Biomedical subjects
Publications and source records attributed to G Lepsien.
Selective proximal vagotomy does not influence the function of the cardia. Only high intrathoracic vagotomy results in a decrease of LES pressure. Esophagitis, which is found in a high percentage of preoperative duodenal ulcer patients, heals after SPV.
The columnar epithelium lined esophagus is usually the result of a chronic reflux disease. In the literature one can find more and more references to a malignant transformation of this columnar epithelium. Our own observations of 14 patients with an adenocarcinoma in a columnar-lined esophagus support this suspicion. Because the adenocarcinoma of the esophagus has therapeutic consequences other than a squamous carcinoma of the esophagus, the surgery has to give attention to this malignant transformation of the columnar-lined esophagus.
Radiology, endoscopy and function tests were performed in 30 patients with primary reflux disease. Follow-up examinations were performed 3.2 +/- 1.5 years later. Esophagitis was more frequent in men. Severity of esophagitis correlated neither with the duration of symptoms before diagnosis nor with the results of function tests. Neither esophagitis nor function tests allowed a prediction on the long-term severity of symptoms. Episodic symptoms were more frequent in patients with esophagitis and constant symptoms more frequent in those without esophagitis. The indication for conservative and surgical treatment mainly depended on chance. Good therapeutic results were obtained in only 11 of 17 patients undergoing conservative treatment and in 9 of 13 patients undergoing surgical treatment. 6 patients of the surgical group had postfundoplication symptoms. Thus, the results of conservative and surgical treatment were quantitatively similar and rather disappointing.
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A careful clinical investigation of 245 patients with hiatus hernia was performed. (History and physical examination, x-ray tests, oesophago-gastroscopy with biopsies, 3-point-manometry, rapid pull-through manometry with pentagastrintest). Classification of hiatus hernia was performed by x-ray test. (222 axial hiatus hernia, 14 mixed hiatus hernia, 9 paraoesophageal hiatus hernia) 3-point-manometry and rapid pull-through manometry with Pg-test were used to differentiate the function of the cardia. In spite of a strong selection in 84 out of 245 patients examined in our hospital, a sufficient cardia could be seen. 161 cases showed a gastro-oesophageal reflux which has been in accordance with a decompensated reflux disease in 97 patients. Solely in these 97 patients an operative correction of the gastro-oesophageal reflux seemed convenient. 84 patients showed a considerable variability of oesophageal disorders. In a final correlation between endoscopy, manometry and x-ray tests our opinion was confirmed that hiatus hernia must not lead inevitably to an insufficiency of the cardia. In the above investigations it could be shown that any therapeutic proceeding in the treatment of hiatus hernia first needs a careful analysis of the cardiac and oesophageal activity and second requires a careful indication for the surgical treatment of hiatus hernia.
The role of the duodenum in the regulation of the lower esophageal sphincter pressure (LESP) was investigated in 4 unrestrained dogs equipped with a chronic Komarov type esophagostomy, a cutaneous duodenal fistula, a gastrojejunostomy, and a Y anastomosis between the distal end of the duodenum and the midjejunum. Installation of NaCl solution into the duodenum or into the stomach did not effect LESP during the following 60-min observation period. Peptone instillation into the duodenum or into the stomach produced a sustained elevation LESP. The rise of LESP was significantly greater after duodenal than after gastric instillation. Duodenal peptone did not raise serum gastrin. It is concluded that the duodenum may be an important regulator of LESP in the dog and that this effect is not mediated by circulating gastrin.
To clarify whether the duodenum is important to the regulation of cardia function, patients with B-I and B-II resections were investigated manometrically. A test meal can stimulate the LES in patients with a B-I resection almost to the same extent as that in healthy test persons. Symptom-free patients with the distal stomach resection and gastrojejunostomy (B-II) do not show this pressure reaction. Therefore, the duodenal passage could be of importance to cardia function. In patients with a transformation operation of B-II in B-I, because of postgastrectomy symptoms a stimulation of the LES cannot be achieved either before or after the transformation operation. We cannot presently clarify the type of the cardia regulation since the IRG levels measured do not explain this phenomenon.
The influence of cimetidine on the lower esophageal sphincter, the intragastric pH and the serum levels of immunoreactive gastrin was investigated in eight volunteers and compared with a control group. After oral application of 400 mg cimetidine, the intragastric pH rose from 1.7 +/- 0.13 to 6.2 +/- 0.4 and the lower esophageal sphincter pressure increased slightly but significantly from 15.6 +/- 1.1 to 22.7 +/- 1.8 mm Hg after 20 min and to 25.8 +/- 2.0 after 30 min, respectively. At the same time the serum immunoreactive gastrin levels did not change. A direct effect of cimetinidine on the lower esophageal sphincter or an indirect effect via gastric alkalinization is discussed.
In investigations with various groups of patients there was no correlation between fasting serum IRG levels and LES pressures in individual subjects with undisturbed for disturbed sphincters. After food ingestion a short phase of LES pressure increase (from 13.5 +/- 1.5 to 21.7 +/- 3.8 mm Hg) could be observed. This peak occurs during the phase of rise in gastrin level, but there was no correlation between IRG levels and LES pressure in individual cases. In patients with gastroesophageal reflux we can demonstrate a diminished release of gastrin after a test meal, but there was also a diminished capacity of the LES. In conclusion, in this investigation it has not been possible to show a clear connection in humans between serum IRG and LES function.
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On the basis of four cases from our own clinic and three outside cases, we describe a so-called, "telescope phenomenon". This involves a specific complication that may arise after fundoplication. The characteristic of this postoperative complication is the slipping down of the fundus cuff, accompanied by a telescopic pushing upwards of the cardia. Recurrent reflux and occasionally new manifestations of dysphagia are the clinical results of this. This paper describes the diagnostic procedure and therapy of the telescope phenomenon.
Based on in vivo studies on isolated muscle strips of the LES and on manometric in vivo studies on 8 mongrel dogs, 6 healthy volunteers, 6 patients with achalasia and 3 subjects with diffuse esophageal spasm we could demonstrate that nifedipine causes a long-lasting relaxation of smooth muscle, the esophagus and LES. In 8 dogs resting pressure at the LES was decreased by 20 mg nifedipine from 18.5 +/- 1.8 mm Hg to 8.2 +/- 0.9 mm Hg. This pressure decrease could not be reversed by pentagastrin stimulation (3.0 microgram/kg KG PG). The resting pressure in LES was decreased from 26.8 +/- 3.8 mm Hg to 16.4 +/- 2.1 mm Hg in healthy volunteers and from 45.5 +/- 2.6 mm Hg to 14.5 +/- 0.4 mm Hg in patients with achalasia. In 3 patients with diffuse esophageal spasm nifedipine (20 mg) caused a mean decrease of 38% of the contraction amplitude. Further clinical studies have to be done to clarify if the spasmolysis by nifedipine may be important in the treatment of spastic or hypertonic motility disorders of the LES and the esophagus.
Instillation of a 20% peptone solution into the isolated duodenum causes a significant increase of LES-pressure in the dog. No comparable increase of LES-pressure after instillation of a 0.9% saline solution into the duodenum or of 20% peptone solution into the stomach is observed. As shown in this investigation, it is possible that the duodenum regulates the LES-pressure in the dog.
The most important tests in esophageal disease are endoscopy and standard X-ray examination. The tests yield valuable information on the structure but little information on the function of the esophagus. Many disorders, however, such as oropharyngeal dyskinesia, diffuse esophageal spasm, achalasia and gastroesophageal reflux are defined by an abnormal esophageal function. In these cases tests such as cinéradiography, manometry, pH-metry and scintigraphy which quantitatively assess esophageal function are necessary. The interpretation of these tests is difficult for the following reasons. 1. Insufficient technical equipment favours false positive and false negative results. 2. Some disorders of esophageal motility exist only temporarily and may be absent at the time of examination. 3. Some disorders such as gastroesophageal reflux are quantiatively defined. Minor or transient disturbancies of esophageal motility may also be found in healthy individuals. The normal range of esophageal function is not sufficiently known in most instancies. Because of these difficulties it is advisable to perform several function tests in each individual patient and to assess the results of these tests together with the slinical symptoms, standard radiology and endoscopy.
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We present a case report of a 60-year-old male patient and subsequently discuss sonographical findings in Whipple's disease. This particular patient showed an intraabdominal tumorous mass. Symptoms of a malabsorption disorder were absent. Computer-assisted tomography and radiological examination could not determine the origin of the tumor. Sonography demonstrated a polycyclic hyperechoic mass in the root of the mesentery. The small intestine was not distended and showed normal peristalsis. Its wall was hyperechoic concentrically thickened. Final diagnosis was established from a diagnostic laparotomy showing enlarged lymph nodes and distended lymphatic vessels. Based on the literature the described sonographical findings seem to be typical in cases of Whipple's disease.