Biomedical subjects
Publications and source records attributed to R Arendt.
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The deep duodenoscopy serves for the endoscopico-bioptic clarification of radiologically unclear findings distally from the bulb (niches, sockets, stenoses) and of the positional relations between diverticulum and papilla. As a rule, it is connected with an endoscopic retrograde cholangiopancreaticography (ERCP). The endoscopic retrograde pancreaticography is indicated in relapsing chronic pancreatitis for proving or excluding of changes needing operation which are taken into consideration as partial factors of the relapsing course as well as in suspicion to a local pancreatitis complication and carcinoma of the pancreas. The endoscopic retrograde cholangiography is a decisive aid for the differentiation of the cholostatic icterus. It improves the diagnostics of complaints after operative interventions at the system of the biliary ducts, facilitates the diagnosis of the papillary stenosis and is indicated in insufficient conventional contrasting the biliary ducts. The complications (pancreatitis, cholangitis, cystic infection) have become rare with increasing experience. Contraindications are the florid pancreatitis and cholangitis.
A survey is given of the present state of the ERCP in the diagnostics of the chronic pancreatitis. The ERCP is not suited for the proof of early changes in the chronic pancreatitis; it does not allow an exclusion diagnosis. The value of the ERCP in the chronic pancreatitis consists in the fact to render the indication to operation by the proof changes which should be operated on, or to precise it, respectively, and to prevent unnecessary test laparotomies. For this reason the ERCP is indicated above all in the ascertained chronically relapsing pancreatitis and in the persistence of symptoms after an acute inflammatory attack. The most comprehensive information about the morphologic state of the pancreas is got by the combination of the ERCP with methods which reflect the size and the external form of the organ and give evidence concerning the structural changes (sonography, computer tomography).
A survey is given on the present state of experience with Cimetidine. Cimetidine significantly promotes healing of duodenal and gastric ulcers; this effect is especially significant in countries with low spontaneous ulcer healing. Prophylactically administered Cimetidine is the only drug capable of decisively lowering the recurrence rate of duodenal ulcers. In certain cases, Cimetidine long-term treatment therefore seems to compete with elective gastric operations. However apart from the operative risk surgery of the stomach (especially selective gastric vagotomy) still provides certain advantages. Controlled long-term trials are still required in order to come to a clear-cut delimitation between the indications for Cimetidine prophylaxis and elective operation. Furthermore prophylaxis with Cimetidine prevents gastric bleeding from erosions in stress-patients. Even in Zollinger-Ellison-syndrome Cimetidine enables ulcers to heal and patients to reach operability. In patients with operable gastrinomas the long-term treatment with Cimetidine seems to replace palliative total gastrectomy by curative resection of the tumour.
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A survey is given on indications, results and complications of the deep duodenoscopy and endoscopic retrograde cholangiopancreaticography. The endoscopic retrograde pancreatography is indicated in the chronic forms of pancreatitis, in suspicion to cysts of the pancreas or tumours. Its results have a decisive influence on the indication to surgical procedure and on the planning of the intervention. The endoscopic retrograde cholangiography is of greatest practical significance for the differential diagnosis of the cholestatic icterus: non-obstructed bile ducts exclude an extrahepatic icterus and render a laparotomy useless. Furthermore, the endoscopic retrograde cholangiography is indicated when the demonstration of the duct is intravenously insufficient, when papillary or prepapillary narrowings are present and in the etiologically unclear syndrome of postcholecystectomy. The most dangerous complications of the endoscopic retrograde pancreatography are the acute pancreatitis and the infection of cysts. Cholangitides and septicaemias appear after the endoscopic retrograde cholangiography only in such cases when obstructions of the drainage are present.
In a short survey recent results of research on gastrin are presented. Special stress is laid upon the mechanism of liberating gastrin, the role of the vagus in this process and the consequences of gastric surgery on serumgastrin. In clinical practice the differential diagnosis of hypergastrinemia in ulcer disease is very important, for it will have a decisive influence on the therapeutic decisions and the specific kind of surgical treatment.
A survey of pathogenesis, pathobiochemistry, pathological anatomy, clinic, diagnostics and therapy of the Zollinger-Ellison-syndrome is given. The Zollinger-Ellison-syndrome is, it is true, relatively rare, but its limitation from the usual peptic ulcer has great practical consequences. The suspicion of a Zollinger-Ellison-syndrome is aroused by therapy-resistent ulcers, which in every third person are associated with a diarrhoea, by recidivations of ulcer after gastric operations and by a large basal secretion of acid. The decisive diagnostic means is the serum gastrin determination. The only promising therapy is, as a rule, the gastrectomy.
A survey of the modern importance of the secretion test of the stomach for diagnostics and differential diagnostics of the gastroduodenal ulcer, for an individualising surgery of the stomach and for the testing of the success in vagotomy is given. In the epoch of the fibre endoscopy the secretion test can scarcely still contribute to the diagnostics of ulcer, but it is now as ever important as screening method for the differentiation of the Zollinger-Ellison-syndrome. The decision on the size of an individual surgical intervention for the treatment of the peptic ulcer should also be based on the result of the secretion test. The usual control of the success of vagotomy by means of the insulin test has its problems.
In the clarification of circumscribed processes in stomach and duodenal bulb radiodiagnostics and endoscopy supplement themselves in an ideal way. The endoscopy seems to have advantages in recognition and explanation of findings on the cardial and subcardial parts of the stomach as well as on the operated stomach. Deformation of the duodenal bulb and changes of the post-stenotic parts can be better judged radiologically. The complete healing of an ulcer is exactly recognisable only by means of endoscopy. Linear ulcers are often not to be seen in radiodiagnostics. With the help of the aimed biopsy the decision on benignity or malignity of the ulcerating process has become easier. Every radiologically not certainly explainable findings and every discrepancy between X-ray picture and complaints of the patients should bring about an endoscopic examination.
In 36 patients with ulcer without Zollinger-Ellison-syndrome (25 patients with recurrent duodenal ulcer, 11 with an ulcus pepticum jejuni after B II-resection of the stomach) and 2 patients suffering from ulcus pepticum jejuni with an ascertained gastrinoma the secretion of acid was compared after stimulation of pentagstrin (6 mug/kg) and calcium (4 mg Ca++/kg/h). The secretion of hydrochloric acid was statistically significantly stimulated in all patients suffering from ulcer by the hypercalcaemia (increase of the serum calcium concentration from 5.0 +/- 0.3 mval/1 to 6.2 +/- 0.8 mval/1). But in patients suffering from ulcer with gastrinoma the stimulatory effect was larger than in such patients without autonomous source of gastrin: the calcium-stimulated secretion of hydrochloric acid was on the average in cases of duodenal ulcer 40% (2 to 68%), in the ulcera peptica jejuni 47% (17 to 75%), in the 4 comparative examinations of the two patients with Zollinger-Ellison-syndrome, however, always more than 100% (106 to 177%) of the pentagastrin-stimulated peak secretion. The comparative test of the pentagastrin and calcium-stimulated secretion of hydrochloric acid could be a help for the proof of autonomous places of the formation of gastrin.
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