High prevalence of abnormal acid gastro-oesophageal reflux in idiopathic pulmonary fibrosis.

The aim of this prospective study was to determine the prevalence and characteristics of acid gastro-oesophageal reflux (GER) in patients with idiopathic pulmonary fibrosis (IPF). Sixty-five consecutive patients with well-defined IPF were subjected to 24-h pH monitoring and oesophageal manometry. A total of 133 consecutive patients with intractable asthma and symptoms of GER were used as comparisons. The prevalence of abnormal acid GER in IPF patients was 87%, with 76% and 63% demonstrating abnormal distal and proximal oesophageal acid exposures, respectively. Abnormal acid GER was significantly more common in IPF patients than asthma patients. Only 47% of IPF patients experienced classic GER symptoms. Despite treatment with standard doses of proton pump inhibitors (PPIs), 12 out of 19 patients receiving PPIs during the 24-h pH monitoring had abnormal oesophageal acid exposures by pH probe. There was no correlation between IPF severity and acid GER severity. In conclusion, abnormal acid gastro-oesophageal reflux is highly prevalent, but often clinically occult in patients with idiopathic pulmonary fibrosis. Standard doses of proton pump inhibitors may not suppress the acid gastro-oesophageal reflux in this population. Therefore, further studies are needed to determine if acid abnormal gastro-oesophageal reflux represents an important risk factor for idiopathic pulmonary fibrosis development or progression, and if optimal suppression of acid gastro-oesophageal reflux slows the progression of idiopathic pulmonary fibrosis and/or decreases episodic exacerbations of idiopathic pulmonary fibrosis.

Gallbladder wall thickening: an in vitro sonographic study with histologic correlation.

RATIONALE AND OBJECTIVES: We compared histologic sections with in vitro sonographic images for 40 resected gallbladder specimens to correlate the histopathologic processes with the sonographic appearance of the gallbladder wall. METHODS: In vitro sonographic images and histologic specimens were obtained by use of a specimen container with a micropositioner. An 8.5-MHz transducer and a scalpel were attached to the micropositioner to obtain the sonographic image and the histologic section. The sonographic images were analyzed for wall thickness and the number and echo texture of the visualized layers and then were correlated with the histologic sections. Each histologic specimen was interpreted as being normal or showing mild, chronic, acute, or gangrenous cholecystitis. RESULTS: One to four sonographic layers were observed in the gallbladder wall specimens. The number of wall layers was fairly evenly distributed among the different types of gallbladder wall inflammation. One to three sonographic layers were observed for most of the different types. In nearly all instances, the findings were attributable to either similar pathologic processes in two or more histologic layers or different pathologic processes in a single histologic layer. The gallbladder wall measured less than or equal to 3 mm in 89% of gallbladders with normal or mild inflammation, greater than 3-6 mm in 71% of cases of chronic cholecystitis, greater than 3 mm in 83% of cases of acute cholecystitis, and greater than 6 mm in 50% of cases of gangrenous cholecystitis. CONCLUSIONS: The sonographic layers in the inflamed gallbladder wall are determined by the pathologic changes present rather than by the normal histologic boundaries. However, because of the overlap of pathologic changes, we cannot predict the type of gallbladder wall pathology on the basis of the sonographic appearance. We found a trend toward gallbladder wall thickening for severely inflamed gallbladder walls.

Appendiceal US scans: histologic correlation.

High-resolution in vitro ultrasonography (US) of 20 surgical appendiceal specimens was performed to compare appearances of appendiceal tissue at US with corresponding histologic features. With an articulated-arm system and micropositioner, precise spatial correlation was achieved. As elsewhere in the gastrointestinal tract, five distinct echo layers were observed. Normal and inflamed specimens demonstrated these layers, but the architecture became disorganized and indistinct in cases of appendicitis. Three measurements were made for each specimen: (a) overall cross-sectional diameter, including the lumen, (b) thickness of the submucosal echo layer, and (c) the combined thickness of both walls, excluding the lumen. For the inflamed specimens, a substantial increase in the thickness of the summed wall measurements was found. Wall US appearance alone may be misleading in differentiation of normal and abnormal appendices.

Beneficial effects of glucose polymer and an H2-receptor blocker in a patient with a proximal ileostomy.

A patient with an ileocolectomy and proximal ileostomy for Crohn's disease had severe diarrhea and steatorrhea. An oral electrolyte solution containing glucose polymer was shown to improve water and electrolyte absorption. Ileal contents were abnormally acidic. Therapy with an H2-receptor blocker raised ileal pH, improved the efficiency of fat absorption, and promoted a gain in body weight.

Absorption of triglyceride by human small intestine: dose-response relationships.

Healthy subjects with ileostomies (ileostomates) were fed six breakfasts of 5-100 g linseed oil. This lipid source was chosen so that linolenic acid could be used as a fatty acid probe. Phenol red was included in the meal so that mouth-to-stoma transit could be measured as the t 1/2 of phenol red. Ileostomy effluent was collected over 24 h and the dose of lipid ingested was related to lipid output and to intestinal transit time. The coefficient of variation for mouth-to-stoma transit was less than 12%. The slopes of the least-square lines relating lipid ingested to lipid output and to mouth-to-stoma transit time were positive and significantly different (p less than 0.05) from 0. The ileostomate's small intestine absorbed linolenic acid with 98% efficiency. A delay in mouth-to-ileum transit, associated with increasing lipid loads, is one obvious mechanism that maintains the intestine's absorptive efficiency.

Absorption of starch by healthy ileostomates: effect of transit time and of carbohydrate load.

Recently, breath hydrogen studies and intubation techniques have indicated that in excess of 10% of starch in normal foods may be malabsorbed in the small intestine and enter the colon. We evaluated starch absorption in healthy subjects with ileostomy. First, unabsorbed starch was quantified in ileostomy effluent from six ileostomates who ingested constant diets of wheat and potato starch for four days. Daily unabsorbed starch ranged from 1.3% to 5.0% of total ingested starch. Second, starch from a radiolabeled solid meal containing 50 g potato starch was measured under control conditions and after altering transit time with either loperamide, or magnesium citrate. Loperamide significantly decreased the amount of unabsorbed starch in all six ileostomates (p less than 0.05), while magnesium citrate significantly increased starch malabsorption in all six subjects (p less than 0.05). Third, starch absorption was measured after single solid meals containing 25, 50, 75, and 100 g potato starch. There was a linear relationship between starch input and output. Mean output expressed as a percent of input remained constant. We conclude that the degree of starch malabsorption by the small intestine of ileostomates may be less than that estimated by indirect methods in intact humans. The amount of unabsorbed starch is directly related to the quantity ingested and to the small intestinal transit time.

Absorption of carbohydrate-electrolyte solutions in rat duodenojejunum. Implications for the composition of oral electrolyte solutions in man.

Commonly used oral electrolyte solutions are based on glucose, or sucrose, and 90 mM Na+. We had been disappointed with the ability of such solutions to improve Na+ absorption in patients with extensive resection of distal small bowel. Therefore, we tested the effect on net Na+ and water transport of combinations of different carbohydrates (glucose, sucrose, and glucose polymers) and NaCl in the rat duodenojejunum. Absorption was measured under steady-state conditions in unanesthetized animals which were infused with a different combination every hour for up to 5 hr. Of the various combinations, 10 mM glucose polymer (equivalent to 56 mmol of glucose as glucose oligosaccharides), or 60 mM glucose promoted net Na+ absorption from 120 mM NaCl and 20 mM KCl, but the glucose polymer infusate promoted more rapid water absorption than did the infusate containing glucose. The infusate of 10 mM glucose polymer in saline was initially hypotonic (276 mosmol/kg), but it became isotonic (298 mosmol/kg) as the glucose polymer was hydrolyzed during its passage through the duodenojejunum. In contrast, an infusate of 60 mM sucrose with 120 mM NaCl and 20 mM KCl remained hypertonic (320 mosmol/kg), and it did not promote water and Na+ absorption by the duodenojejunum. The efficacy of 10 mM glucose polymer with 120 mM NaCl should be tested in patients with short-bowel syndrome due to distal bowel resection.