Effects of conventional and a novel colonic-release bile acid sequestrant, A3384, on fibroblast growth factor 19 and bile acid metabolism in healthy volunteers and patients with bile acid diarrhoea

BACKGROUND

Primary bile acid diarrhoea (BAD) is associated with increased bile acid synthesis and low fibroblast growth factor 19 (FGF19). Bile acid sequestrants are used as therapy, but are poorly tolerated and may exacerbate FGF19 deficiency.

AIM

The purpose of this study was to evaluate the pharmacological effects of conventional sequestrants and a colonic-release formulation preparation of colestyramine (A3384) on bile acid metabolism and bowel function in patients with BAD.

METHODS

Patients with seven-day ⁷⁵selenium-homocholic acid taurine (SeHCAT) scan retention <10% were randomised in a double-blind protocol to two weeks treatment with twice-daily A3384 250 mg (n = 6), 1 g (n = 7) or placebo (n = 6). Thirteen patients were taking conventional sequestrants at the start of the study. Symptoms were recorded and serum FGF19 and 7α-hydroxy-4-cholesten-3-one (C4) measured.

RESULTS

Median serum FGF19 on conventional sequestrant treatment was 28% lower than baseline values in BAD (p < 0.05). C4 on conventional sequestrant treatment was 58% higher in BAD (p < 0.001). No changes were seen on starting or withdrawing A3384. A3384 improved diarrhoeal symptoms, with a median reduction of 2.2 points on a 0-10 Likert scale compared to placebo, p < 0.05.

CONCLUSIONS

Serum FGF19 was suppressed and bile acid production up-regulated on conventional bile acid sequestrants, but not with A3384. This colonic-release formulation of colestyramine produced symptomatic benefit in patients with BAD.

The ileal bile acid transporter inhibitor A4250 decreases serum bile acids by interrupting the enterohepatic circulation

BACKGROUND

Reabsorption of bile acids from the intestine by ileal bile acid transporter is pivotal for the enterohepatic circulation of BAs and sterol homoeostasis.

AIM

To assess tolerability and study, bile acid metabolism in a phase 1 trial with the selective ileal bile acid transporter inhibitor A4250.

METHODS

A randomised double-blind, single-ascending dose (SAD) and multiple-ascending-dose study consisting of five cohorts comprising 40 individuals with a single administration of A4250 (0.1, 0.3, 1, 3, or 10 mg) or placebo and three cohorts comprising 24 individuals with a 1-week administration of A4250 (1 or 3 mg once daily or 1.5 mg twice daily) or placebo. For the multiple-ascending-dose study, bile acids were measured by HPLC-MS in plasma and faeces, and fibroblast growth factor 19 (FGF19) and 7α-hydroxy-4-cholesten-3-one (C4) were measured in plasma.

RESULTS

No serious adverse events occurred and all participants finished the trial per protocol. At the end of the multiple-ascending-dose study, plasma total bile acids and FGF19 decreased by 47% and 76%, respectively, at 3 mg/day (P < 0.01), and by 15% and 16%, respectively, at 1.5 mg twice daily (P < 0.05). Plasma C4 and faecal bile acids increased at all dose regimens, by 555%, 664%, 292% and 338%, 421%, 420%, respectively (P < 0.01-0.05). The primary bile acids cholic and chenodeoxycholic acids constituted the majority of faecal bile acids in the A4250-treated groups.

CONCLUSIONS

A4250 is well tolerated. By blocking ileal bile acid transporter in the terminal ileum, it highly efficiently interrupts the enterohepatic circulation of BAs, and should be of benefit to patients with cholestatic liver diseases. Clinical Trial registration EudraCT 2013-001175-21.

Clinical trial: a multicentre, randomized, double-blind, placebo-controlled, dose-finding, phase II study of subcutaneous interferon-beta-la in moderately active ulcerative colitis

BACKGROUND

Ulcerative colitis (UC) pathophysiology is characterized by an imbalance between pro- and anti-inflammatory cytokines. Interferon (IFN)-beta-1a has potent immunoregulatory properties, including stimulation of host defence mechanisms and thus represents a potential treatment.

AIM

To extend pilot data and identify a suitable dose of IFN-beta-1a to achieve endoscopically confirmed remission (ECR) in patients with moderately active UC and to evaluate safety.

METHODS

In this multicentre, double-blind, placebo-controlled trial, adults with moderately active UC were randomized to IFN-beta-1a 44 or 66 microg, or placebo, subcutaneously three times weekly for 8 weeks, with a 4-week follow-up.

RESULTS

Endoscopically-confirmed remission was observed in 23.4% [95% confidence interval (CI): 13.8-35.7] of placebo patients, 29.2% (95% CI: 18.6-41.8) of the IFN-beta-la 44 microg group and 20.0% (950% CI: 11.1-31.8) of the 66 microg group (P = 0.45). Improvements with IFN-beta-1a 44 microg were greater than with placebo for most secondary efficacy outcomes, although significance was not achieved. Placebo response rates were higher than expected from previous trials. Adverse events were similar to the known safety profile of IFN treatment.

CONCLUSIONS

Interferon-beta-1a was generally well tolerated at the doses tested, but a significant therapeutic benefit in patients with UC was not observed.

Natural history of gastro-oesophageal reflux disease diagnosed in general practice

BACKGROUND

Cross-sectional studies indicate that gastro-oesophageal reflux disease symptoms have a prevalence of 10-20% in Western countries and are associated with obesity, smoking, oesophagitis, chest pain and respiratory disease.

AIM

To determine the natural history of gastro-oesophageal reflux disease presenting in primary care in the UK.

METHODS

Patients with a first diagnosis of gastro-oesophageal reflux disease during 1996 were identified in the UK General Practice Research Database and compared with age- and sex-matched controls. We investigated the incidence of gastro-oesophageal reflux disease, potential risk factors and comorbidities, and relative risk for subsequent oesophageal complications and mortality.

RESULTS

The incidence of a gastro-oesophageal reflux disease diagnosis was 4.5 per 1000 person-years (95% confidence interval: 4.4-4.7). Prior use of non-steroidal anti-inflammatory drugs, smoking, excess body weight and gastrointestinal and cardiac conditions were associated with an increased risk of gastro-oesophageal reflux disease diagnosis. Subjects with gastro-oesophageal reflux disease had an increased risk of respiratory problems, chest pain and angina in the year after diagnosis, and had a relative risk of 11.5 (95% confidence interval: 5.9-22.3) of being diagnosed with an oesophageal complication. There was an increase in mortality in the gastro-oesophageal reflux disease cohort only in the year following the diagnosis.

CONCLUSIONS

Gastro-oesophageal reflux disease is a disease associated with a range of potentially serious oesophageal complications and extra-oesophageal diseases.

The role of the gut flora in health and disease, and its modification as therapy

The gut flora is a vast interior ecosystem whose nature is only beginning to be unravelled, due to the emergence of sophisticated molecular tools. Techniques such as 16S ribosomal RNA analysis, polymerase chain reaction amplification and the use of DNA microarrays now facilitate rapid identification and characterization of species resistant to conventional culture and possibly unknown species. Life-long cross-talk between the host and the gut flora determines whether health is maintained or disease intervenes. An understanding of these bacteria-bacteria and bacteria-host immune and epithelial cell interactions is likely to lead to a greater insight into disease pathogenesis. Studies of single organism-epithelial interactions have revealed the large range of metabolic processes that gut bacteria may influence. In inflammatory bowel diseases, bacteria drive the inflammatory process, and genetic predisposition to disease identified to date, such as the recently described NOD2/CARD15 gene variants, may relate to altered bacterial recognition. Extra-intestinal disorders, such as atopy and arthritis, may also have an altered gut milieu as their basis. Clinical evidence is emerging that the modification of this internal environment, using either antibiotics or probiotic bacteria, is beneficial in preventing and treating disease. This natural and apparently safe approach holds great appeal.

Discordance between the degree of osteopenia and the prevalence of spontaneous vertebral fractures in Crohn's disease

BACKGROUND

A high prevalence of osteoporosis has been noted in Crohn's disease, but data about fractures are scarce.

METHODS

The relationship between low bone mineral density and the prevalence of vertebral fractures was studied in 271 patients with ileo-caecal Crohn's disease in a large European/Israeli study. One hundred and eighty-one currently steroid-free patients with active Crohn's disease (98 completely steroid-naive) and 90 steroid-dependent patients with inactive or quiescent Crohn's disease were investigated by dual X-ray absorptiometry scan of the lumbar spine, a standardized posterior/anterior and lateral X-ray of the thoracic and lumbar spine, and an assessment of potential risk factors for osteoporosis.

RESULTS

Thirty-nine asymptomatic fractures were seen in 25 of 179 steroid-free patients (14.0%; 27 wedge, 12 concavity), and 17 fractures were seen in 13 of 89 steroid-dependent patients (14.6%; 14 wedge, three concavity). The prevalence of fractures in steroid-naive patients was 12.4%. The average bone mineral density, expressed as the T-score, of patients with fractures was not significantly different from that of those without fractures (-0.759 vs. -0.837; P=0.73); 55% of patients with fractures had a normal T-score. The bone mineral density was negatively correlated with lifetime steroids, but not with previous bowel resection or current disease activity. The fracture rate was not correlated with the bone mineral density (P=0.73) or lifetime steroid dose (P=0.83); in women, but not in men, the fracture rate was correlated with age (P=0.009).

CONCLUSIONS

The lack of correlation between the prevalence of fractures on the one hand and the bone mineral density and lifetime steroid dose on the other necessitates new hypotheses for the pathogenesis of the former.

Influence of smoking and Helicobacter pylori on gastric phospholipids

Smokers show higher rates of peptic ulcer disease (PUD) than nonsmokers, probably due to detrimental effects on the gastric mucosa. Surface-active phospholipids (SPL) are believed to play a key part in gastric cytoprotection. The aim of this study was to determine the chronic effects of smoking on the gastric SPL and to relate them to H. pylori (Hp) -induced effects. Gastric juice was aspirated in 52 patients, with normal findings at planned upper gastrointestinal endoscopy, and concentrations of seven phospholipid subclasses were analyzed. Concentrations of lysophosphatidylethanolamine (1-PE) were increased (P = 0.006) in smokers compared to nonsmokers in non-Hp-infected samples. Nonsmokers infected with Hp showed increased levels of 1-PE (P = 0.01) and phosphatidylinositol (PI) (P = 0.02) compared to subjects not infected. In human gastric juice PI seems to be the dominating PL subclass, in contrast to the composition in biopsy specimens. We also found both Hp-infected and smoking subjects to have higher concentrations of more polar phospholipid subclasses, ie, 1-PE, making the mucosa more vulnerable to acid attack as the gastric surfactant becomes less hydrophobic.

Treatment of joint pain in Crohn's patients with budesonide controlled ileal release

1. Joint pain is a frequent manifestation of Crohn's disease. Budesonide controlled ileal release (CIR) is a predominantly topically acting glucocorticosteroid, which is effective in treating active ileal or ileocaecal Crohn's disease. 2. Therefore, it was of interest to study the effect of this predominantly topically acting therapy on the treatment of an extraintestinal symptom of Crohn's disease by analysing data collected from budesonide CIR (Entocort; Astra Draco AB, Lund, Sweden) trials. 3. Three large studies of budesonide CIR treatment in active Crohn's disease provided a reliable source of clinical data. Of the 611 patients treated in the prospective double-blind controlled trials, 291 had joint pain (arthritis/arthralgia) at entry, which was recorded as part of the Crohn's Disease Activity Index. Statistical analysis was based on all patients treated, provided that the patient had joint pain at the start of treatment. 4. Daily oral budesonide CIR (9mg) resulted in clinical remission of joint pain in 74% (95% confidence intervals (CI) 67-82%) of patients. This outcome was nearly twice as good as placebo (41%; 95% CI 34-57%) and as good as the outcome effected by daily oral prednisolone (40mg; 72%; 95% CI 60-84%). The favourable response to budesonide CIR (9 mg) did not correlate with glucocorticosteroid-associated side effects or with adrenal suppression, which were half those in the prednisolone (40 mg/day) group. 5. The favourable outcome may relate to restitution of normal intestinal immune function.

Prospective randomized multicentre study of laparoscopic versus open appendicectomy

BACKGROUND

A prospective randomized multicentre study was performed to compare the outcome of laparoscopic and open appendicectomy in patients with suspected acute appendicitis.

METHODS

A total of 523 patients was randomized, but because of 23 withdrawals the outcome in 500 patients is reported, 244 in the laparoscopic group and 256 in the open group.

RESULTS

Patients having laparoscopic appendicectomy recovered more quickly than those having open surgery (13 versus 21 days, P < 0.001). There was no significant difference in duration of sick leave after operation (laparoscopic group 11 days versus open group 14 days). Postoperative pain (at 24 h, 7 days and 14 days) was less after laparoscopic operations and a functional index 1 week after operation was more favourable in these patients (P < 0.001). Operating time was significantly longer in the laparoscopic group (60 versus 35 min, P < 0.01). Hospital stay and complications did not differ between the groups. Thirty laparoscopic procedures (12 per cent) were converted to open appendicectomy.

CONCLUSION

Laparoscopic appendicectomy is as safe as open appendicectomy and has the advantage of allowing a quicker recovery.

Acute effects of high-dose intragastric nicotine on mucosal defense mechanisms: an analysis of nicotine, prostaglandin E2, phospholipase A2, and phospholipids

Peptic ulcer disease is overrepresented among smokers; they also heal slowly and relapse frequently. Data are accumulating that smoking is detrimental to gastroduodenal mucosal cytoprotection. This study was designed to assess acute effects of high-dose intragastric nicotine, as it has been shown that nicotine is accumulated in gastric juice when smoking. Seven healthy smokers were given nicotine base (6 mg) as tablets, which yielded very high intragastric concentrations and plasma levels comparable to those seen when smoking. In addition to nicotine analysis, concentration levels of prostaglandin E2 (PGE2), phospholipase A2 (PLA2), and phospholipid classes were measured before and after nicotine administration. Nicotine inhibited PGE2 levels by 27-81%, whereas PLA2 and total phospholipids were unaffected. Lysolecithin, a degradation product of the main constituent of gastric surfactant, ie, phosphatidylcholine, tended to increase, but this was not reflected in intragastric phosphatidylcholine levels. In conclusion, nicotine acutely inhibits PGE2 and may thus impair mucosal cytoprotection. The present findings do not imply a central role of surface-active phospholipids with respect to nicotine and gastric cytoprotection, but the chronic effects of nicotine remain to be investigated.

The anti-ulcer drug sucralfate does not affect gastric nicotine levels

OBJECTIVE

It has been claimed that sucralfate can overcome the negative effects of nicotine in patients with peptic ulcer disease, although the possible mechanism being unknown. This study was performed in order to test whether sucralfate was capable of binding intragastric nicotine, thus making it impossible for the substance to exert effect.

METHOD

Nicotine was administered via transdermal patches or as capsules yielding gastric concentrations of 40-2980 ng.ml-1. Gastric juice aspirates (n = 9) were incubated with sucralfate, which was then separated by centrifugation, and the nicotine concentration was compared in incubated and non-incubated samples.

RESULTS

A median decrease of 13% (range 0-27%) in nicotine concentration was seen after incubation with sucralfate (P = 0.01).

CONCLUSION

The binding of nicotine to the precipitating agent sucralfate is not sufficient effectively to remove nicotine from the gastric juice.

Transdermally administered nicotine accumulates in gastric juice

METHODS

Transdermal nicotine patches (Nicorette 15 mg.16 h-1) were administered to 7 healthy volunteers. Nicotine concentrations in gastric juice were monitored for 8 h via a naso-gastric tube and so was nicotine in saliva and plasma.

RESULTS

Nicotine accumulated in gastric juice, the average concentration being 60.6-times higher than in plasma. In saliva, too, the concentration was higher than in plasma, the average ratio being 10.5. These results strongly suggested ion-trapping of nicotine base in the acidic gastric juice and possibly also in the acinar cells, followed by active secretion. It is hypothesised that accumulation in saliva occurs via a similar mechanism. Pretreatment with omeprazole did not increase the pH to a sufficiently high degree to test the hypothesis that the accumulation of nicotine in gastric juice was pH dependent.

CONCLUSION

Transdermal administration of nicotine produced a high intragastric concentration. The clinical consequence of this effect of long-term nicotine replacement therapy during smoking cessation is unclear.

A financial analysis of laparoscopic and open cholecystectomy

Laparoscopic cholecystectomy (LC) is now the method of choice in treatment of symptomatic gallstone disease. Despite its rapidly growing popularity, comparative costs of this new method and open cholecystectomy (OC) remain unclear. The most outstanding feature of laparoscopic cholecystectomy is the period of short recovery. In Sweden the social insurance office documents sick leave period, sickness allowance, as well as diagnosis and therefore provides a reliable basis for an economic analysis. The purpose of this study was to estimate the hospital cost and costs due to sick leave in a series of patients operated on with elective cholecystectomy using the two methods. In each group 50 consecutive patients were studied retrospectively. The total hospital cost was 10% lower in the laparoscopy group--$1,864 as compared to $2,030 per patient in the OC group. Median number of days off work was 14 after LC and 35 days after open surgery, which corresponds to a median sickness allowance of $516 per patient (LC) compared to $1,424 (OC). Laparoscopic cholecystectomy is more cost-effective than open cholecystectomy mainly due to a reduced sick leave period.

Follow-up after curative surgery for colorectal carcinoma. Randomized comparison with no follow-up

PURPOSE

This study investigated the value of intense follow-up compared with no follow-up after curative surgery of cancer in the colon or rectum.

METHODS

One hundred seven patients were randomized to no follow-up (control group; n = 54) or intense follow-up (follow-up group; n = 53) after surgery and early postoperative colonoscopy. Patients in the follow-up group were followed at frequent intervals with clinical examination, rigid proctosigmoidoscopy, colonoscopy, computed tomography of the pelvis (in patients operated with abdominoperineal resection), pulmonary x-ray, liver function tests, and determinations of carcinoembryonic antigen and fecal hemoglobin. Follow-up ranged from 5.5 to 8.8 years after primary surgery.

RESULTS

Tumor recurred in 18 patients (33 percent) in the control group and in 17 patients (32 percent) in the follow-up group. Reresection with curative intent was performed in three patients in the control group and in five patients (four of whom were asymptomatic) in the follow-up group. In the follow-up group two asymptomatic patients with elevated carcinoembryonic antigen levels were disease-free three and five and one-half years after reresection and were the only patients apparently cured by reresection. No patient underwent surgery for metastatic disease in the liver or lungs. Symptomatic metachronous carcinoma was detected in one patient (control group) after three years. Five-year survival rate was 67 percent in the control group and 75 percent in the follow-up group (P > 0.05); the corresponding cancer-specific survival rates were 71 percent and 78 percent, respectively.

CONCLUSION

Intense follow-up after resection of colorectal cancer did not prolong survival in this study.

Budesonide versus prednisolone retention enemas in active distal ulcerative colitis

METHODS

Efficacy and safety of the topically acting glucocorticosteroid budesonide retention enema (2.3 mg/115 mL) were compared with prednisolone disodium phosphate enema (31.25 mg/125 mL) in patients with active distal ulcerative colitis. The study was a randomized, multicentre trial, with two parallel groups and single-blind to the investigator. One hundred patients with active ulcerative colitis, not reaching beyond the splenic flexure as determined by endoscopy, were treated for up to 8 weeks.

RESULTS

Forty-five patients were randomized to receive budesonide and 55 to prednisolone. Both treatment groups improved significantly in terms of endoscopic and histological scoring during the study, but there were no statistically significant differences between the two groups. Clinical remission, defined as no more than three daily bowel movements without blood and endoscopically non-inflamed mucosa, was achieved in 16% of the patients in the budesonide group after four weeks and in 24% in the prednisolone group (N.S.). After 8 weeks treatment the clinical remission rate in the groups had increased to 36% for budesonide and 47% for prednisolone (N.S.). Mean morning plasma cortisol levels were unchanged in the budesonide group, whereas they were significantly suppressed in the prednisolone group after 2, 4 and 8 weeks (P < 0.0001). Side effects were mild and rare in both groups.

CONCLUSIONS

Treatment with budesonide enema in active distal ulcerative colitis was comparable, regarding efficacy, to treatment with conventional prednisolone enema. A prolongation of the treatment time from 4 to 8 weeks doubled the clinical remission rate in both groups. However, budesonide may be preferable to prednisolone since it causes less systemic effects as reflected by a lack of plasma cortisol suppression.

On the natural history of peptic ulcer

BACKGROUND

Three out of 1000 individuals have peptic ulcer every year, and 20% of the ulcer episodes are associated with bleeding. Whether major innovations such as endoscopy and strong acid-suppressing drugs have had any impact on the natural course of peptic ulcer disease is largely unknown.

METHODS

Three hundred and fifty-one patients (median age, 63 years) with endoscopically proven peptic ulcer during 1979-1984 were included in the study and retrospectively followed up via medical records. The total population is based on two different groups of patients, the first comprising 229 consecutively diagnosed ulcer patients during 1979-81 and, to increase the number of bleeders, a second group including 122 bleeding ulcer patients consecutively diagnosed during 1981-84. At the end of the follow-up period all non-ulcer-operated patients were asked to answer a questionnaire on symptoms, investigations, and medication.

RESULTS

The male to female ratio was 2.4:1 in duodenal ulcer patients, but a 1:1 ratio was shown both in gastric and prepyloric/pyloric ulcer patients (p < 0.001). Patients with bleeding ulcers were significantly older than non-bleeders (68 years versus 58 years; p < 0001), as were patients with gastric ulcers compared with prepyloric/pyloric or duodenal ulcer patients (68 years versus 63 and 61 years, respectively; p < 0.01). The 10-year cumulative mortality in the unselected group (median age, 62 years) was 43%, and the annual risk of dying of peptic ulcer disease was 0.6%. No difference in 10-year recurrence rate was seen between patients with bleeding ulcer at inclusion and non-bleeders (46.2% versus 44.3%; p = NS), but the annual risk of bleeding was 5.3% and 0.8%, respectively (p < 0.0001). In the group of patients answering the questionnaire 51% reported upper abdominal pain during the last year of follow-up.

CONCLUSIONS

In spite of today's treatment regimens almost half of the patients with peptic ulcer disease experienced recurrence during a 10-year period, and more than half had ulcer symptoms after 10 years. Most probably, maintenance treatment with H2-receptor antagonists should have been offered more liberally during the 1980s.

Acute effects of smoking during modified sham feeding in duodenal ulcer patients. An analysis of nicotine, acid secretion, gastrin, catecholamines, epidermal growth factor, prostaglandin E2, and bile acids

Smoking is associated with an increased incidence of duodenal ulcer with a high relapse rate, and smokers tend to be slow healers. The etiology responsible for this remains unknown, and there is general disagreement as to whether smoking affects gastric secretion. The aim of the present study was to investigate both aggressive and protective factors in response to vagal stimulation induced by modified sham feeding (MSF) in duodenal ulcer patients when smoking versus not smoking. On smoking days, nicotine concentrations in plasma averaged about 15 ng/ml and were extremely high in saliva and gastric juice (> 1300 and > 800 ng/ml, respectively). MSF induced a significant decrease in intragastric pH during non-smoking (p = 0.01) but not during smoking. Acid output 1 h after MSF was lower on smoking than on non-smoking days (p = 0.02), as was volume secretion (p = 0.02). Plasma gastrin concentrations were significantly increased during MSF on non-smoking days (p = 0.04) but not on smoking days, the concentrations during the whole day being lower on smoking days (p = 0.002). Plasma catecholamine levels were unaffected by MSF, whether smoking or not. However, plasma concentrations of noradrenaline decreased during the smoking of a single cigarette (p = 0.03), whereas those of adrenaline were increased on smoking days (p = 0.02). Epidermal growth factor concentrations were decreased in gastric juice after MSF during non-smoking (p = 0.01) but not during smoking. Although prostaglandin E2 (PGE2) concentrations in gastric juice were unaffected by MSF, PGE2 output increased after MSF whether smoking or not, the increment being non-significantly less during smoking (p = 0.09).(ABSTRACT TRUNCATED AT 250 WORDS)

Omeprazole-induced hypergastrinemia does not influence growth of colon carcinoma

Colonic mucosa and adenocarcinoma are known to possess gastrin receptors. Recent studies have suggested that some patients with large intestinal cancers and polyps have elevated serum gastrin levels and that gastrin may stimulate growth of colonic neoplasms. The aim of the present investigation was to determine whether endogenous hypergastrinemia--induced by the proton pump inhibitor omeprazole--would influence growth in a subcutaneously implanted murine colonic cancer. The results show that despite a fivefold increase in serum gastrin levels (193 pg/ml median value, range 186-252, in the omeprazole-treated group vs 36 pg/ml median value, range 28-37 in controls), there were no differences in tumor size or survival of tumor-bearing animals. Additionally, there were no differences in serum gastrin values between tumor- (29 pg/ml, range 25-38) and non-tumor- (34 pg/ml, range 25-30) bearing, untreated animals. Endogenous elevation of the serum gastrin hormone to five times the normal level does not demonstrate trophic effects on the murine colon tumor MC-26.

Fosfomycin/metronidazole compared with doxycycline/metronidazole for the prophylaxis of infection after elective colorectal surgery. A randomised double-blind multicentre trial in 517 patients

OBJECTIVE

To find out if fosfomycin together with metronidazole was any better than doxycycline with metronidazole for the prophylaxis of infection before elective colorectal operations.

DESIGN

Multicentre, double blind, random control trial.

SETTING

Nine Swedish hospitals. SUBJECTS-559 patients admitted for elective colorectal operations.

INTERVENTIONS

Fosfomycin 8 g and metronidazole 1 g before operation and fosfomycin 8 g eight hours afterwards, or doxycycline 400 mg and metronidazole 1 g before operation, and placebo eight hours afterwards.

MAIN OUTCOME MEASURES

Incidence of all types of infection, mortality, and side effects.

RESULTS

There were no significant differences between the groups for any of the outcome measures studied, the overall abdominal infection rates (wound, deep, and septicaemia) being 4.6% and 7.4%, and the remote infection rates (pneumonia, urinary tract, and central venous line) 15.1% and 12.8%, respectively. Of the predictors studied, only duration of operation was significantly related to risk of infection.

CONCLUSION

The combination of fosfomycin and metronidazole was as safe and effective as that of doxycycline and metronidazole in preventing infections after elective colorectal operations.

Does nicotine administration influence intragastric acidity?

Smokers have an increased incidence of duodenal ulcer with a high relapse rate whether they receive maintenance therapy with H2-receptor antagonists or not. They also tend to be slow healers. The etiology behind this is still unknown, and there is general disagreement as to whether smoking affects gastric secretion. In an earlier study we found a small but significant decrease in intragastric pH a short time after smoking a cigarette. The aim of the present investigation was to study whether intragastric pH changed during nicotine administration per se. Nicotine was given as a nasal spray to eight healthy smokers. Nicotine did not induce any acute detectable changes in gastric acidity when the 5-min period before spraying was compared with the 35-min period after spraying (median pH, 1.47 (25-75 percentiles, 1.40-2.32) and 1.55 (25-75 percentiles, 1.42-2.06), respectively). When different time periods during a day with hourly nicotine administration were analyzed, and the results compared with those of a similar day when placebo was given, nicotine was found to impair postprandial gastric neutralization. Median pH during the lunch hour was 1.93 (25-75 percentiles, 1.80-2.37) after nicotine and 2.86 (25-75 percentiles, 2.37-3.70) after placebo; p less than 0.025. Possible explanations for this might be nicotine-mediated effects on gastric motility or gastrin release.

Anaesthetic agents suppress basal and stimulated gastric acid secretion. Are intramural neurons involved?

Anaesthetized animals are often used in studies of gastric secretion. We have examined the effect of anaesthetics on the acid output in gastric fistula rats and pylorus-ligated rats, both vagally intact and denervated. Diethyl ether, chloral hydrate, and mebumal effectively reduced both basal and stimulated acid output in fistula rats. The acid output in pylorus-ligated rats was greatly reduced by the anaesthetics. In vagally denervated rats local nervous reflexes are thought to play an important role in the acid secretory response to pylorus ligation. Anaesthetic drugs suppressed acid output in both vagally intact and vagally denervated rats. The possibility of an action on intramural neurons cannot be excluded. The neuro-suppressive effect of anaesthesia should be considered in studies of gastric acid secretion.

Estrogen receptors in the external anal sphincter

Inasmuch as anal competence in women is reduced after the age of 50 years, it may be dependent on effects of estrogens. In this study, samples of the external anal sphincter were analyzed for the presence of estrogen receptors and were found to be present at a median concentration of 5.0 fmol per milligram of protein (range, 1.9 to 13) in women (n = 7), and 1.1 fmol per milligram of protein (range, 0 to 3.2) in men (n = 7). These findings are of interest with regard to the treatment of idiopathic anal incontinence.

Helicobacter pylori, smoking and gastroduodenitis

There is epidemiological evidence of an association between cigarette smoking and gastritis. To find out whether the reason for this might be related to the presence of Helicobacter pylori, biopsies were taken from the gastric corpus and antrum and from the duodenal bulb in 106 consecutive patients referred for oesophagogastroduodenoscopy because of epigastric pain. Patients with ulcer disease or cancer were excluded. The biopsy specimens were cultured for H. pylori and examined histologically for the presence and grade of gastritis and duodenitis. Thirty-five percent of the patients were H. pylori-positive and 57% had histological gastritis; 37% were cigarette smokers and among these, H. pylori was found significantly less frequently than in non-smokers (18 and 45%, respectively; 2p = 0.0083). Among patients colonized with H. pylori, gastritis was found in 89% compared to 39% in non-colonized patients (2p less than 0.0001). In spite of this, 51% of the smokers and 60% of the non-smokers (2p = 0.85) had histological gastritic mucosa. No differences in the severity of the gastritis or the duodenitis in patients with histologically positive findings could be seen when comparing smokers to non-smokers and H. pylori-positive to H. pylori-negative patients.

Intrarectal ultrasonography in rectal cancer staging and in the evaluation of pelvic disease. Clinical uses of intrarectal ultrasound

Accurate preoperative staging of a rectal cancer patient may impact heavily on subsequent management. This study attempts to evaluate the accuracy of intrarectal ultrasonography (IRUS) in staging rectal cancers compared to clinical and pathologic examination. In addition the accuracy of IRUS was assessed in a group of patients with uncertain pelvic-perirectal disease after a negative physical examination. In a prospective manner, 52 cancer patients were staged with digital exam and IRUS. Accuracy rates were 48% and 83%, respectively, compared to pathologic evaluation in assessing wall penetration, and IRUS identified positive lymph nodes in 12 of 17 cases. In patients with pelvic disease, IRUS corresponded with pathologic diagnosis in 15 of 17 cases and revealed new information in 6 patients. Intrarectal ultrasonography appears to be the most accurate imaging technique for staging rectal cancers and demonstrates promise in the evaluation of perirectal-pelvic disease.

Effects of physiological increases in plasma noradrenaline on the human endocrine pancreas

The effect of plasma noradrenaline concentrations within the physiological range (less than 5-6 nM) on the endocrine pancreas was investigated in 9 nondiabetic volunteers. Noradrenaline significantly inhibited plasma insulin levels but did not change plasma glucagon and somatostatin concentrations.

Duodenal diaphragm in the adult. Case report

Congenital duodenal diaphragm presenting with symptoms in adult life is a rare entity. Two cases are reported. They were treated with Finney pyloroplasty and excision of the duodenal diaphragm. The literature is reviewed.

Gastric pseudolymphoma. Case report

Gastric pseudolymphoma (GPL) is a rare entity which closely mimicks malignant lymphoma. Controversy still exists concerning the risk of malignant transformation. In this report a case of GPL occurring 8 years after a gastric resection due to duodenal ulcer is described. The patient has been followed for more than 10 years with annually performed upper GI endoscopies. The histological and endoscopic findings are described.

Effects of physiological increases of plasma noradrenaline on gastric acid secretion and gastrointestinal hormones

It is not known if the increased plasma concentration of noradrenaline in patients with chronic duodenal ulcer disease is a pathogenetic factor or not. The aim of the present study was to investigate if physiologic changes of noradrenaline would evoke any alterations in gastric acid secretion or in the plasma concentration of some gastrointestinal hormones (gastrin, secretin, PP, PYY, and GIP) known to affect gastric physiology. The results show that basal plasma noradrenaline concentration was 1.8 nM and after infusion with noradrenaline at 0.04 or 0.2 nmol/kg/min plasma levels of 2.5 and 4.4 nM were obtained. No appreciable changes could be found in basal or pentagastrin stimulated acid secretion or in any of the gastrointestinal peptides studied. If the elevated plasma noradrenaline concentration observed in duodenal ulcer patients is a pathogenetic factor; it is probable that it interferes with other variables such as blood flow, bicarbonate secretion, or prostaglandin synthesis.

One hundred patients ten years after parietal cell vagotomy

One hundred patients with duodenal or pyloric/prepyloric ulcer disease were operated with parietal cell vagotomy (PCV) and followed for a minimum of 10 years. At 6 weeks, 1,5 and 10 years postoperatively gastric secretory tests, haematological work-up and clinical examination or telephone interview were performed. There was no operative mortality and the frequency of postoperative sequelae was minimal. The cumulative ulcer recurrence rate was 18 per cent and another 14 per cent had slight to moderate symptoms of epigastric pain without any signs of ulcer. Upper gastrointestinal endoscopy was used to reveal recurrences but was performed only if the patient had symptoms of recurrence. A rise in basal acid secretion and in pentagastrin-stimulated secretion was observed the first year postoperatively, whereas insulin-stimulated peak acid output increased during the first 5 years. We conclude that PCV has a low rate of per- and postoperative complications and an acceptable recurrence rate. Therefore, it seems that PCV is the method of choice in chronic duodenal ulcer disease.

The frequency of digital and endoscopic examination of the rectum before radiological barium enema

Doctor's delay in patients with rectal carcinoma is common with a frequency between 30% and 60%. The reason for delay has been supposed to be the neglectance to perform digital examination and rigid proctosigmoidoscopy in patients with symptoms of anorectal disease. Especially general practitioners have been blamed for a high percentage of this kind of doctor's delay. In this study 300 consecutive patients referred for radiological examination of the large bowel have been questioned if digital examination and rigid proctosigmoidoscopy have been performed by their referral doctor. The results show that in 19% of the cases neither digital nor proctosigmoidoscopic examination had been performed. Rigid proctosigmoidoscopy had been omitted in 44%. No statistical difference was observed in the frequency of digital examination between general practitioners (79%) and hospital doctors (84%). The low figures, both for digital examination and rigid proctosigmoidoscopy are probably causing many patients a delay in the diagnosis of a rectal carcinoma. Thus, a more intense evaluation in this area should be applied in the medical faculties and also at post graduate courses.

Jejunogastric intussusception through the enteroanastomosis after gastric resection. Case report

A case of mechanical obstruction due to retrograde jejunogastric intussusception through the enteroanastomosis after a Billroth II gastric resection is reported. The literature is reviewed with special attention to the operative procedure performed. Reduction of the enteroanastomosis is proposed as the method of choice in these cases.

Recurrence and survival after anterior resection of the rectum using the end to end anastomotic stapler

With the introduction of the end to end anastomotic stapler there has been an increase in the number of sphincter saving resections for carcinoma of the middle and distal part of the rectum. The results of earlier reports have indicated an increasing number of local recurrences possibly due to less extensive dissection of the lower pelvic area. Ninety-six patients, 46 males and 50 females, with a median age of 68 years (a range in age of 33 to 86 years) were operated upon between 1978 and 1981 for carcinoma of the rectum with anterior resection and stapled anastomosis have been analyzed. All patients were observed for more than three years (a median of 65 months and a range of 36 to 82 months). The hospital mortality rate was 5 per cent. The median distal margin was 2.5 centimeters (a range of 1 to 10 centimeters). Local recurrences occurred in 17 patients. No correlation between the grade of malignant disease and classification according to Dukes' staging and local recurrence was found. The median time between operation and the diagnosis of a local recurrence was 14 months (two to 62 months). Distant metastases developed in 14 of 83 patients who underwent operation for cure. The over-all five year survival rate was 64 per cent. The survival rate for 83 patients who underwent operation for cure was 71 per cent (96 per cent of Dukes' A, 72 per cent for Dukes' B, 45 per cent for Dukes' C and zero per cent for Dukes' D). It is concluded that the use of stapling devices has not been followed by a higher rate of local recurrence or a decreased five year survival rate and that this new technique can be used whenever technically possible.

Patient's and doctor's delay in carcinoma of the colon and rectum

Despite sophisticated diagnostic equipment and modern surgical therapy, the prognosis for patients with colorectal carcinoma has not improved during the last few decades. One of the factors, possibly contributing to the prognosis, is the time between the patient's visit to the doctor and the final therapy. In order to estimate patients' and doctors' delay and to investigate the factors which may influence the time of delay, a prospective study was designed including 50 patients with carcinoma of the rectum or the sigmoid colon and 50 patients with colonic carcinoma above this level. All patients were interviewed by a doctor using a standard questionnaire, and initial symptoms, duration of symptoms, and type of clinical examination leading to diagnosis were recorded. The results show that 16% of the patients in the recto/sigmoid group suffered from patient's delay as opposed to 20% in the group of patients with carcinoma above 25 cm from the anal verge. Doctor's delay was found in 27% of all cases, being evenly distributed in the two groups. The reason for doctor's delay was usually the doctor's neglecting to perform rectosigmoidoscopy or rectal palpation, and in some cases a false-negative X-ray. No significant correlation was found between tumor stage and doctor's or patient's delay.

Acid secretory tests in peptic ulcer disease before and after parietal cell vagotomy

The aim of the present study was to evaluate the role of gastric acid secretory tests in predicting ulcer recurrence in a consecutive series of patients before and up to 5 years after parietal cell vagotomy (PCV). Included in the study are 405 patients with prepyloric or duodenal ulcer disease (57 recurrences). There were no differences in acid secretion in the group of patients with pyloric or prepyloric ulcer disease, with or without recurrences. Thus pre- and post-operative acid secretory tests are of no value in predicting the outcome of PCV in this group of patients. In the duodenal ulcer group both postoperative basal acid output and peak acid output after pentagastrin and after insulin were higher in patients with recurrences. The two best discriminatory values were the ratio between the preoperative and the 6-week value of basal acid output and the 6-week value of peak acid output after insulin. The results of the study suggests that the ratio of the basal output before surgery and 6 weeks after surgery is enough for judging the acid reduction after PCV and that only in the case of a recurrence should an acid stimulation test be used.

Effect of different denervation procedures on catecholamines in the gut

Sympathectomy has been used to study the role of the sympathetic nervous system in the control of gastric acid secretion. Conflicting results may reflect differences in the sympathectomy procedures used. In a previous study we showed a reduction of catecholamines by more than 90% in the gut wall of the rat after surgical upper abdominal sympathectomy. The aim of the present investigation was to ascertain whether chemical sympathectomy was equally effective and whether total denervation, including combined chemical and surgical sympathectomy together with bilateral truncal vagotomy, would lower the catecholamine levels further. The results showed that chemical sympathectomy reduced noradrenaline levels in fundus (oxyntic) and antrum mucosa to levels similar to those after surgical sympathectomy (less than 5%), but the reduction was less pronounced in the muscle layer of the fundus and antrum and in the pancreas and spleen. Combined surgical and chemical sympathectomy did not reduce noradrenaline more effectively than surgical sympathectomy alone. Vagotomy reduced catecholamines in the stomach by about 50%; in extragastric tissues vagotomy was without effect. Total denervation, including combined surgical and chemical sympathectomy plus vagotomy, did not reduce noradrenaline levels more than surgical sympathectomy alone, suggesting that the proportion of adrenergic fibers that derive from the vagus is quantitatively insignificant but that the vagus exerts a local control of the sympathetic stores of gastric catecholamines.(ABSTRACT TRUNCATED AT 250 WORDS)

Ulcer healing and relapse prevention by ranitidine in peptic ulcer disease

Ranitidine, 300 mg daily, was given to 92 patients with duodenal ulcer (DU), 38 with prepyloric ulcer (PPU), and 21 with gastric corporeal ulcer (GCU). The healing rates at 4 weeks differed for the different types of ulcers (P less than 0.01), being 91% for DU, 68% for PPU, and 81% for GCU. After established ulcer healing, maintenance treatment with either ranitidine, 100 mg twice daily or 150 mg at night, or placebo was given for 1 year or until ulcer relapse in a total of 108 patients--71 with DU, 24 with PPU, and 13 with GCU. There were no significant differences in relapse rates between the two groups treated with active drug or between the three ulcer groups. However, the overall relapse rate in the active drug groups was 16%, against 72% in the placebo group (P less than 0.001).

Peptide-containing nerve fibers in the stomach wall of rat and mouse

Peptide-containing nerve fibers were found to be numerous in the glandular stomach of the rat and mouse. The immunoreactive neuropeptides demonstrated included vasoactive intestinal polypeptide (VIP), peptide histidine isoleucine (PHI), gastrin-releasing peptide (GRP), substance P (SP), enkephalin, somatostatin, cholecystokinin, and neuropeptide Y (NPY). The density and distribution of the various peptide-containing fibers did not differ overtly between the pyloric and oxyntic gland areas except for the GRP fibers, which were fewer in the pyloric than in the oxyntic mucosa. The entire VIP nerve fiber population was found to also contain PHI. Immunoreactive NPY was found to occur in the VIP/PHI fibers (VIP/PHI/NPY fibers) in the smooth muscle and intramural ganglia of both rat and mouse and in the mucosa of the mouse. Mucosal VIP/PHI fibers in the rat did not contain any NPY-like material. Perivascular NPY fibers in both species and mucosal NPY fibers in the rat did not contain VIP or PHI. The mucosa harbored numerous GRP fibers and VIP/PHI (rat) or VIP/PHI/NPY (mouse) fibers, and a modest number of NPY (rat) and SP fibers. In the submucosa the peptide-containing nerve fibers were found mainly in the ganglia and around blood vessels. Blood vessels received a rich supply of NPY fibers; the number of perivascular VIP/PHI, GRP, and SP fibers was much lower by comparison. The smooth muscle and myenteric ganglia harbored not only VIP/PHI/NPY, GRP, and SP fibers but also enkephalin, somatostatin, and cholecystokinin fibers. Gastrin-releasing peptide, VIP/PHI/NPY, SP, and enkephalin nerve cell bodies occurred in the myenteric ganglia. As studied in the rat, vagal denervation did not affect the density and distribution of the various peptide-containing nerve fibers. After sympathectomy, mucosal and perivascular NPY fibers disappeared. The other types of peptide-containing nerve fibers were not affected.

Detection of recurrent cancer of the colon and rectum

Outpatient follow-up in patients operated upon due to carcinoma of the colon and rectum is usually performed, due to a high rate of recurrence and with the aim of finding a curable recurrence. Due to the enormous cost of an extended follow-up system, a careful evaluation of the benefit is needed. The aim of the present investigation was to study the efficacy of the different tools in an extended follow-up. One hundred ninety patients with carcinoma of the colon and rectum were--apart from traditional clinical follow-up--followed with an extensive laboratory battery including carcinoembryonic antigen (CEA), erythrocyte sedimentation rate (ESR), hemoglobin (Hb), electrophoresis, ALP, and GT. Forty-seven recurrences were found. Thirty-one of these recurrences were first detected by a rise in CEA. Seven cases were detected at clinical follow-up and six cases due to symptoms suggestive of recurrence. The predictive value of a positive test was 79.4% for CEA but very low for the other tests studied. A negative value for any of the tests in the battery was usually accurate. Follow-up after colorectal carcinoma should include CEA as the only laboratory parameter. Postoperative colonoscopy for removal of missed synchronous lesions, chest X-ray, and endoscopic investigations of the anastomotic region also seem to be of value.

The healing process of anastomoses of the colon. A comparative study using single, double-layer or stapled anastomosis

In spite of modern suture materials and different techniques in colonic anastomoses after resection, leakage is still the most feared complication in colonic surgery. In female pigs of Swedish land breed, standardized 5-cm long colonic resection was performed 10 cm above the peritoneal deflection, using either a single layer of Gambee-stitches (n = 6, Vicryl 4-0), two-layer interrupted stitches (n = 6, Vicryl 4-0) or the intraluminal stapling device (n = 6, ILS Ethicon). After one week, the animals were sacrificed and an anastomotic index was calculated using in vitro x-ray. Also, anastomotic circulation (calculated by the microsphere technique), breaking strength, and histologic evaluation were performed. All animals survived and no leakage was observed. The time to perform the anastomosis was significantly shorter (P less than 0.05) for the stapling device compared with the manual techniques used. The anastomotic index was lower (P less than 0.05) for two rows (0.24) compared with Gambee-stitches (0.38) or stapler anastomoses (0.37). There were no differences in blood flow among the three groups and no differences in breaking strength. Macroscopic investigation revealed mucosal defects in two of the stapled anastomoses and histologic investigation showed small areas of necrosis. The stapling device did not induce any inflammatory reaction. On the other hand, a severe inflammatory reaction was seen when using conventional suture materials. In conclusion, this study shows that a single row of Gambee-stitches is equal to the ILS stapling device when performing colonic anastomoses and these two methods seem to be superior to the two-layer technique.

The healing process in high and low anterior resection of the rectum. A comparative study in the pig, using stapling devices

The reason for the higher leakage frequency after low anterior resection compared with high resection is unexplained. With the development of stapling devices, we have a unique opportunity to investigate anastomotic healing during standardized conditions. In female pigs, six in each group, a high anterior resection was performed by resection of a 5-cm colon segment, 10 cm above the peritoneal fold, and low anterior resection was performed after resection of a 5-cm segment at the peritoneal fold and downward. Differences in healing parameters, i.e., blood flow, breaking strength, and radiologic and histologic appearance between low and high anterior resection, were evaluated. Two leakages occurred after low and none after high anterior resection. The anastomotic index was 0.37 (high) and 0.26 (low) (P less than 0.05). The breaking strength was higher in low resections; this might be due to the thicker wall. There were no differences in blood circulation between high and low anastomoses, but the blood flow was significantly higher in the anastomotic area in both groups. This is probably due to the inflammatory reaction taking place in the healing anastomoses. This study, performed in a standardized fashion with a stapler adjusted to wall thickness and size of the intestine, cannot, on the basis of microcirculation, explain why leakage is more common in lower anastomoses.

The effect of beta-blockade on gastric acid secretion, gastrin release, and plasma catecholamine concentrations during modified sham feeding in duodenal ulcer patients

The effects of beta-blockade (propranolol, 100 mg orally) on gastric acid output and on circulating levels of gastrin, adrenaline, noradrenaline, and dopamine during modified sham feeding (MSF) were investigated by a randomized, double-blind method in six patients with asymptomatic duodenal ulcer disease. No differences occurred in peak acid output during MSF, whereas basal acid output was significantly suppressed by beta-blockade and peak acid output was unaffected. Basal gastrin concentration was lower during beta-blockade but rose in response to MSF. Without beta-blockade serum gastrin levels were unaffected by MSF. Plasma catecholamine concentrations were not affected by the beta-blockade. It is concluded that acid output and gastrin release in response to MSF, unlike that to insulin hypoglycaemia, is not influenced by beta-adrenoceptor blockade.

Effects of upper abdominal sympathectomy on gastric acid, serum gastrin, and catecholamines in the rat gut

Selective upper abdominal sympathectomy increased basal acid output in rats but was without effect on stimulated acid output, serum gastrin concentration, and gastric mucosal histidine decarboxylase activity. The sympathectomy was verified by fluorescence histochemistry and determination of tissue catecholamines. A drastic reduction in tissue noradrenaline, adrenaline, and dopamine levels occurred after sympathectomy, and fluorescence microscopy showed a complete loss of adrenergic nerve fibers. Vagotomy reduced catecholamine levels in the stomach wall by 50% but did not affect the catecholamine content in the pancreas and small bowel. Surprisingly, combined vagotomy and upper abdominal sympathectomy resulted in lower catecholamine levels than sympathectomy alone in extragastric but not in gastric tissues.