Manometrics for preterm and term infants: a new tool for old questions.

OBJECTIVE: The purpose of this study was to use low-compliance, continuous-perfusion manometry to assess motor activity responses of preterm and term infants to three different methods of feeding commonly used in neonatal intensive care units. METHODS: All 48 infants who participated in this study were assigned to one of three feeding trials using a 20-calorie/oz formula. Trial 1 varied the mode of feeding, trial 2 varied the volume of feeding, and trial 3 varied the concentration of feeding. RESULTS: In trial 1, small intestinal motor activity changed similarly and significantly in response to intragastric (P < .005) and transpyloric feeding (P < .02). In trial 2, feeding containing a small volume (4 mL/kg) and a larger volume (10 mL/kg) elicited significant changes in motor activity compared to that seen during fasting (P < .005). In trial 3, motor activity differed in response to varying caloric density. Motor activity failed to change in response to feedings that contained one-third-concentration formula, but it did change in response to the feedings that contained two-thirds- and full-concentration formula (P < .02). Furthermore, the onset of the motor response to feeding was inversely related to the concentration of formula (P < .01), and the duration of the fed response also was related to the concentration of formula (P < .01). CONCLUSIONS: Gastric and transpyloric feedings are equally potent in eliciting an intestinal motor response to feeding. Furthermore, a volume as small as 4 mL/kg is sufficient to elicit such a response. However, preterm intestinal motility responses are affected significantly by changes in the caloric density of formula, suggesting that diluted formula may not provide an optimal stimulant for the preterm intestinal functional responses to feeding.

Long-term efficacy of oral cisapride in symptomatic upper gut dysmotility.

We conducted a 12-month trial of cisapride (10 mg three times a day) in 21 patients with gastric stasis due to clinically and manometrically diagnosed gastroparesis (N = 9; seven due to diabetes) or chronic intestinal pseudo-obstruction (N = 12). Radionuclide solid-liquid gastric emptying tests were performed at baseline and at the end of the 12-month period. Symptoms were assessed monthly by diary and every three months by the investigators; frequency and severity of symptoms were scored in a standardized manner. For the whole group of 21 patients, gastric emptying of both solids and liquids improved significantly after one year of cisapride (P less than 0.05). Among chronic intestinal pseudoobstruction patients, there was predominantly an improvement in gastric emptying of solids; in contrast, patients with gastroparesis had a greater improvement in liquid emptying. Total symptom score improved significantly in the gastroparesis group (median score: 8 at baseline vs 6 at one year, P less than 0.05) but not in the chronic intestinal pseudoobstruction patients (median score at baseline 10 vs 9 at one year). Similarly, body weight showed a trend towards improvement in the gastroparesis group. No significant side effects were noted. We conclude that during a 12-month open trial, cisapride was effective in improving gastric emptying in patients with gastric stasis and consistently improved symptoms in those with gastroparesis.

Postoperative gastric atony after vagotomy for obstructing peptic ulcer.

From 1979 through 1984, truncal vagotomy and drainage were performed in 71 patients with symptomatic obstructing peptic ulcers, whereas proximal gastric vagotomy with or without drainage was performed in 30 patients. Seven patients (7 percent) developed prolonged early postoperative gastric atony. Six of the 71 patients (8 percent) who had truncal vagotomy had atony, whereas only 1 of the 30 patients (3 percent) with proximal gastric vagotomy had atony (p = 0.08). The atony resolved with medical management in all patients after a median of 23 days. At follow-up (median 3 years), 74 percent of patients with truncal vagotomy had an excellent or good result compared with 86 percent of those with proximal gastric vagotomy (p greater than 0.1). The conclusion was that prolonged early postoperative gastric atony occurs uncommonly after vagotomy for obstructing peptic ulcer. Preservation of antropyloric innervation by using proximal gastric vagotomy instead of truncal vagotomy may be helpful, but does not completely prevent the atony.

Effect of six weeks of treatment with cisapride in gastroparesis and intestinal pseudoobstruction.

We have investigated the effect of oral cisapride (10 mg t.i.d.) in a double-blind, placebo-controlled trial in 26 patients with upper gut dysmotility: 11 with gastroparesis (8 diabetic, 3 idiopathic) and 15 with chronic idiopathic intestinal pseudoobstruction. Patients were evaluated at entry and at the end of the 6-wk study by upper gastrointestinal manometry, scintigraphic evaluation of gastric emptying of solids and liquids, measurement of body weight, and scoring of the following symptoms: abdominal pain, nausea, vomiting, early satiety, bloating, and distention. Cisapride and placebo groups were strictly comparable for all parameters assessed. Cisapride resulted in a significant increase in the gastric emptying of solids (p less than 0.05) compared with placebo; cisapride also tended to increase the postcibal antral motility and normalize the abnormal manometric features in the patients with intestinal dysmotility, particularly the characteristics of fasting interdigestive motor complexes and the fed motor pattern. Both cisapride and placebo groups showed an improvement in total symptom scores and there was no significant difference in overall symptom response between the two groups. However, the change in abdominal pain was greater with cisapride (p = 0.07). Cisapride facilitates gastric emptying in patients with upper gut dysmotility. The overall symptomatic benefit during a 6-wk trial of cisapride, 10 mg t.i.d., was not greater than that of placebo, and dose-response as well as longer term trials are necessary to determine the clinical efficacy of this medication.

Diagnostic value of liver biopsy in alcoholic liver disease.

Because it remains debatable whether all patients with a clinical diagnosis of alcoholic liver disease should have a liver biopsy to help confirm the diagnosis, we evaluated the diagnostic value of liver biopsy in alcoholic liver disease. Studied were 108 consecutive patients who had a percutaneous liver biopsy for the first time. In all cases the patient's clinical diagnosis recorded before biopsy was compared with the histological diagnosis of an experienced histopathologist. Prebiopsy clinical data (reported alcohol intake, signs of chronic liver disease) and laboratory data (liver function tests, mean corpuscular volume, ferritin, hepatitis B serology) were reviewed. We found that a prebiopsy clinical diagnosis of alcoholic liver disease (n = 35) was confirmed by biopsy in all but one case. The prebiopsy diagnosis of alcoholic liver disease was significantly associated with a histological diagnosis of alcoholic liver disease (specificity 98%, sensitivity 79%). Individually, alcohol intake, signs of chronic liver disease, the alanine aminotransferase (ALT), the aspartate aminotransferase to ALT ratio, and the mean corpuscular volume were significantly associated with a histological diagnosis of alcoholic liver disease. When clinical and laboratory parameters were considered jointly using stepwise logistic regression, only reported alcohol intake and mean corpuscular volume were significant. Liver biopsy may not always be necessary for the identification of that broad group of patients with alcoholic liver disease.

Cancer of the nongastric hollow organs of the gastrointestinal tract after gastric surgery.

To estimate the risk of esophageal, gallbladder, small-bowel, and colon cancers after gastric surgery for benign disease, all 337 residents of Olmsted County, Minnesota, who had surgical treatment of benign peptic ulcer disease during the years 1935 through 1959, were followed up. Patients were followed up for 6552 person-years of observation. No esophageal cancers developed (0.8 were expected). Members of the cohort developed one small-bowel malignant neoplasm (0.2 were expected), two gallbladder cancers (1.1 was expected), and four colon cancers (11.2 were expected), but these figures do not reflect a significant increase in the risk of these malignant neoplasms. In particular, the relative risk of developing colon cancer was only 0.4 when this analysis had 88% power to detect a relative risk of two or more. When the present investigation and two previous studies of this cohort were taken together, there was no strong evidence for an increased risk of any gastrointestinal cancer following gastric surgery.

Temporal lobe volume measurement from MR images: accuracy and left-right asymmetry in normal persons.

The effect of several magnetic resonance (MR) variables on the accuracy of volume measurements in phantom objects was investigated by use of an off-line automatic border-outlining and internal area pixel-counting computer program, and an optimal set of imaging variables was identified. Measurements were made of the temporal lobe volumes of a gross fixed brain specimen from MR image data. The range in accuracy was from -2 to +7%, and the standard deviation of the difference in right minus left lobe volume measurements obtained from the MR images and those obtained by use of Archimedes' principle was 1 cm3. This volumetric technique was applied to 25 normal persons, most of whom were right-handed. The median ratio of right to left temporal lobe volume was 1.16 (range 0.99-1.23). The nondominant temporal lobe was significantly larger than the dominant. The mean difference (95% confidence interval) between right and left volumes was 7 cm3 (6-9 cm3). This confidence interval was similar to that obtained when the variability within a subject (estimated from the gross fixed brain specimen) was taken into account. Unilateral temporal lobe atrophy, particularly in patients with temporal lobe epilepsy, should be interpreted from MR images with this range of discrepancy in normal left-right size in mind.

Effects of hemorrhage and naloxone on adrenal release of methionine-enkephalin and catecholamines in halothane anesthetized dogs.

Concurrent levels of methionine-enkephalin and catecholamines in adrenal vein, femoral vein and femoral artery were measured under baseline conditions and during graded hemorrhage in halothane anesthetized dogs and compared to a non-bled control group. Naloxone was administered in both groups at the end of the experiment. Normotensive hypovolemia with a remaining blood volume of 76% led to a moderate decrease in mean arterial blood pressure from baseline and a 15- to 20-fold increase in norepinephrine, epinephrine and dopamine, and a 5-fold increase in enkephalin in the adrenal vein. Subsequent induction of hypotensive hypovolemia with a remaining blood volume of 51% resulted in a profound drop in blood pressure and evoked a further increase in the level of catecholamines (40- to 50-fold from baseline) and enkephalin (8-fold from baseline) in the adrenal vein. In the control group only a 3- to 4-fold increase from baseline in adrenal vein hormone levels was observed over time. Naloxone administration at the end of the experiment, led to a 2- to 6-fold further increase in hormones at the 3 collection sites in both groups of dogs. Joint calculation of the partial correlation coefficients for the influence of preceding blood volume and blood pressure, and concurrent blood volume and blood pressure on hormone secretion in the adrenal vein revealed that these variables explained the variation in hormone levels between 56 and 92% during normotensive hypovolemia and 62-83% during hypotensive hypovolemia. In one dog with bilateral adrenalectomy, hemorrhage was poorly tolerated, and naloxone administration did not lead to increased systemic plasma levels of catecholamines and enkephalin or improved hemodynamics. In the hemorrhage group, molar ratios of norepinephrine/epinephrine in the adrenal vein showed a significant increasing trend during the experiment. Findings in these experiments support the idea of differential monoaminergic and enkephalinergic regulation in adrenal medullary cells.

Endoscopic laser palliation of malignant dysphagia: a prospective study.

We prospectively studied the short-term and long-term efficacy and safety of endoscopic laser treatment in 25 patients with dysphagia from advanced esophageal cancer. Malignant stenoses were recanalized in all patients, and the ability to swallow was improved in about 80%. Results were best in patients with adenocarcinomas and in those who reported a good appetite. A single laser treatment provided adequate palliation in more than half the patients until the time of death. In those patients in whom stenosis recurred, re-treatment was necessary a median of 3.2 months after the initial laser treatment. No laser-related mortality or major morbidity occurred. We conclude that endoscopic laser therapy seems to be a feasible method of palliating malignant dysphagia.

Gallstones, gallbladder cancer, and other gastrointestinal malignancies. An epidemiologic study in Rochester, Minnesota.

All 2583 residents of Rochester, Minnesota, who had gallstones initially diagnosed during the years 1950 to 1970 were followed for the development of gastrointestinal malignancies. Although 69 members of the cohort subsequently developed 72 gastrointestinal malignancies, this number of cases did not exceed the 76 cases expected (relative risk, 1.0). The risk for gallbladder cancer was increased threefold, but the increase was significant only in men (p = 0.05; 95% confidence interval, 1.0 to 30.0). The absolute incidence and the total number of men and women who developed gallbladder cancer was low (n = 5). The actual incidence of other gastrointestinal malignancies in our cohort with gallstones did not exceed the expected incidence in the general population of Rochester, Minnesota. Specifically, the risk for colon cancer was not increased, even after cholecystectomy. These data support an association between cholelithiasis and gallbladder cancer. We found, however, no association between cholelithiasis or cholecystectomy and any other gastrointestinal malignancy.

Pancreatic cancer risk following gastric surgery.

To estimate the risk of pancreatic cancer after gastric surgery for benign disease, we followed all 336 residents of Olmsted County, Minnesota, who had surgical treatment for benign peptic ulcer disease during the years 1935 to 1959. These patients were followed for 6549 person-years of observation. Pancreatic cancer developed in only one patient although 1.6 primary pancreatic cancers were expected (relative risk 0.64; 95% confidence interval, 0.02 to 3.53) based on pancreatic cancer incidence rates for the general population of Olmsted County. We conclude that in our study the incidence of pancreatic cancer is not significantly increased after gastric surgery.