The use of endoscopic ultrasound and intravenous secretin as an investigative tool to aid diagnosis in pancreatic sphincter hypertension.

Pancreatic sphincter hypertension (PSH) is one of the causes of recurrent pancreatitis. The diagnosis can be established by direct measurement of pancreatic sphincter pressures at pancreatic sphincter manometry. This procedure is not without risks, and in cases with PSH, it certainly carries a higher risk of post procedure pancreatitis. The treatment of this disorder is pancreatic sphincterotomy, which on its own carries risk of acute pancreatitis. Therefore it is important to establish the diagnosis reliably before undertaking this procedure. In order to overcome the false positive readings that are possible in sphincter manometry, we proposed to use secretin stimulated endoscopic ultrasound (SSEUS) to measure pancreatic ductal response as an adjunctive method to aid and supplement the diagnosis. Here we describe 3 cases in which this was carried out to optimal effect.

Analysis of benzo[a]pyrene partitioning and cellular homeostasis in a rat liver cell line.

The uptake and subcellular partitioning of benzo[a]pyrene (BaP) were examined in a rat-liver cell line (Clone 9) using confocal and multiphoton microscopy. Following a 16-h treatment, intracellular accumulation of BaP increased with increasing concentration, and cytoplasmic BaP fluorescence reached saturation at 10 microM. Analysis of the kinetics of BaP uptake at this concentration indicated that BaP is rapidly partitioned into all cytoplasmic membranes within several min, although saturation was not reached until 4 h. Based upon the rapid uptake of BaP into membranes, the chronology of changes in gap junction-mediated intercellular communication (GJIC), plasma membrane potential (PMP), and steady state levels of intracellular Ca2+ in relation to the time-course for induction of microsomal ethoxyresorufin-0-deethylase (EROD) activity were examined. EROD activity in Clone 9 cells treated for 16 h increased with increasing concentrations of BaP and reached the highest levels at 40 microM BaP. In addition, kinetic analysis of EROD activity in Clone 9 cells treated with 10 microM BaP indicated that significant induction of EROD activity was not detected before 3 h, and it reached maximal levels by 16 h of treatment at this concentration. Both GJIC and PMP were directly affected by the partitioning of BaP into cellular membranes. The most sensitive index of BaP-induced changes in membrane function was GJIC which revealed a 25% suppression in cells exposed to 0.4 microM BaP for 16 h. Kinetic analysis revealed that suppression of GJIC occurred within 15 min of exposure of cells to 10 microM BaP, whereas significant suppression of PMP was not detected prior to 30-min exposure at this concentration. Elevation of basal Ca2+ level was also detected simultaneously with PMP at this dose. These data suggest that early changes in cellular membrane functions occur prior to detectable induction of EROD activity, although basal metabolic activation of BaP may contribute to these changes.

Two cases of severe non-specific oesophageal dysmotility showing different response to botulinum injection therapy.

We report 2 cases where treatment of achalasia type symptoms due to severe non-specific oesophageal dysmotility have shown symptom resolution and manometric improvement to intrasphincteric botulinum injections either by itself or in combination with oesophageal dilatation.

Dietary minerals in the gastrointestinal tract: hydroxypolymerisation of aluminium is regulated by luminal mucins.

The regulation of mineral absorption in the gastrointestinal tract is poorly understood. Recent work has identified an intracellular metal-ion transporter but considerable evidence suggests that both soluble and mucosally associated luminal metal-binding ligands regulate initial uptake. Molecules ranging from low molecular weight organic acids to large glycoproteins have been suggested but a definite role for any such species has remained elusive. Here, a series of analytical techniques, allowing for this wide variation in potential binding ligands, was applied to the study of intestinal contents and tissue of rats following different feeding protocols. Aluminium, that has a low endogenous background and maintains a high concentration in the gastrointestinal tract, was investigated as a suitable dietary metal with hydrolytic behaviour similar, for example, to copper, iron and zinc. High resolution nuclear magnetic resonance spectroscopy identified a number of endogenous low molecular weight weak ligands that are secreted into the intestinal lumen. These may slow the rate of hydroxy-polymerisation of hydrolytic metals, allowing their effective donation to less mobile, higher molecular weight binding ligands. Histochemical staining suggested that such species may be soluble mucins as these were consistently associated with luminal aluminium. Significantly, this interaction prevented hydroxy/phosphate precipitation of aluminium, even at supraphysiological levels of the element. This was confirmed with X-ray micro-analysis investigations of ex vivo luminal contents. Nevertheless, from phase distribution experiments, the majority (60-95%) of luminal aluminium was associated with the intestinal solid phase and further histochemistry confirmed this to be gelatinous mucus, chiefly as the mucosally adherent layer. All results suggest a major role for mucus in regulating the gastrointestinal absorption of aluminium. It is proposed that, initially, soluble luminal mucus prevents the hydroxy-precipitation of hydrolytic metals at intestinal pH, allowing their effective donation to the mucus layer. Based on the differing reported metal-mucus interactions, elements that bind well to mucus (Al3+, Fe3+), with kinetically slow rates of ligand exchange (Al3+ < Fe3+) will be less well absorbed than poorly bound elements with kinetically faster rates of ligand exchange (Cu2+, Zn2+ etc.). This mechanism would readily explain many of the reported observations on mineral availability, including the marked variation in absorption of different elements, the differential effects of dietary ligands on mineral uptake and the competition for absorption between different metals.

Electrophysical factors influencing endoscopic sphincterotomy.

BACKGROUND: Analog computer techniques were used to measure electrosurgical power during sphincterotomy in experimental models and patients. METHODS: Total energy and transient changes in power were measured during sphincterotomy of bile ducts in the livers of pigs, ampullae of humans post mortem, and during clinical sphincterotomy. The effect of waveform on hemostasis was studied in experiments on canine mesenteric arteries. RESULTS: Electrosurgical waveforms (CUT, COAG, BLEND) were measured. Halving wire contact length halved energy needed to initiate cutting. The CUT waveform rarely initiated cutting at lower power settings than the BLEND waveform. With CUT, BLEND, and COAG waveforms, approximately the same energy initiated cutting. Efficiency of cutting increased linearly with power. The COAG waveform required higher power settings than BLEND or CUT to initiate cutting (p < 0.05). Force and wire diameter influenced cutting. BLEND was more effectively hemostatic than CUT (p < 0.05). COAG was significantly more hemostatic than BLEND and CUT. Cutting efficiency during clinical sphincterotomy was poor. CONCLUSIONS: This work has practical implications. Shortening wire contact length was effective in starting a cut at suboptimal settings, whereas changing from BLEND to CUT made little difference. Increasing power setting may help if cutting does not start. BLEND stops bleeding better than CUT. COAG stops bleeding better than BLEND but cuts poorly. Cutting during clinical sphincterotomy is inefficient and can be improved.

Serological response to Helicobacter pylori in gastric and non-gastric cancer.

1. We aimed to evaluate the seroprevalence of Helicobacter pylori (H. pylori) in gastric cancer, non-gastric cancer and outpatients by ELISA and iso-electric focusing, and to compare histology and serology for H. pylori in gastric cancer and outpatients. 2. In 124 patients with gastric cancer, 78 patients with non-gastric cancer and 110 outpatients, H. pylori seroprevalence was assessed by ELISA and isoelectric focusing. Gastric cancer and outpatients underwent endoscopy with biopsies. 3. Seroprevalence by ELISA was significantly higher in gastric cancer compared with non-gastric cancer (84% versus 56%, P < 0.001) but not with outpatients (84% versus 74%). Iso-electric focusing detection of H. pylori was comparable to ELISA: 85, 51 and 75% in gastric cancer, non-gastric cancer and outpatients respectively. Oligoclonal iso-electric focusing was significantly more frequent in gastric cancer compared with non-gastric cancer and outpatients: 69% versus 45 and 46% respectively, P < 0.01. The reliability of H. pylori detection by antral biopsy was significantly lower in gastric cancer compared with outpatients: 36% versus 74% (P < 0.001). In gastric cancer, ELISA and iso-electric focusing were significantly more reliable than histology in H. pylori detection (84 and 85% versus 36% respectively) (P < 0.001). 4. Serological immune response to H. pylori in gastric cancer, non-gastric cancer and outpatients seems different both quantitatively and qualitatively; serology was more reliable than histology in detection of H. pylori in gastric cancer.

Characterisation of inorganic microparticles in pigment cells of human gut associated lymphoid tissue.

Macrophages at the base of human gut associated lymphoid tissue (GALT), become loaded early in life with dark granular pigment that is rich in aluminium, silicon, and titanium. The molecular characteristics, intracellular distribution, and source of this pigment is described. Laser scanning and electron microscopy showed that pigmented macrophages were often closely related to collagen fibres and plasma cells in GALT of both small and large intestine and contained numerous phagolysosomes, previously described as granules, that are rich in electron dense submicron sized particles. Morphological assessment, x ray microanalysis, and image electron energy loss spectroscopy showed three distinct types of microparticle: type I - spheres of titanium dioxide, 100-200 nm diameter, characterised as the synthetic food-additive polymorph anatase; type II - aluminosilicates, < 100-400 nm in length, generally of flaky appearance, often with adsorbed surface iron, and mostly characteristic of the natural clay mineral kaolinite; and type III - mixed environmental silicates without aluminium, 100-700 nm in length and of variable morphology. Thus, this cellular pigment that is partly derived from food additives and partly from the environment is composed of inert inorganic microparticles and loaded into phagolysosomes of macrophages within the GALT of all human subjects. These observations suggest that the pathogenicity of this pigment should be further investigated since, in susceptible individuals, the same intracellular distribution of these three types of submicron particle causes chronic latent granulomatous inflammation.

Photodynamic therapy for malignant tumours of the ampulla of Vater.

Ten patients with ampullary carcinoma, not suitable for surgery, were treated with endoscopic photodynamic therapy (PDT) to evaluate the feasibility and safety of treatment. Patients received 4 mg kg-1 of haematoporphyrin derivative intravenously. Two days later, a duodenoscopy was performed and red (630 nm) light delivered to the tumour at fixed energy densities of 50 J or 200 J cm-1 per application, depending on the type of optical fibre used. The tumours were treated by three or four light applications at each session. Treatment was repeated up to five times at intervals of three to six months. The sole complication of PDT was moderate skin photosensitivity, which occurred in three patients. Tumour size was assessed at four to eight weekly intervals. In the absence of macroscopic tumour, biopsy specimens were taken. In three patients with small tumours confined to the ampulla, remission was obtained for periods ranging from eight to 12 months. In a further four patients with small tumours bulk was greatly reduced. There was little response in three patients with extensive duodenal involvement. Therefore PDT for ampullary carcinoma is both feasible and safe, and with refinement may prove curative for small tumours.

Microwave technology in diagnostic neuropathology.

The microwave oven has a large range of potential applications in diagnostic neuropathology, ranging from tissue fixation and processing for light and electron microscopy to immunocytochemistry and molecular neuropathology. This review highlights the major current applications for the microwave oven and emphasises areas of particular recent interest. Established microwave techniques are discussed and suggested modifications to published staining techniques are included. Future potential diagnostic applications of microwave technology are emphasised, particularly in terms of in situ hybridisation and immunocytochemistry. Although many microwave techniques for use in diagnostic neuropathology are clearly established, widespread use of the microwave oven has not yet occurred in most neuropathology laboratories. The reasons for this apparent delay and some occasional difficulties in the use of the microwave oven are discussed. Increasing clinical demand for rapid diagnosis (particularly with the use of stereotactic brain biopsy techniques in providing tissue specimens for surgical neuropathology) will enable neuropathologists and laboratory technical staff alike to reconsider the use of the microwave oven for many laboratory techniques and reassess the wide range of potential applications and benefits that this useful tool has to offer.

Intestinal perfusion of dietary levels of aluminium: association with the mucosa.

An aluminium (93 microM) sulphate solution freshly adjusted to pH 7.0 was perfused through the rat small bowel to mimic the reported physiological conditions that follow dietary aluminium ingestion. One third of this aluminium was taken up from the perfusate, but > 90% of this was then recovered from the intestinal mucus/mucosa and most (> 70%) from the distal third of the small bowel. The fresh perfusate was shown by ultrafiltration to contain largely particulate/colloidal aluminium-hydroxide, and this probably adhered to intestinal mucus which may be an important barrier to the gastrointestinal absorption of aluminium.

A randomized controlled study of evening primrose oil and fish oil in ulcerative colitis.

In a placebo-controlled study, 43 patients with stable ulcerative colitis were randomized to receive either MaxEPA (n = 16), super evening primrose oil (n = 19), or olive oil as placebo (n = 8) for 6 months, in addition to their usual treatment. Treatment with MaxEPA increased red-cell membrane concentrations of eicosapentaenoic acid (EPA) at 3 months by three-fold and at 6 months by four-fold (both P < 0.01), and doubled docosahexaenoic acid (DHA) levels at 6 months (P < 0.05). Treatment with super evening primrose oil increased red-cell membrane concentrations of dihomogamma-linolenic acid (DGLA) by 40% at 6 months (P < 0.05), whilst treatment with placebo reduced levels of DGLA and DHA at 6 months (both P < 0.05). Clinical outcome was assessed by patient diary cards, sigmoidoscopy and histology of rectal biopsy specimens. Super evening primrose oil significantly improved stool consistency compared to MaxEPA and placebo at 6 months, and this difference was maintained 3 months after treatment was discontinued (P < 0.05). There was however, no difference in stool frequency, rectal bleeding, disease relapse, sigmoidoscopic appearance or rectal histology in the three treatment groups. Despite manipulation of cell-membrane fatty acids, fish oils do not exert a therapeutic effect in ulcerative colitis, while evening primrose oil may be of some benefit.

Eighteen month follow up of Helicobacter pylori positive children treated with amoxycillin and tinidazole.

Sixty three children with dyspepsia (mean age 12 years, range one to 18, M/F 41/22) were Helicobacter pylori positive by histology of gastric antral biopsy specimens and were treated with a six week course of amoxycillin (50 mg/kg) and tinidazole (20 mg/kg). The endoscopic diagnoses were: normal (16), nodular gastritis (19), oesophagitis (four), duodenal ulcer (13), and gastric ulcer (11). H pylori was eradicated in 54 (87%) and histological gastritis resolved in 51 and was improved in the other three. Repeat investigation was offered at six monthly intervals. Reinfection was found in three of 34 (9%) at six months, in none of 22 at 12 months, and in two of 18 (11%) at 18 months, yielding an 18 month cumulative relapse rate of 20%. Children with persisting infection despite treatment remained positive during follow up. Serum H pylori IgG concentrations fell after treatment (p < 0.001), and for individual children during follow up there was a progressive decline, but an increased concentration indicated recurrence. After eradication of H pylori by combined amoxycillin and tinidazole treatment, only a minority of children relapse during the ensuing 18 months.

Double blind trial of colloidal bismuth subcitrate versus placebo in Helicobacter pylori positive patients with non-ulcer dyspepsia.

We have carried out a double blind placebo controlled trial to assess the effects of treatment with colloidal bismuth subcitrate in Helicobacter pylori associated non-ulcer dyspepsia. Eighty patients with dyspepsia, normal upper gastrointestinal appearances at endoscopy and H pylori associated active chronic gastritis on histology of gastric antral biopsies were included in the trial. The patients were randomised to receive colloidal bismuth subcitrate 240mg twice daily for four weeks or matching placebo and were reassessed four weeks after completing treatment. Twenty-six patients (67%) receiving colloidal bismuth subcitrate had normal histology or improved inflammation compared with five (13%) receiving placebo (p less than 0.001), and symptoms were absent or improved in 32 (82%) and two (5%) respectively (p less than 0.001). Serum IgG level was a marker of infection, and fell with successful treatment. Colloidal bismuth subcitrate is effective treatment for H pylori associated non-ulcer dyspepsia with improved gastric antral histological appearances and has a beneficial effect on symptoms.

Selection, management, and early outcome of 113 patients with symptomatic gall stones treated by percutaneous cholecystolithotomy.

Between January 1988 and December 1990, 283 patients with symptomatic gall stones were referred for non-operative treatment. After ultrasound scanning including a functional assessment, 220 (78%) patients were found to be suitable for percutaneous cholecystolithotomy. Of these, 113 underwent the procedure including 10 in whom extracorporeal shock-wave lithotripsy or methyl tert-butyl ether therapy had failed. Forty four patients underwent extracorporeal shockwave lithotripsy, methyl tert-butyl ether therapy or rotary lithotripsy, 46 chose laparoscopic cholecystectomy or minicholecystectomy and 27 declined treatment. Percutaneous cholecystolithotomy was successfully performed in 100 patients. Thirty four patients were a high operative risk and 14 presented with an acute complication of gall stone disease. Complications developed in 15 patients, all of whom were managed conservatively and most occurred during development of the technique. Outcome has been assessed clinically and by ultrasound scanning in 92 patients with a median follow up period of 14 months (six to 37 months). Seventy nine per cent were completely cured of their symptoms. Ninety three per cent of gall bladders were shown to be functioning and nine (9.8%) contained stones, although five of these are believed to have developed from residual fragments. Percutaneous cholecystolithotomy is a safe, non-operative treatment for symptomatic gall stones and enabled the patient to fully recover within two to three weeks; it has a definite role in the management of the elderly and high risk patient but its use for the treatment of other groups is likely to remain controversial.

Detection of Helicobacter pylori-like organisms in the stomach of some food-source animals using a monoclonal antibody.

To investigate a possible animal reservoir of Helicobacter pylori, 15 pigs, 15 rabbits and 5 cows slaughtered for consumption were studied. Raised serum IgG levels were found in 93% of the pigs and 87% of the rabbits, but levels were normal in the cattle. In the controlled testings three of 22 humans had elevated IgG to H pylori and in all three H pylori was detected by the use of monoclonal antibody. Helicobacter pylori were identified in gastric brushings by a monoclonal antibody in 8 out of 10 pigs and 7 out of 10 rabbits. This study suggests an animal reservoir of Helicobacter pylori which may be of importance in human infection.

Gallbladder sepsis after stent insertion for bile duct obstruction: management by percutaneous cholecystostomy.

Of 364 patients undergoing insertion of a biliary endoprosthesis in 1989, six (1.6 per cent) developed gallbladder sepsis. Three patients had cholangiocarcinoma, two had carcinoma of the pancreas and one had a benign biliary stricture. Two of the five patients with malignancy had gallbladder stones, and the patient with a benign stricture developed stones after 3 years of stenting. Three patients developed gallbladder sepsis early after endoprosthesis insertion (less than 6 days), while in the other three it occurred late (greater than 6 months). All six patients failed to respond to antibiotics and were successfully managed by percutaneous cholecystostomy; the patient with a benign biliary stricture also had cholecystolithotomy. The gallbladder drainage tubes were removed or became dislodged at intervals varying from 2 weeks to 6 months without complications. Percutaneous cholecystostomy is the treatment of choice for gallbladder sepsis unresponsive to antibiotics in patients with a biliary endoprosthesis in situ.

The influence of zinc status and malnutrition on immunological function in Crohn's disease.

Cellular immunity is likely to be important in the pathogenesis of Crohn's disease; whether it is abnormal is not clear. The heterogeneity of patients with Crohn's disease probably underlies the disparity of reports, but attempts to determine which clinical features influence cellular immunity have been largely unsuccessful. This is probably caused by the omission of nutritional status as a potential factor, even though zinc deficiency has frequently been linked with abnormal immunity. Therefore, a detailed study of nutritional and tissue zinc status, nonspecific cellular immunity, and a measure of phagocytic function was performed in 32 patients with Crohn's disease and in a control group of 18 normal subjects and 12 patients with anorexia nervosa. Fourteen patients with Crohn's disease, all patients with anorexia nervosa, but none of the normal controls were malnourished. Peripheral blood lymphocyte population levels were normal in patients with Crohn's disease and in normal controls, but there was a small decrease in the levels of patients with anorexia nervosa. In vivo delayed hypersensitivity skin test responses were profoundly depressed in patients with anorexia nervosa and decreased in patients with Crohn's disease who were malnourished or receiving systemic glucocorticoids. In vitro lymphocyte transformation was reduced in malnourished patients with Crohn's disease, but there were only minor changes in patients with anorexia nervosa. There were alterations of in vitro immunoregulation in Crohn's disease, but they were not responsible for the abnormal lymphocyte transformation responses in malnourished patients. In vitro phagocytic function was reduced in patients with active Crohn's disease. These findings suggest that depressed in vivo and in vitro cellular immunity in malnourished patients with Crohn's disease is caused by a qualitative lymphocyte defect and that depressed in vivo but normal in vitro cellular immunity in anorexia nervosa is caused by a quantitative defect. Thus, malnutrition in Crohn's disease resembles kwashiorkor; in anorexia nervosa, it resembles marasmus. Tissue zinc status was mostly normal in Crohn's disease and anorexia nervosa, and zinc deficiency was not responsible for depressed nonspecific cellular immunity in either condition.

Helicobacter pylori in children with peptic ulcer and their families.

Little is known about the source and spread of Helicobacter pylori, but transmission from infected family contacts has been suggested. We have therefore investigated 15 children with peptic ulcer and their first-degree relatives for H. pylori. Serum anti-H. pylori IgG, pepsinogen I, and gastrin levels were measured. Endoscopy was carried out on the children and relatives, and biopsies were taken from the gastric antrum for histology, microbiology, and urease testing. Six of 11 children with duodenal ulcer (55%) and two of four children with gastric ulcer (50%) were positive for H. pylori. Fourteen of 16 parents (87%) and eight of 13 siblings (61%) of H. pylori-positive children with peptic ulcer were also infected compared with eight of 14 parents (57%) and none of four siblings of H. pylori-negative children with peptic ulcer (P less than 0.10, greater than 0.05, and NS, respectively). The children with H. pylori-negative peptic ulcer and negative siblings combined were younger than positive children with peptic ulcer and positive siblings (P less than 0.001). The reliability of serum anti-H. pylori IgG level as a screening test for infection was confirmed. These findings call into question a pathogenetic role for H. pylori in some childhood peptic ulceration, but do suggest that person-to-person spread of infection occurs.

Non-operative management of gallstones--a preliminary review.

We describe our initial experience with extracorporeal shock-wave lithotripsy, direct solvent dissolution with methyl tert-butyl ether and mechanical extraction, in 17 symptomatic patients without significant gall-bladder wall disease using existing criteria for selection. Extracorporeal shock-wave lithotripsy and mechanical extraction are promising techniques. Methyl tert-butyl ether therapy has been fraught with difficulty.