I. N. Marks

PREOPERATIVE EXTERNAL BILIARY DRAINAGE IN OBSTRUCTIVE JAUNDICE: A Prospective Controlled Clinical Trial

57 patients with obstructive jaundice were randomly allocated to surgery with preoperative external biliary drainage (29 patients) and without preoperative external biliary drainage (28 patients). 22 patients ultimately underwent laparotomy after a mean of 11.7 days of drainage and 25 had surgery without preoperative drainage. The postoperative complication rate was low and similar in both groups but complications associated with the drainage procedure were substantial. Perioperative mortality was 4/28 (14%) in the drainage group and 4/27 (15%) in the non-drainage group. There seems to be no advantage associated with routine preoperative external biliary drainage before surgery for obstructive jaundice.

Histamine- and insulin-stimulated gastric acid secretion after selective and truncal vagotomy.

Histamineand insulin-stimulated gastric secretion after vagotomy has been the subject of a number of papers in recent years (Weinstein, Hollander, Lauber, and Colp, 1950; Gelb, Baronofsky, and Janowitz, 1961; Kyle and Stephens, 1961; Payne and Kay, 1962; Austen and Edwards, 1961). Most workers agree that truncal vagotomy associated with a drainage procedure is followed, in the vast majority of patients by an appreciable reduction in the level of acid secretion (Gillespie, Clark, Kay, and Tankel, 1960; Gelb et al., 1961; Bell, 1964). Selective vagotomy, a procedure championed by Burge (1960), has been employed with success by a number of surgeons in recent years but no data are as yet available regarding its efficacy in reducing acid secretion. The purpose of this paper is to re-evaluate gastric acid secretory function after vagotomy and to compare the results obtained after selective and truncal vagotomy. In addition the relationship between insulinand histamine-stimulated secretion after vagotomy will be presented and the interpretation of the insulin test reviewed.

Does progressive pancreatic insufficiency limit pain in calcific pancreatitis with duct stricture or continued alcohol insult

We studied the pancreatic function, alcohol history, and ERCP findings in 26 patients with painless and 34 patients with painful alcohol-induced calcific pancreatitis (AICP). About 50% of patients in both the painless and painful groups continued to take alcohol, the incidence of duct stricture or obstruction was of the order of 62% in both groups, and the proportion of patients with duct stricture or obstruction and continued alcohol intake was comparable. In all instances the patients in the painless category had significantly greater pancreatic insufficiency, or more impaired function, than patients with pain. This applied to those patients who continued to take alcohol, to those with an obstruction or stricture on ERCP, and to the subgroup with both duct narrowing and continued alcohol intake. We conclude that grossly impaired pancreatic function confers a degree of freedom from painful attacks in AICP in those patients who continue to drink even in the presence of duct obstruction or stricture on ERCP; and that patients with AICP become free of pancreatic pain once gross pancreatic insufficiency supervenes.

Relapse rates after initial ulcer healing with sucralfate and cimetidine.

The relapse rate after successful short-term therapy with sucralfate (Sc) or cimetidine (Cm) was studied in a group of 86 patients with recently healed duodenal or gastric ulcers. The patients were endoscoped on clinical relapse or, routinely, at 6 weeks, 6 months, and 1 year. Patients whose ulcers had healed with Cm relapsed earlier than did those whose ulcers had healed with Sc (p less than 0.05 at 12 weeks), but the cumulative relapse rate by the end of 1 year was of the order of 70% in both treatment groups. The mean duration of remission in patients who developed a recurrence was significantly greater in patients treated initially with Sc than in those treated initially with Cm--7.3 and 4.6 months, respectively (p less than 0.01).

The spectrum and natural history of common bile duct stenosis in chronic alcohol-induced pancreatitis

Sixty patients with chronic alcohol-induced pancreatitis with endoscopic retrograde cholangiopancreatography evidence of common bile duct stenosis were studied to determine the clinical spectrum and natural history of this complication, as well as the indications for biliary bypass. In 17% of patients, common bile duct stenosis (CBDS) was an incidental finding at ERCP, while in the remaining cases pain and jaundice were the predominant symptoms in 35% and 48%, respectively. Biliary drainage was performed in 38% of patients for persistent or recurrent jaundice, cholangitis, and while undergoing pancreatic duct or cyst drainage procedures for pain. The benign nature of CBDS in chronic alcohol-induced pancreatitis (CAIP) in patients without persistent jaundice is emphasized. In particular, no histologically proved cases of secondary biliary cirrhosis were noted. The majority of patients with CBDS due to CAIP may be safely managed without biliary bypass but require close follow-up.

Helicobacter pylori lipopolysaccharide stimulates gastric mucosal pepsinogen secretion

The effect of Helicobacter pylori lipopolysaccharide on guinea pig gastric mucosal pepsinogen secretion has been examined using an Ussing chamber technique. Luminal addition of H. pylori lipopolysaccharide resulted in a fifty‐fold stimulation of pepsinogen secretion compared to a twelve‐fold increase with E. coil lipopolysaccharide. Electron microscopy showed marked degranulation of zymogen granules but no evidence of chief cell disruption.

Peptic ulceration and gastrointestinal bleeding in pancreatitis.

Radiological evidence of peptic ulceration is not unusual in patients with pancreatitis. This, coupled with the not infrequent occurrence of gastrointestinal bleeding in pancreatitis, has led many to believe that a high incidence of peptic ulceration exists in patients with this condition (Warren and Cattell, 1959; Fitzgerald, Fitzgerald, Fennelly, McMullin, and Boland, 1963; Howard and Jordan, 1960; Zollinger, Elliot, Endahl, Grant, Goswitz, and Taft, 1962; Eyler, Clark, and Rian, 1962). Others, on the other hand, have reported a low incidence of ulceration in patients with pancreatitis (Marks and Bank, 1963). The purpose of the present paper is to re-examine the incidence of peptic ulceration in pancreatitis, to draw attention to the fact that the radiological changes in pancreatitis may mimic peptic ulceration, and to analyse the causes of gastrointestinal bleeding in patients with pancreatic disease. TABLE I

The role of colonoscopy in the diagnosis of tuberculosis.

The value of colonoscopy in the diagnosis of ileocolonic tuberculosis at Groote Schuur Hospital was assessed and the published world experience reviewed. During a 4-year period, abdominal tuberculosis was diagnosed in 94 patients, of whom 18 manifested involvement of the ileocecal area and/or colon. Colonoscopy, performed in 10 of these, provided diagnostic information in 7. Since the endoscopic appearance of diseased mucosa is nonspecific, adequate bacteriological and histological assessment of biopsied tissue is essential to differentiate tuberculosis from other disorders that may simulate it. We stress the importance of microscopy and culture for Mycobacterium tuberculosis.

Pancreatic enzyme replacement therapy

The relative efficacy of three commercial pancreatic enzyme supplements in improving fat absorption was studied using the [14C]triolein breath test in 12 patients with chronic pancreatitis. Two of the supplements were enteric coated. The one nonenteric coated product was studied twice: with and without ranitidine coadministration. Doses complied with the manufacturers recommendations. Baseline studies included pentagastrinstimulated gastric acids, 72-hr fecal fat excretion, and [14C]triolein absorption while not on supplementation. Acid outputs were variable (BAO: 0.3–4.1 meq/hr; MAO: 3.5–34.6 meq/hr). Three patients had mild steatorrhea (i.e., <10 g/day) and the remaining severe fat malabsorption (56.9±41.5 g/day). Although fat absorption was significantly improved by all three supplements, the nonenteric coated preparation was most effective (P< 0.001). However, laboratory analysis demonstrated that lipase content was four times greater, ie, 17,000 IU/4 tablets. Pretreatment with ranitidine failed to further improve the absorption in patients given nonenteric supplements but was effective in those found to have high or normal acid outputs (P<0.001). Our results suggest that the recommended dosage of enteric coated preparations is insufficient for adult patients with severe chronic pancreatitis. Secondly, the marked variability of acid secretion in such patients possibly accounts for the variability of results obtained by others on the usefulness of coadministration of antacids and H2 antagonists. Routine measurement of gastric acid secretion status may help optimize the choice and form of pancreatic enzyme supplementation.

Malignant Zollinger-Ellison syndrome in a Bantu woman with a prolonged remission after gastric radiotherapy.

Considerable advances have been made in the recognition of the clinical features and in the understanding of the pathogenesis of the ZollingerEllison syndrome during the nine years that have elapsed since the condition was first described (Zollinger and Ellison, 1955). The disease is characterized by the presence of a non-beta cell tumour of the pancreas associated with gross acid hypersecretion, intractable peptic ulceration, and, not uncommonly, with severe diarrhoea. The acid hypersecretion is now known to be due to gastrin or a gastrin-like substance elaborated by the tumour tissue (Grossman, Tracy, and Gregory, 1961). The mortality of the disease remains high. A review of 138 cases of the syndrome reported to date reveals an overall mortality of 58 %, with postoperative deaths accounting for more than half of this figure. The hazard of surgery was particularly great in patients subjected to repeated operations for recurrent jejunal ulceration, and no doubt prompted a few workers to examine the effect of gastric radiotherapy in reducing acid hypersecretion in such patients. The published results of radiotherapy, however, have not been encouraging (Zollinger and Ellison, 1955; Oberhelman, Nelsen, Johnson, and Dragstedt, 1961; Case records of Massachusetts General Hospital, 1960; Oberhelman, Nelsen, and Dragstedt, 1958; MacKenzie and Norvell, 1960). The purpose of the present paper is to show that gastric radiotherapy may indeed be effective in inducing a prolonged remission in patients with the Zollinger-Ellison syndrome and to stress the value of the augmented histamine test in the diagnosis of the condition. In addition, the stimulating effect of the patients serum concentrate on acid secretion in the dog will be briefly presented.