A reappraisal of the utility of somatostatin receptor scintigraphy in patients with ectopic adrenocorticotropin Cushing's syndrome.

Ectopic ACTH hypersecretion is a rare cause of Cushing's syndrome. Bronchial carcinoids are the most common neoplasms causing the occult ectopic ACTH syndrome (EAS). Localization of these tumors is often difficult. The diagnostic utility of somatostatin receptor scintigraphy (SRS) in EAS has been studied in a limited number of patients with conflicting results. Herein we report our experience with 12 consecutive cases. Histological confirmation was obtained in nine patients, the majority being bronchial carcinoids. Among the seven patients with histologically confirmed bronchial carcinoids, SRS was performed in six patients. In three patients SRS correctly localized a bronchial carcinoid tumor at presentation. In the remaining three it became positive after 8, 22, and 27 months during follow-up. In two patients SRS was positive without any finding in the corresponding conventional imaging study. In two patients positive computed tomography/magnetic resonance imaging preceded SRS localization. There was no false positive SRS. Among three patients with highly suspected EAS, SRS was positive in one. Both patients with EAS due to medullary thyroid carcinoma had focal positive uptake. In summary, in this study a substantial number of patients had positive tumor localization by SRS. Therefore, SRS is a useful tool in the evaluation of patients with EAS.

Helicobacter pylori may induce bile reflux: link between H pylori and bile induced injury to gastric epithelium.

Helicobacter pylori and duodenogastric reflux are both recognised as playing aetiological roles in chronic gastritis. This study investigated whether H pylori colonisation of the antral mucosa and duodenogastric reflux are independent phenomena or have a causal relationship. Thirty eight patients (15 men, 23 women) aged (mean (SD)) 48 (17) years participated. Each patient underwent gastroscopy. Antral biopsy specimens were taken to investigate H pylori colonisation. In addition BrIDA-99mTc/111In-DTPA scintigraphy was used to quantify duodenogastric reflux. H pylori positive patients who were found to have duodenogastric reflux were treated with amoxycillin (1 g/d) and metronidazole (1.5 g/d) for seven days and four tablets of bismuth subcitrate daily for four weeks. Follow up antral biopsies and scintigraphy were repeated at six months. Duodenogastric reflux could not be found in 18 patients, including eight (44%) who were H pylori positive. Ten of the 11 patients who had duodenogastric reflux (reflux % 11.6 (9.2)), however, were H pylori positive (chi 2 = 6.26, p = 0.01). These 10 patients were given eradication treatment. At six months, in six patients who became H pylori negative, duodenogastric reflux was significantly reduced from a pretreatment value of 14.3% to 3.3% (two tail, paired t = 2.57, p = 0.016). These data suggest that H pylori may induced duodenogastric reflux which may be important in the pathogenesis of H pylori gastritis or carcinogenesis, or both.

Left systolic atrioventricular plane displacement in the assessment of myocardial viability in patients with previous myocardial infarction.

UNLABELLED: In order to detect myocardial viability in coronary artery disease patients (CAD) with a previous myocardial infarction and dysfunction of the left ventricle (LV), the reliability of the left atrioventricular plane displacement (LAVPD) during low dose dobutamine stress echocardiography (DSE), was validated. The study population consisted of 70 CAD patients and 35 age and sex matched healthy subjects. From the apical four and two chamber views the LAVPD was recorded and measured by M-mode echocardiography, at four sites corresponding to the septal, lateral, anterior and inferior walls of the LV, prior and during the DSE (5-10 micrograms/kg/min). All patients underwent exercise SPECT Thallium-201 with four-hour redistribution and rest-reinjection, in order to determine tissue viability. Intraobserver and interobserver variability for the LAVPD was insignificant (5.8% and 7.2%, respectively). Healthy subjects exhibited a significant and equally distributed maximal increase of the LAVPD, at all sites during dobutamine infusion (DI) (p < 0.001). Patients also, showed a significant maximal increase of the LAVPD during DI, at all asynergic sites in which viable tissue was found (p < 0.001). However, in the asynergic sites without viable tissue the LAVPD did not significantly change (p < 0.05). Selecting a LAVPD increase of > 2 mm to detect viable myocardium at any asynergic site of LV, resulted in a sensitivity of 91% and specificity of 89%. When DSE was used for the detection of viable myocardium, sensitivity and specificity were found to be 80% and 87% respectively. The proportion of agreement between the two above mentioned methods was 82%. When the two methods were in agreement, the positive and negative predictive values were 94% and 97%, respectively. The validity of the above mentioned increase of the LAVPD was also prospectively examined in a similar group of 35 CAD patients exhibiting myocardial dysfunction as a result of a previous myocardial infarction (sensitivity 85% and specificity 90%, respectively). CONCLUSIONS: 1) The assessment of left LAVPD during DI is a new quantitative, accurate method with a low intraobserver and interobserver variability, in detecting viable myocardium. 2) Combination of this method and DSE proved good diagnostic markers of myocardial viability.

Reproducible lactulose hydrogen breath test as a measure of mouth-to-cecum transit time.

Breath hydrogen monitoring after oral lactulose syrup is a conventional measure of mouth-to-cecum transit time (MCTT), but its reproducibility has been questioned. We compared the reproducibility of five measurements of MCTT after a conventional breakfast (380 kcal) taken with tea containing 20 g lactulose to five measurements of MCTT after 20 g lactulose in water in eight normal volunteers. Individual mean breakfast transit time was not significantly different from lactulose transit time in each of the seven subjects, but one had a breakfast transit time of 151 +/- 15 min and a lactulose transit time of 86 +/- 22 minutes (X +/- SD, P less than 0.001). The coefficient of variation of breakfast transit time (11.6 +/- 5.3%, range: 6.9-24.2%) was less than that of lactulose transit time (30.7 +/- 7.8%, range: 22.1-50.0%, P less than 0.001). In a second set of experiments, the liquid phase marker (99mTechnetium-diethylene triamine pentaacetic acid) emptied from the stomach more rapidly after the lactulose solution (T1/2 16.3 +/- 5.4) than after the breakfast (33.9 +/- 10.9 min, P less than 0.01) and MCTT was shorter after lactulose (77 +/- 32 vs 104 +/- 40 min, respectively, P less than 0.05). There was no correlation between MCTT of lactulose and breakfast and between half-time gastric emptying and MCTT of either lactulose or breakfast. We conclude that the ingestion of inert lactulose induces an abnormally rapid MCTT and that breakfast MCTT is a much more reproducible investigation and should be employed in studies requiring serial measurements.