[Persistent diarrhea and loss of weight during therapy with leflunomide]

HISTORY AND CLINICAL FINDINGS

A 55-year-old woman had suffered from diarrhea and a weight loss of 15 kg over the previous six months. Neither the search for a causative pathogen nor coloscopy had provided a diagnosis. She was known to have type 1 diabetes mellitus, previous Hashimoto's thyroiditis, rheumatoid arthritis treated with leflunomide and drug- treated arterial hypertension. She was in a reduced general condition.

INVESTIGATIONS

: The results of extensive initial diagnostic tests were unremarkable. Biopsies obtained at colonoscopy revealed marked lymphocytic colitis (LC).

TREATMENT AND COURSE

When leflunomide was discontinued and replaced by salazosulfapyridine (sulfasalazine) and the steroid budesonide, the diarrhea ceased within a few days and the LC was no longer evident histologically after three months.

CONCLUSIONS

Leflunomide can in rare cases cause a LC. that can quickly regress once the drug has been stopped. If the findings on colonoscopy in a case of otherwise unexplained diarrhea are grossly normal, a biopsy should be taken to rule out microscopic colitis.

Treatment results of the thioether lipid ilmofosine in patients with malignant tumours

In a multicentre study patients with liver metastases stratified to the histology of the primary tumour were investigated. A total of 102 patients with colorectal adenocarcinoma, non-small-cell lung cancer, pancreatic cancer, primary liver carcinoma and malignant melanoma were treated with the thioether lipid ilmofosine. The drug was administered orally as a tablet at a dosage of 150-300 mg/day (75 mg/tablet). The tolerability of ilmofosine was poor. There was a dose-limiting gastrointestinal toxicity with nausea, vomiting and loss of appetite (WHO grade II-IV) in 67% of patients. During the period of therapy (1-29 weeks, 8.5 weeks mean) no complete remission and no partial response were observed. We thus conclude that treatment with oral ilmofosine is not effective in patients with liver metastases due to various malignancies.

Prevalence of lactose malabsorption among patients with functional bowel disorders

To investigate the prevalence of lactose malabsorption among patients with functional gastrointestinal disturbances we prospectively evaluated all patients referred to a gastrointestinal outpatient clinic over a period of 18 months. All patients had a breath hydrogen test following oral lactose in addition to the standard diagnostic procedures. In 37 of the total of 64 patients no organic cause of the gastrointestinal complaints was found. In 9 of these 37 patients (24%) the breath hydrogen test indicated lactose malabsorption. Three to 6 month later most of the patients with lactose malabsorption showed a significant reduction of gastrointestinal complaints after they had maintained a lactose-poor diet. In comparison, patients with functional disturbances but without lactose malabsorption reported nor or only minor improvement of symptoms; most of these patients had consulted another physician since the last visit in the clinic.

[Disorders of esophageal function as a cause of thoracic pain]

Oesophageal disorders can be identified in about one third of the patients with non cardiac chest pain. Motility disturbances and gastro-oesophageal reflux are the leading causes of chest pain of oesophageal origin. Heart diseases and organic lesions of the oesophagus have to be ruled out by cardiological examination and endoscopy, respectively. Oesophageal motility testing and long-term-pH-metry are useful to further characterize the underlying functional disorder. Because of the spontaneous fluctuations of symptoms and the effects of placebo treatment therapy should be conservative and based on the results of these investigational procedures.

[Rectal stenosis due to long-term therapy with ergotamine]

Two patients (a woman aged 39, a man aged 46 years) had developed severe distal rectal stenoses after 20 years of anti-migraine treatment with ergotamine-containing suppositories. The woman required several bougie and laser treatments. In the man a megacolon had developed due to increasing, finally complete, rectal stenosis and this required a double colostomy (transverse colon) as an emergency. Ergotamine-containing suppositories are widely used in the treatment of migraine, but they should not be administered for prolonged periods.

[Diagnosis of achalasia--comparison of methods for the evaluation of severity]

To determine the value of endoscopy, manometry, and scintigraphy in predicting the severity of achalasia, 25 patients with primary achalasia of the esophagus were posprectively studied; 17 patients could be examined prior and post pneumatic dilatation. According to the symptoms, the severity was graded from I to IV. While endoscopic findings did not well correlate with the symptom score, the lower esophageal sphincter pressure and the resting pressure in the esophageal body were significantly correlated with the severity of the disease (p less than 0.01). The esophageal retention of radioactivity rose parallel to the symptom score (p = 0.07). Both manometric and scintigraphic findings changed significantly after therapy (p less than 0.01). Manometry and scintigraphy of the esophagus can be used to measure treatment related effects in patients with primary achalasia. Endoscopic findings are not related to subjective complaints, but an endoscopic examination should always be performed to exclude malignancies of the esophago-gastric junction.

[The aorto-enteric fistula--a rare, but important cause of upper gastrointestinal hemorrhage]

During the last two years two patients with upper gastrointestinal bleeding caused by an aortoenteric fistula were admitted to the hospital. The first patient had a primary fistula between an arteriosclerotic aneurysm of the abdominal aorta and the duodenum. The second patient had an infected aortobifemoral graft which had penetrated into the upper jejunum. The aortoenteric fistula is one of the very rare causes of upper gastrointestinal bleeding. Referring to previous surgery at the aorta a primary and secondary type of fistula are differentiated. The primary fistula often induces a small initial bleeding followed by a severe hemorrhage with hematemesis and melaena. The secondary form is mostly caused by bacterial infection of the graft. Recurrent fever attacks are a common clinical symptom without any evidence of the origin of the bacteriemia. Principally the combination of upper gastrointestinal bleeding and aortic graft is always suspicious of an aortoenteric fistula. The most important preoperative examinations are endoscopy, computed tomography scan, and arteriography. The treatment must be surgical. Either a synthetic graft surrounded by omentum is implanted or an axillobifemoral or aortobifemoral bypass is constructed. Even if the diagnosis is made early mortality of the disease is about 20-30%.

[Achalasia as a mask of cardial carcinoma]

Increasing dysphagia and weight loss between 3 and 30 kg developed in eight patients aged 27-70 years (mean age 53 years) within a period of 1.5 to 12 months. In five patients X-ray film showed the typical pattern of achalasia with dilatation of the tubular oesophagus and a smooth taper of the terminal part. Although in all patients the cardia became patent only after the endoscope had been advanced by pushing it forward to overcome stenosis or after bougienage, and although the malignoma had always been included in differential diagnostic considerations, a malignoma was identified only three times in 30 histological examinations. Oesophageal manometry demonstrated findings characteristic of achalasia in five patients, in three patients the examination could be performed only incompletely. In six patients computed tomography revealed pathological hypertrophy of the cardiac wall. Intraoperatively all cardiac tumours were in an advanced stage.

[Anorectal motility in systemic scleroderma]

We prospectively compared esophageal and rectal motility data from 7 patients with progressive systemic sclerosis (4 females, 3 males) to esophageal recordings in 22 and anorectal recordings in 9 healthy controls. All patients with sclerosis exhibited motility disturbances in the lower esophageal sphincter (LES): LES resting pressure, LES relaxation amplitude and duration, and the number of incomplete LES relaxations were significantly different compared to the controls. All patients had alterations of anorectal motility: resting pressure, maximal squeeze pressure, and sphincter relaxation amplitude following balloon distension of the rectum were significantly decreased as compared to the control subjects. We conclude that esophageal and anorectal manometry are comparable in their sensitivity to differentiate between patients with systemic sclerosis and normal subjects.

HLA antigens in ankylosing spondylitis associated with Crohn's disease. Increased frequency of the HLA phenotype B27,B44

In a consecutive case study 231 patients with Crohn's disease were investigated for ankylosing spondylitis (AS) and HLA-A, B, C, DR antigen association. Eighteen patients (7.8%) had definite AS according to the New York criteria; 13 (72%) were HLA-B27 positive. The phenotype B27,B44 was seen in 8 patients (44%) compared to only 3 (1%) of 300 controls (p less than 10(-7), and 1 (0.5%) of 213 patients with Crohn's disease without AS (p less than 10(-7). We conclude that patients with the phenotype B27,B44 are highly at risk (relative risk = 68.8) for the common manifestation of Crohn's disease and AS.

Family occurrence of achalasia and diffuse spasm of the oesophagus

In view of the unknown aetiology of achalasia and diffuse oesophageal spasm we report four families (father/son, mother/son, brother/brother, cousin/cousin) with achalasia and oesophageal spasm examined by radiology, endoscopy and manometry. Family occurrence of oesophageal motor disorders supports the hypothesis that a genetic trait may play a role in the pathogenesis. The family coincidence of achalasia and oesophageal spasm supports a close relationship between the two diseases.

Association of Crohn's disease with HLA phenotype B44, Cw5

Genetic influence on the development of Crohn's disease (CD) is commonly accepted. However, proof of definite genetic markers is still pending. Most investigations have focused on HLA antigens, and associations with HLA B12 and HLA A2 have been reported, but the design of these retrospective studies is open to criticism. We have undertaken a consecutive study of 96 patients with CD under well-defined conditions in order to test the hypothesis that CD is associated with particular HLA antigens. Our results identify a significant association of CD with the phenotype HLA B44,Cw5. But since a major proportion of the CD patients do not bear this phenotype, other predisposing genetic factors, which have not yet been defined, may exist in addition to environmental factors.

Gastric phytobezoar: endoscopic removal using the gallstone lithotripter

Gastric bezoars are a common late complication of gastric surgery. Their treatment may be difficult. This is the first report on the removal of a very firm gastric phytobezoar by perendoscopic lithotripsy. The bezoar was detected 20 years after an unknown type of operation on the stomach, presumably truncal vagotomy and pyloroplasty. We propose the use of the lithotripter through the endoscope as an alternative treatment of firm and large gastric bezoars.

[Orthotopic liver transplantation in Wilson's disease and acute liver failure]

Liver histology demonstrated progressive cirrhosis in a 19-year-old girl with a subacute form of Wilson's disease. Despite D-penicillamine administration her liver functions rapidly deteriorated further. Orthotopic liver transplantation was performed. Postoperatively there were two mild rejection episodes, an organic psychiatric syndrome and generalized tremor. Copper metabolism and clinical symptoms became normal postoperatively. Five months after the transplantation she was in a good general condition, able to continue her education.

Drug-induced oesophageal lesions

Persisting retrosternal pain of sudden onset is suggestive of a drug-induced oesophageal lesion, particularly if it starts at night. After exclusion of a myocardial infarction, a carefully taken history and oesophagoscopy will rapidly clarify the cause and severity of the injury. Since almost any pill may produce oesophageal lesions, care has to be taken that tablets, capsules and other pills are always taken in an upright position together with a fluid chaser of at least 120 ml. If possible, less harmful liquid preparations of the drugs should be preferred. Lesions in the oesophageal wall and perioesophageal tissue are almost unavoidable side-effects of sclerotherapy of oesophageal varices. The patient and the doctor should be particularly aware of bleeding from oesophageal ulcers during the first week after sclerotherapy. Numerous drugs may weaken or strengthen contractions of the oesophagus and lower oesophageal sphincter. These potentially unwanted motor effects of the drugs have to be kept in mind, especially in patients with pre-existing gastro-oesophageal reflux disease and hypermotility states.

Computer analysis of pressure tracings from the sphincter of Oddi

Since the sphincter of Oddi exhibits very regular phasic motor activity it offers itself to the design of a simple computer program in the analysis of gastrointesinal motility. This investigation is the first attempt of a practical application of such a computer program. The signals coming out of the pressure preamplifier are submitted to active filtering in order to prevent aliasing and then to analog to digital conversion. After being fed into a computer they are precessed in a number of controllable and adaptable steps before the final analysis. Computer analysis then yields a detailed quantitative print out of a large variety of variables which compares very favourably with the visual analysis. It speeds up the time of analysis and allows for a study of long-term recording. Computer analysis of pressure tracings from the sphincter of Oddi may serve as a model for a study of motor activity of all parts of the digestive tract with this modern method of data handling.

[Pathophysiology, clinical aspects and rational diagnosis of gastroesophageal reflux disease and axial hiatal hernia]

Low pressure or inappropriate relaxation of the lower esophageal sphincter, disturbances in esophageal peristalsis and delayed gastric emptying are the most important pathogenetic factors of reflux disease. In general, retrosternal and also epigastric and pharyngeal burning or pain are the leading symptoms, but in mild disease eructation may become the major complaint. Diagnosis is usually made on the basis of a typical history and the results of endoscopy. 24-h-pH-recording is indicated in inconclusive endoscopy, chest pain of unknown origin and preoperative evaluation. Manometry may be indicated to exclude systemic sclerosis.

[Familial dysphagia]

The etiology of achalasia and diffuse esophageal spasm remains unknown. We report on two families (father/son, mother/son) with achalasia and esophageal spasm, respectively, who were examined by radiology, endoscopy and manometry. One patient (mother) died from aspiration pneumonia. These observations support the hypothesis of a genetic trait in some cases of esophageal motility disorders. In addition, the coincidence of familial achalasia and esophageal spasm is in support of a close relationship of both diseases. Achalasia is a potentially letal disorder.

[Intramural pseudodiverticulosis of the esophagus. Clinical aspects, morphologic changes and functional disorders]

Oesophageal intramural pseudodiverticulosis, a rare benign disease with as yet unexplained aetiology, was observed in 4 patients during the course of 2 years. The main symptom is dysphagia. Radiographic and endoscopically detectable diverticula or diverticular orifices are pathognomonic. A prolongation in the duration of oesophageal contractions is the main manometric finding. At autopsy, a reduction in the number of oesophageal intramural ganglion cells was seen in one case. A prolonged pressure-effect on the oesophageal wall could be the cause of the wall pouches.

Esophageal disorders in the etiology and pathophysiology of dyspepsia

Dyspepsia may be caused by reflux esophagitis. We evaluated the symptoms of 45 patients aged 52 +/- 14 years who had a follow-up of 1 to 5 years. Endoscopy and histology demonstrated microscopic inflammation in 14, isolated mucosal defects in 12 and severe inflammation in 19 of the 45 patients. Belching was the leading symptom in patients with microscopic and severe esophagitis, heartburn in mild esophagitis. Upper abdominal pain, nausea and vomiting were present in 31%, 24% and 22% of the patients, respectively. Thus, reflux esophagitis is frequently accompanied by symptoms of dyspepsia which resemble those of other causes of dyspepsia. In contrast, disorders of gastric and intestinal motility may be associated with esophageal motor disturbances, particularly in gastric dysrhythmia, diabetic gastroenteropathy, irritable bowel syndrome, and idiopathic intestinal pseudo-obstruction. How much the esophagus contributes to the clinical symptomatology of dyspepsia awaits further elucidation.

[Alcohol and epithelial regeneration in the rat stomach following experimental lesions]

In man, chronic consumption of alcohol has been incriminated as a promoting factor in the development of columnar-lined lower esophagus (Barrett's syndrome). To test the effects of alcohol on the regeneration of squamous epithelium, rats were fed a diet containing 2,5 g alcohol daily for 6 weeks after the junctional region between the squamous epithelium of their fore stomach and the columnar epithelium of their glandular chamber had been injured and denuded. Compared to animals fed an isocaloric control diet the alcohol-fed rats showed neither major macroscopical nor histological differences in the regeneration process of the epithelium. Under the influence of alcohol the mucosal border did not move in an orad direction. Thus, these results fail to support the hypothesis of alcohol promoting the replacement of defects in squamous epithelium by columnar epithelium which is thought to be the major pathomechanism in Barrett's syndrome.

[Postgastrectomy syndromes with special reference to reflux esophagitis]

60 patients without suspicion of recurrence of stomach cancer have had a follow-up by mean of 65 months after the procedure of a total gastrectomy. In 16 cases an additional esophagomanometric and endoscopic-bioptic examination was performed. Up to 1975 the operative procedure of stomach replacement was a jejunal interposition, afterwards the technique of a jejunoplicationn. Clinical signs of an esophageal reflux were found in one half of the patients with a jejunoplicatio and in a third of the cases with a jejunal interposition. Endoscopic-bioptic evidence of a reflux-esophagitis has been found in 13 of 16 patients. A functioning sphincter mechanism of the lower esophagus could be demonstrated in 5 of 16 cases. There was no proof of a correlation between the results of endoscopic-bioptic and manometric examinations. A prevention or reduction of esophageal reflux is as well possible by the technique of jejunal interposition as by jejunoplication.

Salivary secretion in reflux esophagitis

It has been speculated that impaired salivary flow and contents contribute to abnormal acid clearance in patients with reflux esophagitis. To test this hypothesis, salivary secretion of volume, bicarbonate, and N-acetylneuraminic acid was measured in patients with reflux esophagitis, in age- and sex-matched controls, and in healthy young volunteers. Resting saliva was collected by permitting the saliva to drip into a flask every 30 s. Parotid saliva was collected by means of a Lashley capsule during stimulation by oral infusion of 1 ml/min of 2% citric acid. Total mixed saliva was collected by a dental sucker during esophageal perfusion with water and 10-mM hydrochloric acid. The volume of resting saliva and its concentration of bicarbonate were similar in the three groups. The concentration and the output of N-acetylneuraminic acid were higher in the young volunteers than in the two other groups. The volume flow and the composition of stimulated parotid saliva were similar in the three groups of subjects. Volume of total mixed saliva and concentration of bicarbonate and N-acetylneuraminic acid during esophageal perfusion with water were higher in patients with reflux esophagitis than in age- and sex-matched controls and were similar to the values found in young healthy volunteers. Acid perfusion increased the secreted volume of total mixed saliva by 150% and the concentration of bicarbonate by 30% in healthy young volunteers, but not in patients with reflux esophagitis and in the healthy age- and sex-matched controls; the concentration of N-acetylneuraminic acid was left unaffected by acid perfusion in all three groups. These findings disprove the hypothesis of impaired salivation in reflux esophagitis. The age-related loss of salivary response to acidic esophageal perfusion might be the reason why reflux esophagitis with peptic lesions affects predominantly elder people.

Clomethiazol tablets induce ulcers in the esophoagus

A 55 year old woman developed severe retrosternal pain and odynophagia four hours after taking a tablet of clomethiazol. Endoscopy revealed extensive ulceration of the upper esophagus 19-23 cm from the incisors. Esophageal manometry showed reduced contraction amplitudes in this area. The lesions healed rapidly after the medication was stopped, and the motility disturbances of the esophagus improved. Thus, clomethiazol tablets have to be included in the list of drugs which can damage the esophageal mucosa. This damage is probably due to the acid salt ethanedisulfonate of the clomethiazol tablets. Clomethiazol capsules are preferable since they do not appear to be harmful to the esophagus.

[Motility disorders of the gastrointestinal tract in old age]

Most motility disturbances of the gut in the agenarian are secondary in nature. So far, only in the oesophagus an alteration of the motility due to age has been demonstrated. Difficulties in methodology are a major reason for our lack in knowledge about the bowel movements in old age. Most studies have been done in the oesophagus and distal colon since these organs are easily accessible for intubation. The majority of the motility disorders in old age are due to problems which accumulate when man gets older, like diabetes mellitus, cerebrovascular disease and intake of numerous drugs. These conditions may directly or indirectly affect the motor organic diseases, particularly carcinoma, which may mimick functional disorders, by a careful diagnostic work-up. The therapy should try in the old as in the young to cure the underlying pathomechanism.

[The effects of sympathicolysis on interdigestive small bowel motility (author's transl)]

The effect of the alpha-sympathicolytic agent dihydroergotamin-heparin (DHEH) on small bowel motility was examined in a double-blind cross-over study. Intraluminal pressure of the duodenum and jejunum was measured manometrically in 10 healthy volunteers. Sympathicolysis by subcutaneous injection of DHEH increased the number of contractions in the duodenum and jejunum significantly. Under the influence of DHEH, the number of activity fronts of the interdigestive migrating motor complex was higher than in the placebo experiments; however, the difference was not statistically significant. These results may give an explanation for the beneficial effects of this alpha-sympathicolytic agent seen in the prophylaxis and therapy of paralytic ileus.

[A method to transmucosal transport in the human esophagus (author's transl)]

A modified 9-luminal manometric tube served to perfuse the esophagus with 3.2 mmolar hydrochloric acid containing 2% polyethylene glycol (PEG) and to aspirate the esophageal contents. The esophageal secretion was calculated from the PEG dilution in the aspirates. Neutral red injected intravenously reddened selectively gastric juice. Red esophageal aspirates were discarded., In 6 health subjects esophageal secretion was 1.0/+-0.2 ml/min after 1 hour perfusion. It contained 38 /+-11 mmol/l na+, 3.3/+-1.4 mmol/l K+, 27/+-6 mmol/l Cl-, and 50/+-13 mumol/l N-acetylneuraminic acid (NANA). Thus this method allows measurement of the barrier function of the esophageal mucosa.

[Cervical dysphagia in scleroedema adultorum Buschke (author's transl)]

Scleroedema adultorum Buschke is characterized by progressive hardening of the skin. In contrast to scleroderma the hardening occurs in the skin of the trunk while extremities remain largely free. Internal organs are said not to be involved in scleroedema adultorum Buschke. The full picture of the persistent form of scleroedema adultorum Buschke was observed in two patients. One patient complained of increasing dysphagia with regurgitation and aspiration. Manometry and X-ray cinematographic investigation showed inappropriate relaxation of the upper oesophageal sphincter. In the other patient who had not previously had swallowed difficulties manometry showed achalasia of the upper oesophageal sphincter. The functional disturbances of the upper oesophagus indicate the possibility of an involvement of internal organs in scleroedema adultorum Buschke. However, proof of an aetiological connection between disturbances of oesophageal motility and skin disease requires systematic investigations in a larger group of patients.

[Hiatal hernia--reflux disease. Indications for surgery and initial results of a new treatment method]

Indications for the operative treatment of hiatus hernia with reflux oesophagitis are grade III and IV reflux oesophagitis; if the total acid period equals or exceeds 1.3% of the time of the period of time during which the patient was in supine position (pH-examination); if acid clearance lasts 2.86 min or more after a single reflux period; if radioisotopic counts over the sternal region exceed 3.5--4% of those obtained over the stomach area. Since 1977 we performed a new anti-reflux-operation, which we call "Teres-plasty"in 42 patients with axial hiatus hernia. The procedure is a modified gastropexy by using the ligamentum teres. First results seem to prove that this method can avoid reflux without postoperative syndromes as gas bloat syndrome and dysphagia, which are known to occur after fundoplication.

[Diagnostic problems in the differentiation of achalasia and spasm of the oesophagus (author's transl)]

In 15 patients suspected to have achalasia or diffuse spasm of the oesophagus we were unable to make the final diagnosis of their motility disorder in spite of radiologic, endoscopic, and manometric examinations. In 5 patients the radiologic and manometric results showed a discrepancy. In 4 patients only the lower oesophageal sphincter exhibited failure fo complete relaxations typical of achalasia; however, the motility of the body of the oesophagus was peristaltic in nature. In 6 patients the initial diagnosis had to be changed during follow-up. In conclusion, motility disorders occur in the oesophagus which cannot be classified according to existent definitions. It is possible therefore that achalasia and oesophageal spasm are different and not always fixed expressions of one nosologic entity.

[Esophageal stenosis in sjögren's syndrome]

Dysphagia in Sjögren's syndrome may be caused by xerostomy, pharyngoesophagitis and esophageal membranes. This is the first report on a tubular upper esophageal stenosis in a 71 year old woman with Sjögren's syndrome who developed progressive dysphagia. It is suggested, that this stenosis was due to chronic inflammatory processes and secondary sclerosis of deep layers in the esophageal wall. Bouginage was adequate symptomatic therapy. Tubular esophageal stenosis is regarded as gastrointestinal manifestation of Sjögren's syndrome.

[Ulcer of the esophagus after intake of emeproniumbromide (author's transl)]

Two female patients were treated because of pollakiuria with emeproniumbromide tablets. They developed extended ulcers of the esophageal mucosa. The tablets had been taken late in the evening with only little fluid. Ulcer formation is thought to be due to prolonged passage time and to a locally damaging effect of the hygroscopic compound. There may be lesions of the esophageal musculature as well, as demonstrated by considerable disturbance of esophageal motility. Ulcers tend to be painfull; they heel fast without formation of scars.