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Duodenal cancer in polyposis patients
December
CORRESPONDENCE
1992
Reply. Adenis et al. raise an important issue regarding carryover effects in our study of the effects of calcium supplementation in subjects with sporadic adenoma.’ In our pilot study we considered the crossover design for its most distinct advantage: each subject served as his own control. Adenis et al. are correct in that carryover effects almost certainly did occur in subjects randomized to the calcium intervention in the first phase of the study, followed by the placebo phase. Therefore, we were able to confirm the findings of Rozen et al.,* who reported a decrement in proliferation activity in the colon 9-16 weeks after cessation of calcium supplementation. We agree that current studies should focus on the question of carryover effects. We await the results of several ongoing phase III and phase II calcium chemoprevention trials in subjects at higher risk for colon cancer in the United States and the European Community. MICHAEL J. WARGOVICH,
PH.D., F.A.C.N.
Section of Gastrointestinal Oncology and Digestive Diseases M. D. Anderson Cancer Center 1515 HoJcom be Boulevard, Box 78 Houston, Texas Wargovich MJ, Isbell G, Shabot M, Winn R, Lanza F, Hochman L, Larson E, Lynch P, Roubein L, Levin B. Calcium supplementation decreases rectal epithelial cell proliferation in subjects with sporadic adenoma. Gastroenterology 1992;163:92-97. Rozen P, Fireman Z, Fine N, Wax Y, Ron E. Oral calcium suppresses increased rectal epithelial proliferation of persons at risk of colorectal cancer. Gut 1989:30:6509-655.
Malabsorption Hurry
Secondary
to Intestinal
Dear Sir: The article by Fine and Fordtran describing increased fecal fat excretion due to diarrhea may also relate to D-XylOSt? absorption.’ Over the past 10 years we have been investigating malabsorption physiologically with a D-XylOSe kinetic model in which we administer D-XylOSe orally on one day and intravenously on another.z-5 With this model we have been able to characterize the absorption of D-xylose by two rate constants, Ka, the rate constant for absorption and Ko, the rate constant for nonabsorptive loss of this carbohydrate. Decreased bioavailability of D-XylOSe can be due either to an accelerated rate of nonabsorptive loss (high Ko) or a diminished rate of absorption (low Ka). Physiologically we believe the Ko defects can be caused by small intestinal bacterial overgrowth or intestinal hurry. The latter circumstance relates to Fine and Fordtran’s study because they show that the presence of diarrhea, i.e., intestinal hurry, impairs the absorption of fat. Our investigations have shown that there is a strong correlation between the rate constant for absorption and the l-hour serum concentration of D-XylOSe following oral administration of 25 g. The l-hour serum D-XylOSe level may differentiate those patients with malabsorption of fat or D-XylOSe due to intestinal hurry from those with jejunal mucosal dysfunction. Patients with normal mucosal function should have a normal l-hour serum u-xylose concentration (>25 mg/dL). ROBERT M. CRAIG, M.D. STEPHEN CARLSON, M.D.
Gastroenterology Section Department of Medicine Northwestern University Medical School 1526 Wesley Pavilion Chicago, Illinois 60611
1995
1. Fine KD, Fordtran 2.
3.
4.
5.
JS. The effect of diarrhea on fecal fat excretion Gastroenterology 1992;102:1936-1939. Craig RM, Murphy P, Gibson TP, Quintanilla A, Chao GL, Cochrane C, Patterson A, Atkinson AJ Jr. Kinetic analysis of D-XylOSe absorption in normal subjects and in patients with chronic renal failure. J Lab Clin Med 1983;101:496-506. Worwag EW, Craig RM, Jansyn EM, Kirby D, Hubler GL, Atkinson AJ Jr. D-XylOSe absorption and disposition in patients with moderately impaired renal function. Clin Pharmacol Ther 1987;41:351-357. Breiter HC, Craig RM, Levee G, Atkinson AJ Jr. Use of kinetic methods to evaluate D-XylOSe malabsorption in patients. J Lab Clin Med 1988;112:533-543. Ehrenpreis ED, Gulino SP, Patterson BK, Craig RM, Yokoo H, Atkinson AJ Jr. Kinetics Of D-XylOSeabsorption in patients with HIV enteropathy. Clin Pharm Ther 1991:49:632-640.
Duodenal Cancer in Polyposis
Patients
Dear Sir: The high risk for duodenal cancer in patients with familial adenomatous polyposis (FAP) shown in the retrospective survey by Offerhaus et al.’ reinforces the need for regular endoscopic surveillance of the foregut in asymptomatic FAP patients. Examples of such studies include those in progress at St. Mark’s Hospital, London, and the DAF (duodenal adenomatosis in FAP) project covering Denmark, Finland, Holland, Norway, and Sweden. These studies show that the majority of patients with FAP have duodenal adenomas. In addition, 1 asymptomatic patient of 228 patients screened in the DAF project has been found to have a duodenal cancer. He is alive and well 14 months following pancreaticoduodenectomy for a periampullary cancer. Duodenal cancer in FAP patients can be diagnosed before symptoms occur, allowing the instigation of treatment that at present offers the only chance for survival. All adult patients with FAP should therefore undergo regular upper gastrointestinal endoscopy. ALLAN
D. SPIGELMAN
Leeds Castle Polyposis Subcommittee on Gastroduodenal Polyps Central Middlesex Hospital Acton Lane Park Royal London NW10 7NS, England WILLY JENSEN
Lemvig Hospitai Denmark STEFFEN BULOW
Leeds Castle Polyposis Group and DAF Project Copenhagen, Denmark Offerhaus GJA, Giardiello FM, Krush AJ, Booker SV, Tersmette AC, Kelley NC, Hamilton SR. The risk of upper gastrointestinal cancer in familial adenomatous polyposis. Gastroenterology 1992;102:1980-1982.
Does Erythromycin Really Have a Prokinetic Effect on the Gallbladder? Dear Sir: We read with interest the article by Catnach et al.’ concerning the effect of oral administration of erythromycin on gallbladder motility. The results are interesting; however, we disagree with
CORRESPONDENCE
1992
Reply. Adenis et al. raise an important issue regarding carryover effects in our study of the effects of calcium supplementation in subjects with sporadic adenoma.’ In our pilot study we considered the crossover design for its most distinct advantage: each subject served as his own control. Adenis et al. are correct in that carryover effects almost certainly did occur in subjects randomized to the calcium intervention in the first phase of the study, followed by the placebo phase. Therefore, we were able to confirm the findings of Rozen et al.,* who reported a decrement in proliferation activity in the colon 9-16 weeks after cessation of calcium supplementation. We agree that current studies should focus on the question of carryover effects. We await the results of several ongoing phase III and phase II calcium chemoprevention trials in subjects at higher risk for colon cancer in the United States and the European Community. MICHAEL J. WARGOVICH,
PH.D., F.A.C.N.
Section of Gastrointestinal Oncology and Digestive Diseases M. D. Anderson Cancer Center 1515 HoJcom be Boulevard, Box 78 Houston, Texas Wargovich MJ, Isbell G, Shabot M, Winn R, Lanza F, Hochman L, Larson E, Lynch P, Roubein L, Levin B. Calcium supplementation decreases rectal epithelial cell proliferation in subjects with sporadic adenoma. Gastroenterology 1992;163:92-97. Rozen P, Fireman Z, Fine N, Wax Y, Ron E. Oral calcium suppresses increased rectal epithelial proliferation of persons at risk of colorectal cancer. Gut 1989:30:6509-655.
Malabsorption Hurry
Secondary
to Intestinal
Dear Sir: The article by Fine and Fordtran describing increased fecal fat excretion due to diarrhea may also relate to D-XylOSt? absorption.’ Over the past 10 years we have been investigating malabsorption physiologically with a D-XylOSe kinetic model in which we administer D-XylOSe orally on one day and intravenously on another.z-5 With this model we have been able to characterize the absorption of D-xylose by two rate constants, Ka, the rate constant for absorption and Ko, the rate constant for nonabsorptive loss of this carbohydrate. Decreased bioavailability of D-XylOSe can be due either to an accelerated rate of nonabsorptive loss (high Ko) or a diminished rate of absorption (low Ka). Physiologically we believe the Ko defects can be caused by small intestinal bacterial overgrowth or intestinal hurry. The latter circumstance relates to Fine and Fordtran’s study because they show that the presence of diarrhea, i.e., intestinal hurry, impairs the absorption of fat. Our investigations have shown that there is a strong correlation between the rate constant for absorption and the l-hour serum concentration of D-XylOSe following oral administration of 25 g. The l-hour serum D-XylOSe level may differentiate those patients with malabsorption of fat or D-XylOSe due to intestinal hurry from those with jejunal mucosal dysfunction. Patients with normal mucosal function should have a normal l-hour serum u-xylose concentration (>25 mg/dL). ROBERT M. CRAIG, M.D. STEPHEN CARLSON, M.D.
Gastroenterology Section Department of Medicine Northwestern University Medical School 1526 Wesley Pavilion Chicago, Illinois 60611
1995
1. Fine KD, Fordtran 2.
3.
4.
5.
JS. The effect of diarrhea on fecal fat excretion Gastroenterology 1992;102:1936-1939. Craig RM, Murphy P, Gibson TP, Quintanilla A, Chao GL, Cochrane C, Patterson A, Atkinson AJ Jr. Kinetic analysis of D-XylOSe absorption in normal subjects and in patients with chronic renal failure. J Lab Clin Med 1983;101:496-506. Worwag EW, Craig RM, Jansyn EM, Kirby D, Hubler GL, Atkinson AJ Jr. D-XylOSe absorption and disposition in patients with moderately impaired renal function. Clin Pharmacol Ther 1987;41:351-357. Breiter HC, Craig RM, Levee G, Atkinson AJ Jr. Use of kinetic methods to evaluate D-XylOSe malabsorption in patients. J Lab Clin Med 1988;112:533-543. Ehrenpreis ED, Gulino SP, Patterson BK, Craig RM, Yokoo H, Atkinson AJ Jr. Kinetics Of D-XylOSeabsorption in patients with HIV enteropathy. Clin Pharm Ther 1991:49:632-640.
Duodenal Cancer in Polyposis
Patients
Dear Sir: The high risk for duodenal cancer in patients with familial adenomatous polyposis (FAP) shown in the retrospective survey by Offerhaus et al.’ reinforces the need for regular endoscopic surveillance of the foregut in asymptomatic FAP patients. Examples of such studies include those in progress at St. Mark’s Hospital, London, and the DAF (duodenal adenomatosis in FAP) project covering Denmark, Finland, Holland, Norway, and Sweden. These studies show that the majority of patients with FAP have duodenal adenomas. In addition, 1 asymptomatic patient of 228 patients screened in the DAF project has been found to have a duodenal cancer. He is alive and well 14 months following pancreaticoduodenectomy for a periampullary cancer. Duodenal cancer in FAP patients can be diagnosed before symptoms occur, allowing the instigation of treatment that at present offers the only chance for survival. All adult patients with FAP should therefore undergo regular upper gastrointestinal endoscopy. ALLAN
D. SPIGELMAN
Leeds Castle Polyposis Subcommittee on Gastroduodenal Polyps Central Middlesex Hospital Acton Lane Park Royal London NW10 7NS, England WILLY JENSEN
Lemvig Hospitai Denmark STEFFEN BULOW
Leeds Castle Polyposis Group and DAF Project Copenhagen, Denmark Offerhaus GJA, Giardiello FM, Krush AJ, Booker SV, Tersmette AC, Kelley NC, Hamilton SR. The risk of upper gastrointestinal cancer in familial adenomatous polyposis. Gastroenterology 1992;102:1980-1982.
Does Erythromycin Really Have a Prokinetic Effect on the Gallbladder? Dear Sir: We read with interest the article by Catnach et al.’ concerning the effect of oral administration of erythromycin on gallbladder motility. The results are interesting; however, we disagree with