IgA nephropathy in non-cirrhotic portal hypertension.

Renal glomerular changes are a well recognised complication of cirrhosis and are frequently characterised by mesangial IgA deposition. We report a patient with non-cirrhotic portal hypertension who developed IgA nephropathy and a nephrotic syndrome with renal histological changes classically associated with cirrhosis. Splenectomy with resection of a splenic artery aneurysm resulted in remission of the nephrotic syndrome. This case illustrates the factors which contribute to the pathogenesis of IgA nephropathy in liver disease.

Vomiting after Roux-en-Y biliary diversion: relationship to surgical technique.

Vomiting is a frequent complaint after revisional gastric surgery using a Roux-en-Y biliary diversion. This is believed to be due to gastric stasis or stasis in the jejunal component of the Roux-en-Y. Thirty-three patients, ten with a satisfactory outcome following Roux-en-Y diversion and 23 with an unsatisfactory outcome, were studied using a semisolid, radiolabelled meal and compared with 12 normal subjects. Outcome was assessed by modified Visick grading. Seven patients with an unsatisfactory outcome because of frequent vomiting had gastric stasis and two had delay in emptying of the jejunal component of the Roux-en-Y. Vomiting was more likely in patients with a dependent sump (P less than 0.006) and emptying was significantly prolonged where a sump was present (P = 0.0009). Surgical technique contributed to the dependent sump.

Outcome of revisional gastric surgery using a Roux-en-Y biliary diversion.

One hundred and seven patients with postoperative reflux gastritis treated by Roux-en-Y biliary diversion were reviewed. Three patients died in the postoperative period, and 16 others have since died; cardiorespiratory disease was the most frequent cause of death. Seventy-nine patients were interviewed at a median of 5.5 years (range 0.5-26 years) following Roux-en-Y diversion. At review, a satisfactory result by modified Visick grading was present in 47 per cent of patients. Bilious vomiting (P less than 0.001), food vomiting (P less than 0.01), the severity of upper abdominal pain (P less than 0.001) and heartburn (P less than 0.025) were significantly improved by Roux-en-Y diversion. Weight, haemoglobin levels and employment status were not significantly altered by the procedure. Outcome was related to the surgery preceding Roux-en-Y diversion with significantly better results after partial gastrectomy compared with truncal vagotomy and drainage (P less than 0.01), cholecystectomy (P less than 0.05), or combinations of these procedures (P less than 0.01). Outcome was not predicted by sex, preoperative symptoms, smoking status, consultant surgeon, length of Roux-en-Y or 99Tc-Sn-2,6-di-ethylacetanilidoiminodiacetate (HIDA) scanning results.

Bile acid malabsorption: a complication of conduit surgery.

We examined the possibility that use of a section of the terminal ileum for ileal conduit construction may impair bile acid absorption and cause choloretic diarrhoea. Nineteen normal subjects (mean age 41 years) and 16 patients with conduits (mean age 47 years) were investigated using the SeHCAT retention test. Conduit patients showed significant impairment of SeHCAT retention compared with normal subjects; 82% of patients had a retention below the lower limit of normal. The mean bowel frequency of patients during the test was 3 motions/day this being significantly different from their pre-operative bowel habit. It was concluded that the use of the terminal ileum in conduit construction may impair bile acid absorption, as measured by the SeHCAT retention test, and may cause an increase in bowel frequency.

Total pancreatectomy for chronic pancreatitis.

A survey of six British centres collected data on 83 patients undergoing total pancreatectomy (TP) for chronic pancreatitis between 1977 and 1986. There were 57 men and 26 women with a median age of 38 years (range 19-61 years). Half were alcoholics and half had had previous acute pancreatitis. Besides jaundice (14 per cent) severe pain was the indication for the operation; regular opiates had been needed in 82 per cent of patients and 37 per cent were addicted to these drugs. All but 12 had had previous pancreatic or biliary surgery, with a median of two operations and a maximum of six. TP was a one-stage procedure in 32 patients, 42 had had distal resections and 9 proximal resections in the past; the pylorus was preserved in 30. Median operation time was 4 h (range 2-18 h) and median blood loss was 3 units (1-21 units). Intraoperative complications in 11 patients included haemorrhage in 9. Four deaths occurred within 30 days from bleeding (2), respiratory failure (1) and Roux-loop infarction (1). All but one of the 79 survivors required full pancreatic supplementation and 38 per cent had difficulties in endocrine control. At a median follow-up of 1.5 years (range 0.25-10 years), 57 patients (72 per cent) were pain-free and 9 (11 per cent) needed only occasional analgesia. Though 13 (17 per cent) still took regular analgesics, all were symptomatically improved. There have been 10 late deaths (13 per cent), all but one of which are attributable to the operation.

Effects of bile, infection and pressure on pancreatic duct integrity.

Ionic flux, potential difference and mucosal ultrastructure have been studied in the rat bile-pancreatic duct and the effects of pressure, bile and infection on the duct evaluated. The duct remained stable after perfusion with control solution under low pressure and high pressure produced widening of intercellular spaces only. Perfusion with a bacterial solution of Escherichia coli did not effect significant changes. Sterile human bile disturbed the integrity of the duct by increasing ionic flux, altering potential difference and producing reversible ultrastructural changes of cell oedema. High pressure increased these changes. Infected human bile under high or low pressure was by far the most toxic substance tested. Perfusion with infected bile led to irreversible duct damage and complete loss of duct integrity. Pressure and infected bile may have a role in damaging duct integrity and could thus play an integral part in the genesis of acute gallstone pancreatitis.

Pressure, volume and the pancreas.

The effects of injection volume and pressure on the rat pancreas have been investigated. An experimental model using transduodenal cannulation of the rat bile-pancreatic duct was used. Injection volumes of 100 microliter or above produced gross ductal extravasation regardless of pressure. With a 50 microliter volume leakage from the ducts occurred via intercellular clefts at a pressure of 20 cmH2O and via duct ruptures at 50 cmH2O. Survival experiments (24 hours) were carried out using the 50 microliter volume. Infusion of 50 microliter saline at increasing pressures produced rises in amylase concentrations, pancreatic gland weights and water content of the gland at pressures of 20 cmH2O or above. These changes were maximal when 50 cmH2O of pressure was maintained for 60 minutes. The changes correlated with extravasation shown by Indian ink. Histological oedema related closely to pressure (r = 0.92), and was the most pronounced histological change observed. In experiments using intraduct injection into the rat pancreas a volume of 50 microliter or less should be used with careful consideration given to pressure. Unless these prerequisites are followed the results of experimental investigation cannot be extrapolated to acute gall stone pancreatitis in man.

The surgical factors influencing duodenogastric reflux.

The surgical factors influencing duodenogastric reflux have been assessed in dog and man using the biliary radiopharmaceutical 99mTc-EHIDA. Cholecystectomy led to a significant increase in the amount of reflux (P less than 0.01), but the combination of truncal vagotomy and pyloroplasty in addition to cholecystectomy produced a greater amount of reflux (P less than 0.01). In man, cholecystectomy also resulted in a significant increase in the amount of reflux (P less than 0.01). In ten control subjects reflux occurred but the amount was small and was not significantly different from the modified highly selective vagotomy group (n = 20). Symptomatic patients after truncal vagotomy and pyloroplasty (n = 16) showed a significant increase in the amount of reflux (P less than 0.002) but the combination of vagotomy and pyloroplasty in addition to cholecystectomy (n = 15) demonstrated the greatest amount of reflux (P less than 0.002). Similarly the addition of cholecystectomy to highly selective vagotomy (n = 9) showed a significant increase in the amount of reflux (P less than 0.02). Reconstruction of the pylorus (n = 8) was not a satisfactory procedure for the prevention of reflux but antrectomy and Roux-en-Y biliary diversion (n = 8) resulted in a significant reduction in the amount of reflux (P less than 0.001) and this was associated with clinical improvement.

The effect of cholecystectomy on duodenogastric reflux in dogs and humans.

A prospective study of the effect of cholecystectomy on duodenogastric reflux (DGR) in dogs and humans has been performed and compared with patients presenting with persisting symptoms following cholecystectomy several years earlier. After an intravenous injection of 99mTc EHIDA, assessment of DGR was made by measuring Bilirubin Output and the percentage of 99mTc EHIDA recovered in gastric juice over fifteen minute periods. Cholecystectomy resulted in a significant increase in both amount and frequency of DGR in dogs and patients. Patients with persisting symptoms following cholecystectomy showed the greatest amount and frequency of DGR. We suggest that increased DGR may be an aetiological factor in some patients with persisting symptoms following cholecystectomy.

The effect of cholecystectomy on duodenogastric reflux in patients with previous peptic ulcer surgery.

Duodenogastric reflux (DGR) has been assessed in healthy volunteers, patients after vagotomy and pyloroplasty, and in patients following vagotomy and pyloroplasty in addition to cholecystectomy. DGR has been assessed using bilirubin output and 99mTc EHIDA recovered in gastric juice. The control group demonstrated reflux but the quantity was small. Symptomatic patients after truncal vagotomy and pyloroplasty (V + P) showed a significant increase in DGR (P less than 0.002) when compared with the control group but the greatest reflux was seen in symptomatic patients following truncal vagotomy + pyloroplasty + cholecystectomy (P less than 0.002). AS with pyloric preservation showed no significant increase in reflux but the addition of cholecystectomy increased both frequency (P less than 0.001) and amount of reflux (P less than 0.001). We suggest that cholecystectomy when combined with a pylorus preserving or destroying procedure increases DGR and that such increased reflux may be an important factor in gastritis following peptic ulcer surgery.

A clinical evaluation of isotope scanning, ultrasonography and computed tomography in pancreatic disease.

In a prospective study of 46 patients with suspected pancreatic disease the provisional diagnoses arrived at independently by isotope scanning (IS), ultrasonography (USS) and computed tomography (CT) have been compared. In the control group, IS and CT were associated with a higher false positive rate than USS; The isotope scan was abnormal in most patients with proven chronic pancreatitis and cancer. The results from USS and CT were similar when structural changes were present. USS was superior in diagnosing pancreatic carcinoma and was a convenient means to follow the progression of acute pancreatitis to final resolution or the development of a pseudocyst. CT proved especially useful in accurately delineating cysts, pseudocysts and calculi prior to planning surgery and in assessing disease in contiguous viscera.

Value of bile-acid binding agents in post-vagotomy diarrhoea.

Cholecystectomy increases the incidence of post-vagotomy diarrhoea. The effect of agents which either bind bile acids or prevent their action on the colonic mucosa has been studied in 31 patients with post-vagotomy diarrhoea--15 had had vagotomy and pyloroplasty alone and 16 vagotomy and pyloroplasty and cholecystectomy. Cholestyramine was particularly useful after the combined operation. Aluminium hydroxide in large doses has a similar mechanism of action to cholestyramine and is cheaper and more palatable, but propranolol was of no value. This study suggests that the excretion and chemical composition of bile and the handling of bile acids by the small intestine is of fundamental importance in the pathogenesis of post-vagotomy diarrhoea.

Effect of fasting on mucosal blood flow in antrum and corpus of the stomach.

Gastric mucosal blood flow in the rat was determined by the indicator fractionation technique 86RbCl. Antral and corpus flow rates were determined after increasing periods of fasting, and the effect of vagotomy was assessed. The physiological stimulus of food in the stomach markedly increased antral as well as corpus blood flow, and after vagotomy lower flow rates were recorded in all parts of the stomach. With progressive starvation, the antral:corpus flow ratio decreased. The findings suggest that the antrum plays an active role in response to a physiological stimulus and may, as has been suggested by others, contribute to the control of parietal cell blood flow and secretion.