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Linear gastric erosion associated with diaphragmatic hernia
CORRESPONDENCE
January 1987
CA 19-9 can be detected, especially in patients with severe hepatic dysfunction or with high serum levels of bilirubin. Therefore, in these patients, CA 19-9 should be used carefully as a tumor marker. GIOACCHINO LEANDRO
SERGIOZIZZARI ONOFRIOGIUSEPPE MANGHISI Institute di Ricovero e Cum a Carattere Scientifico Specializzato in Gastroenterologia 70013~CasteIIana Grotte Bari, Italy
provide an impetus to scrutinize even more carefully the details of experimental design in the review process. MEL ALLEN, Ph.D WILLIAMC. ORR, Ph.D. Department of Clinical Physiology Presbyterian Hospital Northeast Thirteenth Street at Lincoln Boulevard Oklahoma City, Oklahoma 73104 1. Shouler P, Keighley MRB. Changes in colorectal function in severe idiopathic chronic constipation. Gastroenterology 1986:90:414-20.
1. Steinberg
2.
3.
4.
5.
6.
WM, Gelfand R, Anderson KK, et al. Comparison of the sensitivity and specificity of the CA 19-9 and carcinoembryonic antigen assays in detecting cancer of the pancreas. Gastroenterology 1986;90:343-9. Itzkowitz SH, Kim YS. New carbohydrate tumor markers. Gastroenterology 1986;90:491-4. Craxi A, Patti C, Aragona E. Serum CA 19-9 levels in patients with hepatocellular carcinoma (HCC) or cirrhosis. Ital J Gastroenterol 1985;17:288-9. Andriulli A, Gindro T, Piantino P, et al. Prospective evaluation of the diagnostic efficacy of CA 19-9 assay as a marker for gastrointestinal cancer. Digestion 1986;33:26-33. Pagliaro L, Rinaldi F, Craxi A. et al. Predictive value of clinical, laparoscopic and histologic indicators of cirrhosis. Ital J Gastroenterol 1982:14:166-8. Rittis RF, Del Villano BC. Go VLW, Herberman RB, Klug TL, Zurawski V. Initial clinical evaluation of an immunoradiometric assay for CA 19-9 using the NC1 serum bank. Int J Cancer
271
1984;33:339-45.
7. Del Favero G. Fabris C, Panucci A, et al. Carbohydrate antigen 19-9 (CA 19-9) and carcinoembryonic antigen (CEA) in pancreatic cancer: role of age and liver dysfunction. Bull Cancer (in press).
Linear Gastric Erosion Diaphragmatic Hernia
Associated
With
Dear Sir: I enjoyed reading the paper concerning linear gastric erosion associated with diaphragmatic hernia by Cameron and Higgins (I). Similar lesions have been described earlier in the thesis of M. Savary (2), as well as in the book by M. Savary and G. Miller (3). I think that these lesions are due to the sliding of the upper parts of the stomach through the hiatal ring. Increased intraabdominal pressure (coughing, vomiting, etc.) which causes sliding leads to trauma of the gastric mucosa. which leads to linear erosions. Moreover, the mucosa may be erythematous, edematous, or will show ecchymotic bleeding. In some cases of hiatal hernia and incompetent low esophageal sphincter, the fundic mucosa may prolapse into the esophagus during retching, coughing, or vomiting and may also bleed. I believe that gastric mucosal damage associated with hiatal hernia and reflux esophagitis is an indication for a Nissen repair. Dr. Med. GAUDENZ MILLER
Importance of Adequate Experimental Design
Controls in
Dear Sir: We would like to bring to your attention a serious methodologic problem in an article appearing in GASTROENTEROLOGY (1). Upon reading the abstract, it was stated that the study patients were compared to sex-matched normal volunteers. It was noted in the tabulated information that there were 18 females in one group and 21 in the other. This precludes matching by sex, if the females are to be considered. Furthermore, the ages of the constipated males were 18, 25, 28, and 33, while the ages of the normal males were 20,39,45, and 75. The authors report in the methods section that the controls were matched within each decade for age. This is not so, if the pairs were also matched by sex. In addition, the mean ages of the two groups were 28.2 (patients) and 44.9 (normals), even though the text reads 26 and 44, respectively. Since the mean ages differ by 16.7 years, the groups cannot be matched by decade, even if sex was not controlled. We considered the article, as a whole, to be informative and useful, although the conclusions reported must be called into question since age and sex, which were clearly not controlled, have been shown to affect bowel function. Thus, the study is quite misleading in the assertion of comparing constipated patients with age- and sex-matched normal controls. We bring these issues to your attention in the hope that it will
Specialarzt for Innere Medizin, F.M.H. Magen- und Darmkrankheiten Zuchwilerstrasse 43 4500 Solothurn Switzerland Cameron AJ, Higgins JA. Linear gastric erosion: a lesion associated with large diaphragmatic hernia and chronic blood loss anemia. Gastroenterology 1986;91:338-42. Savary M. La semeiologie endoscopique de l’incontinence gastrooesophagienne [extended literature). Thesis. University of Lausanne, Switzerland, 1974. Savary M, Miller G. The esophagus-handbook and atlas of endoscopy. 1978.
Reply. I wish to thank Dr. Miller for his kind comments on the paper by Dr. Higgins and myself. I regret that I was unaware of the thesis of Dr. Savary and of the book by Dr. Savary and Dr. Miller. I agree with Dr. Miller that, as noted in our paper, gastric mucosal folds at the level of the diaphragm may be swollen and red as well as exhibiting linear erosions. Inflamed folds without erosions were often seen in our study, but were not quantitated. ALAN J. CAMERON, M.D.
Mayo Clinic Rochester, Minnesota
55905
January 1987
CA 19-9 can be detected, especially in patients with severe hepatic dysfunction or with high serum levels of bilirubin. Therefore, in these patients, CA 19-9 should be used carefully as a tumor marker. GIOACCHINO LEANDRO
SERGIOZIZZARI ONOFRIOGIUSEPPE MANGHISI Institute di Ricovero e Cum a Carattere Scientifico Specializzato in Gastroenterologia 70013~CasteIIana Grotte Bari, Italy
provide an impetus to scrutinize even more carefully the details of experimental design in the review process. MEL ALLEN, Ph.D WILLIAMC. ORR, Ph.D. Department of Clinical Physiology Presbyterian Hospital Northeast Thirteenth Street at Lincoln Boulevard Oklahoma City, Oklahoma 73104 1. Shouler P, Keighley MRB. Changes in colorectal function in severe idiopathic chronic constipation. Gastroenterology 1986:90:414-20.
1. Steinberg
2.
3.
4.
5.
6.
WM, Gelfand R, Anderson KK, et al. Comparison of the sensitivity and specificity of the CA 19-9 and carcinoembryonic antigen assays in detecting cancer of the pancreas. Gastroenterology 1986;90:343-9. Itzkowitz SH, Kim YS. New carbohydrate tumor markers. Gastroenterology 1986;90:491-4. Craxi A, Patti C, Aragona E. Serum CA 19-9 levels in patients with hepatocellular carcinoma (HCC) or cirrhosis. Ital J Gastroenterol 1985;17:288-9. Andriulli A, Gindro T, Piantino P, et al. Prospective evaluation of the diagnostic efficacy of CA 19-9 assay as a marker for gastrointestinal cancer. Digestion 1986;33:26-33. Pagliaro L, Rinaldi F, Craxi A. et al. Predictive value of clinical, laparoscopic and histologic indicators of cirrhosis. Ital J Gastroenterol 1982:14:166-8. Rittis RF, Del Villano BC. Go VLW, Herberman RB, Klug TL, Zurawski V. Initial clinical evaluation of an immunoradiometric assay for CA 19-9 using the NC1 serum bank. Int J Cancer
271
1984;33:339-45.
7. Del Favero G. Fabris C, Panucci A, et al. Carbohydrate antigen 19-9 (CA 19-9) and carcinoembryonic antigen (CEA) in pancreatic cancer: role of age and liver dysfunction. Bull Cancer (in press).
Linear Gastric Erosion Diaphragmatic Hernia
Associated
With
Dear Sir: I enjoyed reading the paper concerning linear gastric erosion associated with diaphragmatic hernia by Cameron and Higgins (I). Similar lesions have been described earlier in the thesis of M. Savary (2), as well as in the book by M. Savary and G. Miller (3). I think that these lesions are due to the sliding of the upper parts of the stomach through the hiatal ring. Increased intraabdominal pressure (coughing, vomiting, etc.) which causes sliding leads to trauma of the gastric mucosa. which leads to linear erosions. Moreover, the mucosa may be erythematous, edematous, or will show ecchymotic bleeding. In some cases of hiatal hernia and incompetent low esophageal sphincter, the fundic mucosa may prolapse into the esophagus during retching, coughing, or vomiting and may also bleed. I believe that gastric mucosal damage associated with hiatal hernia and reflux esophagitis is an indication for a Nissen repair. Dr. Med. GAUDENZ MILLER
Importance of Adequate Experimental Design
Controls in
Dear Sir: We would like to bring to your attention a serious methodologic problem in an article appearing in GASTROENTEROLOGY (1). Upon reading the abstract, it was stated that the study patients were compared to sex-matched normal volunteers. It was noted in the tabulated information that there were 18 females in one group and 21 in the other. This precludes matching by sex, if the females are to be considered. Furthermore, the ages of the constipated males were 18, 25, 28, and 33, while the ages of the normal males were 20,39,45, and 75. The authors report in the methods section that the controls were matched within each decade for age. This is not so, if the pairs were also matched by sex. In addition, the mean ages of the two groups were 28.2 (patients) and 44.9 (normals), even though the text reads 26 and 44, respectively. Since the mean ages differ by 16.7 years, the groups cannot be matched by decade, even if sex was not controlled. We considered the article, as a whole, to be informative and useful, although the conclusions reported must be called into question since age and sex, which were clearly not controlled, have been shown to affect bowel function. Thus, the study is quite misleading in the assertion of comparing constipated patients with age- and sex-matched normal controls. We bring these issues to your attention in the hope that it will
Specialarzt for Innere Medizin, F.M.H. Magen- und Darmkrankheiten Zuchwilerstrasse 43 4500 Solothurn Switzerland Cameron AJ, Higgins JA. Linear gastric erosion: a lesion associated with large diaphragmatic hernia and chronic blood loss anemia. Gastroenterology 1986;91:338-42. Savary M. La semeiologie endoscopique de l’incontinence gastrooesophagienne [extended literature). Thesis. University of Lausanne, Switzerland, 1974. Savary M, Miller G. The esophagus-handbook and atlas of endoscopy. 1978.
Reply. I wish to thank Dr. Miller for his kind comments on the paper by Dr. Higgins and myself. I regret that I was unaware of the thesis of Dr. Savary and of the book by Dr. Savary and Dr. Miller. I agree with Dr. Miller that, as noted in our paper, gastric mucosal folds at the level of the diaphragm may be swollen and red as well as exhibiting linear erosions. Inflamed folds without erosions were often seen in our study, but were not quantitated. ALAN J. CAMERON, M.D.
Mayo Clinic Rochester, Minnesota
55905