natural history.

Raised plasma cholecystokinin aftervagotomy and pyloroplasty

I S BAILEY, T H STUMPF, C D JOHNSON (UniversitySurgical Unit, Southampton General Hospital,Southampton) Truncal vagotomy and pyloro-plasty (V and P) has profound effects ongastrointestinal function. Excessive cholecy-stokinin (CCK) release may be one of severalcomplex mechanisms mediating these effects.Difficulties in measuring CCK in plasma havelimited previous studies.We have developed a CCK radioimmuno-

assay using a rabbit antiserum generated witha CCK1O immunogen. Non-specific plasmaeffects are reduced by ethanol extraction(efficiency 63%+3 9%) and preparation ofstandards in extracts of peptide free plasma.The assay detection limit is 0-25 pM CCK8.The antiserum binds bioactive CCK moleculeswith high affinity and has low cross reactivitywith gastrin 17. Intra- and interassay variationare < 16% and <20% at plasma concentrations1-30 pM.We have measured plasma CCK values

following a standard meal of corn oil andmashed potato in 10 patients after V and P andin six normal volunteers. Fasting CCK valueswere higher after V and P (median 0-83 pMV and P; 0.39 pM control p=0.04 (MannWhitney)). Peak plasma CCK after the mealwas higher after V and P (9-6 pM V and P; 1-6pM control p=0-015). Integrated release ofCCK for 90 minutes after the meal was signifi-cantly higher after V and P (49.5 pM V and P;8-3 pM control p=0006).We have demonstrated high CCK values

in patients after V and P: these may becausally related to vagotomy symptoms aftervagotomy.

Sensitive quantitative method for estimatingpepsin types 1, 3, and 5 in human gastric juicefrom endoscopy

A BLACKBURN, A ALLEN, J P PEARSON, M RHODES,W j CUNLIFFE, C W VENABLES (Department ofPhysiological Sciences, Medical School,Newcastle upon Tyne) Major pepsins 1, 3, and 5in human gastric juice have previously beenestimated semiquantitatively after gel electro-phoresis. We report measurement of pepsintypes by a combination ofHPLC and assayingpepsin by proteolytic activity and ELISA.

Basal gastric juice (2 ml) from endoscopy waschromatographed by HPLC and fractionsassayed for: (i) proteolytic activity measured byfree amino group formation with succinylalbumin substrate, (ii) total pepsin content byELISA using a murine monoclonal antibodyproduced against purified human pepsin 3.This antibody showed cross reactivity to allthree pepsins 1, 3, and 5.

Pepsin 1, 3, and 5 values by ELISA (mean(SEM)) in non-symptomatic subjects were 7 (3)pg ml-l, 833 (265) pg ml-l and 94 (22) [sgml- ' (n= 5) compared with values in duodenaland gastric ulcer patients of 23 (12) pg ml-l,1367 (260) pg ml-l, and 97 (33) pg ml- 1 (n=7), respectively. Pepsin 1, 3, and 5 values byproteolytic assay in non-symptomatic patientswere 8 (2) ,ug ml- ', 621 (195)pg ml- ', and 94(23) pug ml-' compared with values in duo-denal and gastric ulcer patiepts of 11 (6) [sg

ml-l, 758 (110) pg ml-, and 75 (18) [g ml-respectively.These results show (i) ELISA with HPLC is

a sensitive and quick method of estimatingpepsin types in gastric juice, (ii) no significantdifferences exist in the ratio of pepsin typesbetween basal gastric juice samples from non-symptomatic and ulcer patients in contrast toprevious results for stimulated juice samples.

Need for better understanding of gastriclymphoma

N C GALLEGOS, A WOTHERSPOON, P B BOULOS(Departments of Surgery and Pathology,University College and Middlesex School ofMedicine, London) Gastric lymphoma (GL) isstill erroneously grouped with extranodal non-Hodgkin's lymphoma and this bears seriousimplication with regard to prognosis. Theclinical behaviour of a series of patients withgastric lymphoma was therefore analysed.Twenty two patients with GL (M:F 15:7,

median age 60 years) presented to this institu-tion between 1971 and 1989. The ratio ofelective to emergency admissions was 17:5 andthe median length of history, 6-5 months.Endoscopic diagnosis was successful in only 7of 19 patients. On pathological review therewas a complete absence of splenic and bonemarrow involvement and 15 of 22 patients hadearly (stage I) disease.

Eighteen patients were treated by gastrec-tomy with clear resection margins attained in16. Adjuvant treatment was used in eightpatients, but failed to influence the incidence ofrelapse which occurred in six cases at a mediantime of 39-5 months (range 18-96 months). Infour patients relapse presented as a furthergastric lesion without concomitant metastaticspread. The five year cumulative survival ratefor all patients was 72% (95% confidenceinterval 52%-92%).These results support the concept that

primary gastric lymphoma originates frommucosa associated lymphoid tissue (MALT),and explains the favourable prognosis withlocal treatment and low risk of dissemination.

Effect of Helicobacter pylon colonisationon gastric mucosal eicosanoid synthesis inpatients using non-steroidal anti-inflammatory drugs

N HUDSON, S J EVERITT, B FILIPOWOCZ, C JHAWKEY (Department ofTherapeutics, UniversityHospital, Nottingham) Both Helicobacterpylon colonisation and non-steroidal anti-inflammatory drugs (NSAIDs) damage gastricmucosa. Previous data suggest that patients onNSAID therapy may be more susceptible togastropathy and ulceration in the presence ofHpylon. NSAIDs inhibit gastric mucosal prosta-glandin E2 (PGE2) and promote leukotriene B4synthesis (LTB4). Data regarding the effect ofH pylori on eicosanoid synthesis are conflicting.The aim of this study was to examine therelation between gastric mucosal eicosanoidsynthesis and H pylon status in patients onNSAID therapy and control subjects.

Fifty six patients on longstanding NSAIDtherapy and 23 control subjects underwentendoscopy. Ex vivo antral mucosa PGE,,TXB2, and LTB4 synthesis was stimulated byvortex mixing and determined by radio-immunoassay. H pylon status was assessed byurease test and histology.The results showed that in NSAID patients,

antral gastric mucosal PGE2 synthesis wassignificantly higher in those with H pyloricolonisation (n=24) median: 26.6 pg/mg (IQR7.7-68.8) compared with patients who wereH pylon negative (n=32) 9-2 pg/mg (2 2-22 7)(p<001). There was no significant differencein either TXB2 42.8 pg/mg (4.7-53 3) v 17.1pg/mg (5.7-36 4) or LTB4 synthesis 1.6 pg/mg(0.8-3.4) v 0.9 pg/mg (0.2-2.3). In controlsubjects, no significant differences existedbetween those with H pylori colonisation (n=12) or without (n= 11) for either PGE2 61-0 pg/mg (19-2-73-1) v 48-6 pg/mg (24-7-65.5),LTB4 0 0 pg/mg (00-1 0) v 0 0 pg/mg (00-0 3), or TXB2 synthesis 42 1 pg/mg (3 9-61.5)v 47.4 pg/mg (17-5-53-8).

In conclusion, patients on longstandingNSAID therapy with H pylori colonisationhave increased gastric mucosal PGE2 synthesisbut not LTB4 or TXB2 synthesis. The rise inPGE2 may reflect response to mucosal injuryor inflammation. These results suggest thatH pylori does not potentiate NSAID damage byalterations in eicosanoid synthesis.

Performance of a commercially availableserological test for Helicobacter pylori andits relation to age

M A MENDALL, P GOGGIN, A BELLHOUSE,N J MOLINEAUX, J MARRERO, R J TUCKER,C FINLAYSON, T C NORTHFIELD (Department ofMedicine, St George's Hospital Medical School,London) The sensitivity and specificity of theHelico G serological kit (Porton Cambridge)was tested in 355 subjects presenting forroutine endoscopy. Helicobacter pylon' statuswas determined on three antral biopsy speci-mens using both a biopsy urease (CLO) testand blinded histology. Culture was also under-taken in 70 of the subjects. The intra-assaycoefficient of variation was 7-6% and theinterassay coefficient of variation 10-3%,11 9%, and 16- 1% with our low, mid, and highrange calibrators respectively.

Using the calibrator supplied with the kit(value 10 u/ml) as the cut off, the sensitivitv ofthe test was 211/237=89-0% and the specificitvwas 109/118=92-3%. A cut off of less than orequal to 9 u/ml was, however, more appro-priate for our population. This yielded a sensi-tivity 217/237=91-6% and specificity of 108/118=91-5%. Antibody titre was correlatedwith age independently ofH pylori status usingmultiple regression (p<002). The test per-formed better in those aged 45 or over (sensi-tivity 96% specificity 92.2%), than in thoseunder 45 (sensitivity 80-6%, specificitv 2.6%).In this group a lower cut off point mav be moreappropriate for screening purposes - usinga cut off of 6 3 in this group produced asensitivity of 94-4% and specificitv of 81-4%(positive and negative predictive values 91 -1%and 85.0%).

In conclusion, the Helico G kit performswell, but the appropriate cut off is dependenton age and the intended use of the test.

Comparison of the effect of Helicobacterpylori on gastrin in duodenal ulcer patientsversus asymptomatic volunteers

R S CHITTAJALLU, D PHILMORE, K E L MCCOLL(University Department of Medicine and Thera-peutics, Western Infirmarv and Department ofMetabolic Medicine, Roval Victoria Infirmarv,Belfast) Helicobacter pylori infection raisesplasma gastrin concentrations and predisposes

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to duodenal ulceration. The reason why onlyone in five subjects with H pylon developsduodenal ulceration, however, is not knownbut could be related to the degree of hyper-gastrinaemia induced by the infection. In orderto investigate this, we have examined, in thesame study, basal and meal stimulated gastrinconcentrations in 10 H pylon +ve duodenalulcer patients, 10 H pylon +ve healthyvolunteers, and in 10 H pylori -ve healthyvolunteers. Each group was matched for ageand sex.The median basal gastrin in the H pylon +ve

volunteers was 45 ng/l (range 27-95) which wasnot different from that in the H pylon +veduodenal ulcer patients (53 ng/l, 13-103) butsignificantly higher than in the H pylon -vevolunteers (20 ng/l, 7-40) (p<0 001). Themedian integrated gastrin response to astandardised meal in the H pylon +ve volun-teers was 2650 ng/l. minute (900-8500), whichwas again the same as that in the H pylon +veduodenal ulcer patients (2225 ng/l. minute,550-8725) and higher than that in the H pylon-ve volunteers (537 ng/l. minute, 225-1125)(p<O ool).

In conclusion, the degree of hyper-gastrinaemia induced by H pylon is similarin subjects with and without duodenal ulcera-tion and, therefore, stimulation of gastrinrelease is unlikely to be the major mechanismby which H pylori predisposes to ulcerdisease.

Non-Hodgkin's lymphoma and AIDS: fre-quency of gastrointestinal localisation in alarge Italian series.

G BIANCHI PORRO, F PARENTE, M CERNUSCHI,G RIZZARDINI, L VALSECCHI (Departments ofGastroenterology and Infectious Diseases, L SaccoHospital, Milan, Italy) Although the closeassociation between AIDS and non-Hodgkin'slymphoma (NHL) is widely known, no studyhas evaluated the frequency of gastrointestinal(GI) involvement in a large series of AIDSpatients with heterogenous risk factors. FromJune 1985 to May 1990, a total of 70patients (64 male and 6 female, mean (SD) 32-3(8.6) years) with AIDS associated NHL wereevaluated at L Sacco Hospital. Fifty threepatients were intravenous drug addicts and17 homosexuals. All had B cell lymphomasand the histological subtypes were: highgrade malignant NHL in 48 cases (69%),intermediate grade in 21 patients (30%), andlow grade in one case (1%). Sixty five patients(93%) had evidence of extranodal diseaseand in 22 a GI involvement was ascertainedat necropsy. Of these, 13 had complainedof digestive symptoms which allowed us tomake an antemortem diagnosis: sevenpatients had acute GI bleeding, four patientscomplained of recurrent abdominal pain, andtwo patients presented with abdominal massassociated with pain. Three patients hadradiological and/or endoscopic evidence oflymphomatous disease along the entiredigestive tract but, more frequently,isolated involvement of the stomach and/orduodenum (four patients), small bowel(four patients), or colon (two patients) wasfound.We conclude that the GI tract is a

common site of extranodal NHL in HIVinfected patients; in 59% of the cases thislocalisation produces severe clinical manifest-ations.

INFLAMMATION

Altered lymphocyte kinetics early in thecourse of acute pancreatitis may explainsusceptibility to sepsis

P CURLEY, F LANCASTER, J SHEFTA, A BOYLSTON,M J MCMAHON (University Department ofSurgeryand Pathology, General Infirmary, Leeds)Anergy to delayed type skin hypersensitivitytesting correlates with septic complications andmortality in acute pancreatitis. Sepsis remainsthe major cause of mortality in this conditionbut alterations in the immune system have yetto be characterised. Abormally low levels of Thelper cells have been reported after burns andtrauma and correlate with the incidence ofseptic complications in these conditions. Wehave investigated 23 patients with acute pan-

creatitis for evidence of altered circulating Thelper cell numbers using density gradientcentrifugation and flow cytometric analysis.

Patients with a severe outcome (n= 13) hadsignificantly lower circulating T helper cellsthan patients with mild attacks (n= 10;14-73±7-89 v 36-14±11-74; p<0-001). Therewas no significant difference between patientswith mild attacks and healthy controls (n= 11;36-14±11-74 v 36-09±7-13; p>0 1).These results demonstrate that significant

alterations in the circulating lymphocyte pooloccur early in the course of a severe attack ofacute pancreatitis. Reversal of these changesusing immunomodulators has potential thera-peutic significance.

Spectrum of liver disease in cotton toptamarin colitis

B F WARREN, N K CLAPP (Department ofPathology, University of Bristol, UK andMARCOR, Oak Ridge Associated University,Oak Ridge, Tennessee, USA) Spontaneouscolitis of unknown cause is common in new

world monkeys. In the cotton top tamarin,most cases bear a close relation to humanulcerative colitis clinically, endoscopically, andin response to treatment.One hundred necropsy livers were studied

from cotton top tamarins with total severe

ulcerative colitis, negative stool cultures, and a

histological picture resembling human ulcera-tive colitis. Only 39 livers were normal. In 20there was a mild periportal chronic inflamma-tion, 16 had extensive steatosis, four hadan appearance resembling chronic activehepatitis, and in four the histology resembledthat of sclerosing cholangitis. Other hepaticpathologies were seen in smaller numbers.

These changes parallel the liver disease seen

in association with human ulcerative colitis.We believe the cotton top tamarin provides thefirst model of liver disease in ulcerative colitis,which allows study of the pathogenesis of oneof the extraintestinal manifestations of ulcera-tive colitis.

Colitis in the cotton top tamarin - is it a modelof ulcerative colitis?

B F WARREN, G R PEARSON, P WATKINS, J PRICE,J W B BRADFIELD, I A SILVER (Department ofPathology, University of Bristol, Bristol) Con-troversy remains concerning the similarity of

human ulcerative colitis to cotton top tamarincolitis. This paper compares these two condi-tions.The features of 21 rectal biopsy specimens

and 12 necropsy colons from cotton toptamarins were compared with 21 biopsy speci-mens from cases of ulcerative colitis, and 12resected colitis colons from human patients.Most cotton top tamarins have diffuse,

predominantly mucosal, inflammation withcryptitis and crypt abscesses typical of ulcera-tive colitis. However, the features in othercotton top tamarins of microgranulomas andindividual crypt damage in an area of normalcrypts would be more typical ofCrohn's diseaserather than ulcerative colitis. A third group ofcotton top tamarins had patchy inflammationand gross lamina propria oedema withoutmicrogranulomas; but with adherent coloniesof bacteria on superficially biased inflammationand beading of crypt abscesses - features whichare suggestive of infective colitis.The cotton top tamarin, like man, suffers

from more than one form of colitis, themajority of which resemble closely ulcerativecolitis and provide the first real animal model.

Regulation of monocyte lysosomal enzymesecretion by tumour necrosis factor, inter-leukins, and epidermal growth factor

W G JIANG, M C A PUNTIS (Department ofSurgery,University ofWales College ofMedicine, Cardiff)In some pathological conditions both thespontaneous and stimulated (for example, byphagocytosis) secretion of lysosomal enzymeby monocytes is increased. In this study weinvestigated the effects of several cytokines atdifferent concentrations on this enzyme secre-tion. Peripheral blood monocytes were treatedeither by culture medium or by cytokine forfour hours. The lysosomal enzyme, hexo-saminidase, released into the supernatant wasmeasured colorimetrically and expressed as apercentage of the total enzyme content releasedby triton treatment. Interleukins 1, 2, and 6(ILl, IL2, and IL6), tumour necrosis factor(TNF), and epidermal growth factor (EGF)were studied.The median spontaneous secretion of

enzyme was 5-6%. TNF at concentrationsbelow 125 pg/ml caused no increase but 250 pg/ml and 500 pg/ml resulted in secretion of 15-6%and 22-7% respectively, which was signific-antly different from spontaneous secretion. AnILl concentration above 62.5 pg/ml increasedhexosaminidase secretion significantly to16 1% and up to 70.4% at an IL1 concentrationof 500 pg/ml. Wilcoxon signed rank test wasused and p values less than 0.05 were takenas significant compared with spontaneoussecretion. IL2, IL6, and EGF showed nostimulatory effects on enzyme secretion.The effects of TNF and ILl on hexo-

saminidase secretions may in part explain theincreased and possibly harmful lysosomalenzyme values in inflammatory bowel diseasesand jaundice for example.

Education, employment, and inflammatorybowel disease

M K MAYBERRY, C S PROBERT, J F MAYBERRY(Leicester General Hospital, Leicester) Childrenand their parents are often anxious that chronicdisease may interfere with their future. Theprovision within schools for children withinflammatory bowel disease was investigated

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in 70 schools with over 48 000 pupils. Most(95%) provided easy access to lavatoriesduring examinations and told examinationboards of a child's medical problem. Mostheads (80%) want more information, but fewhave facilities to inform teachers aboutchronic illness.

Eighty three patients with Crohn's diseasediagnosed under 40 completed a questionnaireabout educational and employment experi-ences and were compared with controls. Themean age at survey was 31±5 years. Twentyfour patients were diagnosed during schooling;they lost significantly more schooling thancontrols (X2= 14.3, p<0-001) but had similaracademic successes. Their current employ-ment rate was similar, but significantly morepatients had experienced long term unemploy-ment (z=2.6, p<0-01), as a result 30% activelyconcealed their diagnosis.

Personnel managers at 61 national and136 local employers, with over 1 000000employees, were asked about their attitude topeople with inflammatory bowel disease. Theattitude was often positive, although 25%would not continue to employ people afterdiagnosis and 30% would not provide time offwork to attend clinics. Of the expected 457employees with inflammatory bowel disease,employers were only aware of 61, which con-firms concealment of their diagnosis. Inflam-matory bowel disease remains a devastatingdisease.

IgG subclasses in inflammatory boweldiseases

M A QUADERI, D P JEWELL (Gastrointestinal Unit,The Radcliffe Infirmary, Oxford) Previousstudies of immunoglobulin G (IgG) subclassconcentrations in ulcerative colitis (UC) andCrohn's disease (CD) have reported predomi-nant increases in IgG, in active UC and IgG2 inactive CD. We have measured concentrationsof IgGI- in patients with UC (19 active, 17 inremission), CD (14 active, 20 in remission),irritable bowel syndrome (IBS) (15), andnormal volunteers (10). IgG subclass concen-trations were measured by radial immuno-diffusion.Mean (SD) concentrations of IgGi were 6474

mg/I (1706) (UC active), 8481 mg/l (2925) (UCrem), 4549 mg/I (1757) (CD active), 5504 mg/l(756) (CD rem), 5358 mg/l (1188) (IBS), and5303 mg/l (1234) (normal).Mean (SD) concentrations of IgG2 were

2910 mg/l (1228) (UC active), 3158 mg/l(1397) (UC rem), 4690 mg/l (2116) (CDactive), 2454 mg/I (1239) (CD rem), 2574mg/I (742) (IBS), and 2793 mg/l (463)(normal). Thus, IgG, is raised in UC inremission (p<0-0001) and IgG2 in active CD(p<0-0001). IgG3 and IgG4 concentrationswere similar in all groups.We then measured the specific IgG1 response

to vaccination with tetanus toxoid, and IgG2response to pneumococcal polysaccharide inquiescent UC (n= 15) and Crohn's disease (n=14), IBS (n=6), and normal volunteers (n=5)using an enzyme immunoassay. All groupsshowed a similar post-vaccination rise inspecific antibody levels.These data confirm the previously described

pattern of IgG subclass increases in UC andCD, and suggest that these changes are morelikely to be due to a response to the nature ofluminal antigens rather than a genetic predis-position to synthesise individual subclassespreferentially.

Oxygen free radical production in acuteinfective and inflammatory colitis

R J CORSON, I S PATERSON, A M HANBURY, P FSCHOFIELD (University Hospital of South Man-chester, Manchester) Neutrophil dependantoxygen free radical (OFR) production wasinvestigated in patients with acute colitis atpresentation and at six weeks, using flowcytometric analysis of dichlorofluoresceinoxidation quantified in fentamoles (fm) ofdichlorofluorescein/cell. Phorbol myristateacetate (PMA) acted as a standard secondstimulus to access neutrophil responsiveness.Irritable bowel (n= 10) and normal subjects(n= 10) acted as controls. Classification ofinfective (n=9) from inflammatory (n= 12)colitis was made retrospectively.

At presentation the results were 16±4 fm(35±6 fm PMA) in normal subjects,18±6 fm (37±8 fm PMA) in irritable bowel,112±7 fm* (321±19 fm* PMA) in infectivecolitis and 126±14 fm* (340±22 fm* PMA)in inflammatory colitis (*p<0.01 relative tocontrols). By six weeks in infective colitisneutrophil activity returned to 17±5 fm(31±7 fm PMA), a level no different tocontrols, but remained raised at 55±10 fm*(62±11 fm* PMA) in inflammatory colitis(*p<0-01 relative to controls).OFR production is thus: (1) raised in

infective and inflammatory colitis to the samedegree at presentation; (2) returns to normal ininfective colitis by six weeks; (3) remains raisedin inflammatory colitis, a feature which mayexplain the continuing mucosal damage seen ininflammatory colitis.

Helicobacter pylori induced gastritis isnot caused by bacterial ammonia produc-tion

K E L MCCOLL, S DAHILL, A EL NUJUMI, JHARWOOD, P ROWE (University Department ofMedicine and Therapeutics, Western Infirnary,Gasgow) Gastric juice ammonium concentra-tions and the severity of histological antralgastritis were studied in 16 uraemic patients (8H pylon +ve, 8 -ve) and in 16 patients withnormal renal function (8H pylon' +ve, 8 -ve).H pylon status was confirmed by microscopy ofantral biopsy, "4C-urea breath test, culture,and serology. Histological gastritis wasassessed using a standardised score (polymorphinfiltrate 0-6, chronic inflammatory infiltrate0-2, and mucosal erosions 0-2). The H pylon'+ve patients with renal failure had consider-ably higher intragastric ammonium concentra-tions (mean=24 mmol/1, range 14-43) thanthose without renal failure (3.4 mmol/l, range1-13) (p<001), yet the mean aggregategastritis score was similar in the two groups(5 0, range 3-6 and 5-1, range 3-7 respect-ively). All the H pylori -ve patients hadnegligible gastritis (score 0 or 1) in spite of theammonium concentration in those with renalfailure (4.4 mmol/l, range 1-12) being similarto that in H pylon +ve patients without renalfailure and being considerably higher than inthe H pylori -ve patients without renal failure(0-6 mmol/l, range001-1 1).These findings show that antral gastritis

correlates with the presence of H pylori butis unrelated to intragastric ammonium concen-trations.

In conclusion, H pylori induced antralgastritis is not due to mucosal damage bybacterial ammonia.

Specificity of mucosal celi mediatedimmunity in inflammatory bowel disease

J R LOWES, J P IBBOTSON, H CHAHAL, J

ALEXANDER-WILLIAMS, R N ALLAN (GeneralHospital, Birmningham and Department ofMedical Microbiology, University of Birming-ham) There is evidence of activated mucosalcell mediated immune responses in ulcerativecolitis (UC) and Crohn's disease (CD). It isunclear if this is due to a specific pathogen orabnormalities in the mucosal immune system.Both enterobacteria and mycobacteria havebeen implicated in the aetiopathogenesis of UCand CD. We have investigated gut associatedand systemic cell mediated immunity inpatients with CD (n= 15), UC (n=6), andcontrols (n= 21) to a panel of antigens.Mononuclear cells from mesenteric lymph

nodes (MLNC) and peripheral blood(PBMNC) from consecutive patients under-going surgery for UC, CD, or controls (colonicresection, cholecystectomy) were employed insix day lymphocyte proliferation assays. Theantigen preparations studied were the 65 kDrecombinant heat shock protein of Mycobac-tenum leprae; and heat killed preparations ofSalmonella agona; Escherichia coli; Yersiniaenterocolitica; Influenza; Chlamydia trachomatis;and Candida albicans.

Responses (PBMNC and MLNC) to allantigens in UC and CD were greater thancontrols. The greatest MLNC responses wereto antigen preparations from enteric bacteriain UC, CD, and controls. In control sub-jects there was no difference betweenY enterocolitica, E coli, and S agona. In CD thegreatest responses were seen to Y enterocoliticaand these were greater than responses to E coli(p<005) and S agona (p=0058) (Mann-Witney U test). There was no evidence ofspecific sensitisation to mycobacterial antigensin patients with UC or CD.These results do not support a mycobacterial

aetiology for CD or UC, but suggest thatfurther study of cell mediated immunitv toenterobacteria, particularly Yersinia speciesare required.

Expression of neutrophil receptors CR3,FcRl, and FcR3 in Crohn's disease

J C W LEE, C N GUTTERIDGE, D S RAMPTON (StMark's Hospital and Royal London Hospital,London) Complement receptor 3 (CR3) and Fcreceptors for IgG (FcR1, FcR3) are leukocvtesurface receptors with roles in vascular endo-thelial adhesion and phagocytosis respectivelv.Little is known of their involvement in Crohn'sdisease (CD). We have compared their expres-sion on peripheral blood neutrophils in healthvcontrols (n=7) and patients with CD (n= 19)by indirect immunofluorescence and flowcytometry.

Expression ofCR3 was reduced in CD (mean(SD) 52 (27)% compared with controls (85 (4)%(p<0-01)). Similar results were observed withFcR3 (CD 46 (29)%, control 78 (10)%;p<0-01). In contrast, FcRI was increased inCD (14 (19)%, control 2 (1)%; p<0-001). FcRlexpression was directly related to clinicaldisease activity; Harvey-Bradshaw score (R=0 5, p<0-01) and to C reactive protein (R=0-5,p<002). FcR3 expression showed conversecorrelations with these variables (R=-0-5,p<002; R=-0-4, p<004 respectivel) andwas negatively related to FcRI expression (R=-0-45, p<003).

In conclusion, adhesion of activated neutro-

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phils to endothelium in inflamed gut couldaccount for the reduced expression of CR3and FcR3 in circulating neutrophils in CD.Increased FcRl expression in active CD couldbe cytokine induced. FcR receptor assay couldserve as a marker of disease activity in CD.

Interactions between platelet activatingfactor and eicosanoids and their effects onmucosal factors

T D WARDLE, L A TURNBERG (EpithelialMembrane Research Centre, Department ofMedicine, Hope Hospital, Salford) In ulcerativecolitis (UC) inflammatory cells release a varietyof mediators which may stimulate intestinalsecretion and contribute to the production ofdiarrhoea. Colonic mucosal biopsy specimenswere take'n from 30 patients with active colitisand from age and sex matched controls withirritable bowel syndrome. Specimens werecultured (a) untreated; or with (b) plateletactivating factor (PAF); (c) indomethacin andICI 207968 (cyclo-oxygenase and lipoxygenaseinhibitors); (d) mepacrine (phospholipase A2inhibitor); (e) PRA (PAF antagonist); or (f)combined (c) and (e). Culture medium wasassayed for PAF, PGE2, and LTD4 and itseffect on short circuit current (Isc) across ratdistal colonic mucosa in vitro. Results showthat PAF was liberated into culture medium byinflamed tissue only but PGE2 and LTD4 wereliberated by control and inflamed tissue.Medium from inflamed tissue generated ahigher Isc response than control tissuemedium. The production of PGE2 and LTD4and the rise in Isc induced by exogenous PAF(10-5 M) were inhibited by indomethacin plusICI, 207968 and mepacrine but not PRA.Mepacrine produced the greatest attenuationin PAF, PGE2 and LTD4 release and theIsc. Combined indomethacin/ICI 207968/PRAreduced PGE2 and LTD4 release and the Isc,but did not influence PAF generation.

In conclusion PAF is only produced byinflamed tisue, its potent secretory effect ismediated predominantly by stimulatingeicosanoid release.

Model of hapten induced inflammatorybowel disease in the rabbit colon

D C ANTONY, F J SAVAGE, R M HEMBRY, P BBOULOS (Department of Surgery, UniversityCollege and Middlesex School of Medicine,London and Strangeways Research Laboratory,Cambridge) Research on inflammatory boweldisease has been hampered by the lack of asimple, yet clinically relevant, animal model.Our results have shown that chronic colitis,with features similar to human Crohn's disease,may easily be induced in the rabbit by a singleintracolonic instillation of (2-5-50 mg) trinitro-benzene sulphonic acid in a 25% ethanolsolution. This produced a dose dependentinflammation and ulceration, observed byendoscopy, that persisted for at least six weeks;appropriate controls exhibiting no damage.After two weeks the optimum dose of 40 mgconsistently produced skip lesions with acobblestone appearance, strictures, bowel wallthickening, and microscopically there wastransmural inflammation, fissuring ulceration,and crypt abscesses. Presence of blood in stoolwas detected for three weeks. Our immuno-histochemical studies have shown that thedistribution of the metalloproteinases andtheir inhibitor, tissue inhibitor of metallopro-

teinases, closely resemble the pattern reportedfor human Crohn's. Unlike the rat, in which asimilar model has been developed, rabbit distalcolon has a mechanical and pharmacologicalprofile resembling human colon. Additionallythe simplicity, histopathological similarity andits duration make this a suitable model forevaluating the effects of new treatments onpathogenesis.

Bile modulates genotypic and phenotypiccharacteristics of Giardia lamblia

P H KATELARIS, T D MCHUGH, S CARNABY, A MCEVALLOS, S CHAR, M J G FARTHING (Departmentof Gastroenterology, St Bartholomew's Hospital,London) Giardia lamblia consume bile salts andbile stimulates growth of G lamblia in vitro.These observations are relevant to the host-parasite interaction as G lamblia localise to theupper gut where bile is abundant. In this study,the effect of bile on the phenotype and geno-type of 3 isolates (RW6, WB, and GP) wasexamined. G lamblia were cultured in TY1-S-33 medium containing 0-6 mg/ml bovine bile(TYI+B) for 10-20 passages and comparedwith organisms grown in bile free media withrespect to generation times, morphometrics,incorporation of [35S]-methionine, expressionof heat shock proteins, and biotinylation ofproteins. Genotype was assessed using DNAfingerprinting. DNA was cut with restrictionenzymes RSA-1 or PVU-II and probed withthe M13 phage genome.

Generation times in TYI+B were acceler-ated by 32% for RW6 and 31% for WB; meansurface area in stationary phase was increasedby 16% (p<0.01) for RW6. Neither parameterwas significantly altered with GP. [35S]-methionine incorporation was diminished in allthree isolates cultured in TYI+B while expres-sion of heat shock proteins was unchanged.The profile of biotinylated proteins was alteredin all three isolates grown in TYI+B mostnotably in the region of 170 kDa. DNA finger-printing revealed genomic differences betweenisolates grown with and without bile. Moststriking was a band observed at 1-8 kb in WBgrown without bile which was absent in WBgrown with bile.

Bile thus affects phenotypic and genotypicexpression ofG lamblia in vitro, but the effectsare variable between isolates. This may berelevant to parasite virulence as enhancedgrowth of an isolate with bile may confersurvival advantage for the organism.

Intestinal exposure to food allergen duringrecovery from rotavirus infection: effects onIgE production and water absorption uponrechallenge

F H MOURAD, J A DIAS, L J D O'DONNELL, M J GFARTHING (Department of Gastroenterology, StBartholomezv's Hospital, London) Increasedintestinal permeability to antigens has beenshown during recovery from viral enteritis.This may play a key role in the development offood allergy/intolerance in children. We haveexamined the effect ofexposure of rat intestinalmucosa recovering from rotavirus (RV) infec-tion to ovalbumin (OA) on the development oflocal sensitisation and systemic IgE produc-tion. Hooded-Lister (allergy prone) rats aged15 days infected six days earlier with group BRV were inoculated with 100 mg OA bygavage. A second group of similar aged ratswere inoculated ip with 10 ig OA and alum

adjuvant. Fifteen days later net water move-ment was measured by small intestinal per-fusion for 90 minutes with either plasmaelectrolyte solution (PES) or PES+OA (200mg/l). Serum antigen specific IgE titres weremeasured by passive cutaneous anaphylaxis atthe end of the perfusion. In rats inoculatedorally with OA no IgE response was detected,and there was no difference in water absorptionbetween those perfused with PES (n=9) orPES+OA (n=10) (median 92 (interquartilerange 84-109) v 79 (71-107) pl/minute/g; NS).In contrast, rats sensitised by ip route andwhich developed a positive IgE response hadreduced water absorption on antigen challenge(69 (34-73) (n=7) v 23 (6-37) dl/minute/g(n=4); p<0 05).Thus, neither local nor systemic sensitisa-

tion to a food allergen could be elicited by oralexposure during the recovery phase of RVinfection. This suggests that other variables areinvolved in the pathogenesis of food allergy.

Staging and survival of patients withcolorectal cancer: the die is cast at onset ofsymptoms

H MULCAHY, A LOHAN, S PATCHETT, N AFDHAL,D P O'DONOGHUE (Gastroenterology and LiverUnit, St Vincent's Hospital, Dublin, Ireland)Early investigation of lower gastrointestinal(GI) symptoms has been advocated to improvethe five year survival of patients with colorectalcancer (CRC). This is based on the assumptionthat a short duration of symptoms confersbenefit as regards staging and outcome. Since1983 all patients in this institution with newlydiagnosed CRC have had clinical data, includ-ing symptom duration, entered on to acomputer database. The aim of this study wasto examine the relation between duration ofsymptoms and both the extent of disease andsurvival.Some 512 patients admitted between 1983

and 1989 inclusively had a mean duration fromonset of first symptoms to final diagnosis of just16 weeks, considerably shorter than mostpublished series. Dukes' D tumours had asignificantly shorter duration of symptoms(10-5 weeks) than less advanced lesions(p<0-01). A short symptom duration waspredictive of more severe disease (p<0-01),correspondingly fewer advanced lesions beingfound in those with a long duration of symp-toms. This correlation remained true evenwhen Dukes' D lesions were omitted from theX2 tables (p<005)

Kaplan-Meyer survival curves were con-structed for patients whose duration of symp-toms was less than 1 month, 1-6 months, orgreater than 6 months. Five year survival was22%, 40%, and 46% respectively, all differ-ences being highly significant. When correc-tion was made for Dukes' staging this inversecorrelation persisted. No association was foundbetween symptom duration and differentiationof tumour.

In conclusion, these results support theconcept that symptom duration is inverselyproportional to both Dukes' staging andsurvival. Thus the rapid investigation of thecolon once symptoms have developed will notalter the outcome ofCRC. Greater efforts mustbe directed at earlier diagnosis during theasymptomatic phase.

This paper was presented at the BSG meeting inManchester-April 1991 - but the abstract was notpublished

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