Self-expanding nitinol stent for malignant obstructive dysphagia - initial experience.

Between July 1992 and December 1994, a total of 31 patients with inoperable or unresctable malignant obstruction of the esophagus or esophagogastric junction were palliated with self-expanding nitinol stents. They were 33 to 86 years old, 55% being 70 years or older. Twenty patients were male. Twenty patients (65%) had squamous cell carcinoma, 10 (32%) had adenocarcinoma and one (3%) had undifferentiated carcinoma. Twenty-five patients (81%) required prestenting dilatation with balloons, bougies or laser. Stent implantation was successful in 30 patients (97%) but failed in one. Two patients had minor complications and one patient with advanced disease died in the hospital one week after the procedure. All stended patients experienced significant short-term relief of dysphagia. Twenty-two patients (73%) were seen at least once after discharge in a follow-up visit. Twenty (66%) were still swallowing satisfactorily when last seen four to 32 weeks after stenting. We conclude that the new nitinol stent represents an important and valuable addition to the treatment options available for palliation of malignant dysphagia.

Spontaneous esophageal perforation in herpes simplex esophagitis.

A 32-yr-old, previously healthy man with severe chest pain of sudden onset was found to have purulent pericarditis and pleural effusions. Several days later, an esophagogram revealed a perforation of the thoracic esophagus. Endoscopy showed a picture highly suggestive of a late stage of an extensive herpes simplex virus (HSV) esophagitis. Biopsies revealed evidence of massive HSV infection, confirmed by immune microscopy and virus culture. At surgery, a mediastinal abscess was found, and an esophageal perforation was identified. These findings suggest that the etiology of the perforation was an unusually severe herpetic infection. To our knowledge, HSV esophagitis has not previously been implicated as the cause of spontaneous esophageal perforation.

The intragastric milieu during gastric ulcer treatment with pirenzepine 50 mg b.i.d. or cimetidine 400 mg b.i.d.

In a double-blind randomised four-center trial 43 patients with gastric ulcer (20 men, 23 women; mean age 52.2 years) were treated with either pirenzepine (P) 50 mg b.i.d. (n = 24) or cimetidine (C) 400 mg b.i.d. (n = 19) during six weeks. In ten patients gastric juice was examined before and at the end of the treatment for concentration and type of the microbial flora, and for nitrite concentration. After six weeks 83% of the patients in both groups were either symptom-free or clearly improved. In 15/24 patients on P (62.6%) and in 13/18 on C (72.2%) the ulcer(s) were healed at the time of control endoscopy. In the ten patients investigated, intragastric concentrations of fungi, bacteria, and nitrite were not significantly changed by the treatment. In gastric ulcer, treatment with pirenzepine 50 mg b.i.d. or cimetidine 400 mg b.i.d. during six weeks does not result in significant microbial overgrowth or generation of nitrite.

Sucralfate versus placebo in reflux esophagitis. A double-blind multicenter study.

The healing capacity and symptom relief were studied in 138 patients with symptomatic endoscopically verified reflux esophagitis treated with sucralfate (n = 69) or placebo (n = 69), 1 g four times daily (granules suspended in half a glass of water), for at most up to 12 weeks. The reflux esophagitis (modified Savary-Miller scale) was distributed with 71 patients having grade 1, 39 patients having grade 2 or 3, and 28 patients having grade 4. All patients were told to follow the antireflux regimen. Antacid tablets were supplied, to be used only for the relief of severe pain, and were counted. The esophageal lesions were completely healed in 42% (sucralfate) and 35% (placebo) after 6 weeks of treatment (NS). Corresponding cumulative healing rates at 12 weeks of treatment were 54% and 41% (NS), respectively. The symptom improvement, however, was significantly better in the sucralfate group after 3 weeks of treatment. The results indicate a symptomatic benefit of sucralfate in reflux esophagitis.

Geographic differences in the prevalence and distribution of large-bowel polyps--colonoscopic findings.

The large-bowel polyp pattern in two widely separated geographic regions of Sweden, Bollnäs in the central part and Trelleborg in the south, was studied prospectively by colonoscopic polypectomy. In Bollnäs 11.8% of 1,153 patients had neoplastic, and 3.8% hyperplastic, polyps. In Trelleborg 29% of 1,040 patients had neoplastic, and 17.3% hyperplastic, polyps. Furthermore, the Trelleborg patients had, on average, more polyps per patients than their Bollnäs counterparts: 2.0 versus 1.5 neoplastic, and 2.1 versus 1.7 hyperplastic, polyps. There was a marked difference in the anatomic location of the polyps between the two regions: in Trelleborg 55.4% of the neoplastic, and 40.5% of the hyperplastic polyps were distributed above the rectosigmoid, compared with 20.9% and 26.4%, respectively, in Bollnäs. The findings offer an explanation of the fact that the incidence of colorectal carcinoma in the Malmö region, close to the Trelleborg area, is the highest in Sweden.

Enprostil and cimetidine: comparative efficacy and safety in patients with duodenal ulcer.

The safety and efficacy of enprostil, 35 micrograms twice daily, and of cimetidine, 400 mg twice daily, in the treatment of duodenal ulcers were compared in a randomized, double-blind, parallel, multiclinic study. Endoscopy was performed before treatment and at 2-week intervals for 6 weeks or until the ulcer healed. Patients recorded their drug compliance, antacid use, ulcer symptoms, and adverse experiences daily. One hundred and six patients entered the trial, of which 104 were eligible for the initial endoscopy analysis. Base-line characteristics were similar in the two treatment groups. The cumulative healing rates in the enprostil group were 56%, 86%, and 92% at 2, 4, and 6 weeks, respectively, and those in the cimetidine group were 53%, 84%, and 90% (NS). The healing rates for nonsmokers at 6 weeks were 96% in the enprostil group and 97% in the cimetidine group, which were significantly greater than those for smokers--88% and 81%, respectively. There were no significant differences in the duration, severity, or frequency of daytime or nighttime pain between the groups. Seventeen of the enprostil patients (32%) reported 21 adverse experiences during the trial, and 20 of the cimetidine patients (39%) reported 23 adverse experiences. No patients withdrew because of adverse experiences. The two drugs were similarly safe and effective in the treatment of duodenal ulcer.

Pirenzepine versus cimetidine in duodenal ulcer treatment. A clinical and microbiological study.

The therapeutic efficacy of pirenzepine (PIR) and cimetidine (CIM) in duodenal ulcer and their effects on the intragastric milieu have been studied in a double-blind multicentre trial. Seventy-nine patients with endoscopically proven duodenal ulcer were randomly allocated to 4 weeks' treatment with either 50 mg PIR twice daily or 400 mg CIM twice daily. In addition to clinical and endoscopic evaluation and registration of side effects and laboratory test results, endoscopically obtained gastric juice was cultured and its nitrite concentration was measured before and at the end of the treatment. Seventy-five patients completed the study. The treatment groups were comparable with regard to age, sex, smoking habits, and consumption of coffee and alcohol. After 4 weeks, 27 of 37 patients (73%) in the PIR group were completely healed, compared with 29 of 38 (76%) in the CIM group (NS). The number of patients with side effects was similar in both groups, but side effects of antimuscarinic type were more frequently reported by patients in the PIR group. Intragastric microbial concentrations increased significantly during treatment in both groups but remained well within normal limits. No single nitrite concentration before or after treatment exceeded the normal range. In conclusion, the two drugs were about equally effective in the short-term treatment of duodenal ulcer disease. In the doses given they did not adversely affect the intragastric milieu.

Intestinal spirochaetosis of the colon diagnosed with colono-ileoscopy and multiple biopsies.

This paper deals with the clinical history, the histopathological and TEM features of a case of intestinal spirochaetosis associated with ulcerative colitis and tubular adenomas of the colon. It is the fifth described case of intestinal spirochaetosis in Sweden, and the first in the literature in which a complete colonoscopy with multiple biopsies has been performed. Intestinal spirochaetosis might lead to minor complaints as distension and vague abdominal discomfort, as in this case, but also to more prominent symptoms such as diarrhoea. Heavy infestation of the gut surface epithelium by spirochaetes was seen in the total colon, but was not found in the distal ileum.

Bleeding birth of a gallstone from a hanging papilla of Vater.

A case of major gastrointestinal hemorrhage due to the passage of a gallstone from a 20 mm long, hanging papilla of Vater is presented. An upper digestive endoscopy revealed the stone in the very process of expulsion from the papilla into the duodenum in which fresh blood was seen. Bleeding stopped a few days afterwards. Follow-up endoscopic and radiological examinations of the gastrointestinal tract disclosed no other potential source of bleeding.

Gastro-duodenal ulceration in abdominal angina.

Two cases of verified abdominal angina are presented. Multiple, atypical ulcerations in the postbulbar duodenum were diagnosed endoscopically in both cases. Atypical gastric ulcers were also present in one case. The suggestion is made that such ulceration may not be uncommon in intestinal ischaemia. Such findings at endoscopy should arouse the suspicion of abdominal angina, especially when preceding diagnostic procedures, including biopsies, have failed to demonstrate other clear-cut gastrointestinal disease.

Coexistent hereditary haemorrhagic telangiectasia and primary thrombocythaemia--coincidence or syndrome?

Two patients with coexistent hereditary haemorrhagic telangiectasia (HHT) and primary thrombocythaemia (PT) are presented. In one of them, both diseases were detected at the same time. In the other, signs of HHT were present 20 years prior to the diagnosis of PT. Both patients had recurrent gastrointestinal haemorrhage with consequent anaemia, and multiple gastric telangiectases were demonstrated endoscopically. Persistent and severe haemorrhage from gastric telangiectases in one of the patients was successfully controlled by endoscopic monopolar electrocoagulation. The very high platelet counts were reduced with melphalan in one patient and with busulfan in the other. The degree of severity of both disorders was parallel in both cases. We suggest that the coexistence of these two rare disorders in one and the same patient may represent a syndrome that could be more common than hitherto known.