Resection of gastrinoma in the Zollinger-Ellison syndrome.

Patients with the Zollinger-Ellison syndrome have been managed by total gastrectomy and more recently, by the use of H2-receptor antagonists. An alternative approach has been to identify those who might be cured by excision of a pancreatic islet-cell tumor without removal of the stomach. The course of such a patient is reported. A 40-yr-old man with massive gastric hypersecretion, acid-peptic disease, diarrhea, and elevated serum gastrin was treated by excising a pancreatic gastrinoma. Serum gastrin and gastric secretion became and have remained normal for 7 yr. Symptoms ceased and provocative tests with secretin and calcium have remained normal. Three additional patients with Zollinger-Ellison syndrome in whom pancreatic islet-cell tumor resection alone has resulted in long-term cures have been identified. All were middle-aged men with severe diarrhea. These successes, the availability of techniques that permit early identification and localization of gastrinomas, and the advent of H2-receptor antagonists that can control gastric hypersecretion without gastrectomy must be considered in managing patients with gastrinomas.

Effect of bethanechol on gastroesophageal reflux.

In this study we determined the acute effect of bethanechol (5 mg SC) on gastroesophageal reflux (GER) and lower esophageal sphincter pressure (LESP) in 27 patients with symptomatic esophagitis. The effect of bethanechol on esophageal acid clearance was also determined in 7 of the patients. Intraluminal pH monitoring prior to bethanechol administration demonstrated free or stress-induced reflux episodes in 18 of the 27 patients. Following bethanechol (1) LESP increased significantly, (2) GER diminished or ceased in many of the patients, and (3) acid clearance times decreased significantly. Some individuals, however, continued to reflux despite LESP elevation to 30 mm Hg or more. This latter finding suggests that LESP alone is not the sole factor governing LES competency. Other factors such as improved esophageal emptying may also contribute to the beneficial therapeutic effect of bethanechol in patients with heartburn.

Facts, anecdotes, and new horizons in the medical treatment of duodenal ulcers.

There continue to be marked differences of opinion regarding how to manage duodenal ulcer disease. Recent developments in medical management which appear of major importance include the development of antagonists of H2-receptors of histamine, the prostaglandins, and transendoscopic instrumentation. Intractability of duodenal ulcer continues to be an over-used category which disguises situations that are easily remedied. Until we have more long-term and complete evaluations of ulcer treatment, we will continue to base therapy on anecdotes and incomplete data.

Essential tremor, nystagmus and duodenal ulceration. A "new" dominantly inherited condition.

The familial occurrence of essential tremor combined with (congenital) nystagmus, duodenal ulceration and a narcolepsy-like sleep disturbance caused by an autosomal dominant gene with high penetrance and fairly uniform expressivity is reported in a family of Swedish-Finnish ancestry. Twelve of 17 affected family members had essential tremor which began between 30-40 years of age and which could be controlled temporarily by alcohol; this resulted in alcoholism in several affected individuals. The most severly affected persons showed cerebellar signs which may reflect a possible pathogenetic relationship of the syndrome to the genetic cerebellar atrophies. Nystagmus, observed in 12 of 17 affected family members (eight of whom were also affected with tremor) usually was congenital and accompanied by refractive errors. Duodenal ulcers occurred almost exclusively in individuals with the neurological syndrome, and preceded its onset in some cases. The ulcer disease therefore seems to be a component manifestation of the syndrome and is interpreted as a pleiotropic effect of the gene which also causes the nystagmus, tremor and sleep disturbance.

Antacids and anticholinergics. Thoughts on how and when to use them.

The antacids and anticholinergics should be considered potent pharmacologic agents with potentially serious side effects. When the conditions constituting major contraindications to these forms of therapy have been considered and their presence has been ruled out, the antacids and anticholinergics are useful in managing the symptoms and course of disease due to the effects of acid and pepsin. Antacid given an hour or so after meals and at bedtime and anticholinergic given at bedtime to selected patients are especially useful in management of peptic ulcer disease. More or less extensive schedules may be indicated, depending on the severity of disease and symptoms.

Relationship between serum gastrin concentration and lower-esophageal sphincter pressure.

Serum gastrin concentration [G] has been proposed as the major factor regulating resting lower-esophageal sphincter pressure (LESP). Available supporting evidence in man, however, is largely circumstantial. The present study directly compares measurements of LESP with concurrent levels of circulating serum gastrin in fasting human subjects. A direct correlation was not shown between [G] and resting LESP; rather, a trend existed toward an inverse relationship. The study results indicate that the concentration of serum immunoreactive gastrin is not a major determinant of lower-esophageal sphincter tone in humans.