L. M. Blendis

BREATH HYDROGEN AS A DIAGNOSTIC METHOD FOR HYPOLACTASIA

Breath hydrogen (H2), collected by end-expiratory sampling, was measured in twenty-five patients with abdominal symptoms or diarrhoea after ingesting 50 g. of lactose. This was compared with established tests of hypolactasia. Fifteen patients with a blood-glucose rise of more than 20 mg. per 100 ml. had less than 4 parts per million (p.p.m.) rise in breath H2 at 2 hours. In contrast, ten patients with blood-glucose rises of less than 20 mg. per 100 ml. had more than a 20 p.p.m. H2 rise (mean 85.8 p.p.m. plus or minus s.d. 44.3) at 2 hours. Similarly, two patients with normal jejunal lactase activity had no significant H2 production, whereas six patients with hypolactasia had more than a 20 p.p.m. rise in H2. Symptoms related to milk or lactose ingestion were found to be unreliable. End-expiratory sampling of breath H2 would seem to be a simple, non-invasive, and accurate method of diagnosing hypolactasia, which is also very acceptable to patients. This should make it a valuable tool both in diagnostic gastroenterology and in epidemiological surveys.

Breath-hydrogen test for small-intestinal bacterial colonisation.

Breath-hydrogen production after oral glucose administration was examined in patients suspected of having small-intestinal colonisation and compared with the 14C-glycine-cholate breath test (14C-G.C.) and with bacteriological examination of the small intestine. Of 17 patients, 12 had bacteriological evidence of small-intestinal colonisation. Each breath test showed 8 of the 12 patients to be colonised, but only 5 patients gave positive results with both tests. Nevertheless, using both tests only 1 patients out of 12 with small-intestinal colonisation would have been missed. There were no false-positive results in the 5 bacteriologically normal patients when the breath-hydrogen test was used. It is concluded that simultaneous use of these two relatively simple breath tests may improve the indirect diagnosis of small-intestinal colonisation.

Frequency and type of renal and electrolyte disorders in fulminant hepatic failure.

Of 48 patients with fulminant hepatic failure who progressed to grade III or IV encephalopathy 38 showed evidence of renal impairment. In 32 of these patients the underlying cause could be placed initially into one of three categories—prerenal uraemia (4 patients), acute tubular necrosis (16), and “functional renal failure” (12). The latter differed in several respects from that seen with liver failure secondary to cirrhosis. The frequency and type of renal impairment was the same in those patients in whom the fulminant hepatic failure had resulted from an overdose of paracetamol as in the other aetiological groups. Abnormalities in plasma electrolytes were common—in particular hypernatraemia occurred in 11 patients from an osmotic diuresis precipitated by hypertonic dextrose or fructose given intravenously, and from the sodium in the fresh frozen plasma used to correct the coagulation disturbance when renal excretion of this ion was inappropriately low.

TREATMENT OF SECONDARY HEPATIC TUMOURS BY LIGATION OF HEPATIC ARTERY AND INFUSION OF CYTOTOXIC DRUGS

Abstract Eleven patients with symptoms due to secondary tumour deposits in the liver were treated by ligation of the hepatic artery, and in five this was followed by infusion of the portal vein with 5-fluorouracil. Liver function was moderately disturbed in all patients but none went into hepatic failure, and the one postoperative death was due to a cardiac arrythmia. The surviving ten achieved good relief of abdominal pain for up to 10 months, and most gained weight. Serial scintiscans showed reduction in size of the deposits, and tumour necrosis was demonstrated on liver biopsy. In three patients with the carcinoid syndrome the necrosis was reflected biochemically by an immediate and striking rise in urinary 5-hydroxyindoleacetic-acid excretion followed by a return towards normal levels, and in these patients it is preferable to precede hepatic-artery ligation by a period of hepatic-artery infusion with cytotoxic drugs to ensure more controlled release of metabolites.

Observer Variation in the Clinical and Radiological Assessment of Hepatosplenomegaly

The size of the liver and spleen of 32 patients was assessed by four clinicians from a clinical examination and by four radiologists from a plain radiograph of the abdomen. The latter assessment was found to be subject to less variation than the former, particularly in regard to the liver. Large livers and spleens were more easily seen radiologically than small ones. Most of the variation among the radiologists arose because of the 6% and 24% of cases in which the liver and spleen, respectively, were poorly seen on the radiograph. It is concluded that a plain radiograph of the abdomen, including the diaphragm and with the costal margin indicated, is a useful adjunct to clinical examination.

SMALL-INTESTINAL INJURY IN WOMEN WHO HAVE HAD PELVIC RADIOTHERAPY

Abstract 17 women who had had radiotherapy for pelvic malignancy were studied. 12 of them had noted a permanent change in their bowel habit, ranging from abandonment of the use of laxatives to frequent bouts of diarrhœa necessitating a change in life-style. 16 of 17 patients had abnormal cholyl-glycine-1-[ 14 C] breath tests, including all 12 with symptoms. 8 of the 11 small-bowel X-rays were abnormal, but only 1 of 13 rectal biopsies showed changes of inflammation and another showed vascular thickening, which is regarded as characteristic of radiation damage to the gut. No subject had noted blood in her stools. It is concluded that the alteration in stool habit and the interruption of enterohepatic circulation are caused by radiation injury to the small bowel and that such injury is an almost invariable accompaniment to all forms of pelvic radiotherapy.

Abnormalities of sodium excretion and other disorders of renal function in fulminant hepatic failure.

Renal function was evaluated in 40 patients with fulminant hepatic failure, They were divided into two groups on the basis of glomerular filtration rates greater than 40 ml/min or less than 25 ml/min. A number of patients in group 1 had markedly abnormal renal retention of sodium together with a reduced free water clearance and low potassium excretion which could be explained by increased proximal tubular reabsorption of sodium. The patients in group 2 had evidence that renal tubular integrity was maintained when the glomerular filtration rate was greater than or equal ml/min (functional renal failure), but evidence of tubular damage was present when this was less than 3 ml/min (acute tubular necrosis).

Significance of increased `splenic uptake' on liver scintiscanning

Peak activity over the spleen as a percentage of peak activity over the liver was measured in 265 99mTechnetium sulphur colloid liver scintiscans. The value exceeded 70% in 50 cases. In 32 of these cirrhosis was present; the other 18 scans were from patients with a wide variety of conditions, including secondary deposits, hepatitis, and diseases involving the reticuloendothelial system. A measure of the total activity in the spleen was derived from the peak activity and the length of the spleen. In cirrhosis this was closely related to the finding of oesophageal varices thus showing the importance of a collateral circulation (which allows colloid to bypass the liver) in the increased uptake of colloid by the spleen. In eight patients with hepatosplenomegaly due to blood dyscrasia or disease involving the reticuloendothelial system, total activities in the liver and spleen were estimated from the anteroposterior colour dot scan, and both liver and spleen blood flow were measured by methods independent of reticuloendothelial cell function. The results showed that the main factor causing increased uptake of colloid by the spleen in these diseases was an increased blood flow in the spleen relative to that in the liver.

BREATH HYDROGEN IN HYPOSUCRASIA

A simple and reliable test for the diagnosis of hyposucrasia is required, since this may be an unsuspected cause of long-standing gastrointestinal disorder. Furthermore little has been done to define the epidemiology of this condition, possibly because of the limitations of multiple blood-sampling. Breath hydrogen (H2) production after lactose ingestion is a reliable test for hypolactasia, and has now been measured after sucrose ingestion in eleven patients with various gastrointestinal symptoms. Six who had normal sucrase activity on jejunal biopsy produced no H2 after taking 50 g of sucrose. No H2 was produced in three patients with borderline hyposucrasia, either after 50 g sucrose or when retested using 100 g sucrose (two patients). However, the two patients with low jejunal sucrase activity showed rises of breath H2, after only 25 g glucose. Breath H2 measurement is a simple, accurate, and non-invasive test for diagnosing gastrointestinal symptoms due to hyposucrasia.

Calcified collateral veins and gross dilatation of the azygos vein in cirrhosis

Abstract A patient with cirrhosis is described in whom a dilated azygos vein of 40 mm diameter was shown to be associated with dilated and calcified portal venous collaterals. Haemodynamic measurements indicated a splanchnic blood flow of at least 800 ml. per minute into the azygos venous system.