Use of omeprazole in the management of giant duodenal ulcer: results of a prospective study.

BACKGROUND: Giant duodenal ulcer (GDU) is generally thought to require surgical intervention. Proton pump inhibitors have beneficial effects in peptic ulcer disease, but their role in GDU disease is unknown. We examined the use of omeprazole in GDU management. METHODS: Twenty-eight patients were diagnosed with GDU. One patient required immediate operative intervention. The remaining 27 were placed on omeprazole (40 mg daily). When ulcer healing was documented by endoscopy, the patients were placed on oral histamine-2 receptor antagonist therapy. RESULTS: Of the 28 study patients, 20 (71.4%) did not require operative intervention, and 8 (28.6%) required operation for ulcer complications. Of the 15 patients with adherent clot or a visible vessel at initial endoscopy, 7 (46.7%) required operative intervention, as compared with 1 (7.7%) of the 13 patients without a visible vessel or adherent clot. This difference was statistically significant (P < .05). Twenty-three patients underwent antral biopsy and/or enzyme-linked immunosorbent assay for Helicobacter pylori, and 9 (39.1%) had a positive result. CONCLUSIONS: Omeprazole is effective in the treatment of GDU disease. An adherent clot or a visible vessel at endoscopy indicates a higher likelihood of complications requiring operation. The relatively low H pylori infection rate, as compared with other peptic ulcer disease, may indicate a different pathophysiology in GDU.

Does use of the Coloscreen Self-Test improve patient compliance with fecal occult blood screening?

Occult blood-screening methods which do not require stool manipulation have been devised in an attempt to improve patient compliance with fecal occult blood testing. We performed a randomized, prospective study comparing patient compliance with the Coloscreen Self Test, a fecal occult blood detection method which does not require stool manipulation, and standard guaiac-impregnated cards in a VA clinic and a university-based private practice to determine whether the Coloscreen Self-Test would improve patient compliance with fecal occult blood testing. Overall, there was no significant difference in compliance between the two tests, with a compliance of 71% (105/147) for the guaiac cards and 60% (88/136) for the Coloscreen Self-Test (p = 0.49). However, multiple logistic regression showed that, when using the Coloscreen Self-Test, patients at the VA clinic had significantly reduced compliance. Only 46% (23/50) returned the Coloscreen Self-Test compared with 84% (42/50) who returned the guaiac cards (p < 0.05). We conclude that the Coloscreen Self-Test does not improve patient compliance with fecal occult blood testing, and may reduce compliance in some sectors of the population.

Alpha-fetoprotein alterations in alcoholics with liver disease. V.A. Cooperative Study Groups.

Sera on 409 male alcoholics with liver injury were assayed for alpha-fetoprotein (AFP) as part of a VA co-operative study on the natural history and therapy of alcoholic liver disease. In 78% of the patients values below normal were observed and 42% had undetectable levels. Clinically the lowest AFP concentrations were observed in the more severely ill patients with the poorest 1 year survival. Furthermore, improvement in AFP was associated with improved survival. Correlation analysis showed a relationship of AFP to (1) visceral protein concentrations (i.e. albumin, transferrin, retinal binding protein); (2) variables related to hepatic fibrogenesis (i.e. Ito cell activity, quantitative estimates of fibrosis and Kupffer cell abnormalities); and (3) changes in immunoglobulin levels particularly IgG. These findings suggest that AFP is a good index of disease prognosis.

Misdiagnosis of the Zollinger-Ellison syndrome due to hyperlipidemia.

Most authorities feel that diagnosis of the Zollinger-Ellison syndrome is established when the serum gastrin level is greater than 1000 pg/mL (1000 ng/L) in a patient with gastric acid hypersecretion and clinical manifestations consistent with the diagnosis. A patient with recurrent peptic ulcer disease is reported who was thought to have had the Zollinger-Ellison syndrome based on two serum gastrin level measurements greater than 1000 pg/mL (1000 ng/L). Subsequent evaluation revealed the gastrin elevation to be spurious because the sample was hyperlipidemic. Lipemic serum samples may yield falsely elevated serum gastrin determinations as determined by radioimmunoassay.

Longevity among ethnic groups in alcoholic liver disease.

As part of a multicenter V.A. Cooperative Study, 437 male veterans with varying stages of alcoholic liver injury were followed over a 4.5 year period. Their ethnic distribution consisted of 256 Caucasians, 109 black Afro-Americans, 63 Puerto Rican Hispanics, and 9 Native American Indians. Survival analyses revealed significant differences between groups (P = 0.0002): 66% of Afro-Americans were still living at 42 months; Caucasians were intermediate with 40% survival; and only 28% of Hispanics were alive. The number of Native American Indians enrolled was too small to draw conclusions but none of those enrolled survived beyond 24 months. Survival regression analysis of 30 clinical, laboratory, histologic and nutritional parameters, revealed the following significant risk factors: clinical severity (P less than 0.0001), histologic severity (P less than 0.0001), race (P = 0.001), age (P = 0.002), BUN (P = 0.01) and ALT (P = 0.02). These analyses indicated that ethnicity, independent of other variables, is significantly associated with outcome from the disease.

Effect of Strongyloides ratti on small bowel function in normal and immunosuppressed host rats.

Although Strongyloides stercoralis is a common parasite, little is known about its effect on intestinal function. Published clinical studies are difficult to evaluate and compare because of the inability to differentiate the effects of the parasite load from that of various other coexisting features such as bacterial overgrowth, multiparasitism, malnutrition, or tropical sprue. Using a rat model where these problems do not occur, we found that Strongyloides ratti did not inhibit intestinal function in the healthy rat. In fact, in normal rats S. ratti appeared to increase ileal sucrase activity. In contrast, in the methylprednisolone-treated rat, S. ratti produced a decrease in lactase and sucrase activity and an increase in alkaline phosphatase activity. S. ratti had no effect on 3-O-methylglucose uptake or D-xylose absorption in either group. These results suggest that S. ratti has little effect on small bowel function in a healthy rat but can cause minor alterations in intestinal function in an immunosuppressed, methylprednisolone-treated, malnourished host. These results are also consistent with clinical observations seen with S. stercoralis in humans and with another nematode, Ascaris suus, in the pig model.

Lymphocyte subset alterations in patients with alcoholic hepatitis.

Twenty-three patients with alcoholic hepatitis (AH) were entered into a study to evaluate the relationship between alcoholic hepatitis, malnutrition, and immune status. In order to quantify these variables, objective parameters of nutritional status and lymphocyte phenotype and function were used. On admission to hospital, the mean number of CD4 helper/inducer cells, CD8 suppressor/cytotoxic cells, and CD3 lymphocytes were significantly reduced compared to age matched, non-hospitalized laboratory controls. In order to ascertain whether this abnormality was reversible, 12 patients, who were willing to remain in the hospital for 30 days, were treated for this entire period with oral nutritional supplementation using a commercially available preparation high in calories, protein, and branch chain amino acids. After 30 days of this therapy and abstinence, the number of CD4 cells increased from a mean (+/- SD) of 658 +/- 428 to 815 +/- 599/mm3. There was no difference in results of the lymphocyte transformation test comparing pre- and post-therapy values using either fetal calf or autologous serum. For all groups tested, cells cultured in autologous serum exhibited a significantly decreased response to mitogen compared to cells cultured in fetal calf serum. Both the total nutritional and the protein depletion (kwashiorkor) scores improved significantly during the 30 days of nutritional supplementation (p less than 0.0009 and p less than 0.0004, respectively). Therefore, we have observed an alteration in the numbers of helper lymphocytes in patients admitted with AH. This abnormality was modifiable by abstinence and nutritional supplementation over a brief period of hospitalization.

Hepatitis B vaccination. Response of alcoholic with and without liver injury.

Alcoholics are at risk to develop hepatitis B infections, chronic active hepatitis, and even hepatoma. Hence, immunization with hepatitis B vaccine is recommended. However, immune abnormalities may coexist which alter their responsiveness to vaccination. This study compares the immune response to this vaccine in controls (group I), alcoholics without overt liver disease (group II), and alcoholics with clinical liver disease (group III). By the seventh month after the initial vaccination, 89% in group I, 70% in group II, and 18% in group III had a response greater than 36 RIA units. The magnitude of the response was significantly different in groups I, II, and III (19,456 vs 8,326 vs 153 RIA units, respectively; P less than 0.05, group I vs III). In those who did not respond, a significant (P less than 0.02) lower helper/inducer (T4) class of lymphocytes was observed as compared to patients who exhibited an adequate response. These observations suggest: (1) that the response to hepatitis B vaccine is a T-cell-dependent event and (2) that in this population, using the existing vaccine, postvaccination evaluations of antibody concentrations are needed before protection against hepatitis B infection can be assumed.

Escherichia coli peritonitis after left-sided colonoscopy in a patient on continuous ambulatory peritoneal dialysis.

A 69-yr-old man on chronic ambulatory peritoneal dialysis presented with Escherichia coli peritonitis 36 h after left-sided colonoscopy. No evidence for colonic perforation was found and the infection cleared with intravenous and intraperitoneal antibiotics. This case supports the need for further studies evaluating the use of prophylactic antibiotics during colonoscopy of chronic ambulatory peritoneal dialysis patients with diverticula.

Congenital hepatic fibrosis and cerebral aneurysm in a 32-year-old woman.

Congenital hepatic fibrosis has been associated with a number of visceral abnormalities, but only rarely with cerebral aneurysms. We report a case of a 32-year-old woman with congenital hepatic fibrosis and a subarachnoid hemorrhage secondary to a ruptured cerebral aneurysm. A review of the literature reveals only two previous reports of such an association and both were also associated with polycystic kidney disease. Our patient is unique in that she does not have polycystic kidney disease but rather medullary sponge kidney.

VA cooperative study on alcoholic hepatitis. II: Prognostic significance of protein-calorie malnutrition.

Three hundred and fifty-two patients with alcoholic hepatitis were evaluated for protein-calorie malnutrition (PCM). In order to facilitate data analysis of nutritional status, a PCM score was calculated for each patient using eight nutritional parameters. The PCM score correlated significantly with mortality, clinical severity of the liver disease, and biochemical liver dysfunction. When 30 day changes in the PCM scores were compared with 30 day caloric intake (expressed as percent basal energy expenditure (BEE], a marginally significant correlation was observed (p = 0.05). However, those patients who showed improvement in their PCM score over 30 days of hospitalization also improved their 6-mo and 1-yr survival. These data indicate that nutrition, as determined by the PCM score, has prognostic significance. Additional studies are needed to establish the beneficial role for vigorous protein-calorie nutritional therapy in the management of alcoholic hepatitis.

Effect of chronic ethanol consumption on the pancreas of the hamster.

The purpose of this study was to determine the effect of chronic ethanol consumption on pancreatic morphology and biochemistry in the hamster, with special attention to lipid changes. A control group of Syrian golden hamsters fed a synthetic liquid diet was compared to an ethanol group pair-fed the same diet with ethanol substituted for 35% of the carbohydrate calories. The animals were sacrificed at 7 weeks and 3, 6, 9, and 12 months. After 12 months of ethanol consumption, a significant decrease in pancreatic triglycerides and a significant increase in pancreatic RNA was seen. These changes were associated with a rise in pancreatic weight and protein content in the ethanol group, reversing a six-month decline in these values. This rise in RNA and protein in the ethanol-treated group corresponded with the appearance of large abnormal zymogen granules. Other ultrastructural features such as lipid droplets, mitochondria, and endoplasmic reticulum were not altered by ethanol. Ethanol did increase the water content of the pancreas. Although ethanol had no effect on the fasting levels of insulin or pancreatic polypeptide, the fasting serum gastrin immunoreactivity was significantly lower in the ethanol animals. This study shows that chronic ethanol consumption produces a metabolic change in the hamster by 12 months which is suggestive of increased protein synthesis with a decrease in pancreatic triglycerides and no lipid droplet formation.

Protein-calorie malnutrition associated with alcoholic hepatitis. Veterans Administration Cooperative Study Group on Alcoholic Hepatitis.

Three hundred sixty-three alcoholic patients with alcoholic hepatitis were studied in six Veterans Administration medical centers. By history, alcohol consumption was 227.9 g per day, with a mean duration of 23.8 years. Cirrhosis accompanied the alcoholic hepatitis in 58.7 percent of the patients who underwent biopsy or autopsy. Complete nutritional assessment was performed in 284 patients, and observed nutritional changes were classified into those associated with marasmus or those characterizing kwashiorkor. A smaller comparison group of 21 alcoholic patients matched for age and alcohol consumption but without clinically evident liver disease was also studied in an identical manner. None of the patients with liver disease was completely free from malnutrition, whereas 62 percent of the alcoholic patients without liver disease showed abnormalities. In patients with alcoholic hepatitis, some findings associated with marasmus were seen in 86 percent, and some features of kwashiorkor were observed in 100 percent. When present together, the complete picture of kwashiorkor and marasmus correlated closely with the clinical severity of the liver disease (p less than 0.005). The nearly constant association of either complete or partial kwashiorkor or marasmus suggests that the separation of these two entities is artificial in alcoholic patients with liver disease. Although, experimentally, malnutrition may not be essential for the development of alcoholic hepatitis, clinically, it appears to precede the development of the liver injury, which suggests an interaction. Recognition is important so that appropriate nutritional therapy can be provided.

Lipogranulomas in non-fatty human livers. A mineral oil induced environmental disease.

Forty-four cases of lipogranulomas (LG) in non-fatty livers (NFL), consisting of 38 biopsies and six autopsy livers, were studied. LG in NFL have a distinct morphologic characteristic and virtually all are attached to or closely associated with the walls of hepatic venules. The reason for this peculiar location remains unexplained. Our data from lipid histochemistry and analysis of lipid extracts from the livers and foodstuffs by thinlayer chromatography and gas-liquid chromatography indicate that LG in NFL most likely represent a reaction to absorbed saturated hydrocarbons, like mineral oil, used widely in the food industry. The incidence of LG is increasing, as evidenced by a 1.7% incidence in 1952-53 compared with 4.6% in 1978-80. LG seldom present a diagnostic problem provided serial sections are examined. An awareness of the characteristic morphology will prevent an extensive granuloma work-up. They appear to be an incidental finding in liver biopsies, and of no clinical significance at present; however, their long-term implication, if any, must await future observations.

Serum alpha-fetoprotein: changes associated with acute and chronic ethanol ingestion in the resting and regenerating rat liver.

The effect of acute and chronic ethanol consumption on serum alpha-fetoprotein was studied in adult male rats with resting and regenerating livers. Unlike many hepatotoxins, ethanol consumed over both the long and short term suppressed serum alpha-fetoprotein concentrations (p less than 0.05). This suppression was not due to increased degradation, since the half-life of alpha-fetoprotein was not significantly altered by chronic ethanol treatment. However, liver cytosolic alpha-fetoprotein was markedly increased after ethanol consumption, suggesting the presence of impaired secretion or mobilization from the liver cells. During liver regeneration following partial hepatectomy, alpha-fetoprotein increased in both the control (390 ng-hr/ml) and ethanol-treated animals (288 ng-hr/ml). At no time did the ethanol animal values equal the control levels. The change in serum alpha-fetoprotein showed an inverse exponential correlation with the amount of liver removed at hepatectomy and a positive correlation with the amount of nuclear DNA present at sacrifice. However, in the ethanol-treated animals it required the removal of 1.9 times as much liver to stimulate the same degree of liver regeneration as in the controls (p less than 0.001). A significant inverse correlation was observed between 3H-thymidine uptake and the areas under the alpha-fetoprotein time curves in the controls (p less than 0.001). In the ethanol groups the correlation was not statistically significant (p less than 0.2). It is concluded that although changes in serum alpha-fetoprotein may be associated with liver injury and regeneration, they are not a direct result of the regenerative process. The direct correlation with available nuclear DNA indicates the need for existing cells to hypertrophy and produce the alpha-fetoprotein. The depression associated with acute and chronic ethanol ingestion appears to reflect a direct effect of ethanol on protein synthesis and/or release.