Initial experience in sentinel lymph node detection in pancreatic cancer.

BACKGROUND: The local recurrence of pancreatic cancer is around 30% when complete resection can be achieved. Extended lymphatic resections may improve survival, but increases severe morbidity. As accurate patient selection should be mandatory, a new method is presented for pancreatic sentinel lymph node (SLN) detection with lymphoscintigraphy and gamma probe. MATERIALS AND METHODS: Seven patients with cT2N0M0 pancreatic head cancer were enrolled between 2009 and 2012 in this prospective study. One day prior to surgery, preoperative lymphoscintigraphy with echoendoscopic intratumoural administration of Tc(99m)-labelled nanocolloid was performed, with planar and SPECT-CT images obtained 2h later. Gamma probe detection of SLN was also carried out during surgery. RESULTS: Radiotracer administration was feasible in all patients. Scintigraphy images showed inter-aortocaval lymph nodes in 2 patients, hepatoduodenal ligament lymph nodes in 1, intravascular injection in 3, intestinal transit in 5, and main pancreatic duct visualisation in 1. Surgical resection could only be achieved in 4 patients owing to locally advanced disease. Intraoperative SLN detection was accomplished in 2 patients, both with negative results. Only in one patient could SLN be confirmed as truly negative by final histopathological analysis. CONCLUSIONS: This new method of pancreatic SLN detection is technically feasible, but challenging. Our preliminary results with 7 patients are not sufficient for clinical validation.

Laparoscopic myotomy vs endoscopic dilation in the treatment of achalasia.

BACKGROUND: The aim of this study was to compare the results obtained in 14 patients with achalasia who underwent laparoscopic Heller's myotomy and Dor's fundoplication with those of 16 patients who had endoscopic dilation. METHODS: The diagnosis of achalasia was confirmed by manometry, endoscopy, and barium swallow. Esophageal symptoms were quantified before and after treatment using a clinical scale. Six patients had had endoscopic dilation prior to surgery. RESULTS: Before treatment, the patients in the surgical group complained of more severe dysphagia (median, 5; range, 0-5 vs median 4; range, 3-5) and chest pain (median, 3; range, 0-5 vs median, 1.5; range, 0-5), but both groups were comparable with respect to regurgitation, heartburn, and manometric results. Both groups achieved significant clinical improvement. The severity score decreased from 5 (range, 0-5) to 1 (range, 0-3) (p < 0.05) for dysphagia to solids in the laparoscopic group and from 4 (range, 3-5) to 1 (range, 0-5) (p < 0.05) in the endoscopic group. Lower esophageal sphincter (LES) basal pressure decreased significantly in both groups (from 29.3 to 11.8 mmHg in the laparoscopic group and from 28.9 to 16.5 mmHg in the endoscopic group). After treatment, there were no significant clinical differences between the two groups. Two patients in the surgical group were converted to open surgery. CONCLUSION: Laparoscopic myotomy is as save and effective as endoscopic dilation in the treatment of achalasia.

A multicenter, randomized, clinical trial of hormonal therapy in the prevention of rebleeding from gastrointestinal angiodysplasia.

BACKGROUND & AIMS: The efficacy of hormonal therapy for recurrent bleeding from gastrointestinal angiodysplasia remains uncertain. We investigated the efficacy of long-term estrogen-progestagen therapy in the prevention of rebleeding from gastrointestinal angiodysplasia. METHODS: Seventy-two noncirrhotic patients bleeding from gastrointestinal angiodysplasia confirmed by endoscopy or angiography were randomized to receive in double-blind conditions treatment with ethinylestradiol (0.01 mg) plus norethisterone (2 mg) (1 tablet/d), or placebo (1 tablet/d) for a minimum period of 1 year (range: 1-2 years). RESULTS: Four patients could not be assessed because they did not attend the first follow-up visit. Failure of treatment occurred in 13 of 33 (39%) patients in the treatment group and in 16 of 35 (46%) patients in the placebo group (P = NS). No significant differences between groups were found according to number of bleeding episodes (0.7 +/- 1.0 vs. 0.9 +/- 1.5) and transfusional requirements (0.9 +/- 1.9 vs. 0.7 +/- 1.5 units). Treatment received was not an independent predictor for rebleeding prevention in the multivariate regression analysis. Severe adverse events (2 vs. 1) and mortality (0 vs. 1 patient, respectively) were similar between the treatment and placebo groups. CONCLUSIONS: Continuous estrogen-progestagen treatment is not useful in the prevention of rebleeding from gastrointestinal angiodysplasia.

Helicobacter pylori eradication prevents recurrence from peptic ulcer haemorrhage.

BACKGROUND: Successful eradication of Helicobacter pylori infection clearly modifies the natural history of peptic ulcer disease and prevents further recurrences of duodenal and gastric ulcers. However, there are few prospective studies about actual rates of rebleeding after H. pylori eradication, a highly relevant aspect of management as re-infection, relapse of ulcer disease for other reasons (i.e. anti-inflammatory agents) or idiopathic ulcers unrelated to H. pylori may develop and cause further bleeding episodes. OBJECTIVE: To determine the incidence of bleeding episodes after eradication of H. pylori infection in patients who had bled from an H. pylori-positive peptic ulcer. PARTICIPANTS AND INTERVENTIONS: H. pylori-positive patients who bled from a gastric or duodenal ulcer were treated with appropriate triple and/or quadruple therapy. H. pylori eradication was confirmed by urea breath test 4 weeks after treatment. Patients received no further treatment but were followed clinically and additional urea breath tests were performed every 6 months. Endoscopy with antral and corpus biopsies and urea breath test were repeated as soon as patients manifested any dyspeptic symptoms that might signal recurrence. RESULTS: A total of 103 patients with bleeding duodenal ulcer were included in the study; H. pylori was successfully eradicated in 93 of these patients, who were followed for a median interval of 27 months. The yearly re-infection rate was calculated to be 0.6%. There were no instances of rebleeding in any patients during the follow-up period. CONCLUSIONS: Even after prolonged follow-up, successful H. pylori eradication prevents rebleeding.

Somatostatin plus isosorbide 5-mononitrate versus somatostatin in the control of acute gastro-oesophageal variceal bleeding: a double blind, randomised, placebo controlled clinical trial.

BACKGROUND: Variceal bleeding is a severe complication of portal hypertension. Somatostatin reduces portal pressure by decreasing splanchnic blood flow, and nitrates by diminishing intrahepatic resistance. Experimental studies have shown that the combination of somatostatin and nitrates has an additive effect in decreasing portal pressure. AIM: To compare the therapeutic efficacy of either intravenous infusion of somatostatin plus oral isosorbide 5-mononitrate or somatostatin alone in gastro-oesophageal variceal bleeding associated with liver cirrhosis. METHODS: A unicentre, double blind, placebo controlled, clinical trial was conducted. Sixty patients bleeding from oesophageal or gastric varices were randomised to receive intravenous infusion of somatostatin (250 microg/hour) plus oral isosorbide 5-mononitrate (40 mg/12 hours) (group I) or somatostatin infusion plus placebo (group II) for 72 hours. RESULTS: The two groups of patients had similar clinical, endoscopic, and haematological characteristics. Control of bleeding was achieved in 18 out of 30 patients (60%) in group I and 26 out of 30 patients (87%) in group II (p<0.05). There was no significant difference in mean transfusion requirements between the two groups: 2.6 (2.2) v 1.8 (1.6) respectively; means (SD). Mortality and side effects were similar in the two groups, but development of ascites was higher in group I (30%) than in group II (7%) (p<0.05). CONCLUSION: In cirrhotic patients with acute gastro-oesophageal variceal bleeding, addition of isosorbide 5-mononitrate to somatostatin does not improve therapeutic efficacy, induces more adverse effects, and should not be used.

Practicality of 5-aminosalicylic suppositories for long-term treatment of inactive distal ulcerative colitis.

BACKGROUND/AIMS: Topical 5-aminosalicylic acid (5-ASA) is regarded as an effective form of therapy for distal ulcerative colitis. Unfortunately, experience about acceptability and tolerance of long-term treatment with 5-ASA suppositories is still meager. METHODOLOGY: We have evaluated the performance of 5-ASA suppositories as maintenance treatment in 34 patients with inactive distal colitis. Prior to entering the study, all patients were in clinical remission for 1-12 months. A single 500 mg 5-ASA suppository was administered nightly for 12 months in every patient and all other treatments were discontinued. Clinical evaluation was performed at 3, 6 and 12 months. RESULTS: Four patients withdrew from the study within the first 3 months because of local intolerance to the suppositories. Score of both comfort and tolerance was significantly higher in patients who continued treatment than in those who withdrew. Two patients who stayed in remission withdrew, one at 7 months because of thrombocytopenia and the other at 9 months for personal reasons. Of the 28 remaining patients, 7 relapsed and 21 remained in clinical remission at the end of the 12-month study period. Eleven of the 21 responder patients agreed to a sigmoidoscopic examination, that confirmed remission in all of them. Eight out of the 9 patients who had previously received 5-ASA enemas preferred suppositories to enemas. Apart from the 4 patients who did not tolerate suppositories, 26 patients considered this form of therapy quite comfortable. CONCLUSIONS: 5-ASA suppositories are generally well tolerated and considered comfortable for treatments of at least one year.

The impact of delaying gastric emptying by either meal substrate or drug on the [13C]-urea breath test.

OBJECTIVE: Optimal [13C]-urea breath test (UBT) conditions for diagnosis of Helicobacter pylori infection are still being fine-tuned. In the present study we investigated the impact of delaying gastric emptying by different meal substrates or L-DOPA, a drug known to induce gastric stasis, on the performance of the [13C]-UBT. METHODS: A total of 115 patients participated in the study. On two consecutive days, participants ingested [13C]-urea (100 mg) 10 min after either 270 ml of a mixed formula meal (1 Kcal/ml) or an equivalent amount of tap water. In 11 participants two additional tests were performed with or without oral 500 mg L-DOPA given 30 min before [13C]-urea load. The 13C/12C ratio in a basal breath sample was compared with ratios in samples collected 30 and 60 min after [13C]-urea. Histological assessment of H. pylori presence in antral biopsy served as reference standard. RESULTS: Formula UBT showed excellent specificity (100% at 30 and 60 min) and good sensitivity (97% at both time intervals), whereas water UBT had the same specificity but slightly lower sensitivity (94% at 30 min and 73% at 60 min). In formula UBT, 13C/12C ratios were higher at 60 min than at 30 min (21.7+/-2 vs 17.7+/-1.8 per thousand respectively, p < 0.01, whereas in water UBT 13C/12C ratios were higher at 30 min than at 60 min (13.9+/-1.5 vs 8.4+/-0.09 per thousand respectively, p < 0.01). Pretreatment with L-DOPA did not modify either the sensitivity or the specificity of the UBT. CONCLUSIONS: The performance of the [13C]-urea with a formula meal may not be improved by pharmacologically delaying gastric emptying. A short, water-based test may be a sensible approach to worldwide standardization of the [13C]-UBT for H. pylori infection.

[Gastric ulcers as the only manifestation of infection by cytomegalovirus in immunocompetent patients]. / Ulceras gástricas como única manifestación de infección por citomegalovirus en pacientes inmunocompetentes.

Gastritis is an infrequent manifestation of infection by cytomegalovirus (CMV) in a healthy host. This complication is usually associated to a mononucleosic syndrome during the course of a disseminated infection. Macroscopically, it presents with edema and mucosal congestion, multiple erosions or ulcers. Histologic examination of the endoscopic biopsies allows the etiologic diagnosis to be established in most cases. In immunocompetent patients the clinical course of gastritis by CMV is usually self-limited. We herein present two immunocompetent patients with gastric ulcerous disease as the only manifestation of CMV infection. Both patients required antiviral treatment due to refractoryness to the antisecretor treatment and one case evolved to pyloric stenosis requiring surgery.

Usefulness of rectal dialysis to determine intrarectal eicosanoids release in ulcerative colitis.

The quantification of the local production of eicosanoids is of interest because it has been implicated in the mucosal damage of ulcerative colitis. In situ production of eicosanoids is not reflected by its urinary or seric levels, requiring invasive examinations. Thus, new non-invasive techniques such as rectal dialysis have been investigated. The purpose of this study was to assess whether the determination of the intrarectal eicosanoid levels measured by rectal dialysis is useful in detecting the presence of rectal inflammation in patients with ulcerative colitis. Thirty one patients with clinically active colitis and 7 controls with irritable bowel syndrome have been studied. A 10 cm long dialysis bag was placed in the rectum for 1 hour. To determine the variability of the technique, the dialysis was repeated the next day in 6 controls. To detect intrarectal eicosanoids release in inactive colitis, rectal dialysis was performed in another group of 15 patients with clinical and endoscopically inactive colitis and compared with 9 patients with active colitis. PGE2, TXB2, and LTB4 were measured in rectal dialysates by immunospecific RIA. Dialysis was well tolerated by all participants. Intrarectal level of every eicosanoid was much higher in active colitis than in controls (p < 0.05) and in inactive colitis (p < 0.001). The mean coefficient of variation of duplicated dialysis ranged from 15 to 28%. In conclusion, rectal dialysis is a non-invasive technique that allows to prove the presence of active inflammation in ulcerative colitis patients.

Oesophageal tone in patients with achalasia.

BACKGROUND: The diagnosis and classification of oesophageal motility disorders is currently based on assessment of the phasic contractile activity of the oesophagus. Tonic muscular contraction of the oesophageal body (oesophageal tone) has not been well characterised. AIM: To quantify oesophageal tonic activity in healthy subjects and in patients with achalasia. PATIENTS: Oesophageal tone was measured in 14 patients with untreated achalasia and in 14 healthy subjects. In eight patients with achalasia, oesophageal tone was again measured one month after either endoscopic or surgical treatment. METHODS: Tonic wall activity was quantified by means of a flaccid intraoesophageal bag, 5 cm long and of 120 ml maximal capacity, which was placed and maintained 5 cm above the lower oesophageal sphincter and connected to an external electronic barostat. The experimental design included measurement of oesophageal basal tone and compliance as well as the oesophageal tone response to a nitric oxide donor (0.5 ml amyl nitrite inhalation). RESULTS: Oesophageal basal tone, expressed as the intrabag (intraoesophageal) volume at a minimal distending pressure (2 mm Hg), did not differ significantly between patients with achalasia and healthy controls (6.6 (2.5) ml versus 4.1 (0.8) ml, respectively). Oesophageal compliance (volume/pressure relation during intraoesophageal distension) was significantly increased in achalasia (oesophageal extension ratio: 3.2 (0.4) ml/mm Hg versus 1.9 (0.2) ml/mm Hg; p < 0.01). Amyl nitrite inhalation induced oesophageal relaxation both in patients and in controls, but the magnitude of relaxation was greater in the latter (intrabag volume increase: 15.3 (2.4) ml versus 36.2 (7.1) ml; p < 0.01). CONCLUSION: In patients with achalasia, oesophageal tonic activity, and not only phasic activity, is impaired. Although oesophageal compliance is increased, residual oesophageal tone is maintained so that a significant relaxant response may occur after pharmacological stimulation.

Chest pain and reappearance of esophageal peristalsis in treated achalasia.

BACKGROUND: We wanted to evaluate the clinical significance of the esophageal peristalsis that appears in some achalasia patients after treatment. METHODS: We prospectively investigated the reappearance of esophageal peristalsis in 106 achalasic patients treated with forceful dilatation under endoscopic control (86 metallic dilatations and 20 pneumatic dilatations) and followed up clinically and manometrically for 1 year. Patients were divided in two groups in accordance with the presence (n = 26) or persistent absence (n = 80) of postdilatation esophageal peristalsis. RESULTS: Before treatment, clinical data and manometric findings were comparable in both groups except for esophageal wave amplitude, which was higher in patients with postdilatation peristalsis (36 +/- 5 mmHg versus 24 +/- 2 mmHg, P < 0.05). One year after dilatation manometric findings were similar in the two groups, but esophageal wave amplitude remained higher in the group with postdilatation peristalsis (46 +/- 4 mmHg versus 21 +/- 2 mmHg, P < 0.05). The proportion of patients with persistent dysphagia was similar in the two groups (15% versus 12.5%). However, 10 patients with postdilatation peristalsis (38%) complained of chest pain as opposed to only 5 patients (6%) in the group with aperistalsis (P < 0.01). CONCLUSION: The appearance of esophageal peristalsis after forceful dilatation in achalasic patients is frequently associated with persistent or new chest pain.

Bile acid induced colonic irritation stimulates intracolonic nitric oxide release in humans.

AIM: To measure the intracolonic release of nitric oxide end products (nitrates plus nitrites) and eicosanoids in response to intraluminal irritation with deoxycholic acid (DCA). PATIENTS: Seven patients with irritable bowel syndrome. METHODS: The left colon was perfused with a solution with or without 3 mM deoxycholic acid. Aspirates were assayed for eicosanoids by specific radioimmuno-assay, and for nitrates plus nitrites by the Griess reaction. To confirm that stimulated colonic mucosa can produce nitric oxide (NO), ancillary studies were performed in vitro using samples of normal mucosa obtained from five surgically resected colons. Samples were incubated for 30 minutes in Kreb's solution, 3 mM DCA or DCA with 1 mM L-nitro-arginine-methyl-ester (L-NAME) to inhibit the NO synthase. Finally, NO synthase activity was measured in five samples of human colonic mucosa. RESULTS: Intracolonic release of nitrates plus nitrites was basally undetectable in six of seven patients. Bile acid considerably increased the release of prostaglandin E2 and nitrates plus nitrites (p < 0.01). By contrast, no increase in thromboxane and leukotriene was seen. In vitro mucosal incubation with DCA increased the production of NO synthase products, which was blocked by L-NAME. Activity of Ca+2 independent NO synthase was detectable in four of five samples of human colonic mucosa. CONCLUSION: The human colonic mucosa responds to bile acid induced irritation by a surge in NO generation via NO synthase.

Intracolonic release in vivo of interleukin-1 beta in chronic ulcerative colitis.

1. To investigate the role of interleukin-1 beta in chronic ulcerative colitis, we quantified interleukin-1 beta steady-state release into the colonic lumen. 2. We studied 26 patients with untreated chronic ulcerative colitis and seven patients with irritable bowel syndrome who served as disease controls. In seven ulcerative colitis patients, the disease was inactive and in 19 it was mild to moderately active, according to clinical and colonoscopic criteria. Seven patients with active colitis were studied before and after 4 weeks of treatment with oral 5-aminosalicylic acid. 3. Colonic perfusions were performed using a double-lumen technique. An isotonic solution was continuously infused 50 cm from the anal verge at 5 ml/min, and was recovered 30 cm distally by siphonage. Interleukin-1 beta was measured by ELISA, polymorphonuclear elastase by immunoactivation and leukotriene B4 by specific RIA. 4. All control patients and five out of seven patients with inactive colitis had undetectable interleukin-1 beta release. In active colitis, the release of interleukin-1 beta was detected in 17 out of 19 patients (median 500 pg/min, interquartiles 270-1582 pg/min, P < 0.01 compared with control subjects and patients with inactive colitis). Elastase and leukotriene B4 release were also significantly increased in active colitis compared with inactive colitis and controls. Leukotriene B4 release was similar in inactive colitis and controls, whereas elastase release was higher in inactive colitis than in controls. Five out of seven patients with colitis improved after treatment with 5-aminosalicylic acid. In all responder patients, interleukin-1 beta became undetectable or declined. 5. Our results demonstrate under conditions in vivo that active colitis is associated with enhanced interleukin-1 beta release into the colonic lumen whereas such release does not occur in remission, supporting the concept that ulcerative colitis flare-ups involve increased interleukin-1 beta production.

Does Helicobacter pylori infection increase gastric sensitivity in functional dyspepsia?

The role of Helicobacter pylori infection in the pathogenesis of functional dyspepsia is debated. It is known that a substantial fraction of dyspeptic patients manifest a low discomfort threshold to gastric distension. This study investigated the symptomatic pattern in 27 H pylori positive and 23 H pylori negative patients with chronic functional dyspepsia, and potential relations between infection and gastric hyperalgesia. Specific symptoms (pain, nausea, vomiting, bloating/fullness, early satiety) were scored from 0 to 3 for severity and frequency (global symptom scores: 0-15). The mechanical and perceptive responses to gastric accommodation were evaluated with an electronic barostat that produced graded isobaric distensions from 0 to 20 mm Hg in 2 mm Hg steps up to 600 ml. Gastric compliance (volume/pressure relation) and perception (rating scale: 0-10) were quantified. Standard gastrointestinal manometry and recorded phasic pressure activity at eight separate sites during fasting and postprandially were also assessed. H pylori positive and H pylori negative patients manifested similar severity and frequency of specific symptoms and global symptom scores (mean (SEM)) (severity: 9.5 (2.0) v 9.0 (2.1); frequency: 10.8 (2.0) v 9.7 (2.2)). No differences were seen either in gastric compliance (53 (4) ml/mm Hg v 43 (3) ml/mm Hg) or in gastric perception of distension (slope: 0.50 (0.05) v 0.53 (0.06)). Postprandial antral motility was significantly decreased in H pylori positive patients (two hours motility index: 10.4 (0.6) v 12.6 (0.5); p < 0.05). It is concluded that H pylori infected patients with functional dyspepsia present no distinctive symptoms by comparison with H pylori negative counterparts and H pylori infection is associated with diminished postprandial antral motility but it does not increase perception of gastric distension.

Effects of thromboxane synthase inhibition on in vivo release of inflammatory mediators in chronic ulcerative colitis.

OBJECTIVE: To evaluate the effects of a thromboxane inhibitor on the production of eicosanoids by the colonic mucosa of patients with chronic ulcerative colitis. PATIENTS AND METHODS: Fourteen patients with active left-sided ulcerative colitis were divided into in two treatment groups. Seven patients received oral ridogrel (300 mg twice daily) and seven 5-aminosalicylic acid (5-ASA; 1 g twice daily) for 4 weeks. Intracolonic eicosanoid and elastase release were measured using a colonic double-lumen perfusion technique. An isotonic solution was infused 50 cm from the anal verge at the rate of 5 ml/min, and recovered by siphonage 30 cm distally. Effluents were assayed for thromboxane B2 (TXB2), prostaglandin E2 (PGE2), and leukotriene B4 (LTB4) by radioimmunoassay (RIA), and for polymorphonuclear elastase by immunoactivation. Clinical and colonoscopic criteria were used to determine activity before and after treatment. RESULTS: Four of the seven patients in the ridogrel group and five of the seven in the 5-ASA group showed clinical and colonoscopic improvement. Intraluminal elastase release decreased in every responding patient in the 5-ASA group (P < 0.05) and in three out of seven responders in the ridogrel group. Basal eicosanoid release was similar in both groups. In the responders, 5-ASA significantly reduced the release of the three eicosanoids (P < 0.05). Ridogrel reduced the release of TXB2 to 31% of basal levels (P < 0.01) but the release of PGE2 and LTB4 was not affected. CONCLUSIONS: These results suggest that ridogrel is an oral active selective inhibitor of thromboxane synthetase, which modifies the pattern of colonic eicosanoid generation in patients with chronic ulcerative colitis. Oral ridogrel may be a useful treatment for patients with non-severe ulcerative colitis, although specific indications require further studies.

[Estrogen and progestagen treatment in digestive hemorrhage caused by vascular malformations]. / Tratamiento con estrógenos y progestágenos en la hemorragia digestiva por malformaciones vasculares.

The efficacy of an association of estrogens and progestagens in the treatment of gastrointestinal bleeding by angiodysplasia was analyzed. Thirty-three patients with gastrointestinal bleeding due to vascular malformations were admitted from January 1986 to December 1993. Fifteen of the 33 patients were submitted to surgical or endoscopic treatment. The remaining 18 patients underwent daily oral treatment with a combination of estrogens-progestagens containing 2.5 mg of lynestrenol and 0.075 mg of mestranol. One patient presented a venous thrombosis leading to suppression of treatment at one month of initiation. The 17 remaining patients were treated for a mean of 22 +/- 4 months (range: 3-60). During treatment 13 of the 17 patients (76%) did not present evidence of hemorrhage. Likewise, the number of hemorrhagic episodes per year decreased from 4.4 +/- 1.2 prior to treatment to 0.7 +/- 0.5 during treatment (p < 0.05) with transfusional requirements decreasing from 7.9 +/- 2.8 erythrocyte concentrates per year prior to treatment to 1.2 +/- 1.0 during treatment (p < 0.05). In conclusion, the combined treatment with estrogens and progestagens prevents recurrence of gastrointestinal bleeding by angiodysplasia.

Intraluminal colonic release of immunoreactive tumour necrosis factor in chronic ulcerative colitis.

1. Tumour necrosis factor is a proinflammatory macrophage-derived polypeptide cytokine. Its participation in disease processes has been usually inferred from data obtained from experiments in vitro or from measurements of its plasma circulating levels. To investigate its role in chronic ulcerative colitis, we have quantified in vivo the steady-state release of tumour necrosis factor into the colonic lumen. 2. We studied 19 patients with untreated active ulcerative colitis and seven patients with irritable bowel syndrome as controls. A group of seven patients with active ulcerative colitis were studied before and after 4 weeks on treatment with oral 5-aminosalicylic acid. By means of an intracolonic double-lumen perfusion tube, an isotonic solution was continuously infused 50 cm from the anal verge at a rate of 5 ml/min, and was recovered 30 cm distally by siphonage. Effluents were assayed for tumour necrosis factor by a specific e.l.i.s.a. and for prostaglandin E2 and leukotriene B4 by specific r.i.a.s. 3. The intracolonic release of tumour necrosis factor was undetectable in patients with irritable bowel syndrome, whereas measurable release occurred in 15 out of 19 patients with active ulcerative colitis (P < 0.01). Prostaglandin E2 and leukotriene B4 release were also increased in active ulcerative colitis by comparison with irritable bowel syndrome (P < 0.01). Five out of seven patients with colitis improved with 5-aminosalicylic acid treatment, and tumour necrosis factor release became undetectable or decreased markedly (P < 0.05 compared with before treatment). However, tumour necrosis factor release remained high in the non-responder patients. 4. These findings indicate that intracolonic immunoreactive tumour necrosis factor release is enhanced in active chronic ulcerative colitis, becoming undetectable when mucosal lesions are healed. These results suggest that the luminal release of tumour necrosis factor may serve as an objective index of inflammatory activity in patients with chronic ulcerative colitis.

Forceful dilatation under endoscopic control in the treatment of achalasia: a randomised trial of pneumatic versus metallic dilator.

Forceful dilatation under endoscopic control is a well established treatment of achalasia; several different types of dilators can be used. This study prospectively compared the clinical and manometric efficacy of a single dilatation using two different dilators. Forty one patients were randomly assigned to forceful dilatation under endoscopic control with either a pneumatic dilator (n = 17) or a metallic dilator (n = 24). Thereafter, the patients received periodic clinical and manometric evaluation for one year (before and one, six, and 12 months after dilatation). One month after dilatation all but one of the subjects in each group had experienced good to excellent results and their clinical improvement persisted for the one year follow up. Two patients (one in each group) were perforated during the procedure and required surgical treatment. Recovery was uneventful in both cases. Resting lower oesophageal sphincter pressure (mean (SEM)) significantly and similarly decreased after both methods of dilatation (pneumatic dilator: before dilatation 37 (3) mm Hg, one year after dilatation 18 (3) mm Hg; metallic dilator: before dilatation 34 (2) mm Hg, one year after dilatation 17 (3) mm Hg; p < 0.05 for both). It is concluded that in the treatment of achalasia a single dilatation under endoscopic control with either pneumatic or metallic dilator yield comparable clinical and manometric results and similar complication rates. The use of one or other dilator should depend more on the preference and experience of the endoscopist than on the type of device.

[Value of endoscopic ultrasonography in the diagnosis of pancreatic and gastroduodenal endocrine tumors]. / Valor de la ecografía endoscópica en el diagnóstico de los tumores endocrinos pancreáticos y gastroduodenales.

OBJECTIVE: To present our experience in the localization of endocrine-gastroenteropancreatic tumors (EGPT) by endoscopic ultrasonography. METHODS: Endoscopic ultrasonography was performed in 10 patients with 13 pancreatic tumors and four in the digestive tract. RESULTS: Sensitivity and diagnostic efficacy were 69% and 70%, respectively. These values were greater than those observed by other image techniques. Also, additional diagnoses and other three tumors of less than 1 cm undiagnosed by ultrasonography (US), Computer Tomography (CT) and Magnetic Resonance (MR), were detected. Specificity was 80% because among five case-controls a false positive was found. With more experience and the possibility to find small tumors, USE should improve other image techniques in the diagnosis and localization of endocrine digestive tumors.