Haematuria and clot retention after transurethral resection of the prostate: a pilot study.

OBJECTIVE: To determine, prospectively, the effect of clinical factors on the duration of frank haematuria and the incidence of clot retention after transurethral resection of the prostate (TURP). PATIENTS AND METHODS: Seventy-nine men who underwent TURP in a 3-month period were entered into this study, during which the time to cessation of bleeding and the occurrence of clot retention(s) were recorded over a 4-week period. The effect of other clinical factors (histology, weight of tissue resected. operative duration, grade of surgeon and resection rate) was also assessed. RESULTS: Gross haematuria ceased in 47%, 73%, 96%, and 97% of patients at the end of the first, second, third and fourth weeks, respectively. The duration of postoperative bleeding was significantly associated with the weight of tissue resected and the operation time (P<0.001 and <0.05, respectively). Furthermore, five patients were re-admitted with clot retention, but there was no significant correlation between the occurrence of this morbidity and any of the other indices. CONCLUSION: Postoperative bleeding usually stops within 3 weeks of TURP. This period, which is about half the time hitherto assumed, is directly related to the size of the gland resected and the duration of the procedure. However, the occurrence of clot retention is not significantly associated with the duration of haematuria or any of the other clinical factors evaluated. Thus, a high fluid intake is mandatory for 3 weeks after TURP, but men who continue to bleed should be advised to continue with a high-fluid regimen until their urine is clear.

The effect of acupuncture on gastrointestinal function and disorders.

Acupuncture has been used empirically in clinical practice in China for several millenia and has recently drawn interest as a mode of anesthesia. Despite extensive investigation, the exact mechanisms of its analgesic action are unknown, but are thought to involve endogenous opioid peptides. Only recently have studies attempted to evaluate the effect of acupuncture on gastrointestinal function and disease. A review of studies from both the Chinese and Western literature supports the efficacy of acupuncture in the regulation of gastrointestinal motor activity and secretion through opioid and other neural pathways. However, no firm conclusion can be drawn about the effectiveness of acupuncture in the treatment of specific gastrointestinal disorders because of the lack of properly randomized controlled trials.

Effect of acupuncture on gastric acid secretion in healthy male volunteers.

Six randomized, placebo controlled studies were performed to investigate the effect of electroacupuncture on gastric acid output in 38 healthy males. Electroacupuncture decreased basal acid output when compared to placebo acupuncture [from 3.50 +/- 0.59 mmol/hr to 2.54 +/- 0.56 mmol/hr (P < 0.05)] as well as sham feeding-stimulated acid output [from 18.52 +/- 2.25 mmol/hr to 5.38 +/- 2.11 mmol/hr (P < 0.005)], but had no effect on the pentagastrin stimulated acid output. The inhibitory effect of acupuncture on sham feeding-stimulated acid output was not affected by local anesthesia of the acupoint, but was prevented by a prior intravenous naloxone injection. Acupuncture did not alter plasma gastrin levels (20.7 +/- 7.6 micrograms/liter, vs control 21.2 +/- 7.2 micrograms/liter) but naloxone increased it (26.1 +/- 14.5 micrograms/liter) (P < 0.05). We conclude that the antisecretory effects of electroacupuncture do not result from decreased gastrin release or decreased parietal cell sensitivity to gastrin, but are mediated through naloxone-sensitive opioid neural pathways and vagal efferent pathways.

Omeprazole (20 mg) daily given in the morning or evening: a comparison of effects on gastric acidity, and plasma gastrin and omeprazole concentration.

Although omeprazole has a long duration of action and has usually been given in the morning, there are theoretical advantages in administering antisecretory drugs in the evening as has been shown for the H2-receptor antagonists. The aim of this study was to compare the effects of placebo and 20 mg omeprazole given either in the morning or evening, on gastric acidity, plasma gastrin levels and plasma omeprazole in 6 duodenal ulcer patients. The 24-hour mean pH (+/- S.E.M.) was: placebo 1.7 +/- 0.1; morning doing, 3.9 +/- 1.8 (P less than 0.01); evening dosing, 2.9 +/- 1.1 (N.S.). There was a large inter-individual variability of intragastric acidity in response to omeprazole, which was reflected both in the plasma gastrin and in the area under the plasma omeprazole concentration-time curve. Morning administration of omeprazole is optimal, but variability in the patient response to 20 mg omeprazole is still seen.

Is there an optimal degree of acid suppression for healing of duodenal ulcers? A model of the relationship between ulcer healing and acid suppression.

The optimal degree and duration of suppression of gastric acidity required for the healing of peptic ulcers has never been established. Although very potent inhibitors of acid secretion are now available, the need for this degree of suppression has not been shown, and there is a possibility of adverse effects because of pronounced acid inhibition. Therefore, a model has been constructed that defines the relationship between duodenal ulcer healing and antisecretory therapy. Acid suppression data were obtained directly from investigators as raw data from 24-hour studies of acid secretion. Twenty-one experiments from seven investigators provided 490 24-hour studies using 19 different treatment regimens. Healing data were collected from a metaanalysis of published clinical trials of duodenal ulcer healing. A total of 144 published trials in 14,208 patients provided healing data at several endoscopic endpoints for the 19 drug regimens for which acidity data were provided. Weighted least-squares polynomial regression analysis was used to define those parameters of antisecretory therapy that contributed most to duodenal ulcer healing and to define the shape of the response surface. A highly significant correlation (r = 0.9814) was found between healing and the degree of acid suppression, the duration of acid suppression, and the length of therapy. The shape of the contour expression this relationship shows that healing increases as the duration of suppression increases and as gastric pH increases. However, suppression that increased pH beyond 3.0 was not found to increase ulcer healing further. It is concluded that a longer duration of antisecretory effect and/or a longer duration of therapy are of greater importance than potency for duodenal ulcer healing.

Percutaneous cholecystolithotomy: the first 60 patients.

OBJECTIVE: To assess the feasibility and possible complications of percutaneous removal of gall stones. DESIGN: Prospective study of the first 60 patients treated. SETTING: The London Clinic. PATIENTS: 60 Consecutive patients with symptomatic gall stones who agreed to have them removed percutaneously. RESULTS: 56 Patients had stones successfully removed percutaneously. In four patients failure of access necessitated a cholecystectomy under the same anaesthetic. Two patients had an empyema of the gall bladder drained initially, followed by a second operation to remove the stones one week later. Seven patients had postoperative complications, and two had recurrences of biliary calculi. CONCLUSIONS: The techniques and instruments used in percutaneous nephrolithotomy can successfully be adapted for percutaneous removal of gall stones. The procedure is suitable for a wider range of patients than other techniques that leave the gall bladder intact.

Do hourly averaged pH readings correlate with those from point readings of aspiration? Comparison of two different electrode positions with simultaneous aspiration.

Hourly averaged data from continuous intraluminal pH recording were compared with the point aspiration in five 24-hour studies performed on healthy volunteers. Two different electrode positions were compared simultaneously with aspiration. The correlation was performed using the median from the whole hour's recording of the electrode against the aspiration point. There was a significant correlation between both electrodes and aspiration (p less than 0.001), although both electrodes read consistently lower than aspiration: electrode A (gastric antrum), median pH = 1.4; electrode B (gastric body), pH = 1.9; aspiration, pH = 2.3. These findings show that data reported in clinical trials using different recording techniques are not directly comparable and must be interpreted appropriately. The position of the electrode may also be important.

Validation of pH dataloggers for pharmacologic studies.

Twenty-four-hour gastric aspiration studies have been superseded by dataloggers that continuously record intragastric pH. We have studied both techniques in a practical pharmacologic study, comparing early evening versus nighttime dosing with ranitidine and nizatidine against placebo. Whereas there was a highly significant point correlation between aspiration and datalogger pH, the slope was significantly less than 1. The correlation was poorer during the day (r = 0.51) than at night (r = 0.83). Irrespective of the techniques used, however, conclusions reached on drug efficacy were similar, but direct comparison of data from the two techniques is not possible.

Does misoprostol given as a single large dose improve its antisecretory effect?

H2-receptor antagonists have been shown to be effective in the suppression of nocturnal acidity. This double-blind, randomized, crossover Latin-square study of 24-h intragastric pH in 12 normal volunteers investigated the effect of large single-dose administration of misoprostol on intragastric acidity. Efficacy of 800 micrograms misoprostol h.s., 600 micrograms h.s., 400 micrograms h.s. and 800 micrograms after supper was compared to placebo and 200 micrograms misoprostol q.d.s. Twenty-four hour mean pH +/- s.d. was placebo 2.1 +/- 0.3, misoprostol 200 micrograms q.d.s. Twenty-four hour mean pH +/- s.d. was placebo 2.1 +/- 0.3, misoprostol 200 micrograms q.d.s. 2.2 +/- 0.3, 800 micrograms p.m. 2.6 +/- 1.1, 400 micrograms h.s. 2.6 +/- 0.7, 600 micrograms h.s. 2.6 +/- 0.4, 800 micrograms h.s. 2.6 +/- 0.5. The effect of misoprostol on gastric acidity was short and limited to the nocturnal period. Only misoprostol 800 micrograms and 600 micrograms reduced 24-h acidity compared to placebo (P less than 0.04).

Exocrine pancreatic function tests.

Despite the development in the last two decades of new imaging techniques for the detection of pancreatic disease, discrepancies between functional and morphological findings can be remarkable. Pancreatic function tests may aid in the detection of disease at an earlier stage in some patients and can assess the degree of functional damage which is helpful in assessing patients for supplemental therapy. While direct intubation methods are invasive and time consuming, they remain the gold standard against which the other investigations have to be assessed. An indirect test, such as the pancreolaural test, has been shown to be a useful addition to ultrasound for the screening of pancreatic disease. Pancreatic markers and radioisotope methods have failed to live up to early promise, but fecal tests can be used effectively to monitor enzyme replacement. A judicious combination of pancreatic function tests and imaging techniques may be able to rationalize investigation and treatment of pancreatic disease.

Do H2 receptor antagonists have to be given at night? A study of the antisecretory profile of SKF 94482, a new H2 receptor antagonist which has a profound effect on daytime acidity.

Evening dosing has become standard for H2 receptor antagonists, because available agents inhibit nocturnal basal acid secretion more effectively than daytime stimulated secretion. We studied the optimal time of administration of a new high affinity long acting H2 receptor antagonist, SKF 94482, for the suppression of intragastric acidity using intragastric telemetry. Sixteen healthy subjects received SKF 94482 200 mg or placebo at 07:30, 17:30, and 21:30 h during four separate studies. Time (h) above pH 4 was (mean (SD] 1.1 (1.2) on placebo, 7.8 (5.0) on SKF 94482 given at 07:30, 5.75 (3.6) on SKF 94482 given at 17:30, and 6.1 (2.9) when given at 21:30. All treatment regimens were effective in increasing time above pH 4 (p less than 0.01). The efficacy of the morning dose of SKF 94482 indicates that the best time to give H2 receptor antagonists depends on their pharmacological properties.

Initial therapy and relapse of duodenal ulcer: possible acid secretory mechanisms.

Review of the four studies investigating the effect of initial therapy on ulcer relapse indicates that there is an increased rate of relapse after treatment with H2-receptor antagonists compared with placebo or other classes of drugs when combined. When individual drugs are considered, this appears to hold true for colloidal bismuth alone. There are several possible reasons for these differences. The most likely candidate mechanism to account for these differences is an alteration in gastric secretion, which might arise from alterations in gastrin, altered receptor regulation, parietal cell sensitivity, or peptic activity. However, the evidence for such an alteration in secretion is far from conclusive. Other factors that may be important include mucosal defense factors, smoking, Campylobacter pylori, and the statistical methodology.

Smoking and duodenal ulcer disease.

Cigarette smoking has long been thought to be associated with duodenal ulcer disease, there being an increased incidence and an adverse outcome in both healing and relapse. This review evaluates this evidence and the possible mechanisms that might account for a poor outcome in smokers.

Relationship between inhibition of acid secretion and healing of peptic ulcers.

Although current concepts of ulcer pathophysiology postulate an imbalance between the principal aggressive factors of acid and pepsin and an impairment of mucosal defence, effective acid reduction by a variety of antisecretory drugs is associated with a significant acceleration of duodenal and gastric ulcer healing in controlled clinical trials. The healing of duodenal ulcer is related to the degree and duration of acid reduction with currently available H2-receptor antagonists. The highly significant correlation between the reduction of nocturnal acidity and ulcer healing reflects the ability of these drugs to inhibit basal and nocturnal acid secretion to a greater extent than stimulated daytime secretion. The extent to which the addition of daytime acid inhibition to that of nocturnal acid inhibition is responsible for further accelerating ulcer healing has not yet been determined, although a model has been proposed recently to explore this effect. Omeprazole has a marked effect on the duration and the degree of inhibition of intragastric acidity which is dose-dependent. In clinical trials of duodenal ulcer treatment, this efficacy and duration of effect is associated with an increased rate of healing and a leftward shift of the healing time curve.