Liquid chromatographic-thermospray tandem mass spectrometric quantitative analysis of some drugs with hypnotic, sedative and tranquillising properties in whole blood.

Results are presented of a liquid chromatographic-thermospray tandem mass spectrometric method of analysing different drugs in whole blood. Substances with hypnotic, sedative and tranquillising properties from the benzodiazepine, the thioxanthene, the butyrophenone, the methadone and the diphenylbutylpiperidine groups were investigated. It appears that ten to hundred times lower detection limits for the substances in whole blood can be reached with this method compared with methods more commonly used. Detection limits in the range 10-100 pg per injection (equivalent to 0.05-0.5 ng/ml whole blood) were reached for the majority of the compounds.

Early detection and treatment of oesophageal and gastric cancer. The Rotterdam Oesophageal Tumour Study Group.

Early oesophageal and gastric cancer are unique forms of oesophageal and gastric carcinoma with an excellent prognosis. Remarkable changes have taken place in the epidemiology of upper gastrointestinal malignancies. In particular, the incidence of adenocarcinoma of the distal oesophagus and the gastric cardia has risen over the past two decades. In the United States and Europe, early detection is dependent on a low threshold for upper gastrointestinal endoscopy with biopsy, because specific symptoms and physical findings are rarely present in patients with early oesophageal and gastric cancer. In addition to histology, the detection of possible markers of malignancy, such as aneuploidy (detected by flow cytometry) and the presence of oncogenes and tumour-suppressor genes, in biopsy material may be of value in the diagnosis of early cancers. For patients with early oesophageal or gastric cancer, surgery offers the best hope of cure. If patients are at high risk for surgery, an endoscopic resection may be an alternative option. This review discusses the definitions, the changes in epidemiology, the current options for diagnosis and treatment, and the value of screening programs for patients with early oesophageal or gastric cancer.

Restaging after radiotherapy and chemotherapy: value of endoscopic ultrasonography.

The outcome in gastroenterological tumors is determined by many factors. Prospective studies are required to prove the clinical value of endoscopic ultrasonography. Endoscopic ultrasonography as a staging tool may have only indirect influence on the outcome by providing potentially better selection criteria for the application of different treatments that are stage dependent.

Quantitative liquid chromatographic thermospray-tandem mass spectrometric analysis of some analgesics and tranquilizers of the methadone, butyrophenone, or diphenylbutylpiperidine groups in whole blood.

The results of a liquid chromatographic-mass spectrometric method for the quantitative determination of some medicaments of the methadone, butyrophenone, or diphenylbutylpiperidine groups in whole blood are presented. The method includes an extraction procedure with Bond Elut columns. The liquid chromatograph is connected to a mass spectrometer by a thermospray interface, and to obtain as high a sensitivity and selectivity as possible, a selected reaction monitoring mass spectrometric technique in the daughter ion mode is applied.

Case report: solitary ischaemic small bowel stenosis.

A case of a solitary short ischaemic stenosis of the small bowel is presented and the literature reviewed. An ischaemic segmental stenosis of the small bowel is a rare lesion, but can lead to acute or subacute obstructive symptoms. A well conducted small bowel enteroclysis is the diagnostic modality of choice in such a case, which may require surgical resection after the diagnosis is made.

Assessment of response of esophageal carcinoma to induction chemotherapy.

Endoscopic ultrasonography (EUS) is currently considered the best available technique for the local staging of esophageal cancer. In a prospective study 11 patients with esophageal squamous cell carcinoma were investigated to evaluate the usefulness of EUS in the assessment of response to induction chemotherapy. Response to chemotherapy was evaluated by means of history of dysphagia, endoscopy, computed tomography (CT) and EUS to assess relief of clinical symptoms, reduction of tumor bulk and depth of tumor invasion (T-stage). One patient was excluded because EUS failed. Tumor response was best correlated with relief of dysphagia and by tumor bulk reduction as determined on endoscopy and CT. We found it not useful to measure reduction of tumor bulk with EUS because of tumor compression by the instrument, stenosis, or the hypoechoic thickening of the esophageal wall caused by an inflammatory reaction after chemotherapy. There was no change in EUS T-staging after induction chemotherapy compared to prechemotherapy assessment. EUS T-staging after induction chemotherapy was accurate in 6 of 10 patients compared to the histopathologic examination of the resected specimen. There was EUS T3-overstaging in 4 patients, caused by partial or complete replacement of the tumor by an inflammatory reaction due to chemotherapy. We conclude that inflammatory changes induced by chemotherapy lead to EUS overstaging of the T stage thus making it a less reliable tool in restaging after chemotherapy.

Influence of tumor stenosis on the accuracy of endosonography in preoperative T staging of esophageal cancer.

The T stage is an important criterion for determining prognosis in esophageal carcinoma. Endosonography, although established as a highly accurate method in preoperative determination of the T stage, may be less reliable in non-traversable tumor stenoses. In a comparative prospective study, 41 patients with carcinoma of the esophagus were investigated to determine the role of tumor stenosis on the accuracy of endosonography in preoperative T staging. The results were correlated with the histology of the resected specimen. The overall accuracy in T staging with endosonography was 76%, compared with 49% in computed tomography. T staging results of endosonography were good in easily and non-traversable stenoses (92%, 87% respectively), but lower accuracy was obtained in stenoses which could be traversed only with difficulty (46%). Computed tomography was inferior to endosonography in all three groups of patients. The high accuracy of endosonography in non-traversable stenoses might be due to the fact that all tumors were in an advanced stage (T3 or T4). When passage of the echoendoscope proves difficult, the low focal distance between the ultrasonic transducer and tumor may hamper clear visualisation of the wall layers and tumor penetration depth. These limitations of endosonography should stimulate further efforts in improving ultrasonic resolution in these cases.

Differential diagnosis of inflammatory bowel disease. A comparison of various diagnostic classifications.

Fifty consecutive patients with inflammatory bowel disease of the colon who presented at the University Hospital Rotterdam/Dijkzigt were assessed by four methods: clinical diagnosis, criteria defined by Lennard-Jones and by the Organisation Mondiale de Gastroenterologie (O.M.G.E.) scoring systems, and histologic slide review. All cases were classified into three diagnostic groups: established Crohn's disease (CD), indeterminate colitis, or definite ulcerative colitis (UC). The classifications were compared by kappa analysis. Eighteen of the 50 patients were classified as having established CD by the O.M.G.E. scoring system and Lennard-Jones criteria; 17 were so classified by clinicians, and only 8 by histologic slide review. The agreement among clinician's diagnosis, Lennard-Jones criteria, and the O.M.G.E. scoring system was good (Fleiss-Cohen-weighted kappa; p less than 0.001). Agreement among histology, Lennard-Jones criteria, and the O.M.G.E scoring system was less good (p less than 0.05) and not significantly associated with clinical diagnosis. Histology was less prone to diagnose established CD or established UC and more likely to diagnose indeterminate colitis. This study has shown that the systems of disease definition set out by Lennard-Jones and the O.M.G.E. are comparable and agree well with each other and clinicians's diagnosis, but biopsy specimens have a limited diagnostic value in disease differentiation in inflammatory bowel disease.

The management of malignant esophago-respiratory fistulas with a cuffed prosthesis.

Peroral intubation with a standard prosthesis fails to occlude inoperable malignant esophago-respiratory fistulas located above the narrowed segment, or when there is little or no stricture at all. Ten patients with malignant esophago-respiratory fistulas were intubated perorally with a prosthesis surrounded by a foam ruber cuff contained in a silicone sheath, in which a vacuum can be created. The type of fistula was esophago-bronchial in 6 patients, esophago-tracheal in 3 patients, and gastro-tracheal in 1 patient. The fistula was located above the stricture in 8 patients and in a malignancy without a stricture in 2 patients. The diameter of the opening of the fistula ranged between 1 and 3 cm. Complications with the cuffed tube were recurrent leakage after a period of 30 days in situ in 1 patient, and compression of the trachea immediately after intubation in 1 patient. Adequate palliation, that is, no symptoms related to the fistula, good transit of food and discharge from hospital within a few days was achieved in 9 patients for an average period of 37.2 days (10-84 days). The cuffed esophageal prosthesis can improve the quality of life in patients with malignant esophago-respiratory fistulas that do not respond to conventional intubation.

[When latex disintegrates, or a mechanical pyloric ulcer]. / Wanneer latex loslaat, ofwel een mechanisch ulcus pylori.

Complications of Celestin oesophageal tube disintegration are discussed with reference to the case of a patient with a tube inserted because of extrinsic stenosis presenting with upper abdominal complaints.

Crohn's disease: risk of recurrence and reoperation in a defined population.

Two hundred and ten patients with Crohn's disease (CD) were identified in an epidemiological survey of inflammatory bowel disease in the Leiden Health Care Region of the Netherlands. The survey included all patients with CD seen between 1979-1983. The duration of disease ranged from less than one year to 48 years. Of the 210 patients with CD, 118 (56%) underwent surgical resection. Sixty one had an ileocaecal resection, 14 a proctocolectomy, in seven cases as a two stage procedure; 12 a segmental colectomy with end-to-end anastomosis and eight a subtotal colectomy with ileostomy. Twenty-one of these 118 patients (18%) had recurrences requiring reoperation; in 11 because of recurrence at the anastomotic site. Life table analysis showed that after 10 years 17% of patients required further resection for recurrence and 8% for relapse. By 20 years the rate of recurrence had risen to 56%. Patients over the age of 30 at first resection were at 1.5 fold greater risk of requiring further surgery than younger patients. The initial site of disease played no role in recurrence and there was no evidence that preoperative disease duration, delay in diagnosis, or late surgery had any effect on recurrence rates. This is one of the few community based studies to measure recurrence and relapse. A balanced appraisal is that surgery is not permanently curative, but the need for further resection may be lower than previously suggested.

Risk of cancer in inflammatory bowel disease: why are the results in the reviewed literature so varied?

It is important to know the risk of cancer in inflammatory bowel disease and to know the magnitude of the problem. It then becomes possible to answer some questions on the management of patients. It is useful to have a surveillance procedure and follow all patients considered at risk of developing cancer? Should prophylactic surgery be recommended for all patients with long-standing extensive disease, and what will be its impact on the quality of life? There is a wide range of reported incidence of colorectal cancer in inflammatory bowel disease. This is likely to be due to selection bias and problems with generalization and validity of the results rather than any real differences in the underlying cancer incidence. Rigorous methodologic standards must be used to measure the risk of cancer in inflammatory bowel disease.

Inflammatory bowel disease: one condition or two?

Demographic data obtained from epidemiological studies of Crohn's disease and ulcerative proctocolitis in Regio Leiden (Leiden health care region) were compared. Ulcerative colitis (6.8 cases/10(5) population/year) had an incidence almost twice that of Crohn's disease (3.9/10(5)/year; p less than 0.001). Each disease occurred with equal frequency in both sexes and diagnosis of the diseases occurred at similar ages (Spearman's correlation coefficient = 0.84; p less than 0.01). Where ulcerative colitis was common in the various municipalities so was Crohn's disease (Spearman's correlation coefficient = 0.88; p less than 0.001). No cases of Crohn's disease were identified amongst migrants, but 6 cases of ulcerative colitis (prevalence = 85/10(5); 95% confidence interval = 35-195) were found. This difference was significance (p less than 0.05). It seems likely that the two diseases may simply represent the opposite ends of a continuous spectrum of inflammatory bowel disease.