Biomedical subjects
Publications and source records attributed to F Stadil.
From 1984 to 1986 The Medico-Legal Council was heard concerning four cases of iatrogenic lesions of the common bile duct during cholecystectomy. The Council's statements show that lesions of the common bile duct or the common hepatic duct during otherwise uncomplicated, elective cholecystectomy are considered surgical malpractice and not accidental mishaps.
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In the Zollinger-Ellison syndrome, symptoms and complications are due to hypersecretion of acid, and the first therapeutic step is to suppress the acid secretion. Long-term treatment with histamine H2-receptor antagonists was compared with omeprazole treatment. A total of 30 consecutive ZES patients were treated continuously with H2-receptor antagonists. During long-term treatment, a marked tachyphylaxis was noted, more than 50% of the patients had periods of dyspepsia, recurrent ulcers were found in 10 patients and in 16 a decline in the action of the H2-receptor antagonist required a change to omeprazole after a median duration of 36 months. A total of 22 patients were treated with omeprazole. During long-term treatment, the dose could be reduced slightly. Inhibition of acid secretion was maintained in all cases, and none had dyspeptic symptoms. The median duration of treatment was 18 months, with a range of 1-120 months (H2-receptor antagonists) and 27 months with a range of 1-66 months (omeprazole). No side-effects were seen with omeprazole.
During the last 17 years about 100 gastrinomas have been diagnosed in Denmark. With background of the Danish material and the literature the clinical features and pathology of gastrinoma are reviewed and its medical and surgical treatment discussed.
Serum concentration of gastrin was measured before and after renal transplantation in 97 consecutive patients in order to assess possible correlations to gastrointestinal bleeding, allograft function, or graft rejection. In patients with transient signs of allograft rejection (N = 29) or upper gastrointestinal bleeding (N = 12) there was a nonsignificant trend towards higher postoperative gastrin levels, and in patients in whom the graft was removed (N = 29), this tendency was more pronounced (p = 0.06). The study demonstrated that monitoring of serum concentrations of gastrin following renal transplantation is of little clinical value. However, increased gastrin levels in serum may indicate that graftectomy may be the ultimate result.
The functional role of the jejunum and ileum with regard to peripheral plasma levels of intact neurotensin and NH2-terminal immunoreactivity of neurotensin was studied by using jejunoileal bypass as a model. Plasma levels were measured by radioimmunoassay before and after jejunoileal bypass randomized to different jejunoileal ratios. Seven patients were studied before bypass surgery and 28 were examined after end-to-side jejunoileal bypass with 50 cm intestine in continuity and a 3:1 or 1:3 ratio between the length of the jejunal and ileal segments. Fasting levels of intact neurotensin were unchanged by surgery, whereas levels of NH2-terminal immunoreactivity were higher in bypass patients with a long ileal segment (37.5 cm) than in unoperated patients and in those with a short ileal segment (12.5 cm). Meal-stimulated levels of intact neurotensin were higher after 1:3 than 3:1 jejunoileal bypass. The levels of NH2-terminal immunoreactivity in patients with a short ileal segment and in controls were lower than in patients with a long ileal segment. The results show that postprandial levels of both intact neurotensin and NH2-terminal immunoreactivity are related to the length of the functioning ileum and that even a difference in length of 25 cm is reflected in the circulating levels of neurotensin.
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We have investigated the gastric endocrine cells in 19 patients with the Zollinger-Ellison syndrome. Six received a long-term treatment with omeprazole, 5 one with H2 receptor antagonists and 8 had no medical treatment. Fifteen patients (79%) had hyperplasia of the endocrine cells in the oxyntic mucosa independent of treatment. The hyperplasia involved both enterochromaffin-like (ECL) and D1 cells and was positively related to the duration of disease (p less than 0.05). The duration of hypergastrinaemia was longer in the omeprazole-treated patients, but the hyperplasia was not significantly more pronounced in these patients. Gastric carcinoid tumours consisting mainly of ECL cells are rare in man and are most often seen in states of hypergastrinaemia such as chronic atrophic gastritis. It has seldomly been reported in Zollinger-Ellison patients; but now, when potent antisecretory drugs make it possible to avoid total gastrectomy, a raised incidence might result, and an increased attention to this aspect seems appropriate.
Treatment with omeprazole was evaluated in nine patients with the Zollinger-Ellison syndrome, in whom the effect of H2-receptor antagonists had become inadequate. Treatment with 20-80 mg omeprazole daily reduced basal acid secretion by 77-100%. The effect persisted during a continuous treatment of up to 2 years. In five patients the initial dose could be reduced after some time of treatment. In eight patients the treatment promptly relieved all symptoms, and in the last patient, who had disseminated metastatic disease and large anastomotic ulcers, the symptoms disappeared gradually over a period of 10 weeks. No adverse events were seen. We conclude that omeprazole is an effective inhibitor of the acid hypersecretion in Zollinger-Ellison patients, also when H2-receptor antagonists have failed.
Plasma concentrations of pancreatic polypeptide (PP) and vasoactive intestinal polypeptide (VIP) were measured after a meal consisting of 11 ml meat extract and 40 ml of 20% soya oil in 11 patients before and 3 months after gastroplasty for morbid obesity. Gastroplasty results in a small proximal pouch with a narrow stoma allowing delayed emptying into the distal pouch, and consequently postprandial distension of the proximal pouch. Postprandial plasma PP increased significantly (P less than 0.01) independent of gastroplasty. PP is therefore not involved in the early satiety after gastroplasty. Postprandial plasma VIP increased significantly from fasting levels both before and after gastroplasty (P less than 0.05). Only 10 min after a meal, the median value of VIP was significantly higher after than before gastroplasty (P less than 0.02) and may be caused by distension of the proximal pouch.
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In 97 consecutive patients undergoing renal transplantation the incidence of upper gastrointestinal bleeding was registered over 180 days after allocation to treatment with either cimetidine or placebo. Bleeding episodes occurred in 12 patients, 11 of whom were receiving placebo and only one cimetidine (p less than 0.01). All bleeding episodes occurred during the first month after allotransplantation. Treatment with cimetidine did not lead to an increased incidence of rejection of the allograft. It is concluded that cimetidine is effective and safe in protecting against upper gastrointestinal bleeding after renal transplantation.
The emptying of the colon and the side-effects after intraluminal application of prostaglandin E2 and of bisacodyl in 14 patients was studied by employing colostomy irrigation. The design was double-blind with cross-over, the irrigation was one litre of tap water to which was added in randomized sequence placebo, prostaglandin *2 (350, 700 and 1400 micrograms) or bisacodyl (1.25, 2.5 and 5 mg). Neither prostaglandin E2 nor bisacodyl had any significant effect.
Fasting and postprandial plasma levels of the tridecapeptide neurotensin were determined in ten women before and three months after gastroplasty for morbid obesity. Measurements were by radioimmunoassay in unextracted plasma with two antisera recognizing intact neurotensin (NT1-13) or intact neurotensin together with small C-terminal fragments, which may circulate as metabolites of neurotensin. Levels of both intact neurotensin and C-terminal immunoreactivity in obese women were in the same order of magnitude as those found previously in lean persons. Fasting levels measured with both antisera were significantly reduced following gastroplasty (P less than 0.01). Meal-stimulated levels and increments were unchanged. The cause of this prolonged reduction is at present unknown, but may be a reduced luminal stimulation of the small intestine or an altered vagal tonus following gastroplasty.
The influence of the vagal nerve on the inhibitory effect of neurotensin on pentagastrin stimulated gastric acid secretion was investigated in seven duodenal ulcer patients before and after parietal cell vagotomy without drainage. Preoperatively, neurotensin inhibited gastric acid secretion, whereas no effect was found postoperatively. Plasma concentration of neurotensin was identical pre-and postoperatively. This study shows that the inhibitory effect of neurotensin on gastric acid secretion is dependent on an intact vagal innervation of the parietal cell area.
Fasting and postprandial plasma secretin levels were measured in 11 patients before and 3 months after gastroplasty for morbid obesity. Ingestion of a meal significantly increased plasma secretin both before and after gastroplasty (P less than 0.05). After gastroplasty there was an additional but insignificant increase in postprandial plasma secretin. Secretin has evidently no major role in the development of early satiety after gastroplasty and the lack of significantly changed secretin levels after operation indicates an unchanged intraduodenal pH.
Fasting and meal-stimulated serum gastrin and glucose levels were measured in 11 patients before and 3 months after gastroplasty for morbid obesity. Overall blood glucose levels were significantly reduced after surgery (P less than 0.05), whereas the response to a meal was not influenced to any significant degree (P greater than 0.10). The fasting serum gastrin level was not significantly influenced by gastroplasty (P greater than 0.10). Postprandial serum gastrin increased significantly independent of gastroplasty (P less than 0.001). The presence of a marginally significant (0.10 greater than P greater than 0.05) interaction between postprandial gastrin levels and operation raises the possibility that gastroplasty additionally increases the postprandial serum gastrin level.
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