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Elevated canine posthepatectomy insulin levels
234
CORRESPONDENCE
Nevertheless, score results of this group (n = 26) excluded from the initial evaluation of the scoring system may be of interest. We calculated a specificity of 99% for the diagnosis of IBS in patients exceeding 44 points in the score. In the patient group suffering from both IBS and organic disease, 9 of 26 patients had >44 points. Diagnoses of organic disease were as follows: gastroduodenitis (n = 4), gastric/duodenal ulcer (n = 2), fatty liver (n = l), reflux esophagitis (n = l), and cysts of the liver (n = 1). This shows that our scoring system would have erroneously classified 2 patients of this group with clinically relevant diagnoses (ucler). In patients with obvious signs of organic disease it may not be worthwhile to use our scoring system. The aim of our study was indeed the validation of simple clinical diagnostic procedures for the exclusion of organic diseases in patients with nonspecific abdominal complaints. The findings herein in patients suffering from both IBS and organic disease may further support the accuracy of history, physical examination, and basic laboratory tests for the diagnosis of IBS. W. KRUIS Ch. THIEME Department of Internal Medicine II and Department of Medical Information Processing Statistics Klinikum Grosshadern University of Munich Munich, Federal Republic of Germany 1. Drossman DA. Diagnosis of the irritable bowel syndrome: a simple solution? Gastroenterology 1984;87:224-5. 2. Kruis W, Thieme Ch, Weinzierl M, et al. A diagnostic score for the irritable bowel syndrome: its value in the exclusion of organic disease. Gastroenterology 1984;87:1-7.
Low Molecular Weight IgM Anti-HBc in HBsAg Carriers Dear Sir: We congratulate Tsuda et al. (1) for their recent description of low molecular weight IgM anti-HBc in Japanese HBsAg carriers. Their findings are in agreement with our publication (2) of 17 American HBsAg carriers with a predominant low molecular weight IgM anti-HBc. We have now studied 90 American patients chronically infected with hepatitis B virus (manuscript in preparation). We found a low molecular weight IgM anti-HBc in only 74% of our patients, compared with 100% found by Tsuda et al. in his Japanese population. The remaining 26% of our patients showed a predominant 19s IgM anti-HBc, similar to the class of IgM anti-HBc observed in acute hepatitis B. The patients in our 19s group had documented hepatitis B virus infections for several years (mean duration of illness, 3 yr). Our data do not support the concept that testing for 7S IgM antiHBc will distinguish acute versus chronic hepatitis B virus infection in every case, at least not in the American population. Still, the question of why some chronic HBsAg carriers produce a low molecular weight form of this antibody while others produce and maintain 19s IgM anti-HBc despite years of chronic infection requires an explanation. MARIA SJOGREN, M.D. Department of Virus Diseases Walter Reed Army Institute of Research Washington, D.C. 20307-5100 STANLEY LEMON, M.D. Division of Infectious Diseases University of North Carolina Chapel Hill, North Carolina 27514
GASTROENTEROLOGY
Vol. 89, No. 1
1. Tsuda F, Naito S, Takai E, et al. Low molecular weight (75) immunoglobulin M antibody against hepatitis B core antigen in the serum for differentiating acute from persistent hepatitis B virus infection. Gastroenterology 1984;87:159-64. 2. Sjogren M, Lemon S. Low-molecular-weight IgM antibody to hepatitis B core antigen in chronic infections with hepatitis B virus. J Infect Dis 1983;148:445.
Elevated Canine Posthepatectomy Insulin Levels Dear Sir: I have two questions regarding the article by Cohen et al. (1) in a recent issue of GASTROENTEROLOGY. First, the finding of elevated insulin levels in dogs after hepatectomy is perplexing. Previous studies in rats have not only shown suppressed posthepatectomy insulin levels (z), but also a synergistic hepatotrophic effect of insulin and glucagon (3). In dogs, studies have failed to demonstrate such a synergistic effect (4). Could elevated posthepatectomy insulin levels be peculiar to the dog and prevent the insulin-glucagon synergy demonstrated in rats? A possible mechanism for this could be blunting of potential effects of glucagon on membrane hyperpolarization, as discussed in the article by Paloheimo et al. (51, by posthepatectomy-elevated insulin levels found in dogs. Insulin is a wellknown suppressant of gluconeogenesis and glycogenolysis. If hepatocellular hyperpolarization in the regenerating remnant is induced by gluconeogenesis, canine posthepatectomy hyperinsulinemia would be expected to blunt the gluconeogenic effect of glucagon. By necessity, such a hypothesis would suggest a somewhat different regenerative mechanism in the dog as opposed to the rat. Second, although Cohen’s article states that pancreatic polypeptide levels increased after partial hepatectomy, Figure 30 shows a significant decrease for both the limited and extended hepatectomy groups between 7 and 15 days postoperatively. A comment by the authors would be appreciated. CHARLES F. GHOLSON, M.D. Fellow in Gastroenterology Department of Medicine University of Colorado School Denver, Colorado 80262
of Medicine
1. Cohen
2. 3.
4.
5.
DM, Jaspen JB, Polonsky KS, Lever EG, Moosa AR. Pancreatic hormone profiles and metabolism posthepatectomy in the dog. Gastroenterology 1984;87:679-87. Leffert HL, Koch KS, Moran T, Rubalcava B. Hormonal control of rat liver regeneration. Gastroenterology 1979;76:1470-82. Bucher NLR, Swaffield MN. Regulation of hepatic regeneration in rats by synergistic action of insulin and glucagon. Proc Nat1 Acad Sci USA 1975;72:1157-60. Starzl TE, Porter KA, Kashiwagi N, Putnam CW. Portal hepatotrophic factors, diabetes mellitus and acute liver atrophy, hypertrophy and regeneration. Surg Gynecol Obstet 1975; 141:843-58. Paloheimo M, Linkola J, Lempinen M, Folke M. Time-courses of hepatocellular hyperpolarization and cyclic adenosine 3’5’monophosphate accumulation after partial hepatectomy in the rat. Gastroenterology 1984;87:639-46.
Bowel Dysfunction Dear Sir: In the article by Sandler et al. in a recent issue of GASTROENTEROLOGY, it was stated that intestinal dysfunction typical of
CORRESPONDENCE
Nevertheless, score results of this group (n = 26) excluded from the initial evaluation of the scoring system may be of interest. We calculated a specificity of 99% for the diagnosis of IBS in patients exceeding 44 points in the score. In the patient group suffering from both IBS and organic disease, 9 of 26 patients had >44 points. Diagnoses of organic disease were as follows: gastroduodenitis (n = 4), gastric/duodenal ulcer (n = 2), fatty liver (n = l), reflux esophagitis (n = l), and cysts of the liver (n = 1). This shows that our scoring system would have erroneously classified 2 patients of this group with clinically relevant diagnoses (ucler). In patients with obvious signs of organic disease it may not be worthwhile to use our scoring system. The aim of our study was indeed the validation of simple clinical diagnostic procedures for the exclusion of organic diseases in patients with nonspecific abdominal complaints. The findings herein in patients suffering from both IBS and organic disease may further support the accuracy of history, physical examination, and basic laboratory tests for the diagnosis of IBS. W. KRUIS Ch. THIEME Department of Internal Medicine II and Department of Medical Information Processing Statistics Klinikum Grosshadern University of Munich Munich, Federal Republic of Germany 1. Drossman DA. Diagnosis of the irritable bowel syndrome: a simple solution? Gastroenterology 1984;87:224-5. 2. Kruis W, Thieme Ch, Weinzierl M, et al. A diagnostic score for the irritable bowel syndrome: its value in the exclusion of organic disease. Gastroenterology 1984;87:1-7.
Low Molecular Weight IgM Anti-HBc in HBsAg Carriers Dear Sir: We congratulate Tsuda et al. (1) for their recent description of low molecular weight IgM anti-HBc in Japanese HBsAg carriers. Their findings are in agreement with our publication (2) of 17 American HBsAg carriers with a predominant low molecular weight IgM anti-HBc. We have now studied 90 American patients chronically infected with hepatitis B virus (manuscript in preparation). We found a low molecular weight IgM anti-HBc in only 74% of our patients, compared with 100% found by Tsuda et al. in his Japanese population. The remaining 26% of our patients showed a predominant 19s IgM anti-HBc, similar to the class of IgM anti-HBc observed in acute hepatitis B. The patients in our 19s group had documented hepatitis B virus infections for several years (mean duration of illness, 3 yr). Our data do not support the concept that testing for 7S IgM antiHBc will distinguish acute versus chronic hepatitis B virus infection in every case, at least not in the American population. Still, the question of why some chronic HBsAg carriers produce a low molecular weight form of this antibody while others produce and maintain 19s IgM anti-HBc despite years of chronic infection requires an explanation. MARIA SJOGREN, M.D. Department of Virus Diseases Walter Reed Army Institute of Research Washington, D.C. 20307-5100 STANLEY LEMON, M.D. Division of Infectious Diseases University of North Carolina Chapel Hill, North Carolina 27514
GASTROENTEROLOGY
Vol. 89, No. 1
1. Tsuda F, Naito S, Takai E, et al. Low molecular weight (75) immunoglobulin M antibody against hepatitis B core antigen in the serum for differentiating acute from persistent hepatitis B virus infection. Gastroenterology 1984;87:159-64. 2. Sjogren M, Lemon S. Low-molecular-weight IgM antibody to hepatitis B core antigen in chronic infections with hepatitis B virus. J Infect Dis 1983;148:445.
Elevated Canine Posthepatectomy Insulin Levels Dear Sir: I have two questions regarding the article by Cohen et al. (1) in a recent issue of GASTROENTEROLOGY. First, the finding of elevated insulin levels in dogs after hepatectomy is perplexing. Previous studies in rats have not only shown suppressed posthepatectomy insulin levels (z), but also a synergistic hepatotrophic effect of insulin and glucagon (3). In dogs, studies have failed to demonstrate such a synergistic effect (4). Could elevated posthepatectomy insulin levels be peculiar to the dog and prevent the insulin-glucagon synergy demonstrated in rats? A possible mechanism for this could be blunting of potential effects of glucagon on membrane hyperpolarization, as discussed in the article by Paloheimo et al. (51, by posthepatectomy-elevated insulin levels found in dogs. Insulin is a wellknown suppressant of gluconeogenesis and glycogenolysis. If hepatocellular hyperpolarization in the regenerating remnant is induced by gluconeogenesis, canine posthepatectomy hyperinsulinemia would be expected to blunt the gluconeogenic effect of glucagon. By necessity, such a hypothesis would suggest a somewhat different regenerative mechanism in the dog as opposed to the rat. Second, although Cohen’s article states that pancreatic polypeptide levels increased after partial hepatectomy, Figure 30 shows a significant decrease for both the limited and extended hepatectomy groups between 7 and 15 days postoperatively. A comment by the authors would be appreciated. CHARLES F. GHOLSON, M.D. Fellow in Gastroenterology Department of Medicine University of Colorado School Denver, Colorado 80262
of Medicine
1. Cohen
2. 3.
4.
5.
DM, Jaspen JB, Polonsky KS, Lever EG, Moosa AR. Pancreatic hormone profiles and metabolism posthepatectomy in the dog. Gastroenterology 1984;87:679-87. Leffert HL, Koch KS, Moran T, Rubalcava B. Hormonal control of rat liver regeneration. Gastroenterology 1979;76:1470-82. Bucher NLR, Swaffield MN. Regulation of hepatic regeneration in rats by synergistic action of insulin and glucagon. Proc Nat1 Acad Sci USA 1975;72:1157-60. Starzl TE, Porter KA, Kashiwagi N, Putnam CW. Portal hepatotrophic factors, diabetes mellitus and acute liver atrophy, hypertrophy and regeneration. Surg Gynecol Obstet 1975; 141:843-58. Paloheimo M, Linkola J, Lempinen M, Folke M. Time-courses of hepatocellular hyperpolarization and cyclic adenosine 3’5’monophosphate accumulation after partial hepatectomy in the rat. Gastroenterology 1984;87:639-46.
Bowel Dysfunction Dear Sir: In the article by Sandler et al. in a recent issue of GASTROENTEROLOGY, it was stated that intestinal dysfunction typical of