[Recurrent postoperative ulcers. Prospective endoscopic and therapeutic study].
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Adult↗
Biomedical subjects
J Alexander-Williams
Publications and source records attributed to J Alexander-Williams.
Audit of sepsis in operations for inflammatory bowel disease.
We report the results of a prospective audit of the rates of postoperative infection in patients having operations for inflammatory bowel disease. Apart from a single prospective controlled trial, all other groups have been studied sequentially using the original placebo control group for comparison. The rate of abdominal wound sepsis when no antibiotic was used was 37 per cent. This was reduced to 23.3 per cent with 24-hour cover using metronidazole and gentamicin. However, only after prolonged use of metronidazole and gentamicin for five days was there a significant reduction in abdominal wound infections to 13.3 per cent. Prophylaxis, using 24-hour cover with metronidazole combined with five-day therapy with mezlocillin, achieved an abdominal wound infection rate of 15.6 per cent. The most recent group of patients studied have received 24-hour cover with metronidazole and five-day exposure to latamoxef. In the last group the rate of abdominal wound infections was only 13.5 per cent and serious postoperative bleeding was recorded in eight patients (15 per cent) compared with serious bleeding is only three of the remaining 129 patients (2.3 per cent). The only patients in whom streptococcal isolates were eliminated were those receiving metronidazole and mezlocillin. The majority of infections was due to antibiotic-sensitive strains of Escherichia coli, Proteus, and Staphylococcus species.
Abscess↗
Clinical impact of colectomy and ileorectal anastomosis in the management of Crohn's disease.
We report the outcome of 63 consecutive patients with Crohn's colitis treated by colectomy and ileorectal anastomosis between 1951-1981. There were no operative deaths. Serious postoperative complications occurred in 10 patients. The mean follow up since colectomy was 9.5 years. At 10 years the cumulative reoperation rate was 48% and the cumulative recurrence rate (based upon operative, radiological, and sigmoidoscopic evidence) was 64%. Ten patients have died during follow up. Two-thirds of the patients still under review have an intact ileorectal anastomosis. These results show that colectomy and ileorectal anastomosis is a useful operation in young patients with chronic ill health, diarrhoea, and anaemia in whom there is minimal anorectal disease. For suitable patients, the operation avoids the morbidity of a permanent stoma, pelvic dissection, and rectal excision. Recurrence developing in the ileum proximal to the anastomosis can often be resected and intestinal continuity preserved, whereas anorectal recurrence usually requires proctectomy.
Adolescent↗
A prospective randomized study of effect of proximal gastric vagotomy and vagotomy and antrectomy on bile reflux, endoscopic mucosal abnormalities and gastritis.
71 patients participated in a double-blind trial which compared proximal gastric vagotomy (PVG) with vagotomy and antrectomy (V & A). 82 percent of the patients subsequently volunteered for endoscopy 6 to 12 months after operation and 65 percent for measurement of fasting bile reflux (FBR) and peak acid output (PAO). The results of these follow-up assessments are given in this paper. None of the 36 patients who had undergone V & A had a recurrent ulcer; in contrast ulcers or fresh scars were found in 5 of 35 patients after PGV, even in 2 who had no symptoms. Erythema of the gastric mucosa was seen more commonly after V & A than PGV. Such erythema was associated with high levels of fasting bile reflux (an objective measure of reflux of bile into the stomach) and with symptoms of bile vomiting and mild epigastric pain. High levels of fasting bile reflux were not found after PGV. Histological gastritis of the proximal stomach was equally common after both operations in patients without a recurrent ulcer. Gastritis was not related to endoscopic mucosal erythema or fasting bile reflux, but did correlate with peak acid output. These results confirm that bile reflux is associated with mucosal erythema and symptoms after V & A but that significant bile reflux does not occur after PGV. However, bile reflux is not related to gastritis, which appears to be the result of an operation (either PGV or V & A) which successfully reduces peak acid output.
Adult↗
Pathogenesis and pathophysiology of gastric ulcer.
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Adrenal Cortex Hormones↗
The importance of the distal stomach in gastric emptying of liquids in man.
The effects of pyloroplasty and vagal denervation of the distal stomach on gastric emptying of 10% dextrose have been compared. In a randomized trial, 38 male patients having elective surgery were treated by proximal gastric vagotomy (PGV, N = 10), proximal gastric vagotomy and pyloroplasty (PGV + P, N = 9), total gastric vagotomy (TGV, N = 9), and total gastric vagotomy and pyloroplasty (TGV + P, N = 10). Gastric emptying was recorded using an external scanning technique before and after operation. Compared with before operation, all four procedures resulted in significantly faster emptying during ingestion of the meal (the filling phase). This is attributable to failure of receptive relaxation of the proximal stomach. The emptying phase (after ingestion of the meal) was unchanged by PGV, but was significantly altered by PGV + P, TGV, and TGV + P (Principal Component Analysis). Before operation and after PGV, emptying fitted a monoexponential curve. In contrast, after PGV + P, TGV, and TGV + P, the emptying phase fitted a double exponential curve. Emptying was precipitate initially, but slowed later, leaving a large residual volume. We conclude that, when the proximal stomach is denervated, the intact, innervated distal stomach can restore the emptying of hypertonic dextrose to normal; however, when the distal stomach is denervated or pyloroplasty has been performed emptying remains uncontrolled. Since pyloroplasty and vagal denervation have the same effect, it is concluded that the mechanism retarding the emptying of hypertonic dextrose is an active mechanism that resides in the terminal antrum or pylorus.
Adult↗
Gastric histology and its relationship to entero-gastric reflux after duodenal ulcer surgery.
Thirty-six volunteers, asymptomatic 7 to 22 years after various operations for duodenal ulcer, were screened for enterogastric reflux by external scanning following injection of 99mTc HIDA; they also had endoscopy for measurement of the fasting juice pH, and multiple biopsies. In patients with a pH above 4 there was an association between a positive bile reflux test and the presence of pre-malignant changes in the gastric mucosa. Carcinoembryonic antigen in the gastric mucosa was found in all patients and was not, therefore, a useful screening test for stump cancer. Blind examination of two sets of endoscopic biopsies obtained 6 weeks apart in symptomatic patients with post-operative reflux gastritis showed that histological assessment remained reproducible. Gastric biopsies obtained from 16 patients before, and a year after, Roux-en-Y gastro-jejunostomy demonstrated that foveolar hyperplasia tended to regress after bile diversion.
Biopsy↗
The incidence of duodenogastric reflux in peptic ulcer disease.
Using 99mTc diethyl HIDA, a gamma camera was used to assess duodenogastric reflux of bile in the supine position in control patients and patients with active duodenal ulceration. Cholecystokinin was injected intravenously during the test to contract the gall bladder. Patients with benign gastric ulcers, and a group of age matched controls, were investigated for duodenogastric bile reflux in the sitting position by a nasogastric aspiration technique after a 10% dextrose meal. Of 60 patients with duodenal ulceration 32 (53%) were reflux positive, and of 13 control patients 6 (46%) were positive. Of 30 patients with gastric ulceration 17 (53%) were reflux positive, and 8 out of 15 (53%) control subjects were positive. The incidence of duodenogastric reflux assessed supine in the fasting state, and seated after a liquid meal, was similar in patients with peptic ulceration and in normal controls.
Cholecystokinin↗
Bile reflux after duodenal ulcer surgery. A study of 114 asymptomatic and symptomatic patients.
The hypothesis has been examined that the quantity of enteral contents refluxing into the stomach affects the severity of symptoms after peptic ulcer surgery. 99mTc HIDA scintigraphy was used to investigate the incidence and quantity of reflux in 20 normal subjects, in 94 symptomatic or asymptomatic patients after traditional operations for duodenal ulcer, and after revision of surgery for bile reflux gastritis. The percentage of the injected dose of 99mTc HIDA (PID) counted in the stomach area was used as an index of the quantity of refluxed bile. After duodenal ulcer surgery, symptomatic patients had a PID (6.2%) not significantly different (4.5%) from that of asymptomatic patients but higher than (2.1%) that of normals (p less than 0.05). After operations for reflux gastritis, 10 symptom free patients had no reflux, whereas 3 of 8 patients who remained symptomatic and had a short Roux-en-Y gastrojejunostomy, had persistent reflux.
Bile Reflux↗
Does duodenogastric reflux affect the rate of gastric emptying?
The gastric emptying of a liquid meal (10% dextrose solution) and a semi-solid meal (minced meat, peas, potatoes and milk) was measured in the sitting position; both meals were 400 ml. Duodenogastric reflux was assessed supine after intravenous injection of 75 MBq of 99 mTc HIDA and cholecystokinin. Patients were ajudged reflux positive (R+), or reflux negative (R-) by looking at gamma camera pictures. Thirty-two duodenal ulcer patients (DU), 22 patients after truncal vagotomy and pyloroplasty (TV+P) and 21 after proximal gastric vagotomy (PGV) were studied. In DU sufferers the mean volume of early liquid emptying in R+ patients (74 ml) was similar to R- patients (78 ml). After TV+P early liquid emptying was greatly increased (mean 176 ml) but no difference was found between R+ and R- patients. After PGV excessive early emptying was less common but emptying was significantly greater in R+ patients (R+ mean = 132 ml, SD = 48 n = 8; R- mean = 63 ml, SD = 21, N = 13: t = 4.2 p less than 0.001). There was no difference in solid meal emptying between R+ and R- patients in any group.
Cholecystokinin↗
The pharmacokinetics of 99mTc HIDA in man and its relationship to intra-gastric bile acids.
We have examined the pharmacokinetics of 99mTc diethyl HIDA in five patients with a T-tube inserted into their common bile duct after choledocotomy. Blood clearance was rapid with 27.5% of the injected dose in the circulation at 2.5 min and 5% at 30 min. The peak bile excretion of 15.4% occurred between 45 and 60 min after injection of the HIDA. By 2 h 69% of the dose was excreted in the bile and 14% in the urine. In a second group of 33 patients a naso-gastric tube was passed after injection of HIDA. The patients drank 400 ml of 10% dextrose and aliquots of the stomach contents were aspirated every 10 min for an hour. In specimens with a pH greater than 4, the amount of HIDA correlated well (p less than 0.01) with the amount of bile acid determined by an enzymatic method.
Adult↗
Sensitivity and reproducibility of a bile reflux test using 99mTc HIDA.
We have studied the sensitivity and reproducibility of entero-gastric bile reflux measurements using a gamma camera. Aspiration of the stomach at the end of the study in a group of 14 patients showed that less than 1% of the administered HIDA was present in 7 patients who were judged reflux negative. In all 7 patients considered reflux positive, there was more than 1% of the dose in the stomach (median 8.2%, p less than 0.01 Mann-Whitney). The second group of 20 patients was studied twice in the same week with a 48 h interval between the tests. The results were reproduced in 15 patients (75%). Finally, the gamma camera technique was compared with nasogastric aspiration on a separate occasion. There was agreement in 16 patients out of 19(84%). These results suggest that the test is sensitive, and the lack of reproducibility is compatible with day to day variation in entero-gastric reflux.
Bile Reflux↗
Quantitation and the elimination of errors in bile reflux tests using a gamma camera.
Entero-gastric reflux may be assessed quantitatively using 99mTc HIDA and a gamma camera. We have devised a computer program which applies corrections for several sources of error. The technique was validated using naso-gastric aspiration and phantom experiments. In 23 patient studies, 13 patients considered not to show reflux by visual assessment had a mean percentage injected dose (PID) in the stomach of 1.9% before correction and less than 1% after correction. The 10 patients with reflux showed a fall of PID from 5.8% to 1.7% as a result of the correction. In 14 patients the mean PID in the stomach after computer correction (3%) was not significantly different from that (3.5%) measured by aspiration. Computer correction of bile reflux data is essential when attempting to quantify the amount of entero-gastric reflux using a gamma camera.
Bile Reflux↗
Does gastric entubation cause entero-gastric reflux?
Using 99mTc diethyl HIDA, we have examined patients with duodenal and gastric ulceration for the effect of naso-gastric intubation on bile reflux. Fourteen patients with duodenal ulceration were studied supine under a gamma camera. Activity from the stomach area showed no significant change before and after naso-gastric intubation (Mann-Whitney U = 0.18). Nineteen patients with gastric ulceration were investigated for bile reflux using two techniques. One method used the gamma camera but without naso-gastric intubation. The other method involved passing a naso-gastric tube and aspirating aliquots of a liquid meal which were analysed for 99mTc HIDA content. The incidence of bile reflux in patients with gastric ulceration was the same when the results of the two methods were compared. We conclude that investigation of groups of patients for duodeno-gastric reflux by naso-gastric aspiration of gastric contents is a valid technique.
Duodenal Ulcer↗
A simple operative prosthetic treatment for gastro-oesophageal reflux.
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Equipment Failure↗
Causes and management of anal irritation.
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Dietary Fiber↗
Prospective randomised comparison of photocoagulation and rubber band ligation in treatment of haemorrhoids.
Two hundred and sixty eight patients with haemorrhoids were allocated at random to treatment by either photocoagulation (group 1, n=141) or rubber band ligation (group 2, n=127) and followed up for one year. There was no significant difference in the symptomatic outcome of treatment between the two groups at one, four, or 12 months, irrespective of whether first or second degree haemorrhoids were treated. Side effects of treatment (bleeding or severe pain) were significantly more common after rubber band ligation (n=11) than after photocoagulation (n=2; p less than 0.01). Further outpatient treatment, however, was required significantly more often after photocoagulation (n=23) than rubber band ligation (n=6) (p greater than 0.02), and 19 patients (14 in group 1 and five in group 2; NS) subsequently had a haemorrhoidectomy. At one year 26 of 103 patients were dissatisfied after photocoagulation compared with 20 of 88 after rubber band ligation. Photocoagulation is a safe and comfortable treatment which gives long term results that are as good as those of rubber band ligation. Complications are more common after rubber band ligation, but further treatment is required more commonly after photocoagulation.
Adolescent↗