Trace metal requirements in total parenteral nutrition: a theoretical approach by mathematical modeling

A new computer-based approach has been developed to assess the optimal doses of essential trace metal ions which should be included in nutritive mixtures, used in human total parenteral nutrition, to compensate for the ligand-induced losses of these metal ions. An example of application is given for zinc, copper and manganese.

Computer simulation of metal ion equilibria in biofluids. Part 3. Trace metal supplementation in total parenteral nutrition

Computer simulation models have been developed to investigate the effect of intravenous infusions of nutritive amino acid solutions metal equilibria in plasma. The distribution of Ca(II), Mg(II), Zn(II), Cu(II), and Mn(II) among the ligands in the nutritive fluid is calculated and used to estimate the amounts of each metal that should be included in future preparations.

Nodular lymphoid hyperplasia of the small bowel associated with primary jejunal malignant lymphoma. Evidence favoring a cytogenetic relationship

A nonimmunodeficient patient with diffuse nodular lymphoid hyperplasia of the small bowel and a jejunal malignant lymphoma of mixed lymphocytic-histiocytic type is reported. Surface marker and immunohistologic studies of the malignant lymphoma and of histologically benign lymphoid nodules proximal to the tumor showed a similar pattern of monoclonality (IgM-kappa) and gave suggestive evidence of a cytogenetic relation of the lymphoma to nodular lymphoid hyperplasia. It is suggested that intestinal nodular lymphoid hyperplasia may be a condition leading to lymphoid malignancy; its exact incidence in patients with both malignant lymphoma of the gut and a primary immunodeficiency syndrome should warrant further consideration.

Peutz-Jeghers syndrome with metastasizing carcinoma arising from a jejunal hamartoma

The association of Peutz-Jeghers (P-J) syndrome and gastrointestinal carcinoma is well documented, but an unequivocal histologic demonstration that malignancy may originate in a hamartomatous polyp has been very rarely given. A patient with the P-J syndome is described, in whom a definite intestinal adenocarcinoma with metastases to omentum and celiac lymph nodes was shown to originate in a jejunal hamartoma. Evidence that malignancy was derived from hamartomatous structures was given by the following observations: (a) Adenocarcinoma was intimately intricated with smooth muscle bands, and well-defined transitional zone of malignant cells could be observed in several glands of the degenerated P-J polyp; and (b) close to malignant areas, glands of this polyp exhibited a less-differentiated epithelium, but were still intermixed with nonstriated muscle bundles, which strongly suggest dedifferentiation of hamartomatous structures.

Association of cimetidine and bone-marrow suppression in man

A 29-year old woman who was on steroids for Behcet's disease received intravenous cimetidine for severe gastrointestinal bleeding. A bone-marrow examination performed a few days prior to cimetidine treatment showed a normally active marrow. On the fifth day of cimetidine therapy, agranulocytosis (800/ml) and a very low platelet count (40,000/ml) were observed; bone-marrow failure was documented both by biopsy and aspiration. No other drug known to be myelotoxic was given. This severe hematologic side effect of cimetidine resolved within 10 days after discontinuation of the drug.

[Acute ulcerative colitis associated with cytomegalic inclusion virus in a non-immunodepressed patient (author's transl)]

A new case of acute ulcerative colitis associated with cytomegalic inclusion virus within the colonic wall is reported. Some unusual features are discussed, such as the absent defect in cellular or humoral immunity, the location of the lesion which were limited to the sigmoid colon, and the fatal outcome of the disease. The possible pathogenic relationship between cytomegalic infection and acute a chronic ulcerative colitis are reviewed.

Fluid secretion in the duodenum and intestinal handling of water and electrolytes in Zollinger-Ellison syndrome

The slow marker perfusion technique was used in five patients with the Zollinger-Ellison syndrome in order to determine the basal and postcibal flow rates of fluids passing the duodenojejunal junction and distal ileum, and the composition of those fluids. Fecal water and electrolyte excretions were also measured. The 24-hr outputs at the ligament of Treitz were markedly increased, while fecal losses were normal or only slightly increased. Thus, the overall intestinal reabsorption of water was 96%. Fasting rates of fluid and electrolyte flow at the ligament of Treitz were also measured during a basal period, followed by a period of continuous gastric aspiration. Removal of gastric secretion had the following effects on the fluid passing through the duodenum: (1) dramatic decrease in flow rate; (2) an increase in osmolality, from hypotonicity to isotonicity; (3) rise of pH, from acid to alkaline values; (4) a decrease of PCO2, from high to normal values. No increase in fasting plasma levels of immunoreactive secretin and motilin was observed in Zollinger-Ellison syndrome, whereas normal subjects respond to acid in the duodenum by a marked rise in the circulating levels of these hormones. These facts suggest that, in Zollinger-Ellison syndrome: (1) the ability of the small bowel and colon to reabsorb water and electrolytes is normal: (2) duodenal dissipation of hydrogen ions is mainly due to intraluminal neutralization by bicarbonate; and (3) stimulation of water and electrolyte secretion by the pancreas is inadequate.

Jejunal bleeding from a solitary large submucosal artery. Report of two cases

Two young patients with massive intestinal bleeding resulting from a solitary submucosal arterial abnormality of the jejunum are reported. In one case, the bleeding lesion was localized only by emergency abdominal angiography, while a previous exploratory laparotomy proved negative. The vascular lesion encountered in both patients consisted of a wide caliber artery lying in the jejunal submucosa; there was no evidence of true aneurysm on serial sections. The clinicopathological picture closely resembles that of lesions previously described in the stomach under the name of "gastric submucosal aneurysms" in the English literature, or of "gastric Dieulafoy's erosion" in the French literature. It is suggested that the vascular lesions herein reported should be called "solitary large submucosal artery" or "Dieulafoy-like erosion" of the jejunum.

[Acute renal failure in the course of occupational lead intoxication. Chelation therapy responsability (author's transl)]

In a patient with occupational plumbism and a normal kidney function, EDTA therapy (1 g/24 h) resulted in a massive lead excretion (15 000 microgram/24 h) together with acute renal failure. A direct nephrotoxic effect of EDTA was excluded: after renal function returned to normal, EDTA could be subsequently readministered at progressively increasing doses (250 mg to 1 g/24 h) without any renal dysfunction. These findings strongly suggest a close relationship between the burden of lead mobilized by EDTA and the acute renal failure. This case can be classified as acute lead nephropathy of which only a few instances have been reported in the literature. The interest of monitoring lead excretion during chelation therapy is particularly emphasized.

The role of prostaglandins in the study of intestinal water and electrolyte transport in man

The objective of this paper is to assess current knowledge on the pharmacologic and presumed physiologic effects of prostaglandins (PGs) on water and ion transport in the human intestine, from data in the literature and results of authors' studies. PGs, when administered intraluminally or intravenously, induce a profuse net secretion of water and ions into the jejunum or ileum; there is evidence that this effect is unrelated to changes in motility but due to a direct interaction of PGs with mucosal transport processes. Relations of PGs to cholera toxin, gastrointestinal hormones and adenylate cyclase-cyclic AMP system are reviewed. We propose to consider PGs as one of the most convenient model for studying intestinal secretion in vivo in man, in view of the rapid onset, magnitude, reversibility and reproducibility of their striking effect on mucosal transport.

[Massive digestive hemorrhage caused by arterial malformation of the jejunum. Diagnostic value of emergency arteriography]

A case of massive digestive bleeding due to an arterial abnormality of the jejunal wall is reported. Its interest is twofold: a) After a complete endoscopic and operative examination of the GI tract proved negative, an emergency superior mesenteric angiography was the only investigation which allowed to recognize the site and mechanism of the bleeding; b) from a nosologic point of view, the clinico-pathological picture was entirely similar to that of "Dieulafoy's erosion", a syndrome which has been only described, up to now, in the gastric mucosa.

Ulcerative colitis in a patient with anti-B lymphocytotoxin and hypogammaglobulinemia

Lymphocytotoxins (LCT) have been recently reported in the serum of patients with inflammatory disease of the bowel, but up to now these antibodies have shown no specificity for B or T lymphocyte subpopulations. A 32-year-old patient with chronic ulcerative colitis, primary hypogammaglobulinemia and a very low number (0.5 to 1.5%) of B lymphocytes in peripheral blood is described. The presence in the serum of a LCT reacting specifically with B cells was demonstrated by cytotoxicity and direct immunofluorescence experiments. Intestinal immunofluorescence studies indicated a dichotomy between blood and gut immunoglobulins, and showed a heterogeneous distribution of plasma cells of the three major classes from the jejunum to the rectum. The significance of the association of hypogammaglobulinemia, chronic ulcerative colitis, and anti-B LCT is discussed. To explain the dissociation between blood and gut immunoglobulins, it is suggested that the intestine was, in this patient, a privileged site for differentiation of B cells.

Autoantibodies to B lymphocytes in a patient with hypoimmunoglobulinemia. Characterization and pathogenic role

In a young woman with ulcerative colitis, hypoimmunoglobulinemia, and humoral immunodeficiency, lymphocyte counts vary between 600 and 1,000 per mm(3) with 0.5-1.5% bone marrow-derived (B) cells and 98-99% thymus-derived (T) cells. Anti-lymphocyte antibodies were detected by immunofluorescence and by microlymphocytotoxicity with increased reactivity at +4 degrees C. They belonged to the IgM class and were polyclonal. Studies performed with various normal lymphocyte subpopulations, several lymphoblastoid cell lines and lymphocytes from immunodeficiency patients showed that these antibodies reacted with B cells. The corresponding antigen(s) is distinct from membrane-bound immunoglobulins, is not an alloantigen, and is probably unrelated to the la-like molecules. Pokeweed mitogen stimulated B cells appear to lose this antigen. Cells from various lymphoproliferative disorders were tested. T-derived and "non T-non-B" leukemic cells did not react with the antibody. Malignant cells from B-derived lymphomas and prolymphocytic leukemias were reactive. The incidence of positivity of the leukemic cells among patients with common B chronic lymphocytic leukemia was surprisingly low (one-third of the patients). The autoantibody nature of the anti-B-cell antibodies and their pathogenic role in the genesis of the patient's hypoimmunoglobulinemia was demonstrated by the effect of removal of antibodies by massive plasmaphereses which were followed by a dramatic and transitory increase of B-cell figures. Whereas most primary immunodeficiency syndromes appear to result from an arrest in the differentiation capabilities of immunologically competent cells, autoantibodies to circulating B lymphocytes may be incriminated in the pathogenesis of some cases of hypogammaglobulinemia.

Pathological study of alpha-chain disease, with special emphasis on evolution

The pathology of six cases of alpha-chain disease (alpha-CD), four of which were followed until complete remission or death, was studied by histologic, immunofluorescence and ultrastructural techniques. The lesions could be classified in three histopographical stages. The late stage C is an immunoblastic sarcoma probably deriving from the same clone as the initial plasmacytic stage A, stage B being a transitional one between A and C. The asynchronism of the lesions in different organs in the same patient requires a laparotomy for an accurate staging which determines the prognosis and the treatment. Complete and prolonged remissions have been observed at stage A only, sometimes with oral antibiotic treatment alone. At all stages, alpha-CD and the "Mediterranean lymphoma" share identical aetiological, clinical and pathological features. Accurate immunological studies will determine the precise-frequency of alpha-CD protein synthesis in the latter syndrome.

Pathological study of alpha-chain disease, with special emphasis on evolution

The pathology of six cases of alpha-chain disease (alpha-CD), four of which were followed until complete remission or death, was studied by histologic, immunofluorescence and ultrastructural techniques. The lesions could be classified in three histopographical stages. The late stage C is an immunoblastic sarcoma probably deriving from the same clone as the initial plasmacytic stage A, stage B being a transitional one between A and C. The asynchronism of the lesions in different organs in the same patient requires a laparotomy for an accurate staging which determines the prognosis and the treatment. Complete and prolonged remissions have been observed at stage A only, sometimes with oral antibiotic treatment alone. At all stages, alpha-CD and the "Mediterranean lymphoma" share identical aetiological, clinical and pathological features. Accurate immunological studies will determine the precise-frequency of alpha-CD protein synthesis in the latter syndrome.

Further studies on prostaglandin E1-induced jejunal secretion of water and electrolytes in man, with special reference to the influence of ethacrynic acid, furosemide, and aspirin

Perfusion studies were performed in 35 healthy volunteers to investigate further the secretory effect of prostaglandin E1 (PGE1), administered intraluminally, on the human jejunum. A perfusion system with a proximal occluding balloon and continuous aspiration of duodenal secretions was used. The influence of PGE1 (0.9 mug per kg per min) on glucose, fluid, and ion transport was entirely reproducible throughout a 6-hr perfusion experiment and was fully reversible 60 min after the end of PGE1 administration. The influence of ethacrynic acid (EA), aspirin (two agents previously reported to inhibit choleraic secretion), and furosemide was studied both on basal jejunal absorption and on PGE1-induced secretion of water and electrolytes. EA (2.5 mg per kg), administered in jejunal lumen, significantly reduced (P less than 0.001) the net secretory effect of intraluminal PGE1, and suppressed the PGE1-induced increase in plasma-to-lumen unidirectional flux of sodium. Intravenous or intraluminal aspirin (25 to 40 mg per kg) as well as intraluminal furosemide (1.5 mg per kg) did not modify the PGE1-induced secretion nor the basal absorption rates. Plasma immunoreactive levels of PGE1, calcitonin, and diverse gut hormones did not change significantly during PGE1-induced secretion. These results indicate that (1) aspirin, an inhibitor of prostaglandin synthesis, has no influence on the intestinal secretory effect of preformed PGE1; (2) EA, unlike furosemide, inhibits in man PGE1-induced jejunal secretion, an effect of EA similar to that observed in animals on cholera toxin- and cyclic AMP-mediated secretion.

Pancreatic cholera. Sudies on tumoral secretions and pathophysiology of diarrhea

Tumoral secretions and pathophysiology of diarrhea were studied in 1 patient with pancreatic cholera. High concentrations of vasoactive intestinal peptide were found in both systemic blood and tumoral extracts, together with increased plasma levels of calcitonin and protaglandins E and Falpha. Gastric inhibitory peptide and gastrointestinal and pancreatic hormones were absent from the tumor, except for small amounts of glucagon, and their blood levels were normal. Decreased basal but normal pentagastrin-stimulated gastric acid secretion, normal basal and secretin-stimulated pancreatic secretion, increased volume of gallbladder bile with high bicarbonate, and low bile salt concentrations were observed, but the electrolyte content and flow rate of fluid passing the duodenojejunal junction were within normal limits. Small intestine was found to be the origin of the water and electrolyte fasting losses. Jejunum was the site of bicarbonate secretion. Jejunal glucose and leucine-stimulated water and sodium transports were also strikingly decreased, whereas the absorption rates of the sugar and amino acid were normal. Colon reabsorbed high amounts of water and sodium but increased potassium losses. Biological effects of vasoactive intestinal peptide may explain most of the patient's upper digestive secretion abnormalities and small intestinal function impairments, whereas secondary aldosteronism might explain the modified colonic function.

Pancreatic cholera (W.D.H.A. syndrome). Histochemical and ultrastructural studies

Results of light and electron-microscopic studies of primary pancreatic tumor and of metastasis in a new case of Pancreatic Cholera (P.C.) are reported. The primary tumor but not the metastases, contained unusual, large cystic glandular formations, lined both by pancreatic-duct- and small-intestine-like epithelia and closely connected with the endocrine proliferation. A part from a few D-cells, the endocrine tumoral cells could not be identified by histochemical stainings. Their ultrastructural pattern, with small secretory granules (diameter less than 300 nm) and numerous cytoplasmic bunches of filaments, was very similar to that of gastric and duodenal D1-cells. Normal duodenal D1-cells have been said to produce gastric inhibitory peptide, a substance structurally and biologically similar to the vasoactive intestinal peptide actually secreted by the tumor. The normal histological appearance of gastric, gallbladder, jejunal, ileal, right and left colonic mucosae is consistent with the responsibility of the tumoral secretion in the impairment of gut functions in P.C.