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Esophageal histology in gastroesophageal reflux. Morphometric findings in suction biopsies.

Esophageal suction biopsies were taken in 24 subjects with proven gastroesophageal reflux, 12 subjects with suspected reflux, and 20 healthy controls. Sixty-two percent of the patients with proven reflux, 33% of the patients with suspected reflux, and 10% of the control subjects had neutrophilic and/or eosinophilic granulocytes in the lamina propria. Lymphocytes, plasma cells, and basophilic granulocytes were shown to be constituents of the normal esophageal mucosa. All epithelial dimensions showed marked individual variations in reflux patients and controls. The relative length of stromal papillae as expressed in percent of total epithelial thickness showed a linear correlation with relative basal cell thickness and an indirect linear correlation with epithelial thickness. Elongation of stromal papillae in proven reflux could only be demonstrated by arbitrary retrospective stratification of the data. Hyperplasia of the basal zone and thinning of the epithelium were not observed in the reflux patients. It is concluded that granulocytic infiltrates and not epithelial alterations are the most prominent histological finding in gastroesophageal reflux.

When is esophagitis healed? esophageal endoscopy, histology and function before and after cimetidine treatment.

In order to asses whether in reflux esophagitis morphological and functional disorders persist after macroscopic healing, cimetidine was given for 6–12 weeks at a dose of 1.6 g/day to 30 patients with acid gastroesophageal reflux and esophagitis. The mucosal defects healed in 6 patients, improved in 14 patients, and remained unchanged in 10 patients. Lower esophageal sphincter pressure, acid clearance, acid perfusion test, and histological signs of mucosal inflammation were assessed before and after treatment. The histological and functional findings did not improve after healing of the mucosal defects. Therefore, endoscopic normalization in patients with reflux esophagitis is not associated with the disappearance of inflammation and abnormal motor function. The persistence of these abnormalities might explain the tendency of esophagitis to recur after symptomatic and endoscopic “healing.”

Intramural pseudodiverticulosis of the esophagus: Report of seven cases and literature review

Seven cases of esophageal intramural pseudodiverticulosis (EIPD) are presented and compared with 46 cases previously reported. EIPD is mainly a disease of older age with a 3∶2 predominance of male patients. The radiologic appearance of EIPD shows great variation in localization and severity of visible changes. Radiologic examination is far more sensitive than endoscopy in diagnosing EIPD. The most effective therapy for EIPD is dilatation of strictures, leading to amelioration or disappearance of symptoms in over 90% of cases. Visible pseudodiverticula may persist after therapy, even in symptom-free patients.

Inhibition of hepatic demethylation of aminopyrine by oral contraceptive steroids in humans.

Abstract. The effect of oral contraceptive steroids (OCS) on the rate of hepatic demethylation of 14C‐dimethyl‐aminoantipyrine (DAP) was studied directly in healthy young volunteers using a newly developed noninvasive breath analysis technique. After oral administration of a trace dose of DAP the specific activity of 14CO2 in breath was determined during 6 h and expressed as half life. The half life of eighteen female and twelve male control subjects was 2.4 ± 1.2h (2 SD) and 2.2 ± 0.6h (2 SD), respectively. In seven women starting OCS a progressive prolongation of DAP half life during a single menstrual period was observed. In seventeen women who had taken OCS in 21 clay cycles, for more than 3 months, the half life was significantly (P< 0.001) prolonged (4.4 ± 2.1 h) when measured after 21 consecutive days of OCS intake. On average, stopping OCS for 7 days or giving phenobarbital in addition to OCS shortened DAP half life significantly (from 4.4 ± 2.1 h to 3.2 ± 1.1h, n= 17, P 0.005; and from 4.6 ± 2.0 h to 3.2 v 1.0h, n= 12, P<0.01, respectively). Eight of twelve women on OCS responded to OCS intake and to OCS cessation and phenobarbital, whereas four women did not respond to any of these measures. These data suggest that inhibition of hepatic demethylation of DAP by OCS is time dependent and reversible. The extent of inhibition appears to be an individual characteristic of a given person.

Phlegmonous gastritis diagnosed by endoscopic snare biopsy

SummaryA case of phlegmonous gastritis, diagnosed for the first time without laparotomy and with spontaneous recovery, is described. The only procedure allowing nonsurgical diagnosis of this disease is endoscopic snare (“jumbo”) biopsy of the giant folds in the diseased parts of the stomach. Snare biopsy includes submucosal tissue which is the main site of histological changes in phlegmonous gastritis.

Fulminant cholangitis and septicemia after endoscopic retrograde cholangiography (ERC) in two patients with obstructive jaundice.

Fatal septicemia resulted in two patients with obstructive jaundice after endoscopic retrograde cannulation. Both patients appeared to tolerate the procedure, but developed septicemia 1 and 3 days after the procedure, respectively. Surgical drainage of the obstructed biliary tree should be done early once the diagnosis of obstructive jaundice is made by ERC because of the possibility of septicemia occurring.

Helicobacter pylori infection and gastric metaplasia in the duodenum in China.

Biopsy specimens from antral and duodenal mucosa were obtained from 64 patients with active duodenal ulcer and from 78 with nonulcer dyspepsia. Gastric metaplasia in the duodenal bulb was more frequent in patients with duodenal ulcer (82.5%) than in patients with dyspepsia and duodenitis (53.1%) or in patients with dyspepsia without duodenitis (34.5%). Helicobacter pylori infection in the duodenal bulb was found more often in patients with moderate to severe gastric metaplasia (62.3%) than in patients with mild gastric metaplasia (20%). Therefore, patients from a developing country, China, showed the same relationship between duodenitis, gastric metaplasia, duodenal colonization with H. pylori, and duodenal ulcer previously demonstrated in developed countries.

Healing and Relapse of Duodenal Ulcer During Ranitidine Therapy in the Elderly

A total of 2,109 outpatients with active duodenal ulcer (DU) entered an open, prospective study in order to investigate factors influencing healing and relapse during 2 years of ranitidine therapy (300 mg daily for healing, 150 mg as maintenance treatment). In a retrospective analysis, we evaluated the influence of age. Symptoms related to DU in 1,899 evaluable cases in patients over 65 years of age (n = 185) were identical to those of DU patients younger than 65 years old (n = 1,714). Rapid healing within 2 weeks of ranitidine therapy was less frequent in the elderly (32.5%) than in younger patients (40.7%) though identical healing rates (94.1%) in each group were achieved by continuation of ranitidine therapy for 8 weeks. Cumulative recurrence rates during the 2 years of long-term therapy were lower (17.3%) in old age than in patients under 65 years of age (23.3%). Adverse events were rare in both age groups. We conclude that DU healing during ranitidine is delayed in old age. Additional differences in relapse rates in favor of the elderly suggest that DU disease has a different course in the elderly.

Endoscopic retrograde cholangiography

To The Editor: In a recent article (1) Thurnherr et al report the occurrence of fulminant cholangitis and septicemia after Endoscopic Retrograde Cholangiography (ERC) in 2 patients out of 47 in whom extrahepatic obstruction was demonstrated by ERC. The sepsis was fatal in both cases. The authors conclude that ERC should be performed only when surgery is planned within 24 hours and that antibiotics be started as soon as the diagnosis of biliary obstruction is made. They mention as a possible mechanism of sepsis in one of these patients the passage of bile and contrast material across a stenotic area in the course of the procedure. These authors did not cite our case report (2) describing polymicrobial sepsis following ERC in which inadequately disinfected endoscopy equipment was strongly implicated as the source of infection. We described a patient without extrahepatic obstruction who became septic 18 hours following the procedure. The organisms cultured from the blood were Pseudomonas aeruginosa and Enterobacter aerogenes. When the cannula and endoscope used in the procedure were later cultured, these organisms, among others, were identified. Curiously enough, the organisms specifically found on the ERC cannula were the same organisms which were found in the two patients reported by Thurnherr et al, Pseudomonas aeruginosa and Enterobacter cloacae. Meticulous disinfection of our cannulating endoscope with 2% gluteraldehyde before each procedure as described in our article and by others (3), as well as gas sterilization of the cannulae and the use of an antibiotic in the contrast material have resulted in our having no septic complications in the last 50 cases with extrahepatic obstruction. In the previous 50, where no equipment disinfection was used, 3 cases of sepsis occurred, a figure almost identical to that reported by Thurnherr. We, therefore, believe that preventive instrument disinfection may be more pertinent to the problem than surgery or the use of antibiotics after bacteria from the endoscope and cannula have been introduced into the biliary tree.