[Carcinoid tumors, leiomyosarcoma and invasive adenocarcinoma metastasis of the Treitz angle]. / Tumori carcinoide, leiomiosarcom si metastaza invaziva de adenocarcinom, ale unghiului duodeno-jejunal Treitz.

Our paper studies the quite rare occurrence of the digestive superior occlusive pathology, namely some causes which might induce partial or even total obstruction of the digestive tract, at the distal anatomical limits of the duodenum, also known as the Treitz angle. The first two described cases were carcinoid tumors, obstructive and ulcerated in the lumen of the same angle. The last two cases were an obstructive leiomyosarcoma and an invasive mesenteric metastasis from a right colon cancer, which cause a total external compression of the Treitz angle, clinically manifested as a complete food intolerance, as a first symptom. Concerning the clinical evolution, these are totally different lesions, malign, metastasis and neuroendocrine tumors, which occurred at the same level, had a totally different clinical evolution and surgical approach, only three of them developing at good postoperative course. The imaging, clinical and pathological diagnosis problems, the different specific surgical solutions, the postoperative care and finally the rarity of this level of obstruction of the small bowel, are the aim of this paper.

[Recessive hiccup of rare cause (compressive pleuro-pericardial lymphocele). Case report]. / Singultus rebel de cauza rara (Limfocel pleuro-pericardic compresiv cu evolutie lenta) prezentare de caz.

The authors discuss the case of a 40 year-old woman, which was performed surgery for a stenosant duodenal ulcer by bilateral troncular vagotomy and hemigastrectomy, using the Pean-Billroyh 1 anastomosis. Immediately after surgery untractable hicongh gradually set in which lasted over a 14 year, till the moment when a compressive pleuropericardic lymphocele, of the right phrenic nerve was revealed, a very long time growing cyst. After the surgical removal of the lymphocele was performed, which had compressed the right phrenic nerve, singultation totally disappeared, the patient has been monitorized through periodical medical checkings for more than 4 years. The period of 14 years when the patient constantly complained of steady untractable singultation has comprised 30 admission or more, to various surgical, gastroenterology and psychiatry wards. The patient was finally considered an incurable psychotic and was medically pensioned. The authors discuss a number of possible sequels of the initial gastric surgery which could have triggered untractable singultation, without being able to control them or totally ruling out the psychotic causes. There is natural suspicion cast of either existence or beginning of this cyst simultaneous with surgery since clinical tests and explorations were able to reveal it only after 14 years.

An improvement of the endocrine diagnosis by high-performance liquid chromatography.

The assessment of catecholamines (NE, E), essential metabolites (VMA, HVA) and serotonergic metabolite 5HIIA in urine by HPLC with UV detection is of interest for clinical diagnosis concerning HTA, pheochromocytoma, neuroblastoma, carcinoid syndrome, hypotension, etc. In the same urine sample one can detect (following preliminary steps) by HPLC the above--mentioned biochemical parameters with good reproducibility and sensitivity.

Direct assay of 3-methoxy-4-hydroxy-phenylglycol (MHPG) in human saliva; a new approach in the assessment of noradrenergic function.

The present paper offers a simple, reliable and specific method for the evaluation of salivary level of conjugated MHPG in 16 children (5-16 years) selected as control group. In the chosen group, we established the urinary level of NA: 17.64 +/- 1.38 micrograms/24 h, of A: 5.87 +/- 0.44 micrograms/24 h, of MHPG: 1.62 +/- 0.14 mg/24 h, of VMA: 1.54 +/- 10.10 mg/24 h. In all patients we assayed salivary MHPG: 57 +/- 5.25 mg/ml; in only 6 patients we also determined salivary NA: 2.21 +/- 0.11 micrograms/l and A: 0.25 +/- 0.03 micrograms/l. The MHPG in saliva correlates with urinary MHPG but doesn't correlate with NA in saliva or in urine. The assay of salivary MHPG may represent a non-invasive procedure of evaluation of noradrenergic tonus in children.

Low level of urinary 5-hydroxyindole acetic acid (5 HIAA) in obese children having concomitantly high 3-methoxy-4-hydroxyphenyl glycol (MHPG) excretion.

Eighty six obese children and adolescents (44 males) were screened for urinary 5 HIAA and MHPG, noradrenaline (NA), and adrenaline (A) and the results compared with age- and sex-matched controls. Significantly lower amounts of 5 HIAA were found, by contrast to the significantly higher levels of MHPG. These findings cannot be easily explained but an alteration of the normal equilibrium between the adrenergic and the serotonergic tonus may be circumstantially invoked.

Thyroid hormone-induced reduction of urinary 5-hydroxyindole acetic acid (5 HIAA) in obese children. Comparison with hypothyroid patients of similar age having either pituitary dwarfism or congenital myxedema.

Urinary excretion of monoamine metabolites (noradrenaline-NA, adrenaline-A, 3-methoxy-4-hydroxyphenyl glycol-MHPG, homovanillic acid-HVA, 5-hydroxyindole acetic acid-5 HIAA) was studied in four groups of children as follows: Group I consisting of obese children subjected to caloric restriction and to a short term course of thyroid extract in "low" dosage (1-2 mg/kg bwt), Group II consisting of obese children subjected to diet alone, Group III consisting of children myxedema and subjected to a short term course of thyroid extract given in the "high" dosage (3-5 mg/kg bwt) and Group IV consisting of GH deficient short children having (many of them) thyrotropin deficiency and subjected to a short term course of thyroid extract in "very high" dosage (5-10 mg/bwt). In obese, calorie-restricted children, the previously low mean level of 5 HIAA excretion was further lowered by thyroid extract. In obese children subjected to calorie restriction alone no urinary abnormality was noted. The congenitally hypothyroid patients had low levels of basal 5 HIAA when compared to controls. The degrees of 5-hydroxy tryptamine (5 HT) deficiency in Group III was similar to the obese groups. The thyroid extract course did not influence, at least in short term administration, the low 5 HIAA levels in group III. In GH deficient, short children (group IV) thyroid extract had no significant effect on urinary pattern of monoamine metabolites. A central 5 HT deficiency may tentatively explain the mood disturbances and possibly the other psychic disorders in both the obese and myxedematous patients. The different effects of thyroid extract on 5 HIAA may also witness the differences in the food intake behaviour in these two conditions.

The assessment of the dopaminergic tonus by urinary determinations of homovanillic acid (HVA) and dihydroxyphenylacetic acid (DOPAC) in normal, obese and GH-deficient short children.

In order to assess the dopaminergic tonus, urinary determinations of HVA and DOPAC and also of noradrenaline (NA), adrenaline (A), and methoxyhydroxyphenylglycol (MHPG) were performed in 86 obese children, 11 growth hormone (GH)-deficient short children and also in 40 control children. Part of the obese patients were subjected to a low carbohydrate, low calorie diet and also to short-term (9-14 days) courses of diethylpropion (DEP) 50 mg/day, meclofenoxate (MEC) 100 mg/day and thyroid extract (THE) 1-2 mg/kg/day. The GH-deficient patients received only THE in substitutive (5-10 mg/kg/day) doses. Significative correlations between DOPAC and age, weight and height were found in controls. In the obese group a significantly increased mean level of HVA was found (1.45 +/- 0.09 mg/24 h vs 1.15 +/- 0.10 in controls). The excretion of DOPAC was slightly greater but far from significance. There was also a significant decrease of HVA but not DOPAC in the DEP-treated obese. The rest of the drugs and the diet alone were not effective in any way. Normal levels in all metabolites except NA and A were found in GH-deficient short children. The therapy with thyroid extract did not alter the excretion levels. These findings indicate that in infantile obesity the dopaminergic tonus is somewhat increased but its pathophysiological significance is doubtful. In GH-deficient short children of standard appearance the dopaminergic tonus seems to be undistinguishable from normal.

Free 3-methoxy-4-hydroxyphenylglycol (MHPG) in human urine: metabolic routes, biochemical and clinical significance in healthy and obese children.

Conjugated MHPG is an indicator of the adrenergic tonus having clinical use in the follow-up of affective disorders, arterial hypotension, anorexia nervosa and recently of obesity. Little is known about the significance of the unconjugated, free MHPG in various body fluids. Nineteen healthy and 38 obese children were studied as regards the urinary excretion of free MHPG (MHPGF), conjugated MHPG (MHPGC), total MHPG (MHPGT) and also free noradrenaline (NA) valnillyl mandelic acid (VMA) and metanephrines (MN). Part of the obese received a short-term course of drug therapy (diethyl-propion-DEP or thyroid extract) and were subjected to a low-carbohydrate diet containing 800-1000 calories a day. The same urinary determinations were made after diet alone or after diet and drug therapy. MHPGC and MHPGT were significantly higher in the obese children. The level of MHPGF was essentially the same in both groups and did not change significantly following any drug or after diet alone. It was concluded that esterification mechanisms are not involved in the pathological states expressing high or low levels of MHPGC. Suggestion is made that these mechanisms may not be saturated unless huge amounts of MHPG outflow from the brain into CSF.

Decrease of urinary levels of adrenergic metabolites including conjugated MHPG after a short term course of diethylpropion in obese children fed a mixed, low-calorie diet.

A short term course (8-11 days) of diethylpropion 50 mg a day was administered to 12 obese children of both sexes fed a mixed low calorie diet containing about 1000 calories/day. A group of 10 obese children received the same diet and no medication. The sex-distribution was similar in both groups as well as the degree of overweight (appreciated by the Quettelet index). The urinary excretion of some noradrenergic derivative (adrenaline-A, noradrenaline-NA, vanillyl-mandelic acid VMA, metanephrines NM and methoxy hydroxyphenyl glycol-MHPG) and of homovanillic acid (HVA) was measured in both groups before and after drug therapy or diet, respectively. After the diethylpropion course, the urinary mean value of MHPG decreased (2.17 +/- 0.30, mean +/- SE vs 1.47 +/- 0.21) but the significance was borderline. The mean level excretion of NA, VMA, MN and HVA were significantly lower following diethylpropion. No significant change was observed in the diet-only group of patients as regards the same determinations. These observations are not entirely explained by the previous pharmacologic knowledge on diethylpropion and other sympathomimetic amines.

The excretion of noradrenergic metabolites, particularly MHPG, in obese children and adolescents.

Eighty obese children and adolescents (41 males) aged 4-18 were screened for urinary adrenergic derivatives (NA, A, AVM, MN, MHPG) and the results compared with age- and sex-matched controls. Significantly higher amounts of A (8.1 +/- 0.38 micrograms/24 h), MN (0.327 +/- 0.032 mg/24 h) and MHPG (2.74 +/- 0.192 mg/24 h) were found and significantly linear regression curves of MHPG were plotted against urinary creatinine and NA but not against age, weight and Quettelet index. A subgroup of 26 obese having urinary MHPG over 3 mg/24 h ("high MHPG excretors") revealed significantly greater means of weight Quettelet index, A and NA than the remaining 54--member subgroup ("low MHPG excretors"). It was concluded that in randomly selected obese children and adolescents there are obvious humoral signs of sympathetic nervous system overactivity and, possibly, of adrenomedullary increased tonus and that these manifestations may be due, at least in part, to increased central (encephalic) noradrenergic activity, especially in more overweight patients.

Urinary excretion of catechol metabolites particularly MHPG in children. Relation to age, body mass indices and thyroid function.

Determinations of noradrenaline (NA), adrenaline (A), vanillylmandelic acid (VMA), metanephrines (MN), homovanillic acid (HVA) and 3-methoxy-4-hydroxy-phenylglycol (MHPG) were performed in 24 h urine samples of three groups of children: 26 normal children, 7 cases of congenital myxedema (not treated for at least one month) and 8 obese children to whom a short (9-14 days) course of thyroid extract was administered. No sex difference was noted in any group. The results in the control group (mean +/- SE) were as follows: NA 23.8 +/- 2.18 micrograms, A 6.2 +/- 0.35 micrograms, VMA 1.58 +/- 0.22 mg, NM 0.526 +/- 0.079 mg, HVA 1.24 +/- 0.142 mg, MHPG, 1.60 +/- 0.232 mg. The excretion of MHPG was significantly (cor)related to NA (p less than .05) and completely unrelated to the other derivatives. Significant equations and curves were obtained from linear regression analysis of MHPG excretion to age (p less than .025), weight (p less than .025), body surface (p less than .05), and creatinine excretion (p less than .05) but not to height and Quetelet index. No significant change was encountered in both myxedema or thyroid extract-treated obese group in any urinary metabolite determined. It was concluded that in children the urinary MHPG excretion is closely correlated to NA excretion and is linearly dependent on age, weight and creatinine extraction. Thyroid activity seems to have no evident effect on urinary excretion of various catechol metabolites. Suggestion is made that the MHPG (cor)relation(s) found originate(s) in corresponding change(s) of noradrenergic receptor sensitivity within the brain.

Recurrent operated malignant pheochromocytoma.

Pheochromocytoma was diagnosed in a female patient aged 26 with paroxysmal arterial hypertension (AH), profuse sweating, headache, anxiety, tachycardia, transit arrhythmia, high urinary norepinephrine (NE), epinephrine (E) and vanillyl mandelic acid (VMA). Urography with intravenous Odiston revealed a relatively large tumor at the upper pole of the right kidney. Complete removal of the tumor in a 2-step surgical procedure brings apparent clinical and hormonal recovery for 6 years, but then clinical and hormonal relapse occurs through ganglionary metastasis and tumor at the basis of the mesentery. Removal of the metastasis and tumor brings again improvement in the clinical and hormonal picture.

Antagonism between pineal peptides and catecholamines. II. The action of a pineal peptide extract on the process of endogenous catecholamines secretion-excretion.

To determine the processes of adrenaline and noradrenaline secretion-excretion in rats and rabbits with/without associated insulin lente administration (20 U.I./kg rat b.w. and 6 U.I./kg rabbit b.w.), the authors used a pineal peptide extract that has now become available under the trade name of "Crinofizin". Under conditions of natural light, environmental temperature of 18-20 degrees C and fed ad libitum, Crinofizin did not cause significant alterations in the rat 24 hrs urinary excretion of catecholamines. Administration of insulin induced a more than two-fold increase in the two catecholamines both in the rabbit and the rat. Administration of Crinofizin one hour before insulin prevented totally or partially these effects of insulin. The drug acted as a blocking agent in the processes of endogenous adrenaline and noradrenaline secretion-excretion under hormonal stimulation, but not under basal conditions.

The role of the renin-angiotensin system in arterial hypertension in hypercorticism.

The authors have studied on 25 cases of hypercorticism, one of the mechanisms of producing arterial hypertension, the renin-angiotensin system. The study showed that in only 20% of the cases plasma renin activity was high whereas in the remaining 80% other mechanisms were responsible for the hypertension. In the cases in which the plasma activity of renin was high, by studying the changes in the value of electrolytes we were able to derive some understanding of the mechanism of action of the RA2A system. Thus, the literature data show that sometimes the excess of glucocorticoids causes hypertension by activating directly the RA2A system and concomitently inhibiting the renin-kalikrein system (RKKS) and PgS; at other times, the excess of glucocorticoids is exerted on the same renin-angiotensin system, but via ACTH and ADH, the electrolytes values being those that demonstrate the borrowed mechanism.

Hyperthyroidism and pregnancy. II. Thyroid function in normal pregnancy and in pregnancy associated with hyperthyroidism.

Starting from the diagnostic difficulties when hyperthyroidism is associated with pregnancy, PBI, total T4 and free thyroxin, triiodothyronine (T3), rT3, TBG, TSH and LATS were assayed in a group of euthyroid pregnant women (136) more or less equally distributed between month 2 and 9 of pregnancy; the same tests were applied to 14 pregnant hyperthyroid women (month 2-3), the latter also undergiving a test for urinary elimination of catecholamines. The results were referred to the normal values of techniques employed. The work presents the alterations in the thyroid status parameters when pregnancy is associated with hyperthyroidism, as against normal pregnancy, pointing out the need for performing a complex set of assays "in vitro" in order to establish correctly the diagnosis of hyperthyroidism in pregnancy and apply the right therapy at the right moment. Increased T3 and free T4 levels in hyperthyroidism referred to an increased TBG level in euthyroid pregnancy are considered as discriminators.

Knowledge of the hormonal peculiarities of essential arterial hypertension may direct therapy and prevent errors.

The endocrine system becomes involved in the physiopathologic mechanisms of essential arterial hypertension (EAH) by the interference of hormones with the pressor and depressor substances. A "depressor" pharmacodynamic model with beta-blockers based on the variations of hormone-dependent data offers a series of characteristics for assessing the vasoconstrictive and volemic components, evolution (accelerated for instance) and treatment. Hormone data are also useful for avoiding errors and for increasing the efficiency and control of the therapy. It is not uncommon for EAH to become endocrine-dependent, for instance: increase in aldosterone secretion by activation of the renin-angiotensin (RA) system or of the hypophysis- corticoadrenal system and the adreno-sympathetic system, transforms the relatively "benign" evolution of EAH into an "accelerated" one. The incidence of hyperreactive corticoadrenal (with or without altered steroidogenesis), corticoadrenal hyperplasia or adenoma, is in reality higher than commonly diagnosed.