[Renal and adrenal involvement in von Hippel-Lindau disease: clinical features and therapeutic strategies]

OBJECTIVES

We report our experience of renal and/or adrenal manifestations of von Hippel-Lindau disease and propose a practical approach.

METHODS

Eight patients (mean age: 43 years) presented with predominant renal and adrenal lesions in 6 cases and 2 cases, respectively.

RESULTS

All patients are alive with a mean follow-up of 8.1 years. A local recurrence after partial nephrectomy was observed in two cases. Two patients are in renal failure and are treated by dialysis and two patients require hormone replacement therapy for adrenal insufficiency.

CONCLUSIONS

The predegenerative nature of simple renal was not observed. Conservative renal surgery is adapted to small renal tumours, with a low cytological grade and without any distant lesions in the same kidney. Radical nephrectomy is reserved for large lesions (greater than 5 cm) with a high cytological grade. The presence of pheochromocytoma must be systematically excluded. Preservation of the adrenal gland in the case of homolateral renal surgery for cancer is recommended. The reliability of the genetic test allows early diagnosis of this disease.

[Urinary infections in pregnant women]

Urinary tract infection is frequent during pregnancy with a high potential risk for mother and child. Based on a review of the literature and a retrospective survey conducted in 20 representative French university hospitals during 1993, the authors propose a practical review designed to standardize the therapeutic approach to this disease. They define a high-risk group which requires systematic screening and close surveillance during pregnancy. They evaluate the need for complementary investigations in relation to the 3 clinical presentations encountered (asymptomatic bacteriuria, cystitis and acute pyelonephritis) taking into account their respective adverse effects. The therapeutic modalities of the three clinical forms are then described, including drainage of the urinary tract.

[Prognostic factors of survival in infiltrating urothelial bladder carcinoma. A retrospective study of 158 patients treated by radical cystectomy]

The clinical files of 158 patients who were treated by radical cystectomy for infiltrating bladder carcinoma were retrospectively reviewed to define prognostic factors. PATIENTS AND METHODS.--All patients had a radical cystectomy with bilateral pelvic lymph node dissection for an infiltrating operable bladder urothelial tumor. Each tumor was classified according the pTNM staging system and were analysed for the presence of vascular invasion, carcinoma in situ and tumor grade. Twenty-three patients (14.5%) had an irradiation. Sixty-seven patients (42%) received chemotherapy (neoadjuvant in 31, adjuvant in 30, both in 6). RESULTS.--The median overall survival of the whole group was 19 months. The 5 years disease free survival (DFS) and overall survival (OS) were 44% and 31%, respectively. In the univariate analysis, the factors with significant prognostic value were: pT stage and the tumor size for OS, age and lymph node involvement for DFS, presence of carcinoma in situ (CIS) and tumor size for local recurrence free survival (LRFS) and sex and lymph node involvement for metastatic free survival (MFS). The following variables attained significant prognostic value in the multivariate analysis: pT stage and an interaction between lymph node involvement and vascular invasion for OS, pT stage and presence of CIS for LRFS, pT stage for MFS. CONCLUSION.--The pT stage, lymph node involvement and vascular invasion are the most important prognostic factors of survival in infiltrating bladder cancer.

[Early diagnosis and screening of cancer of the prostate]

It is obvious that digital rectal examination and assay of prostate specific antigen are required for all patients presenting signs of prostatism, but the true benefit of such an attitude for all patients is a matter of much controversy. We do know that the incidence of prostate cancer is rising faster than any other cancer and that the cause of death in approximately 3% of the male population over 50 years will be cancer of the prostate. Yet despite this risk, and due to the lack of satisfactory registries, the prevalence of the disease still remains unknown. A well-conducted mass screening programme could be expected to uncover prostate cancer in approximately 6% of the population, which would mean that in the French male population in the 55-70 year range, 348,000 cases would be diagnosed. Assuming that 70% of them would have a localized form theoretically accessible to curative treatment (radical prostatectomy or radiotherapy), the current mortality for prostatectomy (1 to 2%) would mean that at least 2,500 persons would die during the perioperative period. The question of psychological impact of a general screening programme and its cost are other considerations of importance. Under these conditions, can a mass screening programme be proposed? In France, the answer today appears to be no. The arguments in favour of early diagnosis are insufficient for mass screening and will remain so until a certain number of basic questions concerning the efficacy of treatment, the cost-benefit ratio of screening, and the psychological impact of early diagnosis are resolved.

Clinical value of fine-needle aspiration cytology and biopsy in the evaluation of male infertility. A comparative study of 48 infertile patients

OBJECTIVE

To evaluate whether fine-needle aspiration cytology of the testis can be considered as a diagnostic parameter in the evaluation of male infertility.

PATIENTS AND METHODS

We studied 30 oligospermic and 18 azoospermic patients using 63 fine-needle aspiration samples and 57 biopsy samples obtained surgically (10 cases) or with a spring-loaded biopsy device (47 cases). Cytologic evaluation of spermatogenesis was performed by studying longitudinal segments of seminiferous tubules and cytocentrifuged dissociated cells.

RESULTS

Comparison between fine-needle aspiration and the biopsy methods gave concordant results in 72.2% of cases. Discordant findings were recorded in 10 cases (27.8%). In eight cases, significant maturation into spermatozoa was recognized in samples obtained by fine-needle aspiration only, whereas moderate to severe hypospermatogenesis or germ cell aplasia were demonstrated in samples obtained by the spring-loaded biopsy device or by open surgical biopsy. Germ cell aplasia was recognized in samples obtained by both methods in 75.0% of cases. Insufficient specimens were obtained by fine-needle aspiration and the spring-loaded biopsy device in 15.9% and 12.3% of cases, respectively, whereas all surgical biopsy specimens were of good quality. Four bleeding episodes and one case of epididymitis were observed after use of the spring-loaded biopsy device, but no complication was related to either surgical biopsy or fine-needle aspiration.

CONCLUSION

The findings show that fine-needle aspiration cytology could represent a more reliable means of identifying significant numbers of the most mature germ cells.

Pheochromocytoma as the first manifestation of von Hippel-Lindau disease

BACKGROUND

von Hippel-Lindau disease is an autosomal dominant disorder characterized by the development of hemangioblastomas in the cerebellum, spinal cord, and retina, renal cell carcinoma and cysts, pancreatic cysts, and pheochromocytoma.

METHODS

We have studied a series of 36 French patients affected with von Hippel-Lindau disease pheochromocytoma. Thirty (83%) of them were diagnosed as having von Hippel-Lindau disease because the disease occurred in a familial von Hippel-Lindau disease setting; six (17%) were diagnosed as having von Hippel-Lindau disease because they displayed another characteristic manifestation of that disease.

RESULTS

The mean age at pheochromocytoma diagnosis was 29 +/- 14 years (5 to 62 years). Bilateral tumors were documented in 15 (42%) cases, paraganglioma was associated with adrenal pheochromocytoma in four cases, and malignant pheochromocytoma occurred in three cases. Prevalence of pheochromocytoma revealing von Hippel-Lindau disease was 20 (53%) out of 36. In six cases pheochromocytoma was the only manifestation of the disease.

CONCLUSIONS

In the interest of the patients themselves and of family members who are at risk, search for von Hippel-Lindau disease must be systematic in the presence of pheochromocytoma. Basic checkup may be completed with familial inquiry, ophthalmoscopy, cerebral magnetic resonance imaging, abdominal ultrasonography, and computed tomography-scan for detection of latent lesions. In the future, after characterization of von Hippel-Lindau disease gene mutations, molecular diagnosis is going to be possible in individual patients.

Metastatic malignant melanoma: an unusual case presentation

Secondary involvement of the genitourinary tract with malignant melanoma is a common autopsy finding, but rarely evident clinically. We report a rare case involving a previously asymptomatic patient presenting with gross hematuria and a large renal mass, which was found to be metastatic melanoma. We propose that metastatic melanoma to the kidney, although rare, be considered in the differential diagnosis of disease processes causing hematuria.

[Diagnosis and evaluation of spread of prostate cancer]

In more than 50% of the cases, the diagnosis of prostate cancer is made at the time of extra-prostatic or distant disease involving poor prognosis for cure. Small tumours for which curative treatment is possible are asymptomatic. Thus, useful early diagnosis of prostatic cancer is based on digital rectal examination and PSA concentration. PSA levels are also indicative of tumour volume. Thus, determining dissemination becomes significant only in the case of elevated PSA, indicating a large tumour.

[Viewpoints of the urologist on acute pyelonephritis]

For the urologist acute pyelonephritis is a relatively common disease when it is uncomplicated and occurs in otherwise healthy patients. In such cases, admission to hospital is not always required. On the other hand, there are situations in which the disease is more difficult to manage. A poor general condition, the existence of a congenital malformation, the presence of a foreign body in the urinary tract, the occurrence of the disease after a surgical or instrumental procedure may transform acute pyelonephritis into a dangerous condition which sometimes follows a dramatic course.

Thermoregulation during transurethral microwave thermotherapy: experimental and clinical fundamentals

Transurethral microwave thermotherapy of 340 patients treated at our center for benign prostatic hypertrophy shows the importance of the role played by two thermoregulation processes during the procedure. The first one is artificial and automatically driven by the machine (the power output and cooling rate are adjusted to the urethral and rectal temperature safety thresholds). The second one is natural thermoregulation; the latter is species specific, organ specific, zone specific and even cell specific. Thermoregulation variability is linked to the geometry of the gland, vessel distribution, histology and tissue conductivity. This variability has been demonstrated by interstitial thermometry and histological study. Interstitial thermometry was performed during treatment in 30 dogs and 35 patients; a histological study of prostate specimens was performed 1-12 weeks after treatment in 30 dogs and 15 patients. The human prostate is more resistant to heat than the dog prostate of a comparable volume and treated with the same thermal dose. The prostate of a young patient requires a higher thermal dose than that of an old patient with the same prostate volume in order to achieve a comparable intraprostatic temperature, probably due to a more viable blood supply. The transition zone is more sensitive to heat than the peripheral zone, as demonstrated by temperatures recorded at the same distance from the antenna of up to 60 versus 42 degrees C, respectively. Acinar cells seem to be more resistant to heat than smooth muscle cells when exposed to the same temperature level, as demonstrated by microscopic examination at the periphery of the treated area.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pheochromocytoma, first manifestation of Von Hippel-Lindau disease: a possibility to be considered]

Von Hippel-Lindau (VHL) disorder is an autosomal dominant disease characterized by the almost constant development of hemangioblastomas in the central nervous system (cerebellum, spinal cord and retina). In addition, various types of tumors including renal cell carcinomas, pancreatic cysts and pheochromocytomas are frequently observed in VHL gene carriers. Linkage of the VHL locus to the RAF-1 oncogene on the short arm of chromosome 3 (3p25-26) has been recently reported. Pheochromocytoma is of particular interest because of the risk of inaugural malignant hypertensive crisis but especially because of a great degree of interfamily variability (from 0 to 92% of affected members in previously reported large kindreds). We have studied a French series of 25 pheochromocytoma (11 males, 14 females) in VHL affected patients. Twenty pheochromocytoma (80%) occurred in a familial context, whereas 5 (20%) were consistent with "apparent sporadic cases". The mean age at pheochromocytoma diagnosis was 27 years (5-55 years). Bilateral tumours have been documented in 13 cases (52%). The prevalence of pheochromocytoma revealing VHL was 14 out 25 (56%). In these cases, VHL diagnosis was considered up to 25 years later. In 6 cases (2 deceased) pheochromocytoma was the only manifestation of VHL. Thus, search for VHL must be systematic in the presence of pheochromocytoma, in the interest of the patients themselves and of potential at-risk family members (prevention of hypertensive crisis linked to latent tumours). Basic check-up (neurological and somatic examination, ophthalmoscopy, familial inquiry) may be completed with cerebral CT scan or MRI and abdominal ultrasonography followed, if positive or doubtful, by abdominal MRI or selective angiography.

[Deep venous thromboses in erysipelas of the leg. A prospective study of 40 cases]

The treatment of lover limb erysipelas rests on antibiotic therapy directed against streptococci, but the necessity of prescribing a concomitant anticoagulant treatment has not yet been established. The incidence of deep vein thrombosis in patients with erysipelas of the leg in unknown. In a prospective study of 40 patients presenting with this type of skin disease, we looked for deep vein thrombosis, using systematically pulsed Doppler vein exploration combined with ultrasonography and, if necessary, a second Doppler examination and a phlebography. Six cases of deep vein thrombosis were diagnosed. This complication was observed in 5 patients at high risk for deep venous thrombosis; it had never been foreseen at clinical examination.

[Progression after radical prostatectomy of cancer of the prostate: prognostic criteria and the role of PSA in monitoring]

Progression after radical prostatectomy, evaluated by a rise in plasma PSA and/or the appearance of a pelvic nodule positive on biopsy and/or the presence of bone metastases confirmed by bone scan, was studied in a series of patients with prostatic cancer with a follow-up of between 6 months and 5 years. The progression-free survival rate was 86% at 1 year and 60% at 5 years. A progression-free survival rate and the relative risk of progression were established on the basis of the morphological characteristics (anatomical stage, tumour volume, seminal vesicle invasion, condition of the prostatic capsule and lymph nodes, positive resection margins at the apex) and histological features (Gleason's score) of the cancer, allowing determination of the influence of prognostic criteria on the outcome. The positive resection margins at the apex were due to preservation of the nervi erigentes. The preservation of the neurovascular pedicles may not be justified in the case of a tumour confined to the prostatic apex.

Minimal focal dermal hypoplasia in a man: a case of father-to-daughter transmission

Focal dermal hypoplasia is a rare genetic disorder characterized by diffuse and specific cutaneous lesions. Multiple visceral abnormalities are frequently associated. A minimal form of the disease (only cutaneous and localized to one thigh) is reported in the father of a woman who had typical focal dermal hypoplasia.

[Systemic scleroderma and primary bronchopulmonary adenocarcinoma. A new case]

The authors report a case of systemic sclerosis associated with primary lung adenocarcinoma. This association has previously been reported in patients with old scleroderma complicated by extensive fibrosis of the lungs allegedly regarded as a precancerous lesion. The case reported here is of interest owing to the absence of pulmonary fibrosis.

[Kaposi's sarcoma complicating long-term corticotherapy for severe asthma]

Kaposi's sarcoma frequently develops in patients with immune deficiency which may be drug-induced (corticosteroids, immunodepressants). We report a case of Kaposi's sarcoma in a 75-year old man who had been taking oral prednisone continually for 7 years as treatment of severe asthma. Data from the literature clearly show that corticosteroid therapy may trigger the development of Kaposi's sarcoma in patients who usually possess several other pathogenetic factors of that disease, such as pre-existing immune deficiency, environmental (viruses) or genetic factors. In some cases, withdrawing corticosteroids may result in complete remission of the cutaneous lesions.

The significance of the prostatic hypoechoic area: results in 226 ultrasonically guided prostatic biopsies

A total of 666 patients with symptoms of urinary outflow obstruction underwent assessment of the patients 64 had a palpable abnormality suggestive of cancer (stages T1 to T4, or B to C). In the remainder the prostate was either palpably normal, firm or enlarged by benign prostatic hypertrophy. All 64 patients with a palpable abnormality and 162 of 602 with normal rectal examination findings had a hypoechoic area on transrectal ultrasound. Biopsy of the ultrasonic abnormality was done in 148 men by the transperineal route with linear array ultrasound guidance and in 78 by the transrectal route with a mechanical sector scanner in the sagittal plane. Of the 64 patients with a nodular prostate 34 (53%) had cancer (31% of those with stages T1 and 2, 83% with stage T3 and 100% with stage T4 disease). In 14% of the patients with stages T1 and T2 cancer the biopsy showed prostatic intraepithelial neoplasia grade 3. Of the 162 patients with a palpably normal prostate who underwent ultrasound-guided biopsy 11 (6.7%) had cancer and 6 (3.7%) had grade 3 prostatic intraepithelial neoplasia detected in the biopsy material. Patients with stages T1 to T2 cancer and those with ultrasound-diagnosed impalpable cancer were not significantly different with respect to patient age (67 versus 70 years), cancer size (3.0 +/- 1.6 versus 3.9 +/- 2.5 cm.2) or Gleason score (5.4 +/- 1.2 versus 6.5 +/- 0.9). The results demonstrate that ultrasound guidance improves the yield of prostate needle biopsy. Furthermore, it is suggested that prostate cancer found by ultrasound alone is not different from early palpable disease and should be treated in the same manner.

Arteriovenous shunt measured by bolus dye dilution: reproducibility and comparison between two injection sites

Twenty-eight brachial arteriovenous fistulae (AVF) flows were assessed by the Stewart and Hamilton method by bolus dye injection. These measurements were divided in two groups: a first group with dye injection into the AVF artery and a second group with dye injection into the efferent vessel of the AVF in close proximity. The increase and the decrease of dye concentration were regular and the circulation occurred very late in both groups. Reproducibility was assessed by the usual index: the mean of the differences between two successive measurements of each series related to the first of these two and expressed as a percentage, m(Qn - Qn - 1)/Qn%. In the two groups, the reproducibility index was at 10.1%, similar to the index applied to Grimby's results, measuring successive cardiac output by dye bolus injection at 9.8%. Theoretical criteria of validity of the Stewart and Hamilton method were checked for all measurements. Even when the duration of the measurement was very short, arteriovenous flow fulfilled the criteria of validity in the same way as cardiac output. Two AVF flows were measured successively at both injection sites with no difference between the obtained values. The same reproducibility of the efferent vessel injection site group suggests that an arterial puncture is not necessary for a correct assessment of AFV flow.

[Nephrotic syndrome with minimal glomerular lesions, sensitive to corticoids, disclosing a chordoid sarcoma]

A 65 year old woman had a minimal changes nephrotic syndrome (MCNS) with steroid-induced remission. An underlying malignancy was discovered at the time of relapse of proteinuria: it was a retroperitoneal chordoid sarcoma. Even though the tumor could not be excised, complete remission was again observed with corticosteroids. There was no second relapse when prednisone was discontinued and during the seven months before the patient died. This is a new unusual case of MCNS associated with carcinoma. The response of nephrotic syndrome steroid therapy is further suggestive evidence that deficiency in T-cell function may be involved.

[Glomerulopathies in the aged (excluding diabetes)]

Fifty-five cases of glomerular disease in non-diabetic patients above sixty years of age were studied retrospectively. Primary glomerular disease was found in 36 cases, among which 14 cases with minimal changes glomerulopathy (25.4%) and 7 cases with membranous glomerulopathy (12.7%). The remaining 19 patients had secondary glomerular disease, mainly with amyloidosis (12 cases: 21.8%). In these three main forms of glomerulopathy, symptoms were similar, making differential diagnosis impossible before histological examination. Significant responses to treatment can be achieved in minimal changes and extracapillary proliferative glomerulopathies: among the 14 patients given corticosteroids, 9 recovered or experienced very significant improvement. However, one patient under cortico-steroids died from perforation of the sigmoid. In order to establish the best treatment, investigations should be carried out as in younger patients, since they do not seem to involve a significantly higher risk.

Ileal varices revealed by recurrent hematuria in a patient with portal hypertension and Mekong Schistosomiasis

This present report describes a unique case of a patient with ileal varices revealed by recurrent bleeding from vesical varicosities. Ileal varices were associated with portal hypertension secondary to portal thrombosis. An unusual ileovesical shunt was demonstrated by the venous phase of the superior mesenteric arteriogram. This shunt was favored by adhesions between an abnormal ileal loop, which was infiltrated with ova of schistosoma mekongi, and the superior vesical wall. The patient was treated successively by lysis of adhesions and ileal resection. No portacaval shunt was performed.

Peliosis hepatis in a chronic hemodialysis patient

Peliosis has been described rarely in patients with chronic renal failure. The case reported shows the difficulty of diagnosis in a chronic hemodialysis patient with painful hepatomegaly, chronic ascites and cachexia. The rarity of this lesion under such circumstances, if the etiologies described in the literature are taken into account, is discussed.

Nontraumatic intramural hematoma of the duodenum. Report of 4 cases and review of the literature

The authors report 4 cases of nontraumatic intramural hematoma of the duodenum (IMHD), 1 of pancreatic origin, 2 due to anticoagulant therapy while the 4th was an unusual complication of periarteritis nodosa. The principal anatomical, clinical, biological and radiological characteristics of IMHD are reviewed. Therapy is discussed, emphasizing nonaggressive surgery when possible.

[Urologic manifestations disclosing a tumor of the spinal cord. Apropos of a case, ependymoma of the terminal cone]

A twenty-two-year-old man was hospitalized for acute renal failure resulting from long-standing ureterohydronephrosis. An ependymoma of the terminal spinal cord was removed. Physiopathology of micturition and the features which allow differential diagnosis are recalled. Previously reported cases are reviewed.

[Arterial hypertension due to abuse of sympathomimetic drugs. One case (author's transl)]

A 36-year-old woman developed severe arterial hypertension after taking for five consecutive years increasing dose (up to 10 mg per day) of phenoxazoline HCl in nasal spray. A relationship between the abuse of this sympathomimetic drug and the hypertension was suggested by the unusual appearance of renal arteries on arteriography (stenosis and dilatations resembling aneurisms), the increase in renin activity and the disappearance of hypertension after the drug was discontinued. On control examination, two years later, blood pressure, renin activity and renal arteries were normal. The possibility of sympathomimetic drug overdosage must be borne in mind in cases of suspected iatrogenic arterial hypertension.

Hemodynamic effects of arteriovenous fistulae in chronic hemodialysis patients at rest and during exercise

The effects of arteriovenous fistulae (AVF) on cardiac output (CO) and cardiac filling pressures were studied at rest and during exercise in 16 chronic hemodialysis patients. After the occlusion of the AVF, average CO fell but cardiac filling pressures remained unchanged, seven patients had a drop in CO greater than or equal to 1.0 l/min (group A) and nine patients had a drop in CO less than or equal to 0.9 l/min (group B). At rest, average CO was higher in group A than in group B, but cardiac filling pressures were the same in group A and in group B. During maximal exercise, average CO and cardiac filling pressures were the same in both groups.

[Radiological, fibroscopical, histological and secretory gastric aspects in hemodialyzed patients (author's transl)]

Seventeen chronic hemodialyzed patients underwent a baryum meal, a fibroscopy with biopsic studies and an evaluation of gastric acid secretion. No duodenal ulcer was found. The gastric and duodenal folds are the most common anomaly. It has been not possible to correlate these folds to a precise histological entity. None of these patients exhibited an hypersecretory state, on the other hand 3 of them were hyposecreting. A statistical relationship between BAO on the one hand and PTH, CT and Ca on the other hand was found.

[Renal malacoplakia. Report of two cases and review of the literature (author's transl)]

The authors present a study of 38 cases of renal malacoplakia, two of which are personal. The clinical roentgenological and pathological data of such a histologically defined disease are reviewed. Nosological and physiopathological recollection is necessary before discussing management.

[Patients on chronic hemodialysis. Hemodynamic study at rest and during exercise before dialysis, in hypertensive and normotensive patients (author's transl)]

In twenty chronic hemodialyzed patients a hemodynamic study was carried out just before dialysis at bed rest and during sitting bicycle exercise. At bed rest, cardiac index (mean +/- standard deviation = 5.2 +/- 1.1/mn/m2) and pulmonary wedge pressure (17.4 +/- 6.8 mmHg) were increased. At the highest level performed (60 ou 90 W) cardiac index increased in all patients and reached on average normal values as compared to normal sedentary subjects, but heart rate less increased than in normal subjects during maximum effort. These data suggest that these patients had no patent heart failure. Pulmonary wedge pressure was more increased in hypertensive patients (20.7 +/- 6.7 mmHg) than in normotensive patients (13.3 +/- 4.4 mmHg). Since cardiac index was similarly increased in both groups of patients the higher values of pulmonary wedge pressure in hypertensive patients could be related to either an increase in total blood volume, or a reduction in left ventricular compliance or an increase in cardiopulmonary blood volume.

[Relationship between gastric acid secretion and plasma calcium, parathormone and calcitonin levels in patients with chronic renal failure on haemodialysis (author's transl)]

In twelve patients on chronic haemodialysis, a relationship was established between gastric acid secretion on the one hand, and certain parameters of calcium metabolism on the other hand: in a multifactorial statistical analysis, plasma calcium before dialysis (p less than 0,05), plasma parathormone levels before dialysis (p less than 0,05) and plasma calcitonin before dialysis (p less than 0,05) were variable explicatives of basal gastric acid secretion according to a direct relationship, whilst plasma calcium (p less than 0,05) was the only explicative variable of maximal gastric acid secretion after pentagastrin, with an inverse relationship. These preliminary results suggest that gastric acid secretion in the haemodialysis patient must be interpreted in the light of the state of calcium metabolism. Thus hypocalcaemia may be accompanied by decreased basal acid secretion and by contrast by an increased maximal acid secretion. These results require confirmation in a larger number of patients.