- Email: [email protected]
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY AND BILIARY OBSTRUCTION
152 TSH RESPONSES TO TRH IN ENDOGENOUS DEPRESSION
SIR,-Professor Mendlewicz and colleagues (Nov. 17, p. 1079) claim that the impaired TSH response to TRH is a biological characteristic of postmenopausal females with unipolar depression, which persists after clinical recovery, whereas in premenopausal patients with bipolar depression the reduced TSH response returns to normal after clinical recovery. By contrast premenopausal unipolar and postmenopausal bipolar depressions had a normal TSH response to TRH. However, close inspection of their data shows an impaired TSH response in all their four groups of patients with depression and that the response tended to increase after clinical recovery during treatment with amitriptyline. Some years ago we’ noticed a similar increase in the TSH response to TRH after electroconvulsive treatment (ECT) in some patients with endogenous depression, and we proposed that the changes of the peak TSH response to TRH (L’1max TSH) might be of prognostic value in the indi-
patient-i.e., an unchanged L’1max TSH would predict early relapse, whereas an increase in L’1max TSH of more than 2 - 0 fLU/ml would indicate a good prognosis. We have now studied 35 patients with endogenous depression-14 of the unipolar type and 7 of the bipolar type, while in 14 patients the depression could not be classified because they were admitted to the clinic during their first or second depressive episode. 8 patients were men and 27 were postmenopausal females, aged 66 ±11 years. The patients were all euthyroid without endocrine diseases. They had been off lithium therapy for at least 6 months and off other antidepressants for
relapse rate was similar among unipolar (78%) and bipolar (71%) patients. Our results support the idea that in the individual patient with endogenous depression-regardless of the polarity-the &bgr;max TSH is impaired during depression or when antidepressive treatment has had only a symptomatic effect, and that the response returns to normal when the patient is cured and does not need further treatment. The impaired TSH response to TRH may thus reflect an underlying neuroendocrine disorder. This observation has two clinically important implicationsnamely, that long-term treatment with tricyclic antidepressants can safely be stopped when &bgr;max TSH increases2 and that we now have a reliable biochemical index for the evaluation of the curative effect of different antidepressive treatments.
Medical Department E and Psychiatric Department D
C. KIRKEGAARD N. BJØRUM
Frederiksberg Hospital, 2000 Copenhagen F, Denmark
vidual an
at
least
a
week before stimulation with 200 fLg TRH intra-
venously. Venous blood for estimation of TSH was drawn immediately before, and 20 and 60 min after the stimulation. The patients were then treated with ECT until clinical recovery, and then the TRH test was repeated. The patients were then followed up without antidepressive therapy for 6 months or until relapse (defined as reinstatment of antidepressive therapy). The figure shows a bimodal distribution of the changes in L’1max TSH after ECT-one group, with an increase in L’1max TSH 2.0 fLD/ml who all relapsed within 6 months and another group with an increase >2.0 0 uU/ml of whom all but three remained cured. 22 patients relapsed (in 2.8±1-5 months) and 13 remained cured. The two groups did not differ with regard to sex, age, or L’1max TSH before ECT and the
1.
Kirkegaard C, Nørlem N, Lauridsen UB, et al. Protirelin stimulation test and thyroid function during treatment of depression. Arch Gen Psychiat 1975; 32:1115-18.
ON WHOM DOES ECT WORK?
SIR, Your Oct. 27 editorial asks why there has been no "proper testing" of electroconvulsive therapy (ECT). Dr Revill (Nov. 10, p. 1022) has given some reasons. But I think something more fundamental is involved. Anyone treating certain severely ill patients with ECT finds it self-apparent that the is effective in individual cases, although not in all. Instead of "Is ECT effective?" a more reasonable question would be "For which patients will ECT be effective?"-and it would be very difficult to answer this in the present state of our knowledge. Nonetheless, patients must be treated as decisively as possible, even in the absence of scientifically reliable information. The crescendo of demands for proof of efficacy of ECT is uninformed and emotional. It derives from the increasing popular influence of psychodynamic concepts which reassuringly imply that talking about problems and increasing selfunderstanding is adequate for most psychiatric illnesses. On this basis ECT is regarded as irrelevant because it is alleged to succeed therapeutically, at best, by producing loss of memory of personal difficulties or, at worst, by some effect equivalent to striking the head with a hammer. The American, usage, "electroshock" therapy, does not help since it suggests that it is the shock or punishment quality that produces the therapeutic response. This line of thinking is being forced upon contemporary psychiatry which then tends to become involuntarily associated with the practices of the Dark Ages, and the theorists jubilantly come to entwine our use of physical treatments in elaborate and suffocating legal restraints, which leave patients the "freedom" to suffer their psychotic illnesses untreated, as seems to be the disturbing trend in the U.S.A.l treatment
-
Department of Psychiatry, Guy’s Hospital Medical School,
P. K. BRIDGES
London SE1 9RT
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY AND BILIARY OBSTRUCTION
SiR,—Dr Dooley and colleagues (Nov. 17, p. 1040) describe
experience of percutaneous transhepatic cholangiography (PTC) in the management of 41 patients with biliary obstruction. However, the role of endoscopic retrograde cholangiopancreatography (ERCP) has been overlooked. Our experience, and that of others, suggests that ERCP is the technique of their
2.
Relation between increase term outcome.
in &Dgr;max
TSH after ECT and
long-
Kirkegaard C, Smith E. Continuation therapy in endogenous depression controlled by changes in the TRH stimulation test. Psychol Med 1978; 8:
501-03. 1. Dunea G. Psychiatrists in restraints. Br
Med J 1979; ii: 1128-29.
153 CAUSE OF BILIARY OBSTRUCTION
Management choice in the initial investigation of patients with biliary obstruction.’-’ Over a two-year period, ERCP has been attempted in 870 patients, with successful cannulation in 699 (87%). 155 of these patients were jaundiced with the papilla seen in 150 (97%) and cannulated in 138 (89%). The diagnosis of the cause of jaundice could be made by ERCP in 139 (90%) on the basis of endoscopic appearance, duct anatomy (biliary and pancreatic), and histological and/or cytological means (see table). Cholangitis occurred in 3 patients (1.9%) within 24 h of visualisation of the obstructed duct. In 2 of these patients, associated contamination of the endoscope, which grew Pseudomonas on culture, was identified. The 3 patients with cholangitis required emergency surgical decompression. All other patients who were given prophylactic antibiotic coverage did not acquire cholangitis. No deaths or other complications occurred. On the basis of clinical examination and laboratory findings, the precise cause of extrahepatic obstruction can be correctly diagnosed in 90% of cases.4 Differentiation of medical from surgical jaundice by ultrasound has an accuracy of 77-97% in series of proven cases.5,6 Endoscopic cannulation of the ampulla was introduced as a clinical procedure in 1969. Recent reports have indicated that ERCP is well tolerated at all ages with low morbidity (3%) and mortality (0.2%).7 The morbidity of ERCP is less than that of PTC, and the most serious complication in both procedures is that due to cholangitis and septicaemia. In a randomised trial of ERCP and PTC for bileduct visualisation in jaundice, the morbidity was 2% and 7%, respectively.s In our series, the incidence of cholangitis was decreased with the use of prophylactic antibiotic cover when extrahepatic obstruction was suspected. A comparable mortality has been found with ERCP and PTC, using the Chiba needle. 1. Blumgart Lawrie
LH, Salmon PR, Cotton PB, Davies GT, Burwood R, Beales JSM, B, Skirving A, Read AE. Endoscopy and retrograde choledochopancreatography in the diagnosis of the jaundiced patient. Lancet 1972; ii:1269-73.
2. Salmon PR. Re-evaluation of endoscopic retrograde cholangiopancreatography as a diagnostic method. Clinics Gastrœnterol 1978; 7:651-66. 3. Venne JA, Jacobson JR, Silvin JE. Endoscopic cholangiography for biliary system diagnosis. Ann Intern Med 1974; 80: 61-64. 4. Schenker S, Balint J, Schiff L. Differential diagnosis of jaundice: Report of a prospective study of 61 proved cases. Am JDig Dis 1962; 7: 449-63. 5. Vicary FR, Cusick G, Shirley I, Blackwell RJ. Ultrasound and jaundice. Gut
1977; 18: 161-64. JL, Orlando RC, Mittelstaed T, Staab EV. Ultrasonography in the diagnosis of obstructive jaundice. Ann Intern Med 1978; 89:61-63. 7. Bilbao MK, Dotter CT, Lee TG, Katon RM. Complications of endoscopic 6. Lapis
retrograde cholangiopancreatography:
A
study
of 10 000
cases.
Gastrœn-
terology 1976; 70: 314-20. 8. Elias E, Hamlyn AN, Jain S, Long RG, Summerfield JA, Dick R, Sherlock S. A randomised trial of percutaneous transhepatic cholangiography with the Chiba needle versus endoscopic retrograde cholangiography for bileduct visualisation in jaundice. Gastrœnterology 1976; 71:439-43.
of
patient with bileduct obstruction.
ERCP has the added advantages of visualising the upper gastrointestinal tract, providing the means of acquiring histological and cytological material, assessing both the pancreatic and biliary ducts, and permitting transduodenal sphinctero-
tomy at the same examination if a common bileduct stone is demonstrated. Moreover, ERCP is indicated in the presence of coagulation defects. Thus, we disagree with Dooley et al. and would, if experienced personnel are available, advise the use of ERCP following grey-scale ultrasonic demonstration of biliary duct obstruction (see figure). Indications for percutaneous cholangiography would therefore include failed ERCP and biliary drainage, either externally or internally in the inoperable patient. The role of preoperative biliary drainage has not been established and awaits further controlled trials. PTC with the Chiba needle can provide internal or external biliary drainage and is an exciting advance, but further studies are needed to define its precise role in investigation and management of biliary obstruction. In our experience, ERCP is the initial technique of choice in obstructivejaundice. Toronto General
Hospital,
Toronto, Ontario, Canada MSG IL7
J. R. LAMBERT J. J. CONNON
HEPATOBILIARY IMAGING WITH 99mTc-LABELLED COMPOUNDS
SIR,-Mr Down and his colleagues (Nov. 24, p. 1049) have compared hepatobiliary radionuclide imaging with oral cholecystography and ultrasonography and confirm the superiority of the imaging technique in the diagnosis of acute cholecystitiS.1-3 I take issue, however, with the concluding sentence of the paper in which Down et al. state that the iminodiacetic acid derivative 99mTc-HIDA does not appear to have any significant advantage over 99-Tc-pyridoxylidene glutamate (9"mTc-PG), the compound they used.While at the University of Wisconsin Hospitals at Madison, I worked with both 99"Tc-PG and 99mTc-p-isopropyliminodiacetic acid (99mTcPIPIDA), and I would recommend one of the IDA derivatives instead of 99mTc-PG to anyone about to start hepatobiliary imaging with one of the 99"Tc-labelled compounds, for the fol-
lowing reasons. 1.
Davis MA, Seltzer SE, Jones B, Abbruzzese AA, Finberg HJ, Drum DE. Evaluation of hepatobiliary imaging by radionuclide scinti-
Cheng TH,
and contrast cholangiography. Radiology 1979; 133:761-67. 2. Zusmer NR, Maturo M, Stern M, Smoak WM, Janowitz WR, Gilson AJ. Complementary role of sonography and scintigraphy in hepatobiliary dis-
ography, ultrasonography
ease. J Nucl Med 1979; 20:600. 3. Weissman HS, Frank MS, Bernstein LH, Freeman LM. Rapid and accurate diagnosis of acute cholecystitis with 99mTc-HIDA cholescintigraphy. Am J Radiol 1979; 132: 523-28. 4. Pastakia B, Rao B, Lieberman LM. Selection of patients for laparoscopic biopsy using hepatobiliary agents. Radiology (in press).
SIR,-Professor Mendlewicz and colleagues (Nov. 17, p. 1079) claim that the impaired TSH response to TRH is a biological characteristic of postmenopausal females with unipolar depression, which persists after clinical recovery, whereas in premenopausal patients with bipolar depression the reduced TSH response returns to normal after clinical recovery. By contrast premenopausal unipolar and postmenopausal bipolar depressions had a normal TSH response to TRH. However, close inspection of their data shows an impaired TSH response in all their four groups of patients with depression and that the response tended to increase after clinical recovery during treatment with amitriptyline. Some years ago we’ noticed a similar increase in the TSH response to TRH after electroconvulsive treatment (ECT) in some patients with endogenous depression, and we proposed that the changes of the peak TSH response to TRH (L’1max TSH) might be of prognostic value in the indi-
patient-i.e., an unchanged L’1max TSH would predict early relapse, whereas an increase in L’1max TSH of more than 2 - 0 fLU/ml would indicate a good prognosis. We have now studied 35 patients with endogenous depression-14 of the unipolar type and 7 of the bipolar type, while in 14 patients the depression could not be classified because they were admitted to the clinic during their first or second depressive episode. 8 patients were men and 27 were postmenopausal females, aged 66 ±11 years. The patients were all euthyroid without endocrine diseases. They had been off lithium therapy for at least 6 months and off other antidepressants for
relapse rate was similar among unipolar (78%) and bipolar (71%) patients. Our results support the idea that in the individual patient with endogenous depression-regardless of the polarity-the &bgr;max TSH is impaired during depression or when antidepressive treatment has had only a symptomatic effect, and that the response returns to normal when the patient is cured and does not need further treatment. The impaired TSH response to TRH may thus reflect an underlying neuroendocrine disorder. This observation has two clinically important implicationsnamely, that long-term treatment with tricyclic antidepressants can safely be stopped when &bgr;max TSH increases2 and that we now have a reliable biochemical index for the evaluation of the curative effect of different antidepressive treatments.
Medical Department E and Psychiatric Department D
C. KIRKEGAARD N. BJØRUM
Frederiksberg Hospital, 2000 Copenhagen F, Denmark
vidual an
at
least
a
week before stimulation with 200 fLg TRH intra-
venously. Venous blood for estimation of TSH was drawn immediately before, and 20 and 60 min after the stimulation. The patients were then treated with ECT until clinical recovery, and then the TRH test was repeated. The patients were then followed up without antidepressive therapy for 6 months or until relapse (defined as reinstatment of antidepressive therapy). The figure shows a bimodal distribution of the changes in L’1max TSH after ECT-one group, with an increase in L’1max TSH 2.0 fLD/ml who all relapsed within 6 months and another group with an increase >2.0 0 uU/ml of whom all but three remained cured. 22 patients relapsed (in 2.8±1-5 months) and 13 remained cured. The two groups did not differ with regard to sex, age, or L’1max TSH before ECT and the
1.
Kirkegaard C, Nørlem N, Lauridsen UB, et al. Protirelin stimulation test and thyroid function during treatment of depression. Arch Gen Psychiat 1975; 32:1115-18.
ON WHOM DOES ECT WORK?
SIR, Your Oct. 27 editorial asks why there has been no "proper testing" of electroconvulsive therapy (ECT). Dr Revill (Nov. 10, p. 1022) has given some reasons. But I think something more fundamental is involved. Anyone treating certain severely ill patients with ECT finds it self-apparent that the is effective in individual cases, although not in all. Instead of "Is ECT effective?" a more reasonable question would be "For which patients will ECT be effective?"-and it would be very difficult to answer this in the present state of our knowledge. Nonetheless, patients must be treated as decisively as possible, even in the absence of scientifically reliable information. The crescendo of demands for proof of efficacy of ECT is uninformed and emotional. It derives from the increasing popular influence of psychodynamic concepts which reassuringly imply that talking about problems and increasing selfunderstanding is adequate for most psychiatric illnesses. On this basis ECT is regarded as irrelevant because it is alleged to succeed therapeutically, at best, by producing loss of memory of personal difficulties or, at worst, by some effect equivalent to striking the head with a hammer. The American, usage, "electroshock" therapy, does not help since it suggests that it is the shock or punishment quality that produces the therapeutic response. This line of thinking is being forced upon contemporary psychiatry which then tends to become involuntarily associated with the practices of the Dark Ages, and the theorists jubilantly come to entwine our use of physical treatments in elaborate and suffocating legal restraints, which leave patients the "freedom" to suffer their psychotic illnesses untreated, as seems to be the disturbing trend in the U.S.A.l treatment
-
Department of Psychiatry, Guy’s Hospital Medical School,
P. K. BRIDGES
London SE1 9RT
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY AND BILIARY OBSTRUCTION
SiR,—Dr Dooley and colleagues (Nov. 17, p. 1040) describe
experience of percutaneous transhepatic cholangiography (PTC) in the management of 41 patients with biliary obstruction. However, the role of endoscopic retrograde cholangiopancreatography (ERCP) has been overlooked. Our experience, and that of others, suggests that ERCP is the technique of their
2.
Relation between increase term outcome.
in &Dgr;max
TSH after ECT and
long-
Kirkegaard C, Smith E. Continuation therapy in endogenous depression controlled by changes in the TRH stimulation test. Psychol Med 1978; 8:
501-03. 1. Dunea G. Psychiatrists in restraints. Br
Med J 1979; ii: 1128-29.
153 CAUSE OF BILIARY OBSTRUCTION
Management choice in the initial investigation of patients with biliary obstruction.’-’ Over a two-year period, ERCP has been attempted in 870 patients, with successful cannulation in 699 (87%). 155 of these patients were jaundiced with the papilla seen in 150 (97%) and cannulated in 138 (89%). The diagnosis of the cause of jaundice could be made by ERCP in 139 (90%) on the basis of endoscopic appearance, duct anatomy (biliary and pancreatic), and histological and/or cytological means (see table). Cholangitis occurred in 3 patients (1.9%) within 24 h of visualisation of the obstructed duct. In 2 of these patients, associated contamination of the endoscope, which grew Pseudomonas on culture, was identified. The 3 patients with cholangitis required emergency surgical decompression. All other patients who were given prophylactic antibiotic coverage did not acquire cholangitis. No deaths or other complications occurred. On the basis of clinical examination and laboratory findings, the precise cause of extrahepatic obstruction can be correctly diagnosed in 90% of cases.4 Differentiation of medical from surgical jaundice by ultrasound has an accuracy of 77-97% in series of proven cases.5,6 Endoscopic cannulation of the ampulla was introduced as a clinical procedure in 1969. Recent reports have indicated that ERCP is well tolerated at all ages with low morbidity (3%) and mortality (0.2%).7 The morbidity of ERCP is less than that of PTC, and the most serious complication in both procedures is that due to cholangitis and septicaemia. In a randomised trial of ERCP and PTC for bileduct visualisation in jaundice, the morbidity was 2% and 7%, respectively.s In our series, the incidence of cholangitis was decreased with the use of prophylactic antibiotic cover when extrahepatic obstruction was suspected. A comparable mortality has been found with ERCP and PTC, using the Chiba needle. 1. Blumgart Lawrie
LH, Salmon PR, Cotton PB, Davies GT, Burwood R, Beales JSM, B, Skirving A, Read AE. Endoscopy and retrograde choledochopancreatography in the diagnosis of the jaundiced patient. Lancet 1972; ii:1269-73.
2. Salmon PR. Re-evaluation of endoscopic retrograde cholangiopancreatography as a diagnostic method. Clinics Gastrœnterol 1978; 7:651-66. 3. Venne JA, Jacobson JR, Silvin JE. Endoscopic cholangiography for biliary system diagnosis. Ann Intern Med 1974; 80: 61-64. 4. Schenker S, Balint J, Schiff L. Differential diagnosis of jaundice: Report of a prospective study of 61 proved cases. Am JDig Dis 1962; 7: 449-63. 5. Vicary FR, Cusick G, Shirley I, Blackwell RJ. Ultrasound and jaundice. Gut
1977; 18: 161-64. JL, Orlando RC, Mittelstaed T, Staab EV. Ultrasonography in the diagnosis of obstructive jaundice. Ann Intern Med 1978; 89:61-63. 7. Bilbao MK, Dotter CT, Lee TG, Katon RM. Complications of endoscopic 6. Lapis
retrograde cholangiopancreatography:
A
study
of 10 000
cases.
Gastrœn-
terology 1976; 70: 314-20. 8. Elias E, Hamlyn AN, Jain S, Long RG, Summerfield JA, Dick R, Sherlock S. A randomised trial of percutaneous transhepatic cholangiography with the Chiba needle versus endoscopic retrograde cholangiography for bileduct visualisation in jaundice. Gastrœnterology 1976; 71:439-43.
of
patient with bileduct obstruction.
ERCP has the added advantages of visualising the upper gastrointestinal tract, providing the means of acquiring histological and cytological material, assessing both the pancreatic and biliary ducts, and permitting transduodenal sphinctero-
tomy at the same examination if a common bileduct stone is demonstrated. Moreover, ERCP is indicated in the presence of coagulation defects. Thus, we disagree with Dooley et al. and would, if experienced personnel are available, advise the use of ERCP following grey-scale ultrasonic demonstration of biliary duct obstruction (see figure). Indications for percutaneous cholangiography would therefore include failed ERCP and biliary drainage, either externally or internally in the inoperable patient. The role of preoperative biliary drainage has not been established and awaits further controlled trials. PTC with the Chiba needle can provide internal or external biliary drainage and is an exciting advance, but further studies are needed to define its precise role in investigation and management of biliary obstruction. In our experience, ERCP is the initial technique of choice in obstructivejaundice. Toronto General
Hospital,
Toronto, Ontario, Canada MSG IL7
J. R. LAMBERT J. J. CONNON
HEPATOBILIARY IMAGING WITH 99mTc-LABELLED COMPOUNDS
SIR,-Mr Down and his colleagues (Nov. 24, p. 1049) have compared hepatobiliary radionuclide imaging with oral cholecystography and ultrasonography and confirm the superiority of the imaging technique in the diagnosis of acute cholecystitiS.1-3 I take issue, however, with the concluding sentence of the paper in which Down et al. state that the iminodiacetic acid derivative 99mTc-HIDA does not appear to have any significant advantage over 99-Tc-pyridoxylidene glutamate (9"mTc-PG), the compound they used.While at the University of Wisconsin Hospitals at Madison, I worked with both 99"Tc-PG and 99mTc-p-isopropyliminodiacetic acid (99mTcPIPIDA), and I would recommend one of the IDA derivatives instead of 99mTc-PG to anyone about to start hepatobiliary imaging with one of the 99"Tc-labelled compounds, for the fol-
lowing reasons. 1.
Davis MA, Seltzer SE, Jones B, Abbruzzese AA, Finberg HJ, Drum DE. Evaluation of hepatobiliary imaging by radionuclide scinti-
Cheng TH,
and contrast cholangiography. Radiology 1979; 133:761-67. 2. Zusmer NR, Maturo M, Stern M, Smoak WM, Janowitz WR, Gilson AJ. Complementary role of sonography and scintigraphy in hepatobiliary dis-
ography, ultrasonography
ease. J Nucl Med 1979; 20:600. 3. Weissman HS, Frank MS, Bernstein LH, Freeman LM. Rapid and accurate diagnosis of acute cholecystitis with 99mTc-HIDA cholescintigraphy. Am J Radiol 1979; 132: 523-28. 4. Pastakia B, Rao B, Lieberman LM. Selection of patients for laparoscopic biopsy using hepatobiliary agents. Radiology (in press).