Netherlands Society of Gastroenterology and Netherlands Society of Hepatology Abstracts of papers presented at the meeting held in Veldhoven on 27 and 28 October, 1994

The Neth&nds

ELSEVIER

Netherlands Journal of Medicine 46 (1995) Al-A36

Netherlands Society of Gastroenterology and Netherlands Society of Hepatology Abstracts of papers presented at the meeting held in Veldhoven on 27 and 28 October, 1994 Ammonia aad glutamine metabolism during liver failure. Studies in the rat. C.H.C. Dejong. * Department of Surgery, Biomedical Center, University lands (Thesis Abstract).

of Limburg,

Maastricht,

Nether-

Liver failure is associated with diminished hepatic urea synthesis capacity, leading to an impaired capacity to detoxify ammonia. This contributes to the development of systemic hyperammonaemia. Glutamine synthesis from equal amounts of ammonia and glutamate is the most important alternative pathway for ammonia detoxification during diminished urea synthesis. Virtually no attention has been paid to the role of several organs, capable of synthesizing glutamine, in ammonia detoxification during liver failure. The aim of this thesis was to study the net exchange of ammonia and glutamine between several organs to quantitate the relative importance of these organs in alternative ammonia detoxification during acute and chronic liver failure in rats. Acute liver ischaemia (for 2-6 h) was used as a model for acute liver failure. Portacaval shunting combined with bile duct ligation (for l-2 weeks) was validated and used as a new model for chronic liver failure and compared with the more traditional portacaval shunting. Net exchange across an organ was quantitated by measuring organ blood flow and venous-arterial concentration differences, enabling flwr calculation. Pair-feeding techniques were used during chronic liver failure to reduce nutritional influences. Muscle has long been thought to be the most important organ in the alternative ammonia detoxification pathway during liver failure, by taking up ammonia and releasing glutamine. The results presented in the thesis suggest that the role of muscle as an ammonia detoxification organ has been generally overestimated in rats. Cerebral ammonia detoxification by ammonia uptake and glutamine release during acute and chronic liver failure was

* Winner 1994.

of the Glaxo Gastro-intestinal

0300-2977/95/$09.50 SSDI

0300-2977(94)00111-l

Research Prize,

confirmed. Although quantitatively not important, this mechanism might adversely affect excitatory neurotransmission, because glutamine synthesis consumes glutamate, the most important excitatory neurotransmitter in the central nervous system. This could contribute to hepatic encephalopathy. The intestines showed enhanced ammonia release during acute liver failure, whereas glutamine uptake diminished and finally reversed to glutamine release. During chronic liver failure, intestinal ammonia release was not enhanced. Thus, in this situation the gut does not aggravate hyperammonaemia by enhancing glutamine uptake and ammonia release, as has been suggested in the literature. Also, the arterial ammonia levels during chronic liver failure are apparently mainly set by the existence of a portasystemic shunt, rather than by increased intestinal ammonia release. Both during acute and chronic liver failure the kidney reduced total ammoniagenesis ( = ammonia release in renal vein+urinary excretion) and enhanced the fraction of total renal ammoniagenesis excreted in the urine. Thereby the kidney reversed from an organ of ammonia addition to the body pools in normal rats to an organ of ammonia disposal from the body pools in rats with liver failure. This hitherto unknown beneficial (ammonia-lowering) adaptive response may be important in humans, too. The results of a long-term randomised coatreiled trial evahating eadoseopic sclero-therapy (ES) as prophylaxis for variceal bleeding. H.R. van Buuren, M. Rasch, .I. van Hattum, P.L. Batenburg, C.J.M. Bolwerk, J.J. Nicolai, S.D.J. van der Werf, J. Scherpenisse, P.J. de Vries, F. Nooteboom, SW. Schalm. Trial Secretariat, Department of Hepato-Gastroenterology, Universiiy

Hospital,

Rotter&m,

Netherlands.

We previously reported the absence of a beneficial effect of ES and propranolol on variceal bleeding risk and survival as assessed in a randomized controlled trial in which 136 patients participated. We hereby report the results of a second larger trial comparing prophylactic ES with no specific treatment (NT). From May 1986 till May 1993 166 patients

0 1995 Elsevier Science B.V. All rights reserved

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/Netherlands

Journal

(mean age 52+ 13 SD yr) entered the study and were allocated to ES (n = 83) or NT (n = 83). The major criteria for entry were active or progressive liver disease, oesophageal varices larger than Grade II according to Paquet and the absence of previous variceal bleeding. Fifty-nine percent of the patients had non-alcoholic liver disease. According to the Child-Pugh classification 55% were in Class A, 35% in Class B and 10% in Class C. Most patients (55%) had large (Grade III or IV) oesophageal varices. The patients were followed until October 1993; the mean follow-up time was 32* 25 (SD) months (range 0.1-88.5). All analyses were performed on an intention-to-treat basis. Thirteen patients allocated to ES refused this therapy. The number of patients with variceal bleeding (NT n = 23, ES n = 21) the total number of variceal bleeding episodes (NT 39, ES 32) and the number of patients with bleeding from other upper digestive sources (both groups n = 7) was comparable for both groups. During follow-up 62/166 (37%) of the patients died (NT n = 33, ES n = 29). In the ES group 1 patient died from variceal bleeding as compared to 10 in the NT group (p = 0.01, logrank test). Kaplan-Meier survival analysis showed comparable overall survival rates: 3-year survival was 61 and 62% in the NT and ES group, respectively. One patient died from a complication of prophylactic ES. In conclusion, the results of this second trial confirm the results of the previous trial, showing that prophylactic sclerotherapy had no beneficial effect on the variceal bleeding risk and on survival during a relatively long period of follow-up. Moreover, this study shows that sclerotherapy as prophylaxis for variceal bleeding is not acceptable for a significant number of patients at risk. Based on these results, sclerotherapy, as applied in this study, to prevent a first variceal bleeding episode cannot be recommended. Results of high-dose-rate intraluminal brachytherapy @DRIB) for card& and oesophageal cancer. P.J. Bus a, J.H. of Meerwaldt b, N. van Bentem a, P. Noach b. Department ’ Gastroenterology Twente, Enschede,

and b Radiotherapy, Netherlands.

Medisch

Spectrum

To evaluate the results of HDRIB in patients with cardiaand/or oesophageal cancer, all patients treated from January 1992 to January 1994 were included (41 patients; male 28, female 13). According to the stage of the disease 3 different protocols were used. (A) Only locally advanced disease ( < 5 cm) without metastasis (11 patients, med. age 65 years); 2 x 7.5 Gy HDRIB + ext. radiotherapy (ERT) 50 Gy. (B) Tumour > 5 cm, N,-,, Ma (19 pts., med. age 69 years); 10 Gy HDRIB+ ERT 30 Gy. (C) Patients with limited life expectancy (11 pts., med. age 63.5 years); 15 Gy HDRIB. Results: Mean survival duration in Groups A, B and C was respectively 280, 235 and 115 days, with a l-year survival of 36, 27 and 0%. Irrespective of group, 30% of the patients needed dilatation. Histological subtype had no influence on results. Total dose of radiotherapy correlated positively with survival time, but length of the tumour negatively. Complications (stenosis 20%, ulceration 25%) were independent of dose.

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Conclusion: HDRIB gives effective palliation by restoring food passage. It is a safe and well-tolerated procedure. Repeated dilatations can be avoided.

Omeprazole increases the eftkacy of triple therapy. Results of a randomised prospective study of triple therapy with or without omeprazole for the eradication of Heiicobocter pylori. W.A. de Boer, W.M.M. Driessen. Department of Internal Medicine,

Sint Joseph

Ziekenhuis,

Veldhouen,

Netherlands.

Successful eradication of H. pylori (HP) cures peptic ulcer disease. There is ongoing controversy as to the best treatment strategy for eradicating HP. We investigated whether omeprazole should be added to triple therapy (‘IT). 108 Consecutive patients with chronic peptic ulcer disease, referred to us between June 1993 and April 1994, with biopsy-proven HP infection but without active ulceration were randomised to either: omeprazole 20 mg b.d. days l-10, colloidal bismuth subcitrate 120 mg qid days 4-10, tetracycline 500 mg q.i.d. days 4-10 and metronidazole 500 mg t.i.d. days 4-10 (Group I, n = 54); or the same TT without omeprazole from day l-7 (Group II, n = 54). 4-6 weeks after the end of treatment a second endoscopy was performed with 10 biopsies; 2 (antrum) for CLO-test, 2 (antrum) for culture and 6 (2 antrum, 2 corpus, 2 cardia) for histology (Giemsa stain). A patient was considered eradicated if all 3 tests were negative for HP. Follow-up was achieved in all 108 patients, 2 refused endoscopy, but had 14C-breath test (1 positive, 1 negative) instead. Altogether 53/54 (98.1%) patients in Group 1(95% CI: 88.9-100%) were eradicated versus 45/54 (83.3%) patients in Group II (95% CI: 67.0-95.2%) (p = 0.008) Pre-treatment sensitivity testing was performed in 65 patients. 60 were metronidazole-sensitive; of these 27/28 (96.4%) were eradicated in Group I versus 29/32 (90.6%) in Group II (NS). In Group I 3/3 (100%) with a metronidazole-resistant strain were eradicated versus O/2 (0%) in Group II (p = 0.025). Side-effects were mild and did not interfere with compliance. 105/108 (97.2%) patients finished the complete treatment. Gastro-intestinal side-effects were milder in Group I. One patient developed pseudomembranous colitis. Conclusion: 1 week of quadruple therapy is superior to 1 week of TT. At present, it is the best treatment for HP-associated peptic ulcers. It combines excellent efficacy ( > 95%) independent of metronidazole resistance, good relief of ulcer pain and good tolerability. Efficacy of pantoprazole, as compared to omeprazole, in duodenal ulcer - European Multicenter study. J.A. Beker a, G. Bianchi Porro b, G. Devis ‘, H. Gouerou d, C. Maier e. a Hospital Sint Antoniushove, b Ospedale Sacco, Milan, Italy; huis, Brussels, Belgium; d HGpital Gulden, Constance, Germany.

Leidschendam, ’ VUB-Akademisch Morvan, Brest,

Netherlands; ZiekenFrance; e Byk

Pantoprazole, a recently developed benzimidazole derivative, induces a pronounced and long-lasting inhibition of gastric acid secretion by selectively binding to parietal cell Hf/Kf-ATPase. The absence of interaction with the cytochrome P450 enzyme system at therapeutic doses and the

Abstracts/Netherlands

Journal

stability of pantoprazole in neutral environment represent important clinically relevant advantages. This randomized, double-blind study compared the efficacy of pantoprazole (Pan) 40 mg s.i.d. and omperazole (Om) 20 mg s.i.d. in patients with acute duodenal ulcer (1 or 2 DU, diameter 5-20 mm). Endoscopies were performed prior to the treatment and after 2 weeks. If the ulcer was not healed, treatment was prolonged and a final endoscopy performed at 4 weeks. Complete epithelialization of the ulcer was defined as the primary efficacy criterion of the study. Of the 270 enroled patients, 255 completed the study per protocol (Pan = 124, age 20-87 years, median 45 years; Om = 131, age 22-85 years, median 44 years). Ulcer healing after 2 weeks was achieved in 88 (71%) patients treated with Pan and in 85 (64.9%) patients treated with Om (95% confidence interval for the difference: - 5.35% to + 17.51%, p = 0.315, Chochran-Mantel/Haenszel method). After 4 weeks ulcer healing was achieved in 118 (95.2%) and 117 (89.3%) patients, respectively (95% confidence interval: -0.65% to + 12.35%, p = 0.090). Among patients with pain prior to treatment, 87 of 108 (80.6%) treated with Pan and 98 of 120 (81.7%) treated with Om were pain-free after 2 weeks (p = 0.866, Fisher’s exact test). Incidence of adverse events was comparable in both groups (Pan 7.4%, Om 8.4%). Four serious adverse events led to study discontinuation, 3 in the Om group (angina, hypertension, vertigo; classified by the investigators as possibly treatment-related) and 1 in the Pan group (gastrointestinal haemorrhage; classified as not related to treatment). These data indicate that pantoprazole is a highly effective and well-tolerated treatment for acute duodenal ulcer with respect to both ulcer healing and pain relief.

Gastric

lymphoma:

can treatment

adequacy

explain

outcome?

H. Boot a, P. van Heerde b, D. de Jong b, R. Somers ‘, J.V.M. Burgers ‘, F. van Coevorden e, B.G. Taal a. Departments of ’ Gastroenterology, b Pathology, ’ Medical Oncology, d Radiotherapy and e Surgery of the Netherlands Cancer Institute / Antoni van Leeuwenhoek Ziekenhuis, Amsterdam, Netherlands.

Gastric lymphoma (GL) arises from mucosa-associated lymphoid tissue (MALT). Prognosis depends on patient-related factors, tumour-stage/bulk, histological grade and treatment. Achievement of complete remission is the basis of long-term survival. Surgery, chemo- and radiotherapy can all be used to treat GL. Based on literature data, we designed a treatment model comparing adequate and non-adequate treatment related to tumour stage (Ann Arbor system) and histological grade (low- and high-grade MALT-lymphoma: lg-hg). In localized GL (Stage I + II,) radiotherapy or gastric resection with adjuvant radio- or chemotherapy was considered adequate. In bulky disease and advanced GL (Stage II, -IV), treatment should include chemotherapy. Anthracyclines should be included in high-grade GL. We retrospectively analysed the prognostic value of our treatment model in 139 patients treated in the NCI/AvL during 1978-1992. Localized GL was seen in 104 patients (51 lg, 53 hg) and advanced GL in 35 patients (13 lg, 22 hg).

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Adequate treatment was not related to sex or tumour stage, but inadequate therapy was given more often with increasing age ( < 50 years 4%; 50-65 years 17%; > 65 years 44%), high-grade GL (lg, 13%; hg, 37%) and bulky disease (non-bulky, 13%; bulky, 56%). Inadequate treatment was given because of advanced age, fear of complications of chemotherapy and underestimation of stage more often in patients with high-grade GL (4 x in lg and 30 x in hg GL). Administration of adequate treatment resulted in a CR-rate of 99% in Stage I-II, and 73% in Stage II,-IV versus 63% and 44% after inadequate treatment. NHL-related death was increased after indequate treatment both in low-grade (13-63%) and highgrade GL (34-54%). Non-NHL-related death was 16% and was independent of lymphoma- and treatment-related factors. Almost 50% was due to another malignancy. Conclusions: (1) Histological grade, bulky disease and age influenced the administration of adeqate treatment in GL. (2) After adequate treatment a high rate of CR and survival can be obtained. (3) Adequate treatment is the cornerstone of long-term survival in GL.

Pancreatic gas&e&my

enzyme supplementation and steaturrhoea.

in

patients

with

total

R. Bragelmann ‘, U. Armbrecht b, D. Rosemeyer ‘, B. Schneider d, W. Zilly e, R.W. Stockbriigger a. a Department of Gastroenterology, University Hospital, Maastricht, Kissingen, Germany; many; d Institut fiir Hannover, Germany; many.

Netherlands; b Marbachtalklinik, Bad ’ Klinik Rosenberg, Bad Driburg, GerBiometrie der Medizinischen Hochschule, ’ Hartwaldklinik, Bad Briickenau, Ger-

To evaluate the effect of pancreatic enzyme supplementation after total gastrectomy 52 patients [38 m, 14 f; mean age 57.5 (SEM 1.61 years] operated for malignant disease 393 + 68 days previously and free from recurrence and/or metastasis, received 9 times 3 g of Pankreon granulat (Lipase 36000, Amylase 27000, Protease 2400 FIP per 3 g) or placebo daily during 14 days in a double-blind, randomized, parallel trial. Subjective symptoms and objective parameters of malassimilation were evaluated. Both groups were comparable concerning demographic and laboratory parameters. In the verum group 8 patients had a continuous duodenal transit after jejunum interposition (Longmire) compared with 2 in the placebo group ( p = 0.08). Patients on enzyme therapy felt overall better at the end of the treatment period, but this was not reflected in any of the specific symptom scores. No differences were noted between the groups regarding faecal frequency and faecal consistency. Faecal fat excretion marginally increased in the placebo group and decreased in the verum group (ns). There was no significant difference in body weight before and after treatment in either group. There was a significant difference in the amount of kcal per kg body weight necessary to maintain body weight (verum 36.8; placebo 42.2; p = 0.022). Concfusions: After total gastrectomy, pancreatic enzyme supplementation increases overall well-being of the patient and also improves nutrient assimilation. It should therefore be

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tried in patients with clinical symptoms of malassimilation after such an operation. Local resection (LR) versus the Wbipple procedure (NT) for villous adenoma of the ampulla of Vater. D.L. Cahen a, E.A.J. Rauws b, L.Th. de Wit a, Th.M. van Gulik a, H. Obertop a, D.J. Gouma a. Departments of ’ Surgery and b Gastroenterology, Academic

Medical

Centre,

Amsterdam,

Netherlands.

Treatment of villous adenoma of the ampulla of Vater is complicated by difficult preoperative staging, a high recurrence rate and malignant potential. The aim of this study was to assess the accuracy of preoperative staging by endoscopic biopsy and endosonography, and to compare the results of local resection (LR) and the Whipple procedure (WP). During 1985-1994, 20 patients were surgically treated for ampullary villous adenoma, diagnosed by endoscopic biopsy. Biopsies showed moderate or severe dysplasia in 9 patients, and no malignancy. Endosonography was used for staging in 16 patients. Selection for the procedure was according to the surgeon’s preference. LR was performed in 10 patients and 10 patients underwent WP. The two groups did not differ in age, clinical presentation, surgical risk factors and histological diagnosis. One patient died after a WP. Re-laparotomy was required for complications in 7 patients, 2 after LR and 5 after WP. The mean hospital stay differed significantly: 18 days for LR and 36 for WP (p = 0.005). One patient had late complications after LR (pancreatitis) versus 5 after WP (one ileus, exocrine/endocrine pancreas insufficiency in 4). The final pathological diagnosis was adenocarcinoma for 6 patients (3 in each group). LR was microscopically irradical in 5 patients (3 with carcinoma). Additional treatment for these patients was WP, radiotherapy, vulgarization and laser treatment respectively. Endosonography reported depth of invasion in 11 patients; 5 false positive, 4 false negative and 2 correctly negative. Lymphnodes were reported in 8 patients; 5 false positive for metastasis and 3 correctly negative. The duration of follow-up ranged from 4-105 months (median 35 months). One patient died 15 months after irradical LR possibly because of recurrent disease. Three patients died of other causes without evidence of tumour recurrence. For the remaining 15 patients (7 LR and 8 WP) no local recurrences were observed on follow-up (biopsy). Conclusion: Preoperative staging was inaccurate; adenocarcinoma was found in 30%. WP was associated with more complications and longer hospital stay. Local resection was microscopically irradical in 50%. Recurrence was lower (10%) than expected. The incidence of severe osteopenic bone disease in coeliac disease. A.J.M. Rijnders a, C.J.J. Mulder a, J.C. Netelenbos b. a Hospital Rijnstate, terdam, Netherlands.

Arnhem,

‘Free

University

Hospital,

Ams-

Coeliac disease may present with calcium malabsorption and predispose to the development of osteopenia and osteoporosis. The aim of this study was to determine the incidence of severe. bone loss in a population of Dutch female coeliacs.

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Bone mineral density (BMD) measurements were obtained in 75 adult, otherwise healthy, subsequent female coeliacs, regardless of duration of disease and length and quality of dietary measurements. The mean age was 51.6 + 5.75 years, ranging from 28 to 78 years. An arbitrary classification was made between age groups 20-45 (n = 23, mean 39.1) and 46-78 years (n = 52, mean 57.4). BMD was measured at the lumbar spine (L2-4), the femoral neck (FN) and the greater trochanter (Troth) of the left femur, using a Norland XR-26 X-ray densitometer. Measurements were expressed as the difference in standard deviations (SD) from the age/sex/ weight-matched mean (Z-score, database of normals, Norland). Severe bone loss was defined as Z-values below - 1 SD. BMD was moderately lower than the mean at all three sites (LWK -0.3, FN -0.01, Troth -0.66) and relatively lowest in the older age group. Z-values below - 1 SD at one or more sites were found in 29/75 patients (39%) and differed between the age groups (30 and 43% respectively). In the younger age group spine and FN measurements showed less frequently (9 and 17% resp.) severe bone loss compared to the Troth (30%). Spine and FN involvement in the older age group occurred more frequently (29 and 20% resp.) but also in this group Troth measurements were frequently abnormal (35%). Conclusions: (1) The incidence of severe osteopenic bone disease in this random population of female Dutch coeliacs is high. (2) At younger age bone loss at FN and spinal measurement sites is relatively preserved. (3) Routine measurement of BMD in female coeliacs seems indicated.

Validation of the sugar absorption test for use in clinical practic& J.J. Uil a, R.M. van Elburg b, F.M. van Overbeek b, C.J.J. Mulder a, H.S.A. Heymans b. ‘Department of Gastroenterology, terology,

Rijnstate Hospital, Arnhem; Beatrix Children S Hospital,

b Department Groningen,

of GastroenNetherlands

In clinical practice, use of intestinal permeability tests, such as the sugar absorption test (SAT), is hampered by the lack of reference values, repeatability of the test and laboratory assay. In the SAT, a hyperosmolar solution of lactulose, mannitol and sucrose was given to the fasting subject after which the lactulose/mannitol ratio was measured in 5-hour urine. For reference values, the SAT was performed in 40 adults and 30 children. For repeatability of the test, the SAT was performed twice with an interval of 1 day in 15 adults and 14 children. For repeatability of the assay, urine samples of 26 unselected patients were analyzed in both participating hospitals (Arnhem/Groningen). Reference values in mmol/mol creatinine (meanf2SD): For children: mannitol 1087 (3981776); lactulose 46.4 (o-103.6). Lactulose/mannitol ratio 0.043 (o-0.089). For adults: mannitol 606 (231-981); lactulose 23.2 (O-58.7). Lactulose/mannitol ratio 0.038 (o-0.089). Repeatability of the test was good: slope 0.83 (95% CI 0.57, 1.15), intercept 0.005 (95% CI -0.004, 0.010). Repeatability of the laboratoty assay was excellent: slope 1.01 (95% CI 0.87, 1.09), intercept 0.002 (95% CI - 0.005, 0.010).

Abstracts

/Netherlands

Journal

Conclusions: Validation makes the SAT useful as a simple, non-invasive intestinal permeability test for clinical practice. The SAT can be used as a diagnostic test for enteropathy of different aetiologies and evaluation of therapeutic interventions. Studies with the SAT may clarify the role of intestinal permeability in the pathophysiology of various gastrointestinal diseases.

Oral budesonide versus prednisolone for the treatment of active ihcaecal Crobn’s disease, a double-blind controlled t&d. A. v.d. Sluys Veer, G. Griffioen, H.W. Verspaget, C.B.H.W. Lamers. Department of Gastroenterology-Hepatology,

University

Hospital,

Lkden,

Netherlands.

A lo-week double-blind trial comparing the efficacy and safety of oral budesonide (9 mg/dayl in a controlled ileum release (CIR) capsule with oral prednisolone (40 mg/dayl was performed in 26 patients with active (CDAI > 2001 ileocaecal Crohn’s disease as part of a European multicentre trial. Both drugs were tapered during the study; budesonide to 6 mg after 8 weeks and prednisolone after 2 weeks gradually to 5 mg during the last week. Disease activity was calculated with the CDAI (Best) and the AI (van Hees Index). Cortisol in serum (nmol/l) was determined by a RIA. After verbal informed consent 14 patients were treated with budesonide and 12 patients with prednisolone. The groups were well matched, according to disease activity. During the trial 2 patients, 1 from each group, were withdrawn because of deterioration of disease. After 10 weeks remission (CDAI I 150) was achieved in 8 (57%) patients treated with budesonide as compared to 10 (83%) in the prednisolone group (the difference is not statistically significant). The CDAI decreased significantly in 10 weeks in both groups, resp. from 243 f 13 to 137 + 17 (mean f SE) in the budesonide group (p < 0.011, and from’258+ 17 to 93 f 16 in the prednisolone group (p < 0.01). The Al showed initially (2 weeks) a significant (p < 0.01) decrease from 175 + 5 to 151&-3 in the budesonide group and from 177+ 12 to 154 f 11 in the prednisolone group. After 10 weeks the AI was increased in the budesonide group to 166+ 7 but remained almost the same in the prednisolone group (149 f 7, p < 0.05). No serious side-effects occurred in either arm. After 2 and 4 weeks serum cortisol was significantly suppressed in patients treated with prednisolone (resp. llO+ 30 and 130 f 50 vs. 58Ok60, p < 0.01) and less in the budesonide group (resp. 390 * 70 and 340 f 80 vs. 570 f 90, p < 0.05). The serum cortisol from the budesonide group was significantly less suppressed than serum cortisol during treatment with prednisolone (p < 0.05). We conclude that budesonide CIR is effective in active ileocaecal Crohn’s disease, although prednisolone gives more improvement in the CDAI and AI. Budesonide CIR gives significantly less adrenal gland suppression than prednisolone in the doses used in this trial. Uitrasonqrapby in tbe diagnosis of abdominal tuberculosis. J.E.A. Portielje a, P.N.H. Lohle b, R.J. de Knegt a, S.D.J. van

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46 (1995)

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der Werf a, J.B.C.M. Puylaert b. Departments Medicine and Netherlands.

b Radiology,

Westeinde

Hospital,

of The

a Internal Hague>

An increasing incidence of tuberculosis has been observed in Western counties. Immigration from endemic areas and the AIDS epidemic have been implicated as underlying factors. Yet clinical diagnosis of tuberculosis may be difficult to establish in adbominal tuberculosis (AT). A final diagnosis of AT is often made after considerable delay using invasive methods such as laparoscopy or laparotomy. We assessed the role of ultrasonography (USi as a non-invasive modality to diagnose AT according to accepted criteria. US findings and biopsy results were retrospectively and partly prospectively reviewed from all patients in our hospital given a diagnosis of AT between 1987 and 1994. Inclusion in this series required bacteriologically confirmed disease or compatible clinical and pathological findings with a favourable response to antituberculous drug treatment. Out of 19 patients identified, AT had been indicated as US diagnosis in 15 during initial US. Of these 15, 9 cases presented with an ascitic type of peritonitis, 3 with a combination of enlarged lymph nodes and bowel wall thickening and 3 with enlarged lymph nodes only. In 9 of these 15 patients US-guided biopsies of lymph nodes or thickened omentum yielded bacteriological proof of AT within only 2 days. In 2 of the 4 patients in whom AT was not suspected initially from US images, US-guided biopsies yielded the diagnosis of AT. In the other 2 patients US failed to reveal the correct diagnosis. Conclusions: US appears valuable in the diagnosis of AT by reducing diagnostic delay considerably and by avoiding unnecessary laparoscopy or laparotomy. Anorectal pathology in HIV-infected patients and its relation to immune status and survival time. E.C.J. Consten ‘, J.F.M. Slors a, H.J. Noten a, S.A. Danner b, J.J.B. van Lanschot ‘, a Departments of Surgery Academic Medical Centre,

and b Internal Medicine, Amsterdam, Netherlands.

AIDS

Unit,

The anorectum is commonly involved in HIV-infected and AIDS patients. The aim of this study was to determine the spectrum of anorectal disease, its surgical treatment, and the treatment results. Medical records of all HIV-infected patients with anorectal pathology requiring surgical treatment from January 1984 to January 1994 were retrospectively reviewed. Patients were divided into 5 different groups with respect to type of anorectal lesion. Group A consisted of patients with common anorectal disease; Group B condylomata acuminata; Group C perianal sepsis; Group D anorectal ulceration: and in Group E patients suffered from malignancies. During the study period 1117 HIV-positive patients had been admitted to the Academic Medical Centre of the University of Amsterdam; 748 of those patients (67%) had been defined as having AIDS according to the CDC case definition. A total of 355 patients (32%) underwent general surgical treatment. Eighty-three patients (7.4%) needed 205 surgical consultations for 170 anorectal lesions. Fifty-six of these patients were found to have multiple anorectal pathology.

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Surgical treatment of these 170 lesions consisted of conservative measures in 13%, whereas 87% needed operative intervention. Operative intervention resulted in uncomplicated wound healing and symptomatic relief in 55% of operations and 59% of patients. Adequate wound healing without relief of symptoms was found in 24% of operations and 24% of patients. Wound healing disorders without symptomatic relief were found in 21% of operations and 17% of patients. Analysis of perioperative CD4+-lymphocyte counts in patients with or without disturbed wound healing (mean: 104x 106/1 and 310X 106/1 resp.) suggests that immune status is worse in patients with wound healing disorders (RR = 2.4-6.9). Fiftytwo of the 83 patients (63%) had died at the end of the study period. In these patients mean survival time was highest (40 months) after surgery for common anal pathology and lowest (12 months) for ulcers and malignancies. Conclusion: The incidence of anorectal pathology in HIVinfected patients is high. The spectrum of anorectal disease is complex. Immune status, wound healing disorders and postoperative survival time seem to be related to the type of anorectal lesion. Although wound healing disorders were found quite frequently (17% of patients), surgical intervention can be a safe and effective treatment modality. In the majority of patients (59%) this will result in symptomatic relief and undisturbed wound healing. Detection of HBV-DNA: a comparison of methods. M. Damen a, H.L. Zaayer ‘, F. ter Borg b, H.T.M. Cuypers a, P.N. Lelie a. a Central Laboratory of the Netherland Red Cross Blood Centre,

Transfusion Amsterdam,

Service, Amsterdam, Netherlands.

b Academic

Medical

We compared the performance of four assays for detection of hepatitis B virus (HBV) DNA: the polymerase chain reaction (PCR); the branched DNA hybridization assay (Chiron); and two hybridization assays, employing liquid hybridization (Abbott) and direct membrane hybridization (MH). We tested 109 random hepatitis B surface (HBsAg) +ve patient samples (30 samples HBeAg +ve and 79 samples HBeAg -ve>. The numbers and percentages which tested HBV-DNA positive are depicted below. HBsAg +ve (n = 109) PCR bDNA Abbott MH

HBeAg +ve

HBeAg -ve

(n = 30)

(n = 79)

42 (39%) 30 (28%)

30 (100%) 22 (73%) 20 (67%)

20 (25%)

18 (17%)

12 (40%)

101 (93%)

71(90%) 10 (13%) 6

(8%)

For further evaluation of the assays we used 2 Eurohep standard plasma specimens containing approximately 2.5 X lo9 HBV-DNA molecules per ml. By testing dilutions prepared from the Eurohep HBV-DNA standards, the detection limits of the assays appeared to be the following: PCR, 2.5X 10’ HBV genomes (gns)/ml; Chiron, 2.5 X lo6 gns/ml; Abbott and MH, 2.5~10’ gns/ml. Quantitative test results of the hybridization assays maximally differed by a factor of 19 from the Eurohep standard plasma.

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46 (1995)

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Conclusions: In 90% of the HBsAg +ve, HBeAg -ve samples and in 100% of the HBsAg +ve, HBeAg +ve samples, HBV-DNA was detectable with PCR. Quantitative hybridization assays are only suitable for monitoring relatively high levels of HBV-DNA. Further standardization of quantitative HBV-DNA assays is necessary to facilitate comparison of HBV-DNA levels.

Replacement of RIBA- by RIBA- improves confirmation of HCV infection. M. Damen, H.L. Zaayer, H.T.M. Cuypers, H.W. Reesink, P.N. Lelie. Central Laboratory of the Netherland Red Cross Blood lands.

Transfusion

Service,

Amsterdam,

Nether-

Serum samples reactive in HCV-EIA antibody assays need to be tested in confirmatory antibody assays to rule out false-positive test results. We compared the performance of 2 confirmatory antibody assays: RIBAand RIBA(Ortho/Chiron). In period A, from March 1991 to March 1993, we tested in our confirmatory laboratory samples of 2091 donors and patients with RIBA-2. In period B, from March 1993 till May 1994, we tested samples of 750 donors and patients with RIBA-3. All samples were sent to our laboratory because of reactivity in an HCV-EIA (various brands). All samples were tested in the cDNA-PCR for detection of HCV-RNA. The RIBAand RIBA- test results among HCV-RNA + ve subjects are depicted below. RIBA test applied

PCR + ve RIBA test result subjects +ve ind.

RIBARIBA-

n = 593 n = 220

553 (93.3%) 220 (99.5%)

40 (6.7%) 1(0.5%)

-ve * 0 * 0

*p < 0.001

In RIBAthe C22 and Cl00 recombinant antigens were replaced by synthetic peptides. The reactivity of the individual antigens in PCR +ve subjects for RIBA- and RIBA- respectively was as follows: C22,96%/95%; C33c, 94%/99%; ClOO, 63%/88%; 5-l-l (only RIBA-2) 55%; NS5 (only RIBA-3) 68%. The newly added antigen NS5 in RIBA- never contributed to an enhanced sensitivity of RIBA- in our study. Furthermore, isolated NS5 reactivity was observed only among HCV-RNA - ve subjects. Conclusions: The sensitivity of the RIBAis close to 100% because of the improved sensitivity of the C33c and Cl00 antigen. Indeterminate reactivity among HCV-RNA+ve subjects decreased to 0.5% in RIBA3. The NS5 antigen was found to be the least sensitive antigen in RIBA-3. Single NS5 reactivity was only observed in HCV-RNA -ve individuals, suggesting false-positive reactivity. Infectivity of anti-HCV ELISA-positive blood products. H. Vrielink a, C.L. van der Poe1 a, H.W. Reesink a,b, E. Scholten a, M.H.J. van Oers ‘. ‘Red Cross Blood Bank Amsb Central Laboratory of the Netherlands terdam, Amsterdam, Red Cross Blood Transfusion Service, Amsterdam, ‘Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands.

Abstracts/Netherlands

Journal

The aim of the study was to establish the infectivity of anti-HCV ELISA-positive blood products transfused in the past from (A) cDNA-PCR and/or RIBA-2+ve donors, and (B) cDNA-PCR-ve and RIBA- indeterminate or RIBA-ve donors. Donors and recipients of implicated blood products were enroled in a look-back programme. Stored serum samples of Group A donors, before they tested anti-HCV + ve, were also investigated. Of 127/270 (47%) recipients who received blood products from 22 Group A donors and of 455/481 (95%) recipients from 105 Group B donors information could be obtained. Of 127 Group A recipients, 57 (45%) had died, 31 (24%) could not be traced, and 39 (31%) were available for testing. Of these 39 recipients, 7 (18%) had an independent risk factor for HCV infection and were excluded; of the remaining 32, 26 (81%) were RIBA- and/or cDNAPCR +ve. Of 455 Group B recipients, 264 (58%) had died, 43 (9%) could not be traced, and 148 (33%) were available for testing. Of these 148 recipients, 8 (5%) had an independent risk factor for HCV infection and were excluded; of the remaining 140, none tested RIBA- and/or cDNA-PCR+ve. All sera of previous donations (n = 172) of Group A donors tested anti-HCV + ve. Conclusions: 81% recipients of blood products from cDNA-PCR/RIBA-2 +ve donors were infected with HCV, whereas recipients of blood products from anti-HCV ELISA + ve/cDNA-PCR - ve/RIBA-2 - ve (or indeterminate) donors were not infected. What options are left when hepatitis C does not respond to hsterferon? Piacebo-controkd Benelux multicentre retreatmeat trial on ribavirin monotherapy versus combination with interferon. J.T. Brouwer ‘, F. Nevens b, P. Michielsen ‘, M.L.

Hautekeete d, R.A.F.M. Chamuleau e, M. Adler f, J. Delwaide s, R.A. Heijtink a, S.W. Schalm a and the Benelux Study Group on Hepatitis C treatment. University Hospitals of a Rotterdam, b Leuven, ’ Antwerp, dam, f Brussels (Erasme), g Li2ge.

d Brussels

(Free),

’ Amster-

During treatment of hepatitis C with interferon (IFN) about 40% of patients are completely non-responsive; these patients are not likely to profit from higher dosages or longer duration of IFN alone. To test the hypothesis that they might profit from drugs acting on a different antiviral level, we randomly allocated 65 patients to either 24 weeks of placebo monotherapy, ribavirin monotherapy (1200 mg/day) or to combination of ribavirin (1200 mg/day) and IFNa2b (3 MU TIW). All 65 patients had been treated with 3-6 MU of IFN-a2b TIW for at least 24 weeks, and none sustained ALT normalization or HCV-RNA disappearance during therapy. At present 44 patients are evaluable with at least 24 weeks follow-up after treatment. Out of 29 with monotherapy (either ribavirin or placebo) only 2 temporarily normalized ALT levels (7%, 95% CI l-23%). In contrast, 13 out of 15 patients on the combination normalized their ALT’s during therapy (87%, CI 60-98%, p = O.OOO),and 3 had a sustained response during follow-up (20%, CI 4-48%, p = 0.03), with viral clearance in two. Side-effects were restricted to flu-like symptoms and to moderate haemolytic anaemia.

of Medicine

46 (1995)

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Conclusion: Combination of IFNa2b and ribavirin is able to induce biochemical remission in most HCV patients who had a complete non-response to standard monotherapy with IFN. The proportion of sustained response might be further increased by modification of dosage and duration of the combination. Bile acids suppress the secretion of very-tow-density tein by human hepatocytes in primary cnlture.

Havinga, H.J. Verkade,

R.J. Vonk, F.

Institute for Drug Studies, Laboratory Metabolism, Department of Paediatrics, Groningen, Netherlands.

lipoproY. Lin, R. Kuipers. Groningen of Nutrition and Univer~sity Hospital,

The existence of a relationship between bile acid (BA) and triglyceride (TG) metabolism in humans, for instance reflected by the increase in serum TG during BA sequestration, is well-established. The mechanism(s) of the interaction between BA and TG metabolism, however, has remained largely unclear. We have studied the effects of BA on the secretion of VLDL-associated TG and apolipoprotein (apo) B in human hepatocytes in primary culture. The incorporation of [3H]glycerol into cell-associated and secreted TG as well as the amounts of apo-B (Western blot) were determined after incubation for l-3 h in medium containing 1.0 mM oleic acid, 0.25 mM BSA and varying amounts of BA. In 24-h cultured human hepatocytes, physiological (i.e. portal) concentrations of taurocholic acid (TC, lo-200 PM) suppressed [3H]TG secretion to a variable extent (i.e. by O-54%) in the different cell preparations used (n = 4); the degree of inhibition highly correlated (r = 0.79, p < 0.01) with equilibrium TC uptake by the cells. APO-B secretion was inhibited to a similar extent as L3H] TG secretion (r = 0.95, p < 0.01). No effects on intracellular apoB, [3Hl TG or TG mass were observed nor did TC affect protein synthesis, albumin secretion or LDH release. These results indicate that BA interfere with the assembly and/or secretion of the VLDL particles at an intracellular level, suggesting a novel physiological function of the enterohepatic circulation of BA in the regulation of serum lipid levels. The cholesterol content of choIesterol/phospholipid determines the susceptibility to bile salt damage.

vesicles

B.J.M. van de Heijning a,* , A.M.W.C. van den Broek a, K.J. van Erpecum a, W. Renooij b, G.P. van Berge Henegouwen ‘. Departments of a Gastroenterology pital, Utrecht, Netherlands.

and ’ Surgery,

Unir~ersity

Hos-

We previously showed that addition of bile salts to cholesterol/phospholipid vesicles, prepared from model and human gallbladder bile by ultracentrifugation, induced a rise in cholesterol/phospholipid (c/p) ratio, followed by cholesterol precipitation, which is an important step in the pathogenesis of cholesterol gallstones (Van de Heijning et al. J. Lipid Res. 1994;35:1002-1011). To investigate how vesicular composition influences susceptibility to bile salt damage, we prepared by sonication cholesterol/phospholipid vesicles with varying cholesterol (2.5-15 mM) and phospholipid content (2.5-30 mM), and with a c/p ratio of 0.20-1.70. We examined the

A8

Abstracts

/Netherlands

Journal

effect of addition of increasing concentrations (1.5-100 mM) of tauroursodeoxycholate (TUDC), taurocholate (TC), and taurodeoxycholate (TDC) on vesicle integrity as assessed by the change in optical absorbance at 340 nm up to 1 h. Absorption of the bile salt-vesicle mixture decreased, i.e. vesicles dissolved, dependent on bile salt concentration and increasing hydrophobicity: TUDC < TC < TDC. Moreover, bile-salt-induced damage was also dependent on vesicular composition: vesicles containing more cholesterol ( > 5 mM) and with a higher c/p ratio ( > 0.75) were less susceptible to being dissolved by addition of bile salt. Implementing these findings into bile physiology assumes that especially the cholesterol-poor vesicles in the dilute hepatic bile (with a c/p ratio < 0.5) entering the gallbladder are susceptible to damage by the high prevailing bile salt concentration in the concentrated bile of the gallbladder, rendering them cholesterol-rich, and eventually cholesterol-supersaturated and hence prone to nucleation. Conclusion: Apart from the bile salt’s concentration and hydrophobicity, the cholesterol content of the vesicles also plays a role in bile-salt-induced cholesterol crystal formation from cholesterol/phospholipid vesicles. Bile salts determine nucleation behaviour of cholesterol crystals in model bile. K.J. van Erpecum a, P. Portincasa a, M. Gadellaa a, B.J.M. van de Heijning a, W. Renooij b, G.P. van Berge Henegouwen a. Departments of a Gastroenterology and bSurgery,

University

Hospital,

Utrecht,

Netherlands.

Nucleation of cholesterol crystals-an essential step in gallstone formation-occurs from cholesterol-phospholipid (chol-pl) vesicles. Besides the well-known triclinic (tricl) crystals, various crystal shapes were recently discovered in human and model biles such as arcs and needles (AN), spirals (S), tubules (T) and aggregates (Aggr). It is not known what factors determine crystal shape. We compared nucleation from isolated vesicles (chol/pl ratio 1.6) after addition of various bile salts (final B.S. cont. 30 mM) with nucleation from whole model biles (TLC0 10 g/d], CSI 1.4) containing the corresponding bile salt. Nucleation was scored during 10 days using a semiquantitative score (1 + to 4 + ) and polarizing microscopy. As shown by ultracentrifugation, whole biles containing the hydrophobic bile salt taurodeoxycholate (TDC) had a significantly higher vesicular chol/pl ratio (3.8 + 0.8 vs. l.S+O.l) compared to model biles containing the more hydrophilic taurocholate (TC). Various crystal forms (AN, S, T, Tricl, Aggr) appeared within l-3 days in TDC-whole biles, with rapid progression to 4+ score. In contrast, only AN, Tricl and sporadic Aggr appeared in TC-whole bile after 6-8 days with slow progression to l+. Results after addition of bile salts to isolated vesicles were remarkably similar. Integrated lo-day score (max. 40) for TDC-whole bile and after addition of TDC to vesicles were: AN 21.3 and 17.3; S 1 and 1; T 18.3 and 18; Tricl24.6 and 19.5; Aggr 19.3 and 19.5, resp. Values for TC were: AN 2.7 and 1.3; Tricl 3.2 and 9.7; Aggr 0.7 and 1.6, resp. The hydrophilic bile salts tauro- and glycoursodeoxycholic acid (TUDC, GUDC) and taurohydrodeoxycholic acid (THDC) are effective in gallstone and liver dis-

of Medicine

46 (1995)

AI -A36

ease. These bile salts never induced nucleation from vesicles, whereas corresponding whole biles nucleated only at prolonged observation. When THDC-TDC or GUDC-TDC mixtures were added to vesicles, nucleation was inhibited progressively at increasing proportion of THDC and GUDC. Conclusions: Bile salts dictate nucleation behaviour of cholesterol crystals in model bile. Potential mechanisms include modulation of vesicular chol/pl ratio or direct bile salt-vesicle interactions. Effects of pravastatin on biliary lipid composition, nucleation of cholesterol crystals and molecular species of bile salts and lecithin in cholesterol gallstone disease. J.W.A. Smit, K.J. van Erpecum, M.F.J. Stalk, W. Renooy, G.P van Berge-Henegouwen. University Hospital, Utrecht, Netherlands. HMG-CoA reductase inhibitors reduce biliary cholesterol saturation index (CSI) in duodenal bile in hypercholesterolaemic patients and might be useful for gallstone dissolution. However, preliminary data suggest that these drugs are not effective in this respect (Bazolli, Gastroenterology 1992;102: A302). We therefore performed a prospective double-blind, placebo-controlled study in 33 patients with radiolucent gallstones in an opaciljdng gallbladder on OCG scheduled for elective cholecystectomy. Patients were treated with 40 mg pravastatin (prava)/day or placebo during 3 weeks before surgery. In 6 patients, bile was lost during operation. The prava group (n = 13) and placebo group (n = 14) proved to be matched for age, sex, BMI, serum cholesterol (5.9+0.6 vs. 6.1+ 0.8 mmol/l) and the ratio solitary/multiple gallstones. Serum cholesterol fell by 39% in the prava group (p < 0.001) and remained unchanged in the placebo group. Biliary cholesterol (9.5 f 4.6 vs. 14.3 + 5.4 mmol/l, p = 0.03), phospholipid (PL) (24.8 + 13.7 vs. 36.7 $- 14.3 mmol/l, p = 0.04) and bile salt (114 f 73 vs. 152 k 55, mmol/l, p = 0.16) concentrations were lower in the prava group, resulting in a lower total lipid concentration (7.9 +4.6 vs. ll.O+ 3.9 g/d], p = 0.07), whereas molar percentages of bile lipids and CSI were not significantly different (142 + 93 vs. 114 + 23%, p = 0.29). Cholesterol crystals were present in fresh bile in 7/13 patients in the prava group and 11/14 controls (p = 0.17). Nucleation time was comparable between the 2 groups (13&8 vs. 9Lt8 days, p = 0.36). Bile salt species determined with HPLC were similar, whereas there were only minor differences in molecular species of PL (HPLC) between both groups. Conclusion: Not only biliary cholesterol but also PL and bile salt concentrations decrease during pravastatin treatment in cholesterol gallstone patients resulting in unchanged molar percentages of bile lipids and unchanged CSI. Moreover, nucleation time is not affected. This might explain the lack of success in gallstone dissolution with HMG-CoA reductase inhibitors in this group of patients. Hepatic disease after homozygous disruption of the mdr2 gene in mice: morphological aspects. C.M.J. van Nieuwkerk, T.H. Mauad, K.P. Dingemans, J.J.M. Smit, A.H. Schinkel, R.G.E. Notenboom, M.A. van den Bergh Weerman, R.P. Verkruisen, B.K. Groen, R.P.J. Oude Elferink, P. Borst, G.J.A. Offerhaus. Academic

Medical

Centre,

Amsterdam,

Netherlands.

Abstracts

/Netherlands

Journal

The mouse mdr2 gene (and its human homologue MDR3, also called MDR2) encodes a P-glycoprotein that is present in high concentration in the bile canalicular membrane of hepatocytes. 129/0laHsd mice with a homozygous disruption of the mdr2 gene (-/mice) lack this P-glycoprotein in the canalicular membrane. These mice are unable to secrete phospholipids into bile, showing an essential role for the mdr2 P-glycoprotein in the transport of phosphatidylcholine across the canalicular membrane (Smit et al., Cell 1993;75:451-462). Our study analyzed the consecutive ultrastructural and microscopic liver pathology in these mice. The complete absence of phospholipids from bile leads to a hepatic disease, which becomes manifest shortly after birth and shows progression to an endstage in the course of 3 months. The liver pathology is that of a non-suppurative inflammatory cholangitis with portal inflammation and ductular proliferation, consistent with toxic injury of the biliary system from bile salts unaccompanied by phospholipids. The heterozygous (+ / - 1 and wild-type (+ / + 1 mice showed no abnormalities in liver pathology. Thus, the mdr2 (-/-I mice can serve as an animal model for studying mechanisms and potential interventions in non-suppurative inflammatory cholangitis (in a generic sense) in human disease, be it congenital or acquired. When the mice are 4-6 months of age, preneoplastic lesions develop in the liver, progressing to metastatic liver cancer in the terminal phase. The mdr (- / - 1 mice, therefore, also provide a tumour progression model of value for the study of hepatic carcinogenesis. Interestingly, also in this regard the model mimics human disease, since chronic inflammation of the biliaty system in man may similarly carry increased cancer risk. ATP-dependent copper transport in rat liver branes. The molecular defect in Wilson disease?

plasma

mem-

M. Dijkstra a, G. In ‘t Veld *, G.J. van den Berg ‘, M. Miiller b; P.L.M. Jansen b, H.S.A. Heymans a, F. Kuipers a, R.J. Vonk a. ‘De-

partment of Paediatrics, b Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Groningen, ’ Interfaculty Reactor Institute, Delft University of Technology, De& Netherlands.

Copper (Cu) secretion into bile is a key factor in maintenance of Cu homeostasis. Disturbance of this process results in hepatic Cu accumulation and can eventually lead to liver cell damage as occurs in Wilson disease, an inherited disorder of Cu metabolism. The underlying mechanism(s) of biliary Cu secretion, however, are not well understood. Cu secretion as a complex with glutathione and secretion via a lysosomal pathway have been proposed. The recent cloning and sequencing of a candidate gene for Wilson disease predicts that Cu transport in liver cells is mediated by a Cu-transporting P-type ATPase. Biochemical evidence for ATP-dependent Cu transport in mammalian systems, however, has not been reported so far. We have investigated Cu transport in rat liver plasma membrane vesicles enriched in canalicular or basolateral membranes in the presence and absence of ATP (4 mM) and an ATP-regenerating system. The presence of ATP clearly

of Medicine

46 (1995)

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stimulated uptake of radiolabeled Cu fe4Cu, 10 PM) into canalicular plasma membrane vesicles and, to a lesser extent, also into basolateral plasma membrane vesicles. ATP-dependent Cu transport was strongly and dose-dependently inhibited by the P-type ATPase inhibitor, vanadate. Cu transport showed saturation kinetics with an estimated K, of 8.6 PM protein. ATP-stimulated Cu and a V,,, of 6.9 nmol/min/mg uptake was similar in canalicular membrane vesicles of normal Wistar rats and mutant Groningen Yellow (GY) rats, expressing a congenital defect in the activity of the canalicular glutathione-conjugate transporter @MOAT). In a pilot experiment we were also able to demonstrate ATP-dependent Cu uptake in human membrane vesicles. Conclusion: These studies for the first time demonstrate the presence of an ATP-dependent Cu-transporting system in plasma membranes of rat liver, distinct from the ATP-dependent glutathione-conjugate transporter. Frequency and distribution phobilinvgen deztminase phyria patients. F.W.M.

in

of mutations in the gene Dutch acute intermittent

of porpor-

de Rooij a, G. Voortman ‘, E. de Baar ‘, B. Grandchamp b, K. te Velde ‘, J.H.P. Wilson a. a University Hospital, Rotterdam, Netherlands; ” Faculti Xavier Bichat, Paris, France; ‘St. Geertruiden Ziekenhuis. Deventer, Netherlands

Acute intermittent porphyria (AIP) is an autosomal dominant disease, due to a deficiency of porphobillinogen deaminase (PBG-D). We have examined 59 unrelated Dutch AIP families to identify the mutations responsible for this deficiency. Patients were classified by erythrocyte PBG-D activity and antigen content into 3 groups: CRIMi-, with activity approx. 50% of normal and antigen > 75% of normal; CRIM -, activity and antigen 50% of normal and Variant AIP with erythrocyte activity and antigen 100% of normal. Initially, most of the mutations were identified using denaturing gradient gel electrophoresis. Single strand conformation polymorphism (SSCP) on PCR amplification products of most promising exons, with primers in the adjacent introns, was subsequently used. Exon skipping was detected by examination of the size of PCR products after amplification using primers in the adjacent exons and cDNA. Reported mutations were screened using mismatch primers and PCR. All mutations were confirmed by sequencing. 17 different mutations were found in 45 of 59 unrelated Dutch AIP families. CRIM + : 20 families were GRIM+, and 7 different mutations in the PBG-D genome were identified, distributed over all 3 protein domains of PBG-D (cDNA numbering): in exon 4 (5 x m911, exon 7 (1 xm3311, exon 10 (2Xm499, 7xm500, 1 xm517, 1 x m5181 and exon 14 (2 x exon 14 deletion). Variant AIP: in 4 AIP families a IVSl + 1 mutation causing a splicing defect at intron 1 was found. As erythroid cells do not make use of exon 1, this causes a 50% decrease in PBG-D activity only in non-erythroid cells. CRIM-: The other 9 mutations were found in exon 5 (1 X ml74 and 1 X IVSl + 11, exon 6 (1 x m218), exon 7 (2X m287, 1 X m2951, exon 8 (14 X m.7461, exon 12 (1 X m6671 and 2 other mutations (~710, m716). Screening of relatives: 9 of the 17 mutations can be established on the basis

A10

Abstracts

/Netherlands

Journal

of SSCP results and the remaining 8 mutations can be detected with mismatch primers and PCR. Conclusion: Acute intermittent porphyria in the Netherlands is a heterogenous disease, and as not all mutations have been identified, this means that DNA techniques are not suitable for the initial diagnosis of AJP. Identification of the mutations, however helps, in the screening of relatives of AJP patients and provides insights into the mechanisms of action of PBG-D. Prednisone/azathiopriine treatment in primary biliary cirrhosis (PBC). A randomized, placebo-controlled trial. F.H.J. Wolfhagen, H.R. van Buuren, G.P. van Berge Henegouwen, J. van Hattum, J.W. den Ouden, M.J. Kerbert, A.M. Smit, J.C. Thijs, R.A. de Vries, J.H. van Lijf, F.J.W. ten Kate, SW. Schalm and the Dutch Multicentre PBC Study Group. Trial secretariat: Department of Internal pital, Rotterdam, Netherlands.

Medicine

I4 University

Hos-

Forty-four compensated (Child A) PBC patients, without remission on ursodeoxycholic acid therapy (UDCA, 10 mg/kg), were randomized to additional treatment with prednisone 10 mg + azathioprine 50 mg daily (PA) or placebo for 1 year, to assesswhether combined immunosuppressive therapy might induce disease remission. Patients were preventively treated with Didrokit @ (cyclic etidronate + calcium) to reduce steroid-induced bone loss. Symptoms (pruritus and fatigue, measured by a semiquantative score ranging from O-80 points) and laboratory parameters were assessed 3-monthly; liver biopsies, lumbar and femoral bone mass measurements (by dual energy X-ray absorptiometry) yearly. This interim analysis of 25 patients (PA 14, placebo 11) aimed at assessing the effect of PA on symptoms, biochemical parameters and bone density. Two patients withdrew from treatment because of malaise (both PA). After 1 year, median changes from baseline for pruritus (0 vs. + 5 points; p = 0.021, fatigue (- 3.5 vs. + 15 points; p = 0.007), alkaline phosphatase (- 39 vs. - 5%; p = 0.003), AST (-27 vs. +9%; p = 0.003) and IgM (-26 vs. +3%; p = 0.001) were significantly different in the PA vs. placebo group; changes in bilirubin (increased at entry in 9 patients) (0 vs. + 12%; p = 0.8) and albumin (+2 vs. 0%; p = 0.7) were not. Symptomatic and biochemical remission was achieved in 3 patients (all PA). No accelerated bone loss was noted in the PA group. Conclusions: In non-advanced PBC, combined treatment with low-dose prednisone and azathioprine has an additional effect to UDCA on clinical and biochemical parameters. Using Didrokit, no detrimental effect of prednisone on bone mass was observed. Patient recruitment will be continued to prove that disease remissions can be induced with this treatment. Effect on medium-chain triglycerides and long-chain triglycerides on lower oesophageal sphincter pressure. M. Ledeboer, A.A.M. Masclee, C.B.H.W. Lamers. Department of Gastroenterology lands.

and Hepatology,

University

Hospital,

Leiden,

Nether-

Fat-rich meals are known to provoke gastro-oesophageal

of Medicine

46 (1995)

Al -A36

reflux. Dietary fat, mainly consisting of long-chain triglycerides (LCT) significantly reduces lower oesophageal sphincter pressure (LESP), possibly through CCK since LCT potenth stimulates CCK secretion. In contrast to LCT, medium-chain triglycerides (MCT) do not induce CCK release. Aim of the study was to investigate the effect of equimolar amounts of LCT and MCT on LESP. Six healthy subjects (2F, 4M; mean age 26 yr) were studied on 3 separate occasions in random order during intraduodenal infusion of (1) LCT 20 mmol/h, (2) MCI 20 mmol/h, (3) saline (control). LESP (manometry with Dent-sleeve) was registered continuously for 90 min. Plasma CCK levels (RIA) were determined at regular intervals. Results LESP (mmHg) basal 30 min 60 min 90 min

LCI’ 29&3 18*1* 18*1” 19*2*

MCT 30,2 21+2* 18+3* 14f3’

control 27+3 25+2 29&5 25*2

* p < 0.05 compared to basal. LCT significantly (p < 0.05) increased plasma CCK levels from 2.4kO.3 pmol/l (basal) to 4.3 f 0.6 pmol/l (75 min); MCT did not affect plasma CCK levels. Conclusions: (1) LCT, in contrast to MCT, induces CCK secretion. (2) Both LCT and MCT significantly reduce LESP. The effect of MCT on LESP is not mediated through CCK and these findings challenge the concept of a CCK-mediated effect of LCT on LESP. Acute but not chronic cholestyramine (CH) administration profoundly affects gallbladder (GB) and antruduodenal motility. P. Portincasa a, P.C. Van de Meeberg a, K.J. van Erpecum a, A.J.P.M. Smout a, L.M.A. Akkermans b, G.P. van Berge Henegouwen ‘. Department of a Gastroenterology and b Surgery,

University

Hospital,

Utrecht,

Netherlands.

We previously showed that acute oral CH leads to strong GB emptying, probably by interruption of negative feed-back control by intraduodenal bile salts on CCK release (Gastroenterology 1992:102:633-7). However, the effects of CH on antroduodenal motility and on GB dynamics after long-term administration are not known. Hence, we studied interdigestive and postprandial GB and antroduodenal motility in 6 healthy subjects using sonography and ambulatory 24-h 6channel manometry before and after acute (4 g) and 8-day chronic oral CH (8 g/day). Before and after 8 days CH, both postprandial GB emptying after 2814 kJ meal (80.2* 5.8 and 70.2* 7.9% of fasting volume, resp.) and interdigestive GB emptying (19.6 f 3.5 and 18.9% of fasting volume, resp.) were not different. Acute CH (4 g), given 30 min after phase 3 of the concurrently measured MMC, caused a strong decrease in GB volume (starting volume 29.5 f 5.1 ml, residual 8.5 + 3.0 ml) without interrupting the fasting antroduodenal motility pattern. Fasting GB volume 24 h later was still strongly decreased (7.6 f 2.2 ml) but gradually increased to pre-treat-

Abstracts/Netherlands

Journal

ment levels on day 4 (l&8+3.4 ml), 6 (21.2i6.0 ml) and 8 (26.0f5.3 ml) (all p < 0.05 vs. pre-treatment). MMC cycle length before and after 8 days CH (106.4+ 11.5 and 109.1 k7.8 min, resp.) as well % phase 1, 2 and 3 were not different. However, cycle length of MMC following acute CH on day 1 was significantly longer than the cycle immediately preceding CH (164.6* 16.2 and 121.8f7.6 min, resp., p < 0.05) with significantly longer phase 2 (133.2 + 16.9 and 57.6 f 12.4 min, resp., p < 0.005) and shorter phase 1 (27.8 + 1.8 and 43.2 f 2.2 min, resp., p < 0.03). Conclusions: Acute oral CH leads to strong GB emptying which persists beyond 24 h, with gradual adaptation during chronic CH treatment. Chronic CH does not influence the MMC pattern, but acute CH significantly prolongs cycle length, due to longer phase 2. These findings may be explained by a gradual adaptation to intraduodenal bile salt depletion during a chronic regimen with CH. Stmultaueous assessments of gastric emptying and pharmacodynamics of 2-mm enteric-eonted pancreatin microspheres in patients with chronic pancreatitis. M.J. Bruno a, J.J.J. Borm b,

F.J. Hock a,c, B. Delzenne ‘, A.F. Hofmann d, J.J.M. de Goeij e, E.A. van Royen b, D.J. van Leeuwen f, G.N.J. of Gastroenterology, b Department of ‘b&tat ‘. ‘Department Medicine and ‘Department of Clinical Chemistry, Academic Medical Centre, Amsterdam, Netherlands; d Department of Gastroenterology, University of California, San Diego, USA; ’ Interfaculty Reactor Institute, Universi@ of Delft, Netherlands; f Department of Gastroenterology, University of Alabama, Birmingham, AL, USA. Methods: A special batch of a 2-mm enteric-coated pan-

of Medicine

46 (1995)

All

Al -A36

day) due to chronic pancreatitis (CP). In CP, pancreatic function tests were also performed without enzyme supplementation. Results: The gastric emptying time of the pancake was equal in controls and CP. Compared to the solid meal, the gastric emptying time of the 2-mm ECMS was retarded in controls, but accelerated in CP. With the 2-mm ECMS, 14C0, output in CP rose from t = 30, reaching a maximum at t = 120 (as in controls). The area under the curve (AUC) of 14C0, output rose significantly (p < 0.05) from 30% (without 2-mm ECMS) to 70% (with 2-mm ECMS) of controls (significantly different from controls). Plasma PABA concentration rose slowly from t = 30, reaching a maximum at I = 300 (controls r = 120). The AUC of plasma PABA concentration rose significantly from 46 to 87% of controls (not significantly different from controls). The PABA/PAS ratio (6-h urine) rose significantly from 36 to 80% of controls (not significantly different from controls). Conclusion: Compared to a solid meal, gastric emptying of the 2-mm ECMS in CP is not delayed but in fact accelerated. As measured with indirect function tests, the 2-mm ECMS effectively increases both lipase and protease activity in CP with EPI, although lipase activity remains below levels of controls in the above-mentioned dosage.

Nuclear

creatin microsphere preparation (2-mm ECMS) [Panzytrat@] was prepared in which part of the filler compound was replaced by tmEr-enriched ErzO,. Eight hours before ingestion, a capsule containing 50 microspheres was irradiated with fast neutrons in a nuclear reactor, converting t7’Er into the shortliving radioisotope 17iEr. At t = 0 (min), subjects ate a solid testmeal (pancake) containing 15 MBq %Tc, 5 PCi cholesterol-‘4C-octanoate, 1.5 g cholesterol-octanoate, 1000 mg NBT-PABA.Na and 500 mg PAS.Na.2HzO. The capsule with the radioactive 2-mm ECMS was swallowed after the first bite of the pancake, a second capsule with non-radioactive 2-mm ECMS halfway through. The total enzyme dosage was: lipase f 42, COOU (Ph.Eur.U), proteases + 2350 U and amylase *39,500 U. Assessments of gastric emptying of the 2-mm ECMS (171Er) and the solid testmeal (%Tc) were performed by double isotope scintigraphy. Enzyme activities were assessed simultaneously with indirect pancreas function tests. Lipase activity (cholesterol esterase) was assessed with the cholesterol-t4C-octanoate breath test and protease activity (chymotrypsin) with the NBT-PABA/PAS test. PABA was measured in plasma and urine. PAS was measured in urine. Breath and blood samples were collected at 30-min intervals for 4 h and then hourly for an additional 2 h. Urine was collected in a single 6-h sample. Experiments were performed in 9 healthy volunteers (controls) and 8 patients with exocrine pancreatic insufficiency (EPI) (faecal fat excretion > 15 g/

Absence

of

ras gene

mutations

in early

gastric

carcinomas.

M.E. Craanen a,b, P. Blok ‘, B. Top d, W. Dekker ‘, G.J.A. Offerhaus f, G.N.J. Tytgat a. Departments of a Gastroenterology and f Pathology, Academic Medical Centre, Amsterdum; b Department of Medical Oncology and d Division of Experimental Therapy, The Netherlands Cancer Institute, Amsterdam, ’ Department of Pathology, Westeinde Ziekenhuis, The Hague, and e Department of internal Medicine, Kennemer Gasthuis, Haarlem, Netherlands.

The human ras proto-oncogene family includes the homologous Ha-, Ki- and N-ras genes, which encode for closely related 21-kDa proteins (~21’~“). Immunohistochemical studies on ~21’“~’ expression in gastric carcinomas, using a wide variety of antibodies, have found raised ~21’“’ expression in intestinal-type carcinomas compared with diffuse-type carcinomas and in advanced carcinomas compared with early carcinomas. However, ras gene overexpression is not necessarily synonymous with malignant phenotype. In contrast, activating point mutations of the ras genes are thought to play an important role in malignant transformation. Since inconsistent findings on ras gene mutations in gastric carcinomas can be found in the literature, we analyzed 45 early gastric carcinomas (EGC) for the presence of activating point mutations. For this purpose, 6 serial 5-pm sections were cut from each formalin-fixed, paraffin-embedded tumour block (n = 45), as well as one haematoxylin-eosin (H&E)-stained section for precise localization and Lauren typing of the tumour and for estimation of the percentage of tumour cells. The tumour area was selectively scraped off, thereby increasing the tumour cell percentage to at least 50% of the total cell population. Thereafter, genomic DNA was extracted according to standard procedures. Mutations at codon 12 of the K-rus gene

Al2

Abstracts

/Netherlands

Journal

were examined with a polymerase-chain-reaction-based restriction fragment length polymorphism (PCR-RFLP) method and hybridization with allele-specific 3’P-labelled oligodeoxynucleotide (ASO) probes. All other ras genes were analyzed with PCR amplification and hybridization with AS0 probes. Mutations were detected by overnight autoradiography at -70°C. There were 20 intestinal-type and 25 diffuse-type EGC. No point mutations were found in the Ki, Ha- and N-rus genes. Conclusion: ras gene mutation does not play an important role in the development of Caucasian early gastric carcinomas, irrespective of Lauren type. Evaluation of immunodiagnostic tests, including a new Latex test, compared to the [‘4Clurea breath-test, in predicting Helicobacler pylori infections. F.W.M. de Rooij, H. Demirel, P.D. Siersema, J.H.P. Wilson. Department of Internal Medicine, University

Hospital,

Rotterdam,

Netherlands.

The urea breath-test (BT) is used to investigate the presence and extent of a Helicobacter pylori (HP) infection in patients with gastric and duodenal ulcer disease and to evaluate the effect of subsequent therapy. However, at the same time the use of 14C- or 13C-labeled urea in this breath-test has limitations for a widespread application of this test. Immunodiagnostic tests were introduced to provide a non-invasive alternative. To evaluate the predictive value of these immunotests in detecting Hp infections, we applied three antibody tests (EIA-G, EIA-A, and a new Hp Latex test) in a retrospective study on the sera of 197 out-patients with upper GI complaints and compared the results with the urea breath-test results. To determine the Hp prevalence in healthy controls the [ 14C]urea breath-test and immunotests were also performed on 32 asymptomatic control individuals. Methods: 197 out-patients with upper GI complaints (41 were treated for Hp infections with mostly triple therapy) and 32 healthy controls were studied. A [14C]urea breath-test was used to detect Hp according to Rauws et al. The average CO, excretion at t = 50 and t = 60 min > 0.07% was scored as HP-positive. The EIA-G, EIA-A and the latex tests were performed according to the instructions of the manufacturer (ORION). Statistical analysis on the antibody levels before and after Hp eradication was performed using the Wilcoxon test for paired values. Results: Hp prevalence in the control group was 6/32 (19%) and was 130/197 (66%) in the out-patient group. Compared to the urea breath-test the following specificity, sensitivity, positive predictive value, and negative predictive value were found: EIA-G (84, 75, 87, 70%); EIA-A cutoff > 500 (86,39,80,49%); EIA-A cutoff > 350 (76,65,79,70%) and for the Latex test (88, 76, 90, 71%). 41/130 out-patients were treated for Hp infection, 24/41 with a positive eradication (negative breath-test 82 f 33 days after starting therapy) showed a significant decrease in antibody levels (IgG-b 1706 + 1560; IgG-a 1145 + 1198; IgA-b 625 f 667; IgA-a 399 + 419). Conclusion: In a Dutch out-patient population with GI complaints the EIA-A cutoff level > 500 is concluded to be

of Medicine

46 (1995)

AI -A36

too high for acceptable prediction of a Hp infection; we suggest a cutoff level of > 350. The EIA-G and the Latex tests have comparable Hp predictive results compared to the [14C]urea breath-test and the results suggest that these tests can be a good alternative to the urea breath-test in screening patients for Hp infections. Proliferation in colorectal adenomss assessed by mitotic counts in relation to dysplasia and histological type. G.A. Meijer ‘, S.G.M. Meuwissen b, J.P.A. Baak ‘. Departments of a Pathology Amsterdam,

and b Gastroenterology, Netherlands.

Free

University

Hospital,

The proliferative activity of tumours is regarded as reflecting their malignant potential. Furthermore, in colorectal adenomas, the subjective impression of the number of mitoses is one of the criteria used to assess the degree of dysplasia. However, since these subjective impressions of mitotic activity often lack reproducibility, we performed an objective analysis. Mitotic counts were conducted in tissue sections of 59 colorectal adenomas. Of these adenomas, 20 showed mild, 20 moderate and 19 severe dysplasia, according to blind duplicate assessments by two pathologists. As to histological type, 43 were classified as tubular and 16 as “villous” (comprising both tubule-villous and villous adenomas). The number of mitoses both per unit area of epithelium (area-weighted mitotic counts = AWMC) and per colonic crypt (mitotic counts per colonic crypt = MCCC) were scored in the most dysplastic area within the adenoma. Mitotic figures were counted using a light microscope (ocular X 10, objective X40, N.A. 0.75), and the area of the glandular epithelium was measured using an interactive video-overlay measurement system. Twenty glands per specimen were assessed. In the intra-observer reproducibility tests, the coefficients of error for the AWMC and the MCCC were 4.5% and 7.4% respectively. For the AWMC a significant difference was found between mild and moderate as well as between mild and severe dysplasia, but not between moderate and severe dysplasia. The results of the MCCC showed the same trend, but the differences did not reach a significant level. Also, a considerable variation within each grade of dysplasia was found, with typically mild dysplasia cases showing numerous mitoses, while cases of severe dysplasia occurred with only very few mitoses. No significant difference in AWMC was found between tubular and villous adenomas. Thus, the different malignant potential of tubular and villous adenomas was not reflected by a difference in AWMC. A seemingly strong difference for MCCC between tubular and “villous” adenomas appeared to depend completely on the difference in crypt size between these two groups. Conclusion: The AWMC, rather than the MCCC, may be useful for assessing the proliferation rate in colorectal adenomas. Changes in a faecal aerobic flora in patients on long-term treatment with omeprazole. D.M. Jonkers, E.E. Stobberingh, P. Houben, R.W. Stockbriigger. Departments of Microbiology and Gastroenterology, Netherlands.

University

of

Limburg,

Maastricht,

Abstracts

/Netherlands

Journal

Inhibition of gastric acid secretion changes the bacterial flora of the upper GI-tract. Penman et al. (Gut 1993) found an inhibitory effect of omeprazole on azoxymethane-induced colorectal cancer in rats. They hypothesized that an alteration of the colonic microflora could be a reason for this phenomenon. The effect of > 1 year treatment with omeprazole 20-40 mg daily on the facultative aerobic faecal flora was studied in 28 patients and compared with age-matched partners, not treated with gastric acid suppressors. Faecal samples were cultured quantitatively using a spiral plater. The qualitative analysis included identification of Enterobacteriaceae (Gramneg. rods) and of enterococci, staphylococci and streptococci (Gram-pos. cocci). Mean log cfu/g faeces for patients and controls were analyzed by a non-parametric paired Wilcoxon test. A nearly significant difference in Gram-neg. rods was found between patients (median 9.5 log cfu/g) and controls (median 7.5 log cfu/g) (p = 0.051, and there was a significant increase in Gram-pos. cocci in patients (median 7.8 log cfu/g) vs. controls (median 6.9 log cfu/g) (p < 0.05). Summary and conclusions: Patients on long-term omeprazole treatment tend to have an increase in Gram-pos. and -neg. cocci in their faeces. This could be a result of these bacteria surviving in the stomach and entering the intestine. This change may play a role in the protective effect of omeprazole in colorectal carcinogenesis as observed in rats. Further studies are needed to establish the changes in bacterial faecal flora during omeprazole treatment, and to elucidate whether they can be of importance in human subjects.

Serological follow-up

markers for gastric mucosal atrophy; a long-term study. E.J. Kuipers a, C.W.J. van Uffelen b, G. Pals ‘, A. Kok b, G. van Kamp b, AS. Peiia a, S.G.M. Meuwissen a. Departments of ’ Gastroenterology, b Clinical Chemistry and ’ Human Genetics, Free University Hospital, Amsterdam, Netherlands.

Serum levels of pepsinogen A (PGA), pepsinogen C (PGC) and the PGA/PGC ratio have been proposed as useful noninvasive screening tests for gastritis, gastric mucosal atrophy and gastric cancer. The purpose of this study was to investigate the potential utility of serum PG levels for prospective patient control. 120 cases were studied twice before and after a mean follow-up of 11.5 years (10-13). PGA and PGC were determined with the use of ELISA assaysin sera on both occasions. Serum gastrin levels were determined by radio-immunoassay; Helicobacter pylon’ (Hp) IgG antibodies were determined by ELISA. Endoscopic gastric biopsy specimens on both occasions were available in 105 cases. Statistical analysis was performed with Student’s t-test. 64 individuals (53%) had no signs of HP-infection as tested by serology. On the first visit, HpPOS cases had significantly higher mean serum PGA, PGC and gastrin levels and a significantly lower PGA/PGC ratio (p < 0.05) (see table;

of Medicine

46 (15%)

Al.7

AI -A36

mean f SEM results of both visits). After long-term follow-up, no changes were noted in Hpneg individuals. In HppOS cases, however, PGA, PGC and their ratio slightly decreased. These decreases did not reach statistical significance. For the total study group, a significant correlation was noted between individual first and follow-up test results of PGA (c = 0.30, p < 0.05), PGA/PGC ratio (r = 0.54, p < 0.05) and gastrin (r = 0.82, p < 0.05). First and follow-up PGC levels were not significantly correlated (r = 0.24). 17 cases showed significant progression of gastric mucosal atrophy in the repeated histology; in those cases no significant change in serum test results during follow-up was noted.

Visit

PGA (pg/l) I

II

I

II

Hpneg HpP”S

4Ok3.8 .54+4.7

43+3.8 48+4.0

17_+ 1.1 29+2.6

17+

PGC

PGA/PGC Hpneg HP POS

(pg/U

1.2 26 k 2.4

Gastrin (rig/l)

I

II

I

II

2.3kO.2 1.9+0.1

2.6kO.3 1.8+0.1

2.5+ 1.8 74+5.9

28 + 2.0 83 + 7.4

Conclusions: Serum pepsinogen levels are elevated in HpP”” individuals and tend to decrease during long-term follow-up. This supports the concept of development of atrophy with loss of specialised cells during prolonged HP-induced gastritis. Individual differences are only minor and do not correlate well with histological changes. Thus, the use of these serum markers for prospective control of individual patients to detect development of atrophy and cancer is unreliable.

Salivary, systemic, gastric juice, and gastric mucosal Helieobacter pylon’ antibodies in patients with and without pylori-related gastritis. R.A. Veenendaal ‘, J.M. Giitz

IgA H.

a, V. Schroyen a, A.S. Peiia ‘, R. Roosendaal d, M. Veselic b, C.B.H.W. Lamers ‘. Departments of a Gastroenterology and

Hepatology and ’ Pathology, University Hospital. partments of ’ Gastroenterology and d Clinical Free University Hospital, Amsterdam, Netherlands.

Leiden, DeMicrobiology,

In this study we investigated the presence of salivary, plasma, gastric juice and local gastric mucosal specific IgA Helicobacter pylon’ antibodies in 44 consecutive, previously untreated, patients with severe dyspeptic complaints. The samples studied were obtained, after an overnight fast, at upper gastrointestinal endoscopy. The presence of H. pylon’ in these patients was determined by culture and histology. Specific IgA H. pylon’ antibodies were measured with a previously validated and published modified ELISA technique and expressed as an absorbance index (Al).

A14 Specific H. pylon’ antibodies (AI x 100)

Saliva IgA Plasma IgA Antrum IgA Corpus IgA Gastric juice IgA

Abstracts

/Netherlands

p-Value

H. pylon’

H. pylori

positive patients [n = 24, mean (SEM)]

negative patients [n = 20, mean (SEM)]

16.2 (5.0) 79.8 (9.9) 108.4 (10.1) 79.8 (8.2) 28.4 (12.7)

22.0 (4.8) 15.0 (1.9) 2.9 (1.1) 2.5 (1.2) 5.1 (2.5)

Student’s t-test; * significant after Bonferroni

Journal

0.42 -=c0.01 * ---c0.01 * -=-SC 0.01 * 0.11 correction.

Systemic IgA H. Pylon’ antibodies were higher [mean (SEM), 61.6 (16.0) vs. 99.0 (13.8), p < 0.011 with active pangastritis (n = 10) than in patients with active antral gastritis (n = 11) only, while there was no difference for antrum or corpus IgA H. pylori antibodies between these groups. Salivary IgA H. pylon’ antibodies were not correlated to the local gastric mucosa or systemic IgA antibody response or to the presence of H. pylori in saliva as indicated by PCR. Gastric juice IgA H. pylon’ antibodies were however significantly correlated to the systemic (r = 0.43, p +z 0.01) IgA H. pylon’ antibody response and to the gastric pH (r = 0.46, p = 0.01). We therefore conclude that a significant systemic and mucosal (in both antrum and corpus) IgA H. pylon’ antibody response is present. Gastric juice IgA H. pylori antibodies do reflect local H. pylon’ infection but are absent at low pH levels. Salivary IgA H. pylon’ antibodies do not reflect ongoing gastric or oral H. pylon’ infection. Correlations between local and systemic pepsiaogen C concentrations in patients with Helieobacter pylon’ infection. F. Kurban, J.M. Giitz, R.A. Veenendaal, I. Biemond, C.B.H.W. Lamers. University Hospital, Leiden, Netherlands. Helicobacter pylon’ infection has an influence on the serum pepsinogen levels. In this retrospective study, the diagnostic value of both antral and serum pepsinogen C, with determination of the optimal cut-off value by receiver operating characteristic (ROC) curves, was investigated in 194 previously untreated patients with dyspeptic complaints, referred for upper GI endoscopy. A positive culture and/or histological identification of H. pylon’ in gastric biopsies was used as the diagnostic criterion for gastric H. pylon’ infection. Serum pepsinogen C (pg/l) and antral pepsinogen C (/*g/g tissue) were measured by specific and sensitive radio-immunoassays (RIA). Results: H. pylon’-positive patients had significantly higher serum pepsinogen C, but significantly lower antral pepsinogen C concentrations. No significant correlation was found between antral and serum pepsinogen C (r = -0.06, p = 0.54). H. pylori-positive patients with duodenal ulcer (DU) or gastric ulcer (GU) had a significant increase in serum pepsinogen C levels compared to patients with non-ulcer dyspepsia (NUD). The 95% confidence interval of the mean serum pepsinogen C level was 23.8-33.4 in NUD patients, 35.1-53.4 in DLJ patients and 30.7-67.3 in GU patients. The sensitivity and specificity of serum pepsinogen C for distinguishing NUD

of Medicine

46 (1995)

AI -A36

patients from DU and GU patients was 64.3 and 61.4% for a cut-off point of 28.6 fig/l. The sensitivity and specificity of antral and serum pepsinogen C in diagnosing H. pylon’ infection were 70.6 and 76.9% for antral pepsinogen C (optimal cut-off value 1.5 fig/g), and 71.8 and 65.7% for serum pepsinogen C (optimal cut-off point 20 pg/l), respectively. Conclusion: Compared to the high sensitivity and specificity of H. pylori antibodies ( > 90%), serum and antral pepsinogen C are less suitable for diagnosing H. pylori infection. For clinical purposes, serum pepsinogen C appears to be a suitable non-invasive marker to distinguish NUD patients from DU and GU patients; prospective studies are needed to assess this hypothesis. Assessment of Helicobacter pylori in gastric mucosal biopsies by different staining methods. D.M. Jonkers, E.E. Stobberingh, A.P. de Bruine, J.W. Arends, R.W. Stockbriigger. Departments University

of Microbiology, Pathology and Gastroenterology, of Limburg, Maastricht, Netherlands. histological assessment of Helicobacter pylori (HP)

The in gastric mucosa may be confounded by other bacteria. Two microbiologists and 2 pathologists assessed the presence of HP in l-3 gastric biopsies taken from 40 patients during upper GI-endoscopy. Culturing was performed and histological slides of the biopsies (formalin-fixed and paraffin-embedded) were stained with a modified Giemsa (MG), the Warthin-Starry (WS) and an immunohistochemical method using purified polyclonal HP antiserum (DAK0 B471). 21/40 specimens were positive by immunostaining scored by an independent experienced observer, confirmed by culturing in 19 cases. These were used as standard. lo/19 HP-negative cases revealed oral flora upon culturing. The table gives the number of true and (false) HP-positive slides for all stains and each observer. Observer 1 pathologist 2 pathologist 3 microbiologist 4 microbiologist

MG 21 (10) 15 (7) 21 (3) 20 (12)

ws

DAK0

16 (2) 12(0) 18 (0) 18 (4)

20 (0) 16 (0)

21(O) 18 (0)

Almost half of false-positive cases were probably due to other bacteria. False-negative results of immunostaining were cases with low numbers of HP. Sensitivities were 91.7* 13.7% for MG, 76.2 + 13.5% for WS and 89.3 +_10.5% for DAKO. Specificities were 57.2 f 21.2, 92.1+ 10.1 and lOOk 0%, respectively. Conclusion: Immunohistochemistry for HP is highly specific and causes the lowest inter-observer variation. Histochemical stains are less specific (MG), less sensitive (WS), and seem less reproducible. Expression of cholecystokinin-B (gastrln) receptors in VIPomas. C. Tang, I. Biemond, C.B.H.W. Lamers. Department of Gastroenterology,

University

Hospital,

Leiden,

Netherlands.

Pancreatic endocrine tumours secret several peptides which cause the corresponding clinical hormonal syndrome.

Abstracts

/Netherlands

Journal

Up to now, peptide receptor study in the tumour is largely unknown except for somatostatin receptor. In the present study, 14 pancreatic endocrine turnours (10 gastrinomas, 4 VIPomas) from 10 patients have been tested for their content of specific cholecystokinin (CCK) receptors using storage phosphorus autoradiography. Cryostat tumour sections were incubated with radioactive-iodine-labeled CCK in the absence or presence of unlabeled CCK (1 FM). CCK receptors were detected positively only in 3 VIPomas from 2 patients. Dose inhibition curve revealed a single high-affinity binding site for CCK with Kd ranging from 0.299kO.0766 to 9.65 +0.69 nM and B,,, ranging from 17.2+ L.27 to 200.8+26.5 fmol/mg protein in 3 VIPomas. Gastrin presented an inhibition of labeled CCK binding to VIPoma sections. The half-maximal inhibition (IC& of I365,260 (a CCK-B antagonist) was 0.0439 f 0.001 MM. It is about 200-fold more potent than the CCK-A antagonist, lorgiumide (IC,, = 8.76 f 0.4 PM). Thus, labeled CCK appeared to be bound to CCK-B (gastrin) receptors. The biological function of CCK-B (gastrin) receptor in VIPoma is unknown. If they can mediate proliferative properties, the present data would be of potential therapeutic interest. Satiety

effect

of cholestyramine

in lean

healthy

volunteers.

M.J. Luijerink, R.J. Lieverse, H.A.J. Gielkens, C.B.H.W. Lamers, A.A.M. Masclee. Department of Gastroenterology and Hepatology,

University

Hospital,

Leiden,

Netherlands.

Recently we have shown that cholecystokinin (CCK) at physiological plasma levels significantly increases satiety in man. Nutrients such as fat and protein potently stimulate CCK secretion but also have a high caloric load. Substances that stimulate CCK secretion but are devoid of caloric energy are of potential clinical interest in order to induce satiety, decrease food consumption and result in weight loss. We have studied the satiety effect of a substance that meets these criteria: cholestyramine (Questran), a bile-salt-binding resin that releases CCK by interrupting the negative feedback mechanism between intraluminal bile salts and CCK-releasing cells. Ten lean healthy volunteers (6M, 4F, age 22-50 yr, body mass index 22f 2 kg/m*) participated in the study. In a double-blind randomized fashion they received after an overnight fast either cholestyramine (12 g) or placebo at time 0 min followed by a lunch (430 kCa1) at time 15 min. Subjective feelings of hunger, wish to eat, fullness and prospective feeding intentions were measured on visual analogue scales for 240 min. At time 195 min a pasta meal was offered, of which each subject was free to eat as much as he or she wanted. Plasma CCK (RIA) was measured at regular intervals. Results: After ingestion of cholestyramine, meal-stimulated endogenous CCK release was significantly increased compared to control (911+ 130 vs. 220 + 35 pM. 195 min). Cholestyramine augmented subjective feelings of satiety of which the effect on fullness and wish to eat were statistically significant (p < 0.05). However, cholestyramine did not significantly reduce food intake (575 &51 vs. 602+ 36 g) of pasta meal. Conclusions: Cholestyramine significantly increases nutri-

of Medicine

46 (1995)

AI5

Al -A36

ent-stimulated endogenous CCK secretion. Cholestyramine augments subjective post-meal feelings of satiety, but food intake in lean individuals is not affected by cholestyramine. The satiety effect of cholestyramine deserves further evaluation in obese subjects. Intestinal due to

permeability cystic fibrosis

in exocrine or chronic

pancreatic panereatitis.

insufficiency

R.M. van Elburg a, J.J. Uil b, W.M.C. van Aalderen *, C.J.J. Mulder b, H.S.A. Heymans ‘. a Beatrix Children’s Hospital, Groningen, b Department of Gastroenterology, Rijnstate Hospital, Arnhem, Netherlands.

Controversy exists about whether increased intestinal permeability in cystic fibrosis (CF) is due to CF itself or is a consequence of concomitant exocrine pancreatic insufficiency (PI). To elucidate this controversy, intestinal permeability was measured by the sugar absorption test (SAT) in 32 PI patients: 20 CF, 12 non-CF with PI caused hy chronic pancreatitis, and 50 controls. In 10 and 9 CF patients, the SAT was repeated after increasing pancreatic enzyme supplementation by 30-50% for 2 weeks, after decreasing the osmolarity of the solution by 75%. In the sugar absorption test, a solution of lactulose and mannitol, hyperosmolar by the addition of sucrose, was given to the fasting subject after which the lactulose/mannitol ratio was measured in 5-h urine. The lactulose/mannitol ratio was increased in both CF and non-CF patients with PI versus controls (p < 0.0001). The lactulose/ mannitol ratio in CF did not change by increasing the pancreatic enzyme supplementation (p = 0.41) or decreasing the osmolarity of the test solution (p = 0.24). Conclusions: An increased intestinal permeability in CF is probably a consequence of PI, and not related to the dose of pancreatic enzyme supplementation or the osmolarity of the test solution. An increased intestinal permeability points to impaired functional integrity of the small bowel which may contribute to gastrointestinal dysfunction in pancreatic insufficiency. The effect tients with

of erythromycin diabetes mellitus.

on pancreatic

poiypeptide

in pa-

B.J.M. Witteman a, K. Edwards ‘, W.P.M. Hopman a, J. Lutterman b, P.M. Netten ‘, Th. Thienb, J.B.M.J. Jansen a. Departments of’ Gastroenterology and Hep-

atology and b Internal Netherlands.

Medicine,

University

Hospital,

Nijmegen,

Pancreatic polypeptide (PP) release in response to intravenous erythromycin (ERY) is dependent on intact vagal cholinergic pathways and requires an intact antrum. Since autonomic neuropathy (AN) of the gastrointestinal tract damages vagal nerve integrity and frequently complicates the course of diabetes mellitus, we have studied whether the PP response to ERY is diminished in 17 insulin-dependent diabetics [9F, 8M; 56 (30-79) yr] with abnormal cardiovascular reflex tests (FINAPRES) and with (n = 8; DMl) or without (n = 9; DM2) symptoms suspicious of AN of the gastrointestinal tract such as anorexia, nausea, vomiting, early satiety, fullness, bloating or upper abdominal pain. Twenty-one healthy controls [HS; lOF, 11M; 47 (22-72) yrs] and 5 vago-

Al6

Abstracts/Netherlands

Journal

tomized patients [VP; lF, 4M; 49 (28-68) yr] were also studied. ERY dose-dependently stimulated PP in HS: IO82k 152 pM * 20 min (0.4 mg/kg) and 1753 f 351 pM * 20 min (1.2 mg/kg) and DM2 (165.5+313 and 2250+461 pM* 20 min, respectively). The responses to ERY were significantly (p < 0.01) lower in DMl (453& 182 and 697+ 178 pM*20 min, respectively), and VP (275 f 121 and 672 f 284 pM * 20 min, respectively). Conclusion: In a subgroup of DM patients with gastrointestinal complaints suspicious of AN, ERY-stimulated PP release is decreased. Cardiovascular reflex tests are not helpful in discriminating these patients from other DM patients with AN. Morphometry and intestinal permeability in paediatric coeliacs. R.M. van Elburg a, P.G.J. Nikkels b, F.T.M. Kokke a, F.M. van Overbeek a, C.M.A. Bijleveld a, C.J.J. Mulder c, H&A. Heymans a. a Beatrix Children’s Hospital, Groningen, b Department ’ Department Netherlands.

of Pathology, University Hospital, Groningen, of Gastroenterology, R&state Hospital, Arnhem,

To elucidate the possible mechanisms of intestinal permeability for macromolecules of different sizes, we determined the relation of the sugar absorption test (SAT), using lactulose and mannitol, with morphometric characteristics of the small bowel mucosa in 10 active coeliacs and 10 controls. In the SAT, a solution of lactulose and mannitol was given to the fasting subject after which the lactulose/mannitol (L/M) ratio was measured in S-h urine by gas chromatography. Morphometric characteristics such as the surface and volume of both villi and crypts were measured in an isotropic test system (after Merz) by the point count method according to Weibel (Stereological methods, Vol. 1. Practical methods for biological morphometry. London: Academic Press Inc., 1987). Permeability for mannitol was positively related with the villus surface (r = 0.67, p = 0.000, the surface villus/crypt ratio (r = 0.75, p < O.OOl), and negatively related with the crypt volume (r = -0.57, p = 0.02). There was a trend towards a positive relation between permeability for lactulose and crypt volume (r = 0.41, p = 0.081, and the L/M ratio and crypt volume (r = 0.39, p = 0.09). These findings suggest that permeability for mannitol predominately takes place in the villi whereas permeability for lactulose more likely takes place in the crypts. Furthermore, these findings are in accordance with the changes in the hyperplastic and destructive phase of coeliac disease. Is circulating cholecystoklnin an enterogastrone? Maas, W.P.M. Hopman, J.B.M.J. Jansen. Department troenterology,

University

Hospital,

Nijmegen,

M.I.M. of Gas-

Netherlam&.

Fat in the lumen of the small intestine inhibits gastric acid secretion. The factors responsible (“enterogastrones”) are not known. Since fat is a potent stimulus of cholecystokinin (CCK) release, circulating CCK might have enterogastrone activity. In order to test this hypothesis, 6 healthy subjects (6M; 20-26 yr) were studied on 3 separate occasions. After a l-h basal period, gastric acid output (AO) was measured by the phenol

of Medicine

46 (1995)

AI-A36

red recovery technique during continuous i.v. infusion of gastrin (10 pmol/kg . h) until the end of each experiment. At 60 min of i.v. gastrin either saline or corn oil (60 ml) was perfused intraduodenally for 90 min, or increasing doses of CCK (0.06, 0.12 and 0.5 IDU/kg.h) were infused i.v. for 45 min each. Results of the last 30 min of each experimental period were compared. During the first hour of i.v. gastrin, plasma gastrin increments (24 f 4, 30 k 6 and 26 + 3 pM; NS) and A0 (9.2 f 0.9, 8.3 + 0.8 and 7.9 + 1.4 mmol/30 min; NS) were similar in the 3 experiments and comparable to values obtained after ingestion of a meal. Perfusion of saline did not influence A0 (9.2+ 0.9 vs. 8.3 f0.5 mmol/30 min; NS) or integrated plasma CCK (76 + 7 vs. 79 + 6 pM/30 min; NS). On the other hand, perfusion of corn oil stimulated plasma CCK from 75 + 6 to 98 f 7 pM/30 min (p < 0.005) and markedly inhibited A0 from 8.3kO.8 to 2.lkO.4 mmol/h (p < 0.005). Infusion of CCK dose-dependently increased plasma CCK to 74 f 4, 79 f 3 and 136 + 6 pM/30 min respectively, but did not inhibit A0 output (8.4+ 1.7, 8.6 + 1.7 and 7.3 f 1.9 mmol/30 min, respectively; NS). Conclusion: The present study does not support the hypothesis that circulating CCK in response to intraduodenally administered fat is an enterogastrone. Effects of dietary flavone and a-aagelicalactone, individually and in combination, on oesophageal, gastric, intestinal, colonic and hepatic glutathlone S-transferase enzyme activity and isozyme levels. W.A. Nijhoff, M.A. Bosboom, W.H.M. Peters. Department of Gastroenterology, boud, Nijmegen, Netherlands.

Academic

Hospital

St Rad-

Many studies have linked naturally occurring anticarcinogenie compounds, constituents of commonly consumed vegetables and fruits, to the prevention of gastrointestinal tumours. However, the protective mechanism is still unclear, but induction of glutathione S-transferase (GST) seems crucial. GSTs are a family of isozymes, divided into classes a, p and r, which serve a major role in the detoxification of many substances including carcinogens. In order to understand better the anticarcinogenic potential of flavone and cY-angelicalactone we have determined their effects, either incorporated in the diet individually or in combination at 0.5, 0.1, 0.05 and 0.01% w/w, on oesophageal, gastric, intestinal, colonic and hepatic (1) GST enzyme activity and (2) GST isozyme levels. Male rats were fed normal or supplemented lab chow for 2 weeks. Organs were isolated and cytosolic fractions were prepared. Herein, GST activity towards 1-chloro-2,4-dinitrobenzene was measured and levels of GST isozymes were determined by densitometrical analysis of Western blots after immunodetection with monoclonal antibodies. Wilcoxon’s rank-sum test was used to assess statistical significance of differences. AI1 3 treatments tested increased GST activity at one or more sites. The largest inductions were seen in oesophagus and stomach by 0.5% a-angelicalactone (1.9X and 2.3 x , respectively); in small intestine, colon and liver by 0.5% combination treatment (2.5 X , I.4 X and 4.0 X , respectively). The inducing capacity declined with decreasing concentrations. However, hepatic GST activity was induced by flavone

Abstracts

/Netherlands

Journal

and combination treatment at concentrations as low as 0.05% (1.5 x and 1.9x, respectively). Interestingly, colonic GST activity was significantly increased in 0.5% combination group (1.4 x ), whereas flavone and cr-angelicalactone given individually were not able to induce GST activity. Concomitant changes in GST isozyme levels occurred. The involvement was the highest for GST-u (75%), followed by -p (58%) and -n (33%). Conclusion: Individual dietary administration of flavone and, more especially, a-angelicalactone may result in strong chemoprotective effects in stomach, small intestine, liver and, to a lesser extent, oesophagus by enhancing the GST detoxification system. Furthermore, combined exposure to flavone and a-angelicalactone may result in anticarcinogenic effects in the colon by the same principle. Effects urinary

of consumption of Brussels glntathione S-transferase-a

sprouts on plasma and -T in humans.

and

W.A. Nijhoff a, T.P.J. Mulder a, H. Verhagen b, G. van Poppel b, W.H.M. Peters a. * Department of Gastroenterology, University Hospital Research

St Radboud, Nijmegen, b TN0 Institute, Zeist, Netherlands.

Nutrition

and

Food

Many studies have linked diets rich in glucosinolate-containing cruciferous vegetables, such as Brussels sprouts (Brassica; Oleraceae), to the prevention of gastrointestinal tumors. A possible anticarcinogenic mechanism may be the induction of glutathione S-transferases (GST), a family of detoxification enzymes with tissue-specific distribution which serves a major role in detoxification of carcinogens. In this study, we evaluated the effects of consumption of Brussels sprouts on plasma and urinary GST-(Y and -rr levels. Five male and 5 female non-smoking volunteers were randomly assigned to two groups in a cross-over design. Five persons started on a glucosinolate-free diet for a week (control period), while the other 5 consumed 300 g of cooked Brussels sprouts per day, at the expense of 300 g of glucosinolate-free vegetables (sprouts period). GST levels were measured by enzyme-linked immunoabsorbent assay (ELISA). At the end of the sprouts period, a significant 1.5-fold increase in plasma GST-a levels was observed in males but not in females (control vs. sprouts, Wilcoxon matched-pair sign test; p-values 0.040 and 0.250, respectively), while plasma GST-n levels as well as urinary GSTiv and -rr levels remained unchanged. In addition, no change in liver function parameters (alanine aminotransferase, aspartate aminotransferase and y-glutamyltransferase) were observed between the two periods. These data strongly suggest that the increased plasma GSTa levels are the result of normal hepatic cell-turnover, with higher GST-a levels in the liver cell at the end of the sprouts period. We hypothesize that this increased hepatic detoxification capacity may reflect a lower susceptibility to toxicants for males, but not for females, after consumption of glucosinolate-containing Brussels sprouts. Cakium in mtlk products precipitates and inhibits luminal cytotytk activity

intestinal in healthy

surfactants subjects.

M. Govers”, J.H. KIeibeuker b, J.A. Lapre a, R. Vonk b, R. van der Meer a. a Netherlands Institute for Dairy Research, Ede;

of Medicine

46 (1995)

b University

Al7

Al -A36

Hospital,

Groningen,

Netherlands.

Supplemental dietary calcium may reduce the risk of colon cancer by precipitating hydrophobic surfactants such as bile acids and free fatty acids and thus decreasing their cytolytic activity. In rats, cytolytic activity of faecal water and colonic proliferation were decreased by milk mineral. which is an important source of dietary calcium. We have studied the effects of calcium in milk on metabolic risk factors in healthy subjects. In a double-blind cross-over design of 2 X 1 wk, 13 healthy men (24-53 y) kept a constant habitual diet containing +20 mmol ( = 800 mg) Ca/d, which was supplemented with either regular (30 mmol Ca/ll or placebo (3 mmol Caill milk and yogurt, total 1 l/d. Faeces were collected for 3 X 24 h and urine for 1 x24 h. Faecal water was prepared from fresh faeces. Cytolytic activity was determined as lysis of erythrocytes by faecal water. Data are mean+SE, n = 13. Supplemental calcium was completely ( > 99%) recovered, mainly in faeces. Milk calcium increased faecal pH and faecal excretion of phosphate (132%), total fat (139%1, free fatty acids (195%) and bile acids (141%), indicating intestinal complexation. Faecal water parameters

Placebo-milk

Calcium-milk

PH Fatty acids (mM1 Total bile acids &Ml Esterified bile acids (FM) Bile acid hydrophobicity ’ Phospholipids (mM) Cytolytic activity (%o)

6.3kO.l 8.8+2.6 298+41 193 + 29 10.4 f 0.2 0.96kO.19 68+9

6.XiO.l * 3.9+1.3 * 221 -t41 * 126+28 ’ 6.4506 * 0.54+0.16 * 2x*12 *

’ p < 0.05 (one-tailed Wilcoxon’s signed-ranks test). ‘Expressed as the ratio of (mono- + dihydroxyl to (trihydroxy + keto) bile acids. Conclusions: Milk calcium (equivalent to almost 1 litre of milk per day) precipitates cytolytic surfactants and thus inhibits luminal cytolytic activity in healthy subjects. Therefore, dairy products may contribute to the nutritional prevention of colorectal cancer. Supported by NWO-grant 900-562-078, Medical Sciences.

Body composition analysis (BIA)

measurements in patients with

by bioekctrkal cystic Bbrosis

impedance (CF). G.R.

Swart a, S.E. Gverbeek b, J.K. van Vuure ‘, J.W.O. van den Berg a. Departments of a Internal Medicine II and ’ Pulmonology. University

Hospital,

Rotterdam,

Netherlands

Cystic fibrosis is frequently accompanied by low body weight or even clinical malnutrition due to exocrine pancreatic insufficiency and the catabolic effects of chronic infection. During admissions, on treatment for pulmonary infections and on nutritional therapy, patients usually gain weight with improvement of their condition. BIA is a simple method to determine body composition in healthy individuals; its value in clinical medicine has not yet been established. We performed consecutive BIA measurements in CF patients in the out-patient clinic as well as before and after clinical admis-

Al8

Abstracts

/Netherlands

Journal

out-patient clinic as well as before and after clinical admissions. In non-fasting CF patients BIA was measured with a RJLlOl analyser; calculations of body compartments were performed with RJL-supplied software. In out-patients, measurements were repeated every 6 months while during admissions measurements were performed during the initial days and on discharge. Compared to the control group (n = 64), CF patients (n = 64) have a lower body height (1.71 kO.1 vs. 1.74kO.l m; p < 0.05) and body weight (.58.4* 9.5 vs. 66.7& 9.4 kg; p < 0.01). Body cell mass (BCM; 24.3 f 5.7 vs. 28.4 + 6.1 kg; p < 0.01) and extracellular mass (ECM; 21.7+ 3.1 vs. 24.6 f 4.1 kg; p < 0.01) are lower in both sexes while fat mass is reduced in males (9.6 +3.9 vs. 12.Ok3.4 kg; n = 30, p < 0.05) but not in females (14.9 f 4.4 vs. 14.9+ 2.9 kg; n = 34; ns). During 2 years of follow-up, no changes in these parameters were found. During admissions for treatment of pulmonary infections (n = 33; interval 17.4 f 8.3 days), body weight increased (53.9 f 9.3 vs. 55.5 +9.7 kg; p < 0.01). Fat mass increased (11.9k4.1 vs. 13.3 f3.8 kg; p < 0.01) while lean body mass and its constituents body cell mass (21.7f4.8 vs. 21.8+ 4.9 kg; ns) and extracellular mass (20.3 +3.3 vs. 20.6k3.0 kg; ns) did not change. In patients needing in-clinic treatment within 1 year following a BIA measurement, body cell mass was lower than in those who were not hospitalised. Conclusions: CF patients have a lower body height and weight; otherwise, body composition in these patients is not markedly different from normal and changes little over time. During clinical treatment, the gain in body weight is mainly due to an increase in fat mass. BIA measurements, especially the calculation of BCM, seem to have some prognostic value. Influence of the emulsifier in parenteral polymorphonuclear leukocyte function.

lipid

emulsions

on

J.W. Kruimel ‘, M.A.M. Wenker a,c, A.H.J. Naber a, J.H.A.J. Curfs b, J.A.A. Hoogkamp-Korstanje b, J.B.M.J. Jansen a, M.B. Katan ‘. Departments of a Gastroenterology and b Medical Microbiology, University Hospital, Ntjmegen, ‘Department of Human Nutrition, Agricultural University, Wageningen, Netherlands.

The effects of parenteral lipid emulsions on leukocyte function are unclear. We studied the in vitro effect of lipid emulsions on zymosan-stimulated phagocytosis by human polymorphonuclear leukocytes (PMN’s), measuring chemiluminescence (CL). CL is the emission of light by a chemical reaction and occurs during the production of reactive oxygen metabolites (ROM’s) in the respiratory burst of phagocytosing PMN’s. Previously, we reported a different pattern of CL with a physical mixture of medium-chain and long-chain triglycerides (Lipofundina: MCT/LCT) compared to long-chain triglycerides (Intralipid a.. LCT) and structured triglycerides (STG). The production of ROM’s was faster and the peak level was higher with MCT/LCT compared to LCT and STG. This can be detrimental when ROM’s play a pathogenetic role (MOF) or beneficial when rapid phagocytosis is needed. We have now studied whether these differences in CL were due to the triglycerides or the emulsifier.

of Medicine

46 (1995)

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We tested 3 LCT-emulsions: Lipofundin S@ (emulsifier: soya phospholipids), Intralipid” (emulsifier: egg yolk phospholipids) and Emulsana (emulsifier: a different egg yolk phospholipid). Isolated PMN’s from 10 volunteers were incubated without and with the lipid emulsions (1.0 mmol/l). No differences in CL between emulsions were observed. Compared to controls, the lipid emulsions showed a slower production of ROM’s with lower peak levels (both p < 0.05); the overall production of ROM’s was equal to controls. Conclusion: We found no differences in CL between LCT-emulsions with various emulsifiers. Differences in CL are probably due to a different structure of the triglycerides. Arginine metabolism after partial enterectomy in rats. C.H.C. Dejong, C.F.M. Welters, E. Heineman, N.E.P. Deutz. Department of Surgery, Netherlands.

BMC,

University

of

Limburg,

Maastricht,

Arginine (ARG) is a semi-essential amino acid that can be produced in the kidney from citrulline (CIT). An important source of circulating citrulline is the intestinal breakdown of glutamine. Accordingly, we have previously shown that partial enterectomy leads to decreased plasma citrulline levels, which could diminish renal citrulline uptake and arginine production, and reduce the body free arginine pool. This hypothesis was studied by measuring renal amino acid metabolism, 24 h after partial (75%) small bowel resection in overnight (16 h) fasted rats CENT group, n =,12; total fast 40 h). Sham-operated (SHAM, n = 9), and non-operated 16 and 40 h fasted controls were studied in parallel (CON& CON& n = 8, n = 7). During anaesthesia, L-[2,3-3H]Arginine and PAH for plasma flow (2 kidneys) were infused until steady state and arterial (Art) and venous blood samples were taken. PAH and amino acid concentration and specific activity of ARG and CIT were measured to calculate net renal flux, production, consumption and whole-body ARG turnover (WB-ARG). Art-CIT (not shown) was decreased in the ENT group compared with SHAM rats. Net renal CIT consumption and ARG production were nearly stoichiometric and were both diminished in ENT versus SHAM (ARG 19*2 VS. 38 i6; CIT -15 +3 VS. -36 & 7 nmol/lOO g bw/min; both p < 0.05). Net renal ARG production accounted for less than 10% of WB-ARG in all groups. Despite decreased net CIT consumption and ARG production in ENT rats, WB-ARG and Art-ARG were similar in ENT and SHAM rats (WB-ARG 385 +31 vs. 488*44; Art ARG 93 f 13 vs. 107 + lo; both p > 0.05). Conclusion: Net renal ARG production is reduced after enterectomy in rats. However, this does not affect whole-body ARG production. The discriminatory value of patient characteristics and dyspeptic symptoms for upper gastrointestinal endoscopic flndings. R.P. Adang a, A.W. Ambergen b, J.L. Talmon ‘, A. Hasman ‘, F-J.F.E. Vismans d, R.W. Stockbriigger a. ‘Department of Gastroenterology, Universi@ Hospital and Departments of b Statistics and Methodology / ’ Medical Informatics, University of Limburg, Maastricht, and d Department of Internal Medicine, Kennemer Gasthuis, Haarlem, Netherlands.

Abstracts

/Netherlands

Journal

Aims were to assess (1) whether patients with a specific endoscopic diagnosis have a typical symptom profile which distinguishes them from symptomatic patients with normal endoscopy, and (2) whether it is possible to discriminate patients with clinically relevant endoscopic disease from those without by analysing patient characteristics and dyspeptic symptoms. This prospective study was performed at an open-access endoscopy unit from January 1989 until October 1990, and included 1147 patients attending for their first diagnostic upper GI endoscopy who answered a paper questionnaire (n = 431) or a computerised history-taking system (n = 7161. The questionnaires delivered detailed information (55 items) concerning past history, present dyspeptic symptoms, with special attention to relieving and provoking factors, and alcohol and cigarette consumption. The following data were collected: age, gender, referral indication(s) (extracted from the request form), pain localisation(s) and previous drug treatment (obtained by an interview conducted by the endoscopistl, and predefined endoscopic diagnoses. After univariate analysis of all 73 variables available, those with p-values < 0.25 were entered in a forward stepwise logistic regression analysis. In the logistic regression models each of a number of specific endoscopic diagnoses was contrasted to normal endoscopy (n = 3901, and “relevant” endoscopic findings (oesophagitis; peptic ulcers; cancers) were contrasted to “irrelevant” findings and normal endoscopy (n = 878). From the regression models a receiver operating characteristic (ROC) curve was constructed. The area under the ROC curve (AUC) was calculated to summarise the discriminatory power of the regression models. Diagnostic category

AUC

Gastric ulcer (n = 56) Duodenal ulcer (n = 78) Hiatus hernia (n = 186) Oesophagitis (n = 141) Duodenitis/bulbitis (n = 152) Endoscopic gastritis (n = 167) Relevant disease (n = 269)

0.86 0.85 0.78 0.77 0.75 0.73 0.63

The best discrimination from patients with a normal endoscopy was achieved for patients with peptic ulcers, followed by patients with hiatus hernia or oesophagitis. The regression models had the least discriminatory value for duodenitis/

ND p53-overexpression Conventional PRODIT [%I Ki67-IHC Index [%] Surface labelling

0 0 45.2 + 1.8 0

of Medicine

46 (1995)

A19

Al -A36

bulbitis and endoscopic gastritis. It was hardly possible to predict the presence of clinically relevant disease in patients undergoing endoscopy by analysing their symptoms. Conclusion: This study suggests a limited value of historytaking for the prediction of endoscopic findings in an openaccess unit.

~53 and Ki67 as markers metaplasia-dysplasia-carcinoma

for tumour

progression

in Barrett’s

sequence. W. Polkowski ‘, J.J.B. van Lanschot a, F.J.W. ten Rate b, J.P.A. Baak b, G.N.J. Tytgat ‘, H. Obertop a, G.J.A. Offerhaus b. Departments of ’ Gastroenterology, ’ Surgery, b Pathology, Center, Amsterdam, Netherlands.

Academic

Medical

Barrett’s oesophagus (BE) is considered a premalignant condition. The morphologic progression from metaplasia via dysplasia to invasive adenocarcinoma is probably 3 multistep process with different genetic mutations in association with increased cell proliferation. The p53-tumour suppressor gene is a key factor in this progession. Mutation of the p53-gene results in the production of a mutant peptide, detectable by immunohistochemical (IHC) techniques and is deprived of its normal regulatory function. Ki67-monoclonal antibody recognises a nuclear protein, which is only present during cell proliferation. The aim of this study was to test the metaplasia-dysplasia-carcinoma model by correlating between grade of dysplasia, p53-overexpression, and Ki67-proliferative parameters. In 25 oesophagectomy specimens 32 areas were selected: 7 negative for dysplasia (ND), 5 indefinite for dysplasia (ID), 11 low-grade dysplasia (LGD) and 9 high-grade dysplasia (HGD). Overexpression of ~53 was scored by conventional microscopy; percentage of p53positive cells was automatically quantified using Professional Digitizing Interactive Tool (PRODIT). Proliferative index (percentage Ki67positive cells) and expansion of proliferative zone tKi67-labelling of mucosal surface) were determined for each group. Results are presented in the table (mean +SEM). Trends were statistically analyzed using Cochran’s linear trend-test or linear regression analysis when appropriate. Conclusion: Both genetic aberration (p53-overexpression) and proliferative activity Ki67-parameters) increase significantly in correlation with increased morphological dysplasia. These data support the concept of Barrett’s metaplasia-dysplasia-carcinoma sequence as a multistep process.

ID

LGD

HGD

Trend-test

l/5 (20%) 6.3 + 6.3

6/11 (55%) 26.6 + 9.4

8/9 (89%) 55.8 + 12.7

0.0002 < o.ou I

45.3 + 6.0 l/5 (20%)

46.1 + 3.8 4/11(36%1

68.4 + 4.9 9/9 (loo%1

< 0.00s 0.0001

A20 Assessment carbohydrates.

Abstracts of glycogen

stores

using

/Netherlands

naturally

Journal

“C-enriched

R. Kroneman, G.R. Swart, J.L.D. Wattimena, B. Nieland, T. Rietveld, J.K. van Vuure, J.W.O. van den Berg. Department of Internal dam, Netherlands.

Medicine

II, University

Hospital,

Rotter-

Liver glycogen is an important energy store for short periods of fasting. The contribution of glycogenolysis to total hepatic glucose production is about 80% in a normal overnight-fasted subject. In liver disease, glycogen stores are expected to be limited, which may impair availability of carbohydrate substrate and lead to early onset of gluconeogenesis or proteolysis. The classical method for glycogen determination by liver biopsy is invasive and is prone to sampling errors. Therefore we developed a new method to assessbody glycogen stores using carbohydrate (CHO-4) produced by the C4 plants corn and sugar cane. Carbohydrates (starch and sugar) from these plants have a higher natural abundance of 13C than those from the more common CJ-plants (potatoes, wheat, rice etc.) Method: Glycogen stores were depleted by feeding 80% energy needs (predicted by the Harris-Benedict formula) as a CHO-4 free diet for 1 day. The background t3C-enrichment in expired air was determined during that day using hourly samples. Expired air was sampled using simple vacutainers and a drinking straw. The following day an adequate ( > 100% energy by H-B) CHO-4 enriched diet was used and the increase in 13C0, in expired air was monitored. On the 3rd day the subject fasted, while exhaled air was sampled halfhourly starting at 8.00 h with the same technique. 13COz was measured by isotope ratio mass spectrometry. Results: 14 healthy subjects participated in the study (5 males and 9 females). Basal breath 13C0, enrichment was 1.0826 At% (sd = 0.0004). Then, on 13C-CHO-4 loading, breath 13COz increased up to 1.104%. On the following fasting day, breath i3C0, enrichment declined linearly, and a regression line was calculated. The point where the regression line reached the subject’s own basal level of 13CQ, enrichment was taken as the point in time where glycogen supply for oxidation was finished. This depletion time was 18 + 2.8 (mean f sd) h after the last meal (n = 14). Preliminary results of this test in patients with liver cirrhosis show markedly shorter depletion times, suggesting smaller glycogen stores in these patients. Conclusion: Glycogen reserves available for oxidation can be determined non-invasively with the disappearance time of breath 13C0, enrichment after loading the glycogen pool with natural 13C-enriched carbohydrate on the previous day. Recurrence of hepatitis B after liver transplantation in the pre-immunoprophylaxis era. E.B. Haagsma, L. Meerman, ASH. GOUW, H.T. Cuypers, M.J.H. Slooff, P.L.M. Jansen. Liver Transplant Group, Groningen, and CLB, Amsterdam, Netherlands.

When we started our liver transplant program in hepatitis B was considered an absolute contraindication. reports showed reasonable survival rates despite HBV rence. Between January 1992 and July 1993 we have

1979, Later, recurtrans-

of Medicine

46 (1995)

AI -A36

planted 14 HBsAg-positive patients. Anti-HBs immunoglobulin was not yet available at that time. The overall survival in this group was below average: 6 patients died within 2 months due to various causes unrelated to HBV. In the remaining 8 patients liver biopsies were taken 1, 6, 12 and 26 weeks and every year after OLT. Seven patients had cirrhosis and one acute hepatic failure. Median age was 43 years (32-58); 6 were males. Pre-OLT serum HBeAg was positive in 2/8, HBV-DNA by hybridization in 6 and HBV-DNA by PCR in 7 patients. HBV recurrence, defined as positive immunostaining of liver tissue for HBsAg and HBcAg in combination with a positive serum HBV-DNA hybridization test, occurred in 5/8 patients; 4/5 were HBV-DNA-positive before OLT. Recurrence occurred 3-4 months after OLT and in these patients serum HBV-DNA levels became very high. 3/5 patients died from liver failure, 8-16 months after OLT. 2/5 patients are alive and well 16 and 22 months after OLT with histological signs of inflammation and fibrosis. No HBV recurrence occurred in 3 patients despite a positive serum HBV-DNA by PCR in 2. One of these 3 patients was retransplanted because of chronic rejection. He died shortly thereafter, 18 months after the initial transplantation. Conclusion: A HBV recurrence rate of about 65% was seen in this cohort and this contributed to a low survival rate. At present, only HBsAg-positive patients that are negative in the HBV-DNA hybridization test (may have a positive HBVDNA PCR test) are considered for OLT. They receive antiHBs immunoglobulins after OLT. HBV-DNA-positive patients will be pre-treated in trial form and become OLT candidates when the serum HBV+DNA test becomes negative. Inflammatory mass in the head of the pancreas in chronic pancreatitis: pathophysiological and clinical implications. H.G. Beger *. Department of General Surgery, University of Ulm, Ulm, Germany.

About one-third of patients with chronic pancreatitis (CP) suffer from a disease dominated by increasing abdominal pain and an inflammatory mass in the head of the pancreas (IMH). In this subgroup of CP-patients the clinical course of the disease, mostly caused by alcohol overconsumption, reveals after a period of 4-5 years an enlargement of the head of the pancreas. Common bile duct (CBD) stenosis in the prepapillary intrapancreatic segment as well as pancreatic main duct stenosis in the head are frequent; in some patients an additional duodenal stenosis develops. Vascular involvement is also frequent, resulting in portal vein compression with signs of portal hypertension. Macroscopically, parenchymal calcifications, pancreatic duct calculi, small or occasionally large cystic cavities and small areas of necrosis are found within the IMH. Microscopically, atrophy of the exocrine pancreas as well as local increase in collagen and other fibrotic tissues, and specific inflammatory changes in the nerves are typical features.

* SmithKline Beecham Visiting Lecturer.

Abstracts

/Netherlands

Journal

CP-patients with an IMH, besides attacks of pain, have abdominal complaints caused by compression of the CBD in 60%; 50-70% develop a pancreatic main duct stenosis in the head, .5-10% have clinical symptoms secondary to a severe stenosis of the duodenum, and lo-20% of patients have signs of portal hypertension. Alcohol-induced CP-patients with an IMH suffer more frequently from severe abdominal pain, have significantly more often a CBD stenosis, a pancreatic main duct stenosis, a severe duodenal stenosis and/or portal vein compression but significantly less often diabetes mellitus than CP-patients without an IMH. In 4% of CP plus IMH-patients with a history of chronic pancreatitis pathological examinations revealed an adenocarcinoma in the head. Molecular biological investigations of patients with CP and an IMH showed a higher percentage of growth receptor positivity for pancreatic ductal and acinus cell tissue from the inflammatory head region than for the tissue of the left pancreas. Up to 12/1993 847 patients with CP received surgical treatment in this institution. In 317 patients (37% of all CP patients) a duodenum-preserving head resection instead of a Whipple procedure was performed. The medium time for medical treatment prior to surgery was 4; years. Objective criteria indicating surgery were daily upper abdominal pain, IMH, CBD stenosis, severe duodenal stenosis and portal hypertension. Hospital mortality after duodenum-preserving head resection in this series of 317 patients was 0.8%. The frequency of re-intervention was 5.4%, the medium hospital stay 13 days. In the follow-up period, ranging from 3 months to 17 years, 77% of patients were completely free from abdominal pain; 12% complained of upper abdominal discomfort. 89% of patients were cured of the upper abdominal pain. ll%, however, continued to suffer from attacks of pain. Hospitalisation for further attacks of chronic pancreatitis in the postoperative course was necessary only in 11% of patients. Regarding glucose metabolism, 82% of the patients demonstrated a stable glucose metabolism in the late post-operative period; 10% developed diabetes mellitus; however, 8% showed an improvement of the diabetic state; late mortality was 5%. Conclusion: CP with IMH constitutes a subgroup of patients, covering 30% of all patients with alcohol-induced CP. The inflammatory process is the pacemaker of this disease, leading to severe upper abdominal pain, common bile duct stenosis and portal vein compression. The duodenum-preserving head resection is the standard surgical treatment of CP with IMH. Colon cleansing in the outpatient: a comparison of three methods of preparation for colowscopy. J. Haringsma, W. Dekker, J. Fenverda. Department of Internal Medicine, Kennemer Gasthuis, Haarlem, Netherlands.

In a randomized, single-blind fashion we compared three methods of colon cleansing for effectiveness, side-effects and patient acceptance. Fifty-four patients undergoing colonoscopy on an outpatient basis were randomized to a regimen of (A) whole gut irrigation, (B) a l-day clear-liquid diet plus 2 litres

of Medicine

46 (1995)

A21

AI -A36

of oral polyethylene-glycol-based lavage solution (PEG) on the evening prior to the examination and (Cl a l-day dietary restriction in combination with rinsing enemas immediately prior to the examination. All three regimens were combined with the use of laxatives. Immediately prior to colonoscopy subjects were asked to fill out a short questionnaire. After colonoscopy the overall cleansing result was graded by the colonoscopist on a 4-point scale. Results were analyzed on an intention-to-treat basis. In both Group A and Group B one subject could not complete the preparation. Whole gut irrigation (n = 12) was better in achieving an excellent (67%) or good (25%) cleansing score compared with oral PEG lavage (5 and 50%; n = 20, p < 0.01) or rinsing enemas (27 and 50%; n = 22, p = 0.06). Enemas, again, were superior in cleansing to PEG (p < 0.05). There were no major differences in reported side-effects (nausea, vomiting, bloating, pain and cramps). Whole gut irrigation WaS considered by the subjects as very uncomfortable in 38%. oral PEG in 32% and rinsing enemas in 18% of preparations (n.s.). Conclusion: Best colon cleansing is achieved with whole gut irrigation. However, rinsing enemas are effective and seem better tolerated by the patients. A 2-litre oral PEG lavage as used in this study is an inadequate preparation for colonoscopy.

variation on endoscopic observations. P.W. Moorman aSb,P.D. Siersema b, A.M. van Ginneken a. Depart-

Interobserver

ments of a Medical Informatics and b Internal mus University, Rotterdam, Netherlands.

Medicine,

Eras-

Little is known about the interobserver variation between endoscopists on descriptive morphological features. This study describes the agreement among 10 endoscopists on their description of 12 morphological features, using photographs of gastric ulcers, and on their eventual interpretation. The endoscopists used a form with predefined options for description. To analyze agreement, we assigned the descriptions given, to one of three categories: statement A, statement B, or not possible to give a reliable statement. Two measures of agreement were calculated: kappa (constructed to range from -1 to 1) and the proportion of agreeing endoscopists konstrutted to range from 50 to 100%). Kappa value was on average 0.36 for descriptive features, and 0.31 for interpretation. The proportion of endoscopists agreeing on descriptive features was on average 84%, and 81% on interpretations. The chance of an endoscopist describing all 12 morphological features of an ulcer on a photograph exactly the same as a colleague ranged from 4 to 46% (average 15%). These results indicate poor agreement between endoscopists in their translation of visual observations in descriptive terms. The positive correlation between agreement in description and interpretation (0.75, p < 0.05) suggests disagreement in description as an important cause for disagreement in interpretation. We believe that making the meaning of descriptive terms explicit may improve agreement in description and in subsequent interpretation.

A22

Abstracts/Netherlands

Amyotrophic lateral tion: is percutaneous

sclerosis and impaired endoscopic gastrostomy

pulmonary feasible?

Journal func-

E.M.H. Mathus-Vliegen, E.S. Louwerse, M.P. Merkus, G.N.J. Tytgat, J.M.B.V. de Jong. Department of Gastroenterology and Neurology,

Academic

Medical

Centre,

Amsterdam,

Netherlands.

In amyotrophic lateral sclerosis (ALS), a rapidly progressive disease resulting in tetraparalysis, dysarthria, dysphagia and ultimately death from respiratory insufficiency, artificial enteral nutrition is often necessary. Nasoenteral tube placement is inconvenient and unattractive. Percutaneous endoscopic gastrostomy (PEG) seems a better though potentially hazardous alternative in view of the severely restricted pulmonary function. We therefore prospectively investigated the use of a PEG in 68 consecutive patients with ALS. A minimally required pulmonary function, defined as a forced vital capacity (FVC) of 1 litre or more and a pC0, of 45 mmHg or less, had to be present. The placement technique had to be adapted to minimize air insufflation, to facilitate adequate and early removal of gastric air and to avoid intravenous sedation. Fifty-five patients (FVC 1.7L; pCOz 40 mmHg) were eligible for the PEG, and 13 patients (FVC 0.8L, pC0, 47 mmHg) were not. Although modification of the method of insertion rendered the procedure more difficult, the success rate was 89% (49/55) and 96% (49/51) when failures related to distorted anatomy were excluded. The procedure-related mortality was 1.8%; 24-h in-hospital mortality was 3.6%, mainly related to respiratory insufficiency; two major complications of cutaneous abscesses were seen (3.6%). Minor complications consisted of peristomal redness (6 cases) and wound pain (5 cases). Median survival in the PEG group (122 days) was not different from median survival in the group that did not receive a gastrostomy (92.5 days). In the latter group, repeated episodes of choking in foods and drinks and tube-related complaints interfered with the quality of life. Conclusions: PEG placement is successful, safe and convenient in respiratory-compromised patients with far-advanced neurological disease, provided that attention is paid to minimal air insufflation and above all to immediate and early removal of gastric air. Percutaneous ultrasound-guided gastrostomy (PUG): trespass or real entry to the stomach? H. Boot a, R. Kroger b, B.G. Taal ‘. Departments of a Gastroenterology and ‘Radiology, Netherlands Cancer Institute / Antoni van Leeuwenhoekziekenhuis, Amsterdam, Netherlands.

Percutaneous endoscopic gastrostomy (PEG) is an accepted method of feeding selected patients and it can also be used for decompression in patients with extensive peritoneal carcinomatosis. PEG requires endoscopy. Safe access to the stomach with fluoroscopic and ultrasound guidance is possible (PUG). The procedure requires sufficient insufflation of the stomach. Glucagon is used for hypotonia. The stomach is entered by direct puncture after local anaesthesia. The whole procedure is guided by fluoroscopy. The stomach is secured to the abdominal wall. After the procedure aqueous contrast can be given to check the proper position.

of Medicine

46 (1995)

Al -A36

The possible complications are not different from the endoscopic procedure. The low risk of metastatic seeding in the abdominal wall after PEG with the pull method is avoided. We used this PUG method in 23 patients, 12 males and 11 females, mean age 61 years (range 36-89). The indication was alimentary access in 19 and decompression in 4 patients. The original malignancies were: ENT 16, oesophageal 5, ovarian 3 and other 2. Three patients had two primary malignancies. The indication for this method was impossible/difficult endoscopic access in 16 patients and logistics in 7 patients. Gastric access was impossible in 1 patient. Minor complications were seen in 5 patients: 2 minor wound infections and in 3 the catheter was lost. Median follow-up was 96 days. Nine patients died: 6 with tumour progression, 2 possibly procedure-related with signs of peritonitis 2-3 days after the procedure and 1 with aspiration. Conclusions: (1) Non-surgica! gastrostomy can be performed without endoscopy. (2) The method can be performed by 1 operator. (3) The procedure is simple in most cases, often slightly more cumbersome when used for decompression, and often takes only lo-15 min.

Polyurethane-covered self-expanding metal stents for anastomotic fistulas in postoperative patients with oesophageal tumours. L.C. Baak, M.H. Otten. Department of Internal Medicine, Eemland Hospital (Lichtenberg), Amersfoort, Netherlands.

Oesophageal-respiratory fistula formation is a well-known complication of oesophageal and bronchial tumours. In patients with oesophageal carcinoma anastomotic fistulas have been reported following oesophagectomy, increasing postoperative morbidity and mortality. We report our experience with a polyurethane-covered self-expanding metal stent (Wallstent) in 2 patients (2 females, age 72 and 60 years). Both had an oesophageal carcinoma (1 adeno, 1 squamous cell) without (lymph node) metastases, and surgical resection was considered feasible. Operation appeared to be radical. In the postoperative period both patients developed an anastomotic fistula. Stents were inserted under combined endoscopic and fluoroscopic control. Efficacy of sealing the fistula was checked by X-ray studies with water-soluble contrast. In both patients the insertion was successful. No procedure-related complications were seen. Successful occlusion of the fistula allowing intake of semi-solids was seen in one patient. In the other recurrent periods of fever and persistent coughing were observed. The Wallstent appeared not to be completely dilated at the proximal site, allowing leakage of fluids. Eventually a second stent (Nothingham) was inserted into the Wallstent, sealing the gap. Both patients are still alive and well, 210 and 90 days after the procedure. Conclusion: The polyurethane-covered self-expanding stent may be effective in managing anastomotic fistulas in patients with oesophageal carcinoma following (radical) surgical resection. Insertion of these stents may improve postoperative morbidity and mortality.

Abstracts

/Netherlands

Journal

Technical aspects of diagnostic laparoscopy combined with laparoscopk sonography in preoperative staging of cancer of the pancreatic bead region. W.A. Bemelman a, L.Th.de Wit ‘, O.M. van Delden b, N.J. Smits b, H. Obertop a, E.J.A. Rauws ‘, D.J. Gouma a. Departments of a Surgery, b Radiology and ’ Gastroenterology, Netherlands.

Academic

Medical

Center,

Amsterdam,

Since the revival of minimally invasive surgery, diagnostic laparoscopy has gained ground in the preoperative staging of pancreatic cancer. Small liver and peritoneal metastases can be detected with a high accuracy rate. The development of a laparoscopic sonography probe made it possible to evaluate the solid organs and retroperitoneal space during the same procedure without disturbance of overlying bowel gas or thick abdominal wall. In the past year experience has been gained with this new diagnostic modality. This video shows the technique and possibilities of laparoscopy combined with ultrasound in the preoperative staging of pancreatic cancer. Using a three lO/ll-mm trocar approach the abdominal cavity is investigated for peritoneal and hepatic deposits and malignant infiltration of mesocolon and Treitz ligament. Laparoscopic exploration of the lesser sac and biopsy of lymph nodes around the coeliac axis are demonstrated. Laparoscopic ultrasound of the liver and of the tumour with regard to vascular involvement (local unresectability) is shown. Biopsies of suspicious lesions are taken under direct laparoscopic or ultrasound guidance using biopsy forceps or Tru-cut and Rotex biopsy needles. In 70 patients with a presumed Stage I tumour of the pancreatic head region, local vascular involvement was correctly predicted in 93% and laparotomy was avoided in 19%. Endoscopic stenting for pancreatic duct leakage after necrosectomy for acute haemorrhagic necrotising pancreatitis. M.J. Boom a, W. Dickey b, T.M. van Gulik a, P.C.M. Verbeek a, E.A.J. Rauws b, D.J. Gouma a, H. Obertop a. Departments of a Surgery Amsterdam,

and b Gastroenterology, Netherlands.

Academic

Medical

Centre,

Acute haemorrhagic necrotising pancreatitis is preferably treated conservatively, while necrosectomy and (open) drainage are performed for septic complications. This latter treatment is sometimes associated with leakage of the pancreatic duct and/or formation of pancreatico-cutaneous fistula. Management of this complication consists of fasting, total parenteral nutrition and, more recently, somatostatin analogues. This policy eventually will lead to reduction of leakage or closure of most fistulas, but can take up to 6 months. Stenosis of the pancreatic duct or spasm of the papillary sphincter could preclude closure. Therefore, the aim of this study was to evaluate the effect of pancreatic duct stenting on the closure of pancreatic duct lesions and reduction of leakage via the open abdomen. In the period 10/94-5/94 we treated 4 patients with pancreatic duct leakage. They underwent from 2 up to 9 surgical debridements for pancreatic necrosis, leading to open laparostomas (and eventually pancreatico-cutaneous fistulas) in 3 patients and a persisting

of Medicine

46 (1995)

A23

Al -A36

drain production in 1 patient. Production of the fistulae was 120-600 ml/day, with an amylase content of 20000-190000 U/l. Presence of the fistulas since the first exploration ranged from 3 weeks to 7 months. Successful placement of an endoprosthesis was achieved after a mean of 2 attempts in all patients. There were 2 normal pancreatic ducts at endoscopy and 2 with a proximal stenosis. Duct disruption, with leakage, was seen in all. Leakage of pancreatic juice ceased after a maximum of 3 days. The endoprosthesis was removed after 6 weeks without recurrence. From these preliminary results we conclude that endoscopic stenting of the pancreatic duct can be useful in the management of panceatico-cutaneous leakage after surgical debridement for acute haemorrhagic necrotising pancreatitis, thus leading to early closure of pancreatic duct leakage. Endoscopic sphincterotomy (EST) versus endoscopic balloon dilation (EBD) for removal of common bile duct stones (CBDS): initial report of a prospective randomized trial. J.J.G.H.M. Bergman, E.A.J. Rauws, G.N.J. Tytgat, K. Huibregtse. Department of Gastroenterology, .4rademic Medical Centre, Amsterdam, Introduction: EST

Netherlands.

is an effective treatment for CBDS. However, complications occur in 10% and long-term effects of loss of sphincter function are unknown. EBD could be an alternative to EST because it carries a potentially lower risk of acute complications, such as bleeding and perforation, and may preserve sphincter function. However, the risk of acute pancreatitis might be increased after EBD. We present initial results of an ongoing prospective randomized trial comparing EST with EBD in patients with CBDS. Methods: Seventy-eight consecutive patients with CBDS were randomized to undergo either EST or EBD using an 8 mm dilating balloon (Microvasive@). Stone removal was carried out with balloons or Dormia baskets. Whenever necessary, mechanical lithotripsy was allowed. EST was performed in case of failure after EBD. Treatment outcome was assessed at 24 h, 30 days and 6 months by interview, questionnaires and blood tests. Complications were graded by a forum of experts not involved in the actual treatment and blinded to the treatment allocation. Results are shown in the table.

Median number of stones (range) Median stone diameter (mm) Initial success for CBD clearing EST after EBD Failed stone extraction Mechanical lithotripsy ( *p < 0.05) Acute pancreatitis Other acute complications Late complications ( > 15 days)

EST(n = 39) 1 (1-S)

EBD(n = 39)

7 (4-18) 37

9 (4- 30) 3”

N.A. 2 5’

4 1 I.!

2 3 8

I -I ---

‘11-9)

A24

Abstracts

/Netherlands

Journal

Conclusions: CBDS of all sizes could be completely removed in one session after EBD in 82% (32/39). In the case of failed stone extraction after EBD secondary EST was able to further increase the success rate to 92% (36/39). EST led to successful stone removal in one session in 95% (37/39). Mechanical lithotripsy was more frequently necessary after EBD. Complications of EST and EBD seemed to be comparable. For many individuals EBD and stone removal may be a valid option.

Guidelines for diagnostic laparoscopy combined with laparoscopic sonography in preoperative staging of oesophageal cancer. W.A. Bemelman a, O.M. van Delden b, J.J.B. van Lanschot a, L.Th. de Wit ‘, N.J. Smits a, P. Fockens c, D.J. Gouma a, H. Obertop a. Departments of a Surgery, ‘Radiology and ’ Gastroenterology, Netherlands.

Academic

Medical

Centre,

Amsterdam,

The objective of this prospective study was to assess the additional role of diagnostic laparoscopy combined with laparoscopic sonography in the preoperative staging of patients with cancer of the oesophagus and cardia. Fifty-six patients underwent staging laparoscopy prior to a planned resection of cancer of the oesophagus or cardia that was deemed resectable with curative intent by routine preoperative work-up. The peritoneal cavity was investigated for peritoneal deposits, intrahepatic metastases, malignant infiltration of the diaphragm and lymph node metastases around the coeliac axis either by laparoscopy and/or laparoscopic sonography. All patients without histologically proven metastases proceeded to laparotomy. Morbidity was 3.5% (superficial wound infections). Fifty-two patients (10 middle and 25 lower oesophagus carcinoma, and 17 cardia carcinoma) were eligible for evaluation. In 3 of the 52 (6%) patients laparotomy was avoided because of liver and/or peritoneal metastases (2X M,) and extensive lymph node involvement of the coeliac axis (1 x N,). In 3 patients laparotomy was necessary to confirm the suspected liver and/or peritoneal metastases (3 X M,), because histological proof was not obtained at laparoscopy. In 1 patient laparoscopic sonography failed to detect a small liver metastasis. Preoperative stage was altered by laparoscopy in 9 (17%) patients (M, 5 X, N, 1 X , T4 3 X ). All patients with M, disease detected by laparoscopy had cardia carcinoma which was 29% (5/17) of all patients with cardia carcinoma. Conclusion: Preoperative staging of oesophageal cancer by laparoscopic sonography combined with laparoscopic sonography is only indicated in patients with cardia cancer infiltrating the lower oesophagus. The management of radiation-associated oesophageal carcinoma. B.G. Taal a, B.P.M. Aleman b, H. Boot a, J.M.V. Lebesque b. Departments of a Gastroenterology and b Radiotherapy, hoekhuis,

Netherlands Amsterdam,

Cancer Institute Netherlands.

/ Antoni

van

Leeuwen-

Secondary or treatment-induced cancer following irradiation or chemotherapy may limit treatment options and lead to a poor prognosis. Radiation-associated oesophageal cancer is

of Medicine

46 (1995)

AI-A36

defined as a malignancy developing in a previously irradiated section of the oesophagus. To evaluate treatment modalities and clinical outcome, we conducted a retrospective analysis of 20 patients treated in our institution for this condition between 1977 and 1992. Nine patients were men, 11 women; their median age was 60 years; oesophageal carcinoma was diagnosed 2-63 years (median 11 years) after irradiation for malignancy (n = 16) or benign disorders (n = 4). Most patients presented with rapidly progressive dysphagia, but long-standing intermittent dysphagia of l-3 years duration was present in 5 cases. Endoscopic biopsies revealed squamous cell carcinoma, usually localized in the proximal third of the oesophagus (16 cases or 80%), with a median length of 5 cm (range 2-12 cm). Only 3 patients were eligible for curative surgery, resulting in long-term survival (5 and 6 years respectively) and 1 postoperative death. Radiotherapy, considered in the remaining 17 patients, was rejected in 5 in view of the total dose of previous irradiation, in 2 cases because of involvement of the trachea. A full course of external beam irradiation was applied in 6 cases, resulting in marked relief of dysphagia and median survival of 11 months (range 2-16) without serious complications. Limited dosage radiotherapy was performed in 4 cases, resulting in only minor improvement. An endoprothesis was inserted either as a primary or secondary palliative measure in 8 patients. Overall median survival in the palliative group (n = 17) was 6 months (range 2-27). Conclusion: Treatment options and outcome in radiationassociated oesophageal cancer appear to be comparable to those of its non-radiation-associated counterpart. Even fullcourse radiotherapy can be applied in selected patients with good prospects. Previous irradiation does not exclude the new technique of intraluminal radiotherapy. Risk factors for benign strictures after oesophagectomy and gastric tube reconstruction with cervical anastomosis. P. Honkoop a, P.D. Siersema *, W. Hop b, M. van Blankenstein a, H.W. Tilanus ‘. Departments of a Gastroenterology and b Surgery, University Epidemiology and Netherlands.

Hospital, Statistics,

Rotterdam Erasmus

and ’ Department of University, Rotterdam,

Benign stricture formation at the cervical anastomosis after oesophagectomy and gastric tube reconstruction is a frequent problem, possibly caused by local ischaemia. Between January 1987 and July 1993, 274 patients with adenocarcinoma (40%) of the oesophago-gastric junction, and squamous cell carcinoma (34%) Barrett-carcinoma (20%) or “other” carcinoma (6%) of the oesophagus underwent oesophagectomy performed by blunt dissection and gastric tube reconstruction. The cervical anastomosis was performed by hand (n = 117) or by circular stapler (n = 157). Mean age of the patients was 61 years (35-82), 74% men and 26% women. In all patients a contrast-swallow study was performed. During follow-up, 114 patients (42%) developed a benign stricture at the anastomosis, 4-150 weeks postoperatively (median 11 weeks); all strictures were confirmed endoscopitally. To determine which factors contributed to the develop-

Abstracts

/Netherlands

Journal

ment of these strictures we assessed preoperative (age, sex, cardiac history, diabetes, pulmonary function, Astrup ECG, localisation of the tumour), perioperative (histology of the tumour, TNM classification, length of operation, type of resection, method of reconstruction, anastomotic technique, Hb decrease) and postoperative (clinical and radiological evidence of leakage at the anastomosis, surgical- and non-surgical complications) data. Only the presence of preoperative cardiac disease (p = 0.03), stapled anastomosis (p = 0.04) and postoperative leakage (p = 0.002) were found to be independent risk factors for stricture formation. Postoperative radiographic examination (contrast-swallow) had shown leakage in 62 patients (23%) of whom 44% were without clinical symptoms, and of these 62 asymptomatic patients 67% got a stricture at the anastomosis. Anastomotic strictures were treated endoscopically by repeated bougie dilatation. In 78% of patients dilatation was successful. In 3% of patients dilatations are still being performed and 19% of patients had died from recurrent illness before dilatations were finished. In 5 of 519 (1%) dilatationsessions, one-night observation in hospital was necessary. In 2 patients perforation occurred, one with mediastinitis and one with major bleeding. Conclusions: (I) Patients with preoperative cardiac disease are at an increased risk of developing a stricture. (2) Even in asymptomatic patients a contrast-swallow can detect patients with anastomotic leakage which results in an increased risk of developing anastomotic strictures. (3) The benefit of the stapler gun for anastomosis remains to be determined. Laparoscopic multicenter

Nissen study.

fundopkation:

2-year

results

of a Dutch

M.B.E Menke-Pluymers, J. Ringers, M.A. Cuesta, P. de Ruiter, J. Jakimowicz, A. Jansen, C.J. van Steensel, W.F. Weidema. Department of Surgery, Reinier de Graaf

Gasthuis,

De&

Netherlands.

From March 1991 until March 1993, 42 laparoscopic Nissen fundoplications were performed in 6 Dutch hospitals. The indication for surgery was failure of adequate medical therapy for GORD. Preoperatively 24-h oesophageal pH-monitoring, endoscopy and manometry were performed in all 42 cases. Conversion to laparotomy had to be performed in 4 patients. Complications during and after operation were: pneumothorax, oesophageal perforation, haemorrhage (2), and atelectasis (2). The follow-up was 21 f 4 months and 38 patients were available for follow-up. After 21 months 34 patients (89%) were free of symptoms or had fewer symptoms. Four patients still had retrosternal pain, 1 had gas-bloating, 1 dumping syndrome and 1 still had diarrhoea based on enzyme deficiency. In 32 patients the postoperative 24-h pH-test was normal, 3 patients (8%) had abnormal postoperative 24-h pH-scores and 3 patients had refused the test. A recurrence was found in 4 patients (11%): in 2 patients after dilatation of the oesophagus because the fundoplication or the closure of the crura was too tight; 1 patient had a hiatal hernia based on an insufficient fundoplication and 1 had an abnormal 24-h pH-score without symptoms. Conclusion: Nissen fundoplication by laparoscopy seems to

of Medicine

46 (1995)

A25

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be a safe anti-reflux procedure with the same short-term results as the traditional approach. Massive surgery.

delayed

haemorrhage

after

pancreatic

and

bilialy

M.I. van Berge Henegouwen, J.H. Allema, T.M. van Gulik, P.C.M. Verbeek, H. Obertop, D.J. Gouma. Depart-

ment of Surgery, lands.

Academic

Medical

Centre,

Amsterdam,

Nether-

Massive delayed haemorrhage is a severe postoperative complication after pancreatic and biliary surgery, with a high mortality. Because of the different causes (i.e. ulcer disease, suture line bleeding, false aneurysm, erosion of the hepatic or splenic arteries) and treatment modalities, the management of these massive bleedings is under discussion. Therefore, in this study, we assessed the incidence, the symptoms, the aetiology and the optimal diagnostic and interventional procedures of severe delayed bleeding. Of the 686 patients who underwent major pancreatic and biliary surgery (from 1983 to 1993) patients with massive haemorrhage (> 6 packed cells within 24 h) in the “late” postoperative period ( > 24 h after initial surgery) were selected. Massive p.o. haemorrhage occurred in 22 patients (3.2%); two subgroups were formed, according to aetiology of bleeding, i.e. bleeding caused by erosion from a major artery (n = 12) or bleeding from the (gastro)intestinal suture line (n = 10). Both groups were compared with respect to bleeding parameters, symptoms, diagnostic and interventional procedures and management of the bleeding. Hb level (means 4.4 vs. 5.0) and transfused units of blood (means 15.9 vs. 11.0) were not significantly different between the two groups. Patients with an arterial erosion had a longer interval between initial surgery and haemorrhage (p < 0.05) more often had septic complications (p < 0.05) and had a higher mortality than patients with suture line bleeding (50% vs. 0%, respectively, p < 0.01). Conclusions: Delayed massive haemorrhage was due to either erosion of a major artery or suture line bleeding, both giving equally severe symptoms. Especially a longer interval and septic complications are suspicious for a bleeding from an erosion of a major artery near the pancreatic or biliary anastomosis. Emergency GI endoscopy is the first step in the diagnostic process and is useful to exclude, as well as treat (by means of sclerotherapy), ulcer disease and suture line bleeding. Angiography and, if possible, embolization is the next step. If not successful, early aggressive surgical intervention is mandatory, including thorough exploration of the resectional area, ligated artery stumps and eventually opening of the Roux-Y limb. Oversewing of the bleeding site may lead to recurrent bleeding within 24 h in most patients Portal vein resection in patients undergoing denectomy for carcinoma of the pancreatic

pancreaticoduohead region.

J.H. Allema, M.E. Reinders, T.M. van Gulik, D.J. van Ineuwen, D.J. Gouma. Departments of Surgery and Gastroenterologv, Academic

Medical

Centre,

Amsterdam,

Netherlunds.

The aim of this study was to evaluate the benefit of portal vein resection for macroscopic portal vein invasion in patients

A26

Abstracts

/Netherlands

Journal

undergoing pancreaticoduodenectomy for carcinoma of the pancreatic head region. Of 176 patients with carcinoma of the pancreatic head region 156 patients underwent standard pancreaticoduodenectomy (Group II) and 20 patients who had macroscopic suspicion of invasion of the portal vein (PV) or superior mesenteric vein (SMV) underwent pancreaticoduodenectomy with partial resection of the PV or SMV (Group I). In 16 of 20 patients in Group I an end-to-end anastomosis was used for reconstruction of the vein. Morbidity in Groups I and II was not different (55 and 63%). Hospital mortality was 15% in Group I and 7% in Group II (p = 0.22). Histology confirmed the tumour invasion of the PV or SMV in 10 patients (50%) in Group I. Invasion of the PV/SMV was significantly more frequent in patients with pancreatic carcinoma than in patients with distal bile duct or ampullary carcinoma. Of the 20 patients in Group I only 3 had a curative resection (tumour-free margins). The median survival after PV/SMV resection was 8 months. The 2-year survival was 19%. Comparison of survival in Group I with survival in matched subgroups of patients undergoing standard pancreaticoduodenectomy (with or without invasion of the PV/SMV margin and matched for all other histological parameters) showed no significant differences. Conclusions: Partial resection of the PV or SMV for macroscopic tumour invasion of the PV/SMV in patients undergoing pancreaticoduodenectomy did not lead to a higher rate of curative resections or to better survival than in patients having standard pancreaticoduodenectomy, matched for invasion of the PV/SMV margin and all other histological parameters. The effect of erythromycin on pancreatic polypeptide in patients with cirrhosis of the liver. B.J.M. Witteman ‘, W.P.M. Hopman a, P.M. Netten b, Th. Thien b, J.B.M.J. Jansen a. Departments nal Medicine,

of a Gastroenterology University Hospital,

and Hepatology and b InterNijmegen, Netherlands.

The release of pancreatic polypeptide (PP) in response to intravenous erythromycin (ERY) is dependent on intact vagal pathways and an intact antrum. Since autonomic neuropathy (AN) of the gastrointestinal tract damages vagal nerve integrity and complicates the course of chronic liver disease, we have studied whether the PP response to ERY is diminished in patients with cirrhosis of the liver and we have compared the results with those obtained after modified sham feeding (MSF) and cardiovascular reflex tests (FINAPRES). Eleven patients with liver cirrhosis (LC, 4 F, 7 M; 49 [28-681 yr, Child A, 8; Child B, 3), 21 healthy controls (HS; 10 F, 11 M; 47 122-721 yr) and 5 vagotomized patients (VP; 1 F, 4 M; 49 [28-681 yr) were studied. ERY dose-dependently stimulated PP in HS: 1082 + 152 pM * 20 min (0.4 mg/kg) and 1753 f 351 pM *20 min (1.2 mg/kg). In LC (706k 190 and 907+260 pM *20 min, respectively), and VP (275 f 121 and 672+ 284 pM * 20 min, respectively) these responses were significantly (p < 0.05) lower. FINAPRES proved to be abnormal in 4 LC-patients (36%), but in none of the HS. MSF in LC-patients (1470 + 441 pM * 60 min) was not significantly different from HS (2342 + 562 pM * 60 min). There was no significant correlation between MSF, FINAPRES and ERY results.

of Medicine

46 (1995)

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Conclusion: PP responses to ERY but not to MSF are decreased in LC-patients, where AN is frequently found. Because damage to different autonomic nervous systems may occur independently of one another, we speculate that the PP response to ERY may contribute to assessing AN of the gastrointestinal tract in LC-patients.

Gastric tonometry: correction factors for various equilibration periods in healthy volunteers differ from recommended correction factors. J.J. Kolkman a, A.B.J. Groeneveld b, S.G.M. Meuwissen a. Department of ’ Gastroenterology and b Medical Intensive lands.

Care,

Free

Uniuersity

Hospital,

Amsterdam,

Nether-

Gastric tonometric determination of an elevated pCOz is a promising method for the detection of gastric ischaemia, provided acid secretion is suppressed. This method uses a balloon-tipped catheter, placed in the stomach and filled with saline. pC0, diffuses from the gastric mucosa to the balloon. After aspiration of the saline, pC0, is determined using a blood gas analyzer. Since complete equilibration of pC0, between the gastric mucosa and the Tonomitor saline takes at least 60 mitt, correction factors determined in vitro are provided by the manufacturer to correct for shorter equilibration periods. However, the validity of these correction factors have never been confirmed in vivo. We therefore studied the diffusion curve of pC0, in the tonometer in 18 healthy fasting volunteers, after suppression of acid secretion. Two hours prior to the study either ranitidine alone (100 mg iv., followed by 25 mg/h, n = 6), or ranitidine combined with pirenzepine (10 mg bolus, followed by 3 mg/h, n = 12) was administered. A glass pH-electrode and a Tonomitor-catheter were placed 10 cm distally from the gastro-oesophageal junction. Equilibration times were 10, 20, 30 and 60 min. The capillary pC0, was measured. There was no difference between gastric juice pH and tonometer pC0, for the two acid suppression regimens; therefore data were pooled. The gastric juice pH was > 4.0 for 92% of the study time. The capillary pC0, was 41+2 mmHg. The tonometer pC0, was 23*2 mmHg after 10 min, 29 + 3 mmHg after 20 min, 31+ 2 mmHg after 30 min and 33 + 3 mm Hg after 60 min. The standard diffusion curve was derived from the means of the individual curves, which were calculated using non-linear regression analysis. The equation is derived from Fick’s law of diffusion: Y = Y,,, *(Ie-9. Y,,, was 32.7 mmHg, k was 0.119 and R2 was 0.91. The correction factors, calculated from this formula and the blood pC0, value, were different from those recommended by the manufacturer: for 10 min l&4+0.15 vs. 1.54 (p < O.OOOl), for 20 min 1.40k0.11 vs. 1.36 (p > 0.05), for 30 min 1.3OkO.10 vs. 1.26(p>O.O5), and for 60 min 1.26f0.10 vs. 1.16 (p < 0.001). Conclusion: The precise characteristics of the diffusion curve of pC0, in the gastric tonometer were determined in healthy volunteers. Since the correction factors derived from this in-vivo curve differ significantly from the correction factors recommended by the manufacturer, which were determined in vitro, the latter should be adjusted.

Abstracts Validation of adequate

/Netherlands

Journal

of gastric tonometry with a test meal: importance acid suppression and timing of measurement. J.J.

Kolkman ‘, A.B.J. Groeneveld b, S.G.M. Meuwissen a. Department of a Gastroenterology and Free University Hospital, Amsterdam,

b Medical Intensive Netherlands.

Care,

Gastric tonometric detection of an increased pC0, can be used to detect gastric ischaemia, provided acid secretion is suppressed. To increase the sensitivity of this method, the use of a meal was used. The rationale is that the test meal increases the gastric metabolic demand and thus provokes ischaemia. Two methodological problems hamper the valid use of a test meal in tonometry. First, it is unclear whether currently used HZ-antagonists sufficiently suppress mealstimulated acid production, and thus prevent production of CO, by acid buffering. Second, the diffusion characteristics of pC0, from the gastric mucosa to saline in the tonometer balloon may be influenced by the test meal. We therefore studied tonometry of gastric pC0, before and after a standardized liquid test meal (Pulmocare@, 500 ml, 750 kcal). Two hours before measurements of pCO,, a combination of ranitidine (100 mg i.v., followed by 25 mg/h) and pirenzepine (10 mg bolus, followed by 3 mg/h, Groups I and II, n = 12) or ranitidine alone (Group III, n = 6) was administered. A glass pH-electrode and a Tonomitor-catheter were placed 10 cm distally from the gastro-oesophageal junction. Before the test meal, equilibration times were 10, 20, 30 and 60 min in all groups. After the test meal, equilibration times were 10, 20, 30 and 60 min in Group I, and four 30-min periods in Groups II and III. The gastric juice pH was > 4.0 for 94% of the study time. The calculated correction factors before the test meal were (correction factor = blood pCO,/tonometer pC0,) were: 1.84, 1.40, 1.30 and 1.26, respectively. In Group I, the post-test-meal pC0, was 16* 1 mmHg after 10 min, 20+ 1 mmHg after 20 min, 27f 1 mmHg after 30 min and 38+4 mmHg after 60 min equilibration. In Group II, the post-test-meal pC0, was 21 f 1 mmHg in the first (p < 0.0001 vs. pre-test meal), 26*3 mmHg in the second (p < 0.001 vs. pre-test meal), 31 f 3 mmHg in the third and 35 & 5 mmHg in the fourth 30-min period. The calculated correction factors for the 30-min periods following this test meal were 1.95, 1.58, 1.33 and 1.17, respectively. In Group III, in 1 patient a persistently high pC0, ( > 50 mmHg) was found, probably due to buffering of produced acid. Conclusion: The combined regimen of ranitidine and pirenzepine prevented pC0, elevations due to gastric acid production, whereas ranitidine alone did not. The introduction of a test meal changed the diffusion characteristics of pC0, in the tonometer balloon in healthy volunteers. Therefore, correction factors for short equilibration periods should be adjusted to the timing after the test meal. Hyperglycaemis atic secretion.

reduces

cephalic-stimulated

exocrine

panwe-

W.F. Lam, A.A.M. Masclee, M. Lindeboom, C.B.H.W. Lamers. Department of Gastroenterology and Hepatology,

University

Hospital,

Leiden,

Netherlands.

In healthy subjects acute hyperglycaemia inhibits gastrointestinal motility, possibly through vagal cholinergic mecha-

of Medicine

46 (1995)

A21

Al -A36

nisms. We have investigated whether hyperglycaemia influences exocrine pancreatic secretion during cephalic stimulation which is vagal-cholinergically mediated. Six healthy subjects (age 24-32 yr> were studied twice, in random order, during normoglycaemia (5 mmol/l) or acute hyperglycaemia (15 mmol/l) using a glucose clamp technique. Duodenal juice was collected in lo-min periods through a 4-lumen tube using PEG as recovery marker. Pancreatic and biliary secretion were measured unstimulated for 90 min and for 90 min after cephalic stimulation with modified sham feeding (MSF) of a meal (hamburger, bread, butter. tea). Results (mean f SEMI (Output/30 min) Bilirubin (pmol) Trypsin (U) Lipase (KU) HCO, (mmol)

Basal

MSF 5 mmol/l

MSF 15 mmol/l

2+1 9+3 14_+5 0.6kO.l

lb*4 * 26+6 ’ 36_+9 * 0.8,O.l

4*2 * * ?t4 * * 15*5 ** 0.6*0.1

* p < 0.05 vs. basal; * * p < 0.05 vs. MSF S mmol/l Pancreatic polypeptide (PP) secretion after MSF was significantly (p < 0.05) decreased during hyperglycaemia compared to normoglycaemia (56 f 23 vs. 172 rf:41 pM ‘30 min). Conclusions: MSF significantly increases biliay and pancreatic enzyme secretion (PES) during normoglycaemia. During hyperglycaemia MSF-stimulated PES is significantly reduced. Since the cephalic phase of digestion is vagalcholinergic-dependent, these results suggest that hyperglycaemia reduces MSF-induced PES by inhibition of vagalcholinergic activity. [‘3C1Lactose breath activity in children.

test for detection

of low intestinal

lactase

H.A. Koetse, F. Stellaard. H. Elzinga, R.J. Vonk, C.M.A. Bijleveld, H.S.A. Heymans. Beatrix Children’s

Hospital,

University

Hospital,

Groningen,

Netherlands.

We performed 33 [‘3C]lactose breath tests in 28 children (aged 11 months-19 years) using naturally enriched [“Cl lactose. The substrate was given as a 20% solution in water in a dosage of 2 g/kg body weight (max. 50 g). All subjects were fasted overnight. Before and during 4 h after substrate ingestion half-hourly breath samples were collected. Following this breath test all patients underwent an endoscopically performed jejunal biopsy for several clinical conditions. The biopsies were taken with a modified Cosby capsule near the Treitz ligament. The breath samples were analysed with Isotope ratio mass spectrometry for 13C0, / ‘?CO, ratio’s and with gas chromatography for H, concentration. Positive ‘3co, breath test was defined as recovery of less than 10.5% of administered dose 13C in 4 h following substrate ingestion. Positive H, breath test was defined as more than 20 ppm concentration rise above basal concentration. Lactase activity of jejunal biopsy specimens was measured by a modified Dalqvist method and expressed in units/g protein. Hypolactasia was defined as lactase activity below 10 U/g protein. The results of both breath tests were related to the measured lactase activity. H, breath test vs. lactase activity: In 7 of 13 tests with low lactase activity a positive H, test was found

A28

Abstracts/Netherlands

Journal

(sensitivity 0.54), in 18 of 20 tests with normal lactase activity a negative H, test was found (specificity 0.90). 13C0, breath test vs. lactase activity: In 8 of 13 tests with low lactase activity a positive 13C0, test was found (sensitivity 0.61), in 18 of 20 tests with normal lactase activity a negative 13C0, test was found (specificity 0.90). Combined breath test results vs. lactase activity: In 11 of 13 tests with low lactase activity at least one of both breath tests was positive (sensitivity 0.85), in 16 of 20 tests with normal lactase activity both breath tests were negative (specificity 0.80). Conclusion: The 13C0, breath test for detection of low jejunal lactase activity in children has almost the same (low) sensitivity and specificity as the traditionally used H, breath tests, but combination of both test results has a much higher sensitivity, with only a very slight loss of specificity. Furthermore we expect that the sensitivity of the 13C0, breath test on its own can be improved by modification of experimental factors (dosage, physical activity, actual CO, production measurement), that up till now always have been adapted to the conditions of the H, breath test. Regulation of lactase and sucrase-isomaltase gene expression during Caco-2 cell differentiation. E.H. van Beers, R.H. AI, E.H.H.M. Rings, A.W.C. Einerhand, J. Dekker, H.A. Biiller. Paediatric Gastroenterology, dam, Netherlands.

Academic

Medical

Centre,

Amster-

The human Caco-2 cell line spontaneously differentiates into an enterocyte-like phenotype during O-37 days post-plating (dpp), and expresses both lactase and sucrase-isomaltase. We used differentiating Caco-2 cells to study their gene regulation at the mRNA, biosynthesis and activity levels, using ribonuclease protection assay, metabolic labeling and activity assays, respectively. Lactase and sucrase-isomaltase mRNA, protein and enzyme activities appeared consecutively, reaching maximum levels at 8-11 dpp (lactase) and 11-21 dpp (sucrase-isomaltase). Sucrase-isomaltase mRNA, biosynthesis and activity levels are highly correlated, whereas lactase expression appeared biphasic. After a linear upsurge in lactase mRNA and biosynthesis, both steeply declined, but lactase activity declined much slower. Conclusions: (1) Sucrase-isomaltase and lactase biosynthesis are regulated by the amount of their mRNA’s, indicating transcriptional regulation. (2) Sucrase activity appeared transcriptionally controled at all timepoints. (3) Lactase activity prior to 8 dpp is regulated by its biosynthesis-level, but, contrary to sucrase, the slow decline in lactase activity indicated a high stability of lactase. (4) Different profiles for lactase and sucrase-isomaltase mRNA levels indicated different gene regulation. Relevance of haplotypes in the TNF region in coeliac disease. J.B.A. Crusius a, X. Bing a, C.J.J. Mulder b, M.L. Mearin ‘, A.S. Peiia a. ’ Departments of Gastroenterology and Gastrointestinal Immunogenetics, Free University Hospital, Amsterdam, b Department of Hepatogastroenterology, Rijnstate Hospital, Arnhem, ‘Department of Paediatrics, Universiiy Hospital, Leiden, Netherlands.

of Medicine

46 (1995)

AI -A36

Gluten-sensitive enteropathy or coeliac disease (CD) is strongly associated with the extended haploepe HLA-DQ2, -DR3, -B8. A primary association with’ the HLA-DQ heterodimer, encoded by the HLA-DQAl * 0501 and the HLADQBl * 0201 genes in cis- or trans-configuration has been proposed. However, genes coding for immune modulators at the tumour necrosis factor-lymphotoxin (TNF-LT) locus may also contribute to CD susceptibility. A total of 74 unrelated CD patients and 29 unrelated healthy controls were typed for the published di-allelic RFLP’s in the first intron of TNF by NcoI (TNF-NcoI alleles 1 and 2) and by AspHI (TNF-AspHI alleles 1 and 2) digestion of PCR products, and polymorphisms at positions -308 (TNFA -308 alleles A and G) and -238 (TNFA -238 alleles A and G) in the promoter region of TNFa by both NcoI digestion and non-radioactive PCR-SSCP. Our findings are consistent with the presence of only five haplotypes in the Dutch group of patients and controls: TNFB-NcoI * 2, TNFB-AspHI * 1, TNFA -308-G, TNFA -238-G (haplotype TNF-P, 2,1,G,G); haplotype TNF-I, 2,2,G,G; haplotype TNF-H, 2,2,G,A; haplotype TNF-E, 1,2,A,G; and haplotype TNF-C, 1,2,G,G. The frequency of haplotype TNF-E is significantly increased in the CD patient group (70 of 148 in CD vs. 10 of 58 in the control group; p < 0.0001). Haplotype TNF-P was significantly decreased in the CD group (p = 0.01). Moreover, individuals homozygous for this latter haplotype were significantly less frequently found in the patient group (p = 0.04). Interestingly, the frequency of individuals homozygous for the haplotype TNF-E did not differ between patients and controls. The relevance of these haplotypes in expression and heterogeneity of the disease will be studied in patients and their relatives. This research was financially supported by Tramedico B.V. Holland and the Falk Foundation, Germany. Macrophages and lymphocytes in acute and chronic dextran sulfate sodium (DSSbinduced colitis in mice. L.A. Dieleman a, M.B. van der Ende ‘, E. Bloemena b, A.S. Peiia a, E.P. van Rees ‘, S.G.M. Meuwissen ‘. Departments of ’ Gastroenterology, b Pathology and ’ Cell Biology Medicine, Free University, Amsterdam,

/Immunology, Netherlands.

Faculty

of

Oral administration of DSS (MW 40000-54000) has been reported to induce colitis in mice. The aim of our study was to evaluate chronic effects of DSS and to assessthe involvement of several macrophage and lymphocyte subpopulations in acute and chronic phases of DSS-induced colitis. Swiss Webster mice were fed 5% DSS in their drinking water for 7 days, followed by 2-5 weeks’ consumption of water. Control mice received only water. The mice given DSS were divided into 3 groups and sacrificed after 7 days DSS and 2 or 5 weeks respectively after stopping DSS administration. The different parts of their colons were isolated for histology and for immunohistochemistry on cryostat sections using specific monoclonal antibodies for different macrophage subpopulations, T- and B-cells. Acute DSS-induced colitis was most severe after 7 days DSS, manifested by weight loss, diarrhoea, colon shortening and oedema of particularly the proximal colon. The microscopy showed large areas of focal

Abstracts/Netherlands

Journal

crypt loss, infiltration of MOMApositive macrophages and some granulocytes in the mucosa and submucosa. Two weeks after stopping DSS the colonic epithelium had partially healed, showing remarkable regeneration from the neighbouring epithelium, bridging over crypt defects, particularly in the proximal colon. There was an accumulation of macrophages and some granulocytes, but especially the amount of T- and Blymphocytes had increased around the lesions. These inflammatory changes decreased towards the caecum and the more distal colon. Five weeks after stopping DSS, some crypt LOSS was still present in the proximal colon of some animals as well as epithelium regeneration and focal aggregations of B- and T-lymphocytes in the mucosa. Conclusions: Oral DSS administration in mice proved to be an easily reproducible model to study intestinal inflammation as well as colonic healing. The acute phase is mediated particularly by macrophages, whereas during the chronic stadium lymphocytes are more prominent. Further receptor

evidence antagonist

for a genetic with ulcerative

association colitis.

of interleukin-1

G. Bioque a, J.B.A. Crusius a, P.J. Kostense b, S.G.M. Meuwissen a, A.S. Pena a. Departments Biostatistics,

of a Gastroenterology Free University Hospital,

and b Epidemiology and Amsterdam, Netherlands.

Clinical studies argue strongly for a genetic predisposition in the pathogenesis of ulcerative colitis. The importance of the interleukin-1 receptor antagonist (IL-lra) in inflammatory bowel diseases has been pointed out by recent studies. In animal models, the exogenous administration of IL-lra markedly reduces inflammation and anti-IL-lra treatment exacerbates and prolongs inflammation. It has been suggested that a defective production of IL-lra may exist in patients with inflammatory conditions. The characterization of an 86base pair of identical tandem repeats within the intron 2 of the IL-lra gene resulted in the first reported association outside the HLA region between ulcerative colitis and the IL-lra allele 2 in a North European Caucasian population. Our aim was to study this polymorphism in a Dutch population of patients with ulcerative colitis and Crohn’s disease as well as healthy controls. Genotype and allelic frequencies of the polymorphic region in the IL-lra gene were determined in patients with ulcerative colitis (n = 74), Crohn’s disease (n = 54) and healthy controls (n = 53). DNA fragments reflecting the 3 alleles were generated by PCR amplification and analyzed by agarose gel electrophoresis. Allele 2 frequency of IL-lra in ulcerative colitis (29%) and Crohn’s disease patients (26.8%) was not significantly different from that in healthy controls (22.6%). However, carriage of allele 2 gave an odds ratio of 1.519 for ulcerative colitis with a 95% confidence limit of 0.7035-3.321 compared with healthy controls, thus confirming the recent findings in the United Kingdom. Similar analysis of patients with Crohn’s disease also support the British finding of a lack of an association. Conclusion: Our data indicate that the polymorphism in intron 2 of the IL-lra gene is a genetic marker for ulcerative colitis but not for Crohn’s disease.

of Medicine

46 (1995)

A29

Al -A36

Hapbtype

restricted differences in in vitro production of tumour necrosis factor alpha and Iymphoto%in alpha in patients with inflammatory bowel disease and he&by controls.

G. Bouma a, J.B.A. Crusius a, M. Oudkerk Pool a, J.J. Kolkman a, B.M.E. von Blomberg b, S.G.M. Meuwissen a, A.S. Peiia a. Departments of a Gastroenterology and ’ Pathologx Free

University

Hospital,

Amsterdam,

Netherlands

Although the aetiology of the chronic inflammatory bowel diseases (IBD), Crohn’s disease (CD) and ulcerative colitis (UC) is still unknown, it is established that disease occurs in a genetically susceptible subject. Tumour necrosis factor alpha (TNFa) and lymphotoxin alpha (LTa) are potent proinflammatory and immunoregulatory cytokines. The genes for these cytokines are tandemly arranged in the central region of the MHC, between the HLA-B and HLA-D locus, at the short arm of chromosome 6. This location has prompted much speculation about the role of TNFcr and LTu in the aetiology of MHC-associated diseases. In order to study the effect of gene polymorphisms on the production of TNFo and LT~Y, we performed a prospective study in which we determined the production of these cytokines in relation to bi-allelic polymorphisms in the TNFa and LTCK genes in 30 patients with IBD and 12 healthy controls. Individuals were typed for two polymorphisms in the TNFa gene, and two polymorphisms in the LTu gene, resulting in 4 haplotypes (TNF-C, -E, -I and -P). Peripheral blood mononuclear cells were cultured in the presence of the T-cell activators anti-CD3 and anti-CD28, and TNFcY and LTa production was measured by commercially available ELISA’s. No statistically significant differences in TNFa and LTa secretion were observed between UC patients, CD patients and controls. However, large differences in production were found in relation to the TNF haplotypes. Individuals carrying the E haplotype are the highest producers of TNFQ (p = 0.008, as compared to individuals without this haplotype). The lowest production was found in individuals carrying the C haplotype (p = 0.012, as compared to individuals without this haplotype). The only difference between the C and E haplotypes is the nucleotide position at position -308 in the promoter region of the TNFa gene. The production of LTcr in relation to the genotypes showed that individuals carrying the TNF-I haplotype showed a statistically very significantly lower production of LTa as compared to individuals who lack this haplotype ( p = 0.002). Conclusion: We have shown strong correlations between TNF haplotypes and TNFo and LTa secretion. These findings may contribute to defining the genetic heterogeneity of IBD. This study was financially supported by a grant from the Nederlandse Lever-Darm Stichting. Glucocorticoid receptor content and inhibition of TNFa, IM, PGE, and LTB, production by dexamethasone in pertpheral blood mononuclear cells. G.S. Madretsma”, A.P.M. van Dijk a, J.H.P. Wilson b, F.J. Zijlstra a. Departments of a Pharmacology and b Internal Medicine Ii, Erasmus University, Rotterdam. Netherlands.

A30

Abstracts

/Netherlands

Journal

A minority of patients with inflammatory bowel disease (IBD) do not respond to high doses of glucocorticosteroids. Variation in response to corticosteroids could be due to variation in number or affinity of glucocorticoid receptors (GR) on mononuclear cells (MNC). In order to test this hypothesis, we assessed if inhibition by dexamethasone (DEX) of the LPS-stimulated production of TNFar, IL6, PGE, and the Ca-ionophore (A23187) enhanced LTB, release by MNC is determined by the number or the affinity of the GR of these cells. MNC were isolated from peripheral blood from healthy donors, incubated with DEX (cone: 10e9 to lo-’ mol/l) and stimulated with LPS or A23187. GR-number and GR-affinity of MNC were determined. DEX caused a concentration-dependent inhibition of enhanced TNFo, IL6 and PGE, production with IC,, (and 95% confidence interval) of 39 (7-199) 158 (19-1258) and 125 (25-630) nmoI/l respectively. DEX had no effect on LTB, production. GR content was 4431+339 sites per cell and K,, was 9.5 kO.7 nM. No correlations were found between the inhibition of mediator release and the K, or receptor number. Conclusion: DEX inhibits the LPS-stimulated release of TNFa, IL6 and PGE, by MNC. Considering that this inhibitory effect does not correlate with GR content or GR affinity in MNC of healthy humans, the susceptibility of mediator release by MNC for inhibition by DEX could be a better tool for distinguishing responders from non-responders to corticoid therapy in IBD than GR determination. Impairment of superoxide patients with inflammatory

dismutases in inflamed intestine of bowel disease. H.W. Verspaget,

A.J.H.M. van Ierssel, W. van Duijn, M.A.C. Mieremet-Ooms, R.A. van Hogezand, G. Griffioen, C.B.H.W. Lamers. Department of Gastroenterology Leiden, Netherlands.

and Hepatology,

University

Hospital,

Reactive oxygen radicals are implicated in the initiation and promotion of inflammatory bowel disease (IBD). Cells are endogenously protected against the first oxygen radical produced, i.e. superoxide anion, by superoxide dismutases (SOD). Copper/zinc(Cu/Zn)-SOD is present in the cytoplasm and manganese(Mn)-SOD in mitochondria of cells. We developed an immunoblotting technique, ELISA’s, and enzyme activity assays for both SOD’s and determined antigen and activity levels in inflamed and non-inflamed intestinal mucosa of resection specimens from 21 patients with IBD (6 ulcerative colitis, 15 Crohn’s disease). Inflamed tissue was found to contain significantly decreased amounts of Cu/Zn-SOD (975 f 107 VS. 1175 f 119 ng/mg protein, p < 0.05) but increased amounts of Mn-SOD (932 f 132 vs. 513 + 88 ng/mg protein, p < 0.02) compared to non-inflamed tissue. The activity levels of both SOD’s were found to be changed similarly, though not significantly, in the inflamed tissue in comparison with the non-inflamed tissue (Cu/Zn-SOD 6.4 f 1.3 vs. 7.4+ 1.5 and Mn-SOD 7.1+0.7 vs. 6.3 + 0.4, U/mg protein, both ns.). The differences in relation to the inflammation were most prominent in Crohn’s disease. Remarkably, in these patients the 2- to 3-fold increase in the

of Medicine

46 (1995)

AI -A36

amount of Mn-SOD (968 f 179 vs. 337 f 43, p = 0.005) probably induced by cytokines like TNFa, were accompanied by a marginal increase only, approximately 25%, in activity of this enzyme (8.2+0.8 vs. 6.5kO.4, p < 0.05). Conclusion: IBD, particularly Crohn’s disease, is characterized by a decrease in amount and activity of cytoplasmic Cu/Zn-SOD in inflamed intestinal tissue. Although the amount of mitochondrial Mn-SOD is almost 3-fold enhanced with inflammation, its activity is only marginally increased. Thus, intestinal inflammation in IBD is accompanied by a dysfunction of superoxide dismutases which might render the tissue vulnerable to damage by reactive oxygen radicals. Intravenous and transit

amino time.

acids

terology lands.

Hepatology,

influence

small

intestinal

motility

H.A.J. Gielkens, A. van de Biggelaar, C.B.H.W. Lamers, A.A.M. Masclee. Department of Gastroenand

University

Hospital,

Leiden,

Nether-

Patients on total parenteral nutrition have an increased risk of developing gallstones because of gallbladder hypomotility. Separate and pulsatile iv. administration of high doses of amino acids may prevent bihary stasis by stimulating gallbladder contraction. We have investigated whether intravenous amino acids (IVAA), apart from the gallbladder, also influence other gastrointestinal motor functions. Both small intestinal motility and small intestinal transit time were studied simultaneously in 6 healthy volunteers (age 20-29 yr) after an overnight fast on two separate occasions in random order during (1) continuous iv. infusion of amino acids (Vamin; 250 mg protein. kg-‘. h-‘) or (2) infusion of saline (control). Gastrointestinal motility was recorded with a 6-channel water-perfused system (1 X antrum, 3 X duodenum, 2 x jejunum) for 390 min after the spontaneous occurrence of a Phase III of the migrating motor complex (MMC) defined as time 0 min. At time 15 min i.v. infusion of saline or amino acids was started and Iactulose (6 g in 60 ml water) was administered into the duodunum to measure duodenocaecal transit time (DCIT) by breath hydrogen analysis. Gallbladder contraction was measured with ultrasonography. Results: IVAA induced a gallbladder contraction of 40+ 10% whereas no contraction was observed during saline infusion. DCTT increased significantly (p < 0.05) from 91 f 16 min (control) to 212 + 24 min (IVAA). IVAA did not include a feeding motor pattern. On the contrary, a fasting motor pattern was maintained and the reoccurrence of a Phase III of the MMC was significantly (p < 0.05) accelerated during IVAA (41+ 12 min) compared to saline (110_+31 min). The MMC cycle length decreased significantly (p < 0.05) during IVAA from 106 f 18 to 61 f 7 min. Apart from cycle length, the relative contribution of Phase I and II to the MMC changed significantly (p < 0.05) from 39 and 56% resp. during saline infusion to 67 and 28% resp. during IVAA. Conclusions: Separate intravenous infusion of high doses of amino acids stimulates gallbladder contraction, decelerates small intestinal transit time and influences small intestinal motility by reducing MMC cycle length with suppression of Phase II activity.

Abstracts Long-term gastrectomy

efficacy of dumping.

Hepatology,

University

octreotide

therapy

/Netherlands in

severe

Journal post-

J. Vecht, F. van der Kleij, C.B.H.W. Lamers, A.A.M. Masclee. Department of Gastroenterology and Hospital,

Leiden,

Netherlands.

The somatostatin analogue octreotide has been shown to suppress signs and symptoms of early and late dumping in short-term intervention studies. Little is known, however, about the long-term clinical efficacy of octreotide therapy in these patients. We report on our experience with 20 patients (12 M, 8 F, mean age 54 years, range 31-74 yrl treated with octreotide S.C. at our department between 1987 and 1994 because of severe and disabling dumping symptoms refractory to dietary measures or other medical therapy (13 patients with early dumping, 1 with late and 6 with early and late dumping). All patients previously underwent gastric surgery: partial gastrectomy n = 11, total gastrectomy n = 2, vagotomy n = 7. The diagnosis of dumping syndrome was confirmed by a positive provocation test with 50 g oral glucose, which became negative after pretreatment with octreotide. Mean treatment duration at follow-up was 29 months, range l-86 months. The daily dose of octreotide varied from 50 to 200 wg. Eleven patients currently use octreotide; 9 patients have discontinued octreotide therapy because of lack of improvement of symptoms in the long term in 3 patients, and because of side-effects in 6 patients (diarrhoea n = 3, alopecia n = 1, painful injections n = 1, weight loss n = 1). Of the 11 patients on octreotide therapy subjective improvement of symptoms varies from moderate (n = 2) to excellent (n = 9). Faecal weight was not influenced by octreotide (290 & 50 vs. 315 f 50 g/24 hl but faecal fat excretion increased significantly (p < 0.011 during octreotide therapy from 17 f 6 to 31 f 7 g/24 h (normal value < 7 g/24 h). Despite an increase in steatorrhoea, a mean gain in body weight of 2.1+0.4 kg was observed because of increased caloric intake. Conclusions: Octreotide is an effective symptomatic therapy in the long-term management of patients with severe early and late post-gastrectomy dumping. The occurrence of sideeffects often limits prolonged clinical use of octreotide. Steatorrhoea increases during octreotide therapy but does not result in further weight loss. Responses

to

gastric

distention

in

functional

dyspepsia.

G.A.M. Salet ‘, M. Samsom b, J.M.M. Roelofs a, G.P. van Berge Henegouwen b, L.M.A. Akkermans a, A.J.P.M. Smout b. Departments of a Surgery and b Gastroenterology, University

Hospital,

Utrecht,

Netherlands

Recent studies in functional dyspepsia have shown that an altered visceral perception threshold plays a role in the pathogenesis of upper digestive symptoms. It is not clear, however, what the contribution is of compliance and adaptive relaxation of the proximal stomach to the lower visceral perception threshold in functional dyspepsia. In this study the responses of the proximal stomach to distention by an air-filled bag and to a liquid meal (200 ml, 200 kCa1) were evaluated with the use of a barostat. Perception of nausea, bloating and pain were evaluated during both distention stimuli, using a visual analogue scale. Ten healthy volunteers (5 6 and 5 9: 26-38

of Medicine

46 (1995)

A31

Al -A36

yr) and 12 patients with dysmotility-like functional dyspepsia (5 d and 7 0 : 22-62 yr), as defined by the presence of chronic upper digestive complaints related to food ingestion, were included. The minimal distending pressure (MDP) needed to overcome the intra-abdominal pressure (first pressure level that provided an intrabag volume of 2 30 ml) was similar in patients and healthy volunteers (6.33 f 0.52 and 6.23 f 0.41 mmHg). There was a significant difference in the volumepressure curve between the dyspeptics and the controls, the compliance (AV/AP) being significantly higher in the dyspeptics (p = 0.022). In both patients and controls the symptom score increased with increasing intrabag pressure. However, dyspeptic patients had a significantly higher increase of nausea and pain scores with increasing pressure than the healthy controls (p = 0.02, p = 0.006). After ingestion of a liquid meal (intragastric pressure kept at MDP + 1 mmHg) the increase in intragastric bag volume (adaptive relaxation) in the dyspeptic patients was significantly less than in the healthy volunteers (area under the time-volume curve of 1081.9k685.6 vs. 2839.5 5464.0 ml (p = 0.011). The maximum volume increase was not significantly different between patients and controls (150+42 and 242&31 ml, resp. (p = 0.1811, but the time interval between the start of ingestion of the meal and the time at which the maximum volume was reached was significantly shorter in patients than in controls (12?3 and 185 3 min, resp. (p = 0.02)). Conclusion:

This is the first study to show that in patients with functional dyspepsia the compliance and accommodation of the proximal stomach to a liquid meal are significantly disturbed. These abnormalities are likely to play a role in the genesis of dyspeptic symptoms in these patients

Cholecystokinin tients with I&IX

provokes disease,

gas&o-oesophageal

reflex

in

pa-

A.A.M. Masclee, I. Schrijver, M. Ledeboer, I. Biemond, C.B.H.W. Lamers. Department of Gastroenterology Netherlands.

and

Hepatology,

University

Ho.ypital,

Leiden.

Ingestion of a fatty meal stimulates cholecystokinin (CCK) release and provokes gastro-oesophageal reflux (GER). GER results predominantly from transient lower oesophageal sphincter relaxations (TLESR) although other mechanisms, such as low basal LES pressure, are also involved. We investigated the effect of CCK infusion, leading to physiological postprandial plasma CCK levels on GER, LES pressure and TLESR’s. Ten healthy subjects (age 20-57 yrl and 10 patients with reflux disease (endoscopic oesophagitis grade l-3; age 25-70 yr) were studied with combined oesophageal pH-metry and manometry (Dent-sleeve) for 90 min on 2 separate occasions in random order during (11 continuous gastric load of dextrose 5% + i.v. infusion of CCK-33 (1.0 IDU.kg“b ‘1 and (21 gastric load + saline i.v. (control). Results: Infusion of CCK resulted in significant (p < 0.01) increases in plasma CCK from 2.2+0.2 to 9.X10.6 pM in both patients and controls (see table).

A32

Abstracts

/Netherlands

Journal

Basal LESP (mmHg) CCK: LES (mmHg) Time pH < 4 (%) Reflux episodes by TLESR (N/90 min) Reflux episodes by low LESP (N/90 min)

CCK

22+3

20+4

21+3 0.2kO.l

14+3 * * 0.3kO.l

LO&O.4

2.2+0.5

0

0

Saline 12+2 * 10&l *

CCK

9+3 3.8kO.4

*

30*7 3.7kO.8

*

2.4kO.3

0.6kO.2

troenterology Nieuwegein

* * * * *

* p < 0.05: patients vs. controls; * * p < 0.05: CCK vs. saline. Conclusions: CCK reduces LES pressure in both patients and controls. In patients the number of reflux episodes caused by TLESR’s is significantly higher than in controls. CCK significantly increases reflux time in reflux patients due to an increase in reflux episodes caused by low basal LESP and not by an increase in TLESR’s. Symptom dependent

perception in gastro-oesophageal reflux on spatiotemporal refhm characteristics.

disease

is

B.L.A.M. Weusten a, L.M.A. Akkermans b, G.P. van Berge Henegouwen a, A.J.P.M. Smout a. Departments of a Gastroenterology and b Surgery,

University

Hospital,

Utrecht,

angina-like disorders.

chest

J.H. Voskuil a, M.J. Cramer b, R. Breumelhof a, R. Timmer a, C.A.P.L. Ascoop b, A.J.P.M. Smout ‘. Departments of a Gas-

11+2 * 6+1**

*

Al -A36

Newly referred cardiology out-patients with pain have a high prevalence of oesophageal

Patients Basal LESP (mmHg1 CCK: LES (mmHg) Time pH < 4 (%) Reflw episodes by TLESR (N/90 min) Reflux episodes by low LESP (N/90 min)

46 (1995)

criminant analysis using episode duration and proximal extent as discriminating variables resulted in a correct classification of symptomatic reflux episodes in 84.2% and of asymptomatic reflux episodes in 89.5% of the patients. Conclusion: The perception of reflux symptoms depends on the duration of acid exposure episodes and on the proximal extent of the refluxate.

Controls Saline

of Medicine

Netherlands.

Gastro-oesophageal reflux disease (GORD) is a common disorder. The mechanisms responsible for the development of reflux symptoms are poorly understood. Recent technological developments have made it possible to measure intraluminal pH at multiple oesophageal sites simultaneously. We performed S-channel oesophageal pH-metry (3, 6, 9, 12, and 1.5 cm above the upper border of the LOS) in 19 symptomatic GORD patients (6 female, 13 male; age 21-73 yr) in order to identify differences in dynamic reflwc variables (proximal extent and duration of reflux episodes, ascending velocity of the refluxate) between symptomatic and asymptomatic reflux episodes. One patient had reflux oesophagitis Grade I, 7 Grade II, and 2 Grade III. In all patients, the median proximal extent, the median duration at the most distal sensor and the median ascending velocity of the refluxate were assessed separately for symptomatic and asymptomatic reflux episodes. Median episode duration (at 3 cm above the LOS) was longer and the proximal extent was higher in symptomatic than in asymptomatic reflux episodes (p < 0.0005 and p < 0.001). A significant correlation was found between the duration (at 3 cm) and the extent of the refhrx episodes (p < 0.01). No significant differences were found in ascending velocities between symptomatic and asymptomatic reflw episodes. Dis-

and b Cardiology, and ’ University Hospital,

St. Antonius Hospital, Utrecht, Netherlands.

The prevalence of oesophageal disorders (dysmotility and/or gastro-oesophageal reflux) in new patients with chest pain referred to a cardiological clinic for the first time is unknown. We evaluated 28 of these patients (15 M/13 F, median age 53 yr, range 33-69 yr). Patients with evidence of severe myocardial ischaemia were excluded. In the first days after referral all patients underwent gastroenterological evaluation consisting of medical history, oesophageal manometxy, upper endoscopy and 24-h ambulatory oesophageal pH and pressure monitoring. Twelve patients had a pathological 24-h pH-profile, 4 of whom also had reflux oesophagitis. No motility disorders were found. Eleven patients experienced chest pain during the 24-h monitoring. Although in only 2 of these patients the SI for reflux was > 75%, chest pain disappeared in 9 out of 12 patients with pathological reflux upon treatment with omeprazole. Based on history alone, the chest pain had been classified by the gastroenterologist as oesophageal in origin in only 3 of the 9 patients with symptomatic reflux. In the cardiological follow-up (range 2-10 months) significant myocardial ischaemia was diagnosed in 6 of the 28 patients. Based on history alone, the chest pain had been classified as cardiac in origin in only 2 of these 6 patients. In 4 patients a combination of cardiac and oesophageal pathology was found. In 3 of these patients the chest pain was considered to be of cardiac origin. Conclusion: As many as 30% of out-patients with anginalike chest pain referred to the cardiologist for the first time have symptomatic pathological gastro-oesophageal reflux. Neither cardiological nor gastroenterological history data have a high predictive value in assessing the origin of the chest pain. Based on these results, we suggest a combination of upper endoscopy and 24-h ambulatory pH-monitoring to exclude oesophageal function disorders early in the workup of patients with chest pain. Does subclinical hepatic encephalopatby have an influence on the quality of life? J.C. Quero, I. de Bruijn, SW. Schalm. Department of Internal Medicine II (Hepatology Section), University Hospital, Rotterdam, Netherlands.

Subclinical hepatic encephalopathy (SHE) is assumed to have a negative effect on patients’ daily functioning, but no quality-of-life studies have been performed to document this.

Abstracts

/Netherlands

Journal

In order to measure the impact of SHE on the quality of life, 67 consecutive patients (27 female, mean age 49.8 years, SD 13.5, range 15-74) with liver cirrhosis were screened for SHE using psychometric tests (NCT-A, NCT-B, SDT) with normal values corrected for age and spectral-EEG. SHE was defined as 2 1 abnormal psychometric test and/or abnormal spectralEEG. In addition, quality of life was measured by administering the ‘Sickness Impact Profile’ (SIP) questionnaire to the patients. Eighteen patients (27%) had SHE according to our definition. There was no statistical difference with regard to age (p > 0.10) between patients with and without SHE. Patients with SHE differed significantly from those without SHE (n = 49) in the total SIP score, based on differences in the physical (PC), psychological (PSY) and independent (IC) categories of the SIP. Patients with SHE reported significantly more disturbances of sleep/rest (SR), ambulation (A), social interactions (SI), home management (HM), and bodycare and movement (BCM) (see table). % dysfunction in different categories Total score PC PSY IC SR A SI HM BCM

No SHE 7 2 9 9 11 3 10 6 1

SHE 12 7 14 16 22 8 18 15 5

Conclusions: These results suggest that patients with SHE have a decreased quality of life. The clinical association of these findings should be evaluated by measuring quality of life before and after specific therapy for SHE. Kupffer in rat

ceil elimination livers after 8-h

does not attenuate reperfusion i&y and 24-h cold preservation. B.A. van

Wagensveld a, M.E. Reinders a, E.P.M. Corssmit b, T.M. van Gulik a, N. van Rooijen ‘, W.M. Frederiks d, R.A.F.M. Chamuleau b, P.J. Klopper a. Departments of a Surgery, b Medicine, ‘Histology, Free Universi@, Amsterdam and d Department of Cell Biology, Academic Medical Centre, Amsterdam, Netherlands.

Cold ischaemia and reperfusion are major contributors to preservation injury in liver grafts. Reperfusion damage occurs when organs are recirculated with oxygenated and normothermic blood. Especially liver sinusoidal endothelial cells (SEC) are prone to this kind of injury. Activated Kupffer cells may play a role in this process by release of inflammatory cytokines. In earlier studies we have shown that uptake of hyaluronic acid (HA), a proteoglycan specifically internalized by SEC, is a useful parameter of SEC function and damage. Wistar rats (275 g) were given (group-LIP) or withheld (group-CONTR) liposome-encapsulated C12MDP pre-treatment to eliminate Kupffer cells. The livers were flushed in

qf Medicine

46 (1995)

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situ with cold UW preservation solution and stored at 4°C for 8 or 24 h (cold ischaemic time, CIT). The livers were then reperfused with 200 ml of oxygenated Krebs-Henseleit solution (37”) in a recirculation system. At t = 0, HA (56-75 pg) was added to the reperfusion medium. HA was measured at intervals up to 90 min of reperfusion, and expressed as the percentage of the initial concentration at t = 0. SGOT (U/l) was also determined as a parameter of hepatocellular damage. After 8 h CIT, in the LIP-group (n = 6), 15.3 Ifr2.2% (mean of:s.e.m.) of the initial concentration of HA was taken up during 90 min reperfusion; in the CONTR group (n = 6) this was 28.8 + 6.6%. (n.s.). SGOT release increased in both groups from 0.6 to 11.6k1.7 and from 0 to 12.8k1.5 U/l, resp. (n.s.). After 24 h CIT, in both LIP as CONTR group (n = 3), livers showed no uptake of HA during 90 min reperfusion, indicating abolished SEC function irrespective of pretreatment with liposomes. SGOT levels increased from 2.3 to 40.7+3.8 and from 0.7 to 29.7k7.5 U/l, resp. (n.s.). Elimination of Kupffer cells did not result in reduction of reperfusion damage, measured by the functional capacity of the SEC to take up HA, or SGOT-release. This reperfusion model shows a clear distinction (p < 0.001) between adequate and abolished SEC function after 8 and 24 h of CIT. resp. Local

messenger

RNA

cytokine

expression

in liver

al&rafts.

W.M. Mol a, H.J. Metselaar a, C.C. Baan a, H.W. Tilanus h, P.E. Zondervan c, H.G.M. Niesters d, W. Weimar ‘. Departments of * Internal d virology / MBDI, lands.

Medicine University

I, b Surgery, ’ Pathology and Hospital, Rotterdam, Nether-

Rejection is a major complication after liver transplantation. Cytokines are thought to play a central role in the inflammatory and allospecific components of allograft rejection. The purpose of this study was to characterize the local messenger RNA (mRNA) cytokine profile in relation to allograft rejection. We used the reverse-transcriptase polymerase chain reaction to analyse the presence of IL-2, IL-4 and IL- 10 cytokine mRNA in liver allografts. We studied 60 liver allograft biopsies obtained from 19 liver allograft recipients 2-512 days post-transplant. Liver allograft biopsies were grouped into those without rejection or with mild (not treated) rejection and into those with severe rejection for which the patient was treated. At the time of severe rejection, b/l6 (37%) biopsies showed transcription of the IL-2 gene, while only 4/44 (9%) biopsies without rejection or with mild rejection expressed the IL-2 gene (p = 0.02, Fisher’s exact test). mRNA for IL-4 was found in 4/16 (25%) biopsies with severe rejection and in 14/44 (32%) biopsies without rejection or with mild rejection. IL-10 mRNA was detectable in the majority of liver allograft biopsies regardless of their histopathological status. Conclusions: These results suggest that locally expressed IL-2 may be an important regulator in the graft during severe rejection. Serum lowing

glutathione S-transferases alpha liver transplantation: comparison

concentrations with ASAT.

fol-

M.N.

A34

Abstracts

/Netherlands

Journal

Aparicio Pages a, T.P.J. Mulder b, H.J. Metselaar a, W.H.M. Peters b, H.W. Tilanus ‘. Departments of a Internal Medicine II and ’ Surgery, University of 2 Gastroenterology Nijmegen, Netherlands,

Hospital, Rotterdam and b Department and Hepatology, University Hospital,

Information about graft function is of primary importance in liver transplantation. Recent data suggest that glutathione S-transferase alpha (GSTa) is a more sensitive indicator of hepatocellular integrity than ASAT. GSTa constitutes 2% of soluble protein of the liver, the enzyme has a uniform hepatic distribution and its plasma half-life is less than 2 h. In a retrospective study GSTa was measured in serum samples from 24 liver graft recipients (median age 54 years, range 22-66, 9 males) and compared with ASAT. Serum samples had been collected from day 1 until day 20 post-transplantation at 24-h intervals and 362 serum samples (75%) were available. Serum GST Al-l, one of the three GSTa isoenzymes, was measured by specific sandwich ELISA. Day l-3 post-operation samples were available from 18 patients. On day 1 all had elevated ASAT levels, but 3 patients had normal GSTcr levels. After reaching peak levels GSTa decreased more rapidly (median decrease of 74%/day, range 20-99%) than ASAT (median decrease Sl%/day, 294%, p < 0.02) in the 15 patients with raised ASAT and GSTa levels. In 21 patients GSTa levels increased by at least a factor of 2 above the last trough level during 32 episodes. In 27 of these episodes a concomitant increase in ASAT was noted. An increase in ASAT of more than a factor of 2 above the last trough level was always accompanied by a corresponding rise in GSTa. Increases in GSTa were also significantly greater (median 4.1 X, range 2.0-73.0X the last trough level) than increases in ASAT (median 2.0 X , range 1.2-21.0 X , p < 0.01). Acute rejection was observed in 11 patients. In 5 of these patients GSTo concentrations started rising 1 day in advance of the increase in ASAT levels and in the other 6 patients ASAT and GSTo started to rise simultaneously. Conclusion: GSTo is an earlier and more sensitive marker of hepatocyte integrity after liver transplantation than ASAT.

Endotoxin and interleukin-1 related hepatic inflammatory response, and its effects on liver cell proliferation and f’unction following partial hepatectomy in the rat. M.A. Boermeester a, I.H. Straatsburg b, A.P.J. Houdijk a, W.M. Frederiks b, C. Meyer ‘, R.I.C. Wesdorp ‘, C.J.F. van Noorden b, P.A.M. van Leeuwen a. a Department of Surgery, Free University Hospital, Amsterdam and b Department of Cell Biologv and Histology, Academic Medical Centre, Amsterdam, Netherlands. Objective: During the early phase after partial hepatec-

tomy, liver function depends on adequate functioning of the remnant liver until regeneration has restored its capacity. We investigated in a rat model whether local hepatic inflammatory responses were related to endotoxin and whether interleukin-1 was an important mediator in this respect. Secondly, we evaluated the relation between this inflammatory response and liver cell proliferation and function.

of Medicine

46 (1995)

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Methods: Wistar rats received a two-thirds partial hepatectomy (phx), and a continuous infusion of saline (phx-con, n = 81, N-terminal bactericidal/permeability-increasing protein (rBPI,,l (phx-bpi, n = 8) or interleukin-1 receptor antagonist (phx-IL-lra, n = 71. Sham-operated rats infused with saline were used for comparison (n = 8). At 24 h, blood was drawn for biochemical analysis, and rats were sacrificed to remove the liver remnant for histological and immunohistochemical studies. Liver cell proliferation was assessed by staining with proliferation cell nuclear antigen (PCNA). Results: Following partial hepatectomy, a profound influx of mononuclear phagocytes as well as a moderate infiltration of neutrophils was found in the liver. In pbx animals treated with rBPI,,, an endotoxin-neutralizing protein, or IL-lra, an inhibitor of IL-1 activity, a clear reduction in the number of these newly recruited cells was observed. In addition, phx-bpi and phx-IL-lra rats demonstrated a significant increase in liver cell proliferation compared to phx-con rats (both p < 0.01 vs. phx-con). Together with these changes, rBPI,, and ILlra-treated phx animals had lower aspartate and alanine aminotransferase plasma levels than saline-treated phx animals (all p < 0.05). Only phx-IL-lra rats had significantly lower plasma levels of ammonia (p < 0.05 vs. phx-con). Conclusion: Endotoxin induces a significant inflammatory response in the remnant liver following partial hepatectomy, which is at least partly mediated by IL-l. Our results suggest that this local hepatic inflammation inhibits liver cell proliferation and promotes liver dysfunction.

The effect of preoperative biliary drainage on the inflammatory cascade in patients with obstructive jaundice undergoing a mdor surgical procedure. A.N. Kimmings a, S.J.H. van Deventer b, E. Rauws b, K. Huibregtse b, L. de Wit a, H. Obertop ‘, D.J. Gouma ‘. Departments of’ Surgety and b Gastroenterology, lands.

Academic

Medical

Centre,

Amsterdam,

Nether-

Surgery in patients with obstructive jaundice (OJ) is associated with higher morbidity than comparable surgery in nonjaundiced patients with septic complications being the most frequent. This is thought to be due to increased susceptibility to endotoxin and to bacterial translocation, with the production of cytokines inducing the inflammatory cascade of the sepsis syndrome. Previous (animal) experiments have shown portal and systemic endotoxaemia, the presence of different cytokines (TNF, IL-6, soluble TNF receptors), depression of cellular immunity and reduction of this inflammatory response after internal biliaty drainage. This has not been studied in a clinical setting. Therefore the aim of the study was to investigate the effect of preoperative drainage on the inflammatory cascade. Patients (n = 7) were included with OJ (bili > 100) and a distal “resectable” obstruction (stent placement possible). t = 0 is the time of endoprosthesis placement; t = 3 is 3 weeks after drainage at the time of operation. Parameters measured at both timepoints are: routine risk factors, bacterial translocation (cultures), endotoxin and cytokine levels and cellular immunity.

Abstracts

/Netherlands

Journal

Preoperative drainage reduced bilirubin from 277.3 to 74.7 pmol/l (p = 0.02). No significant influence was seen on other routine measurements (I-lb, albumin or creatinine). There was systemic endotoxaemia of 0.036 U/ml pre-drainage and 0.057 U/ml post-drainage (p = 0.08). Cytokines were detectable and were not reduced significantly after biliary drainage. t = 0 versus t = 3: TNF 1.5 and 7.9 pg/ml. sTNFr55 3.99 and 3.96 rig/ml. sTNFr75 8.58 and 7.0 rig/ml. IL-6 2.3 and 3.2 pg/ml. IL-10 394 and 296 pg/ml. Bacterial cultures were positive in 2/7 bile samples at t = 0 and 7/7 at t = 3 (p = 0.04). 2/7 patients had a postoperative septic complication. Conclusions: Despite adequate biliary drainage there was no reduction of endotoxaemia or cytokine levels, although soluble TNF receptor ~75 did show a correlation with the bilirubin level. After 3 weeks drainage all bile samples were infected. The findings seem to indicate that the reduction in the inflammatory response observed in previous studies in animals may be prohibited in patients with a stent by the intrinsic infective or inflammatory component related to the endoprosthesis itself. Perioperative morbidity in 50 consecutive hepatic resections. F. van Coevorden ‘, L.F.M. Beenen a, E. Gortzak a, H. Boot ‘, C. Blackburn ‘, F.A.N Zoetmulder a. Department of ’ Surgery, b Gastroenterology Institute / Antoni Netherlands.

and ’ Anaesthesiology, Netherlands Cancer van Leeuwenhoek Ziekenhuis, Amsterdam,

Hepatic resection for metastatic and primary cancer has become a feasible procedure, performed with increasing frequency. Pringle’s clamping of the hepatoduodenal ligamental structures and the introduction of new technical possibilities such as the Cavitron Ultrasonor Surgical Aspirator (CUSA) have decreased perioperative mortality and morbidity. Our experience with 50 consecutive hepatic resections in 49 patients (26 male, 23 female; age 27-77 yr, median 56 yr) in the period January 1989-April 1994 is reported here. The indication for surgery was metastatic cancer in most cases, the majority of colorectal origin (38/47 cases). Hepatic resections were also performed for primary hepatic carcinoma (11, a large haemangioma (l), and a case of hepatic haemorrhage as complication of a blind liver biopsy (1). The diseasefree interval between primary tumour treatment and metastatic disease ranged from 0 to 144 months (mean 22.2 months, median 8). 24 patients had solitary metastasis, 23 multiple. Diaphragm involvement was seen in 9 patients. The extent of surgery was at least 3 segments in 28 patients. Operation time ranged from 80 to 330 min (median 175 min). Pringle’s procedure was performed in 45 hepatic resections. The total clamping time ranged from 25 to 120 min. In almost all cases the CUSA parenchymal dissection technique was used. Total blood loss during surgery was < 1500 ml in 24, 1500-3ooO ml in 20 and > 3000 ml in 6 resections and was unrelated to the extent of the resection. No blood transfusion was required in 27 patients; only 2 patients needed more than 6 units blood. Abdominal drains were used routinely and removed within

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46 (I 995) AI -A36

8 days in 38 patients, and were needed for > 2 weeks in 4 patients. An uneventful postoperative course was Seen after 39 resections. P.o. bile leakage occurred in 9 patients. In 11 patients 13 complications were seen: subhepatic fluid collection (4 x ), subphrenic abscess (3 X 1, jaundice (3 X 1 and other (3x). Four surgical reinterventions were needed. There was no peri- or postoperative mortality. Hospital discharge within 14 days p.o. was possible for 25 patients. Only X patients stayed in the hospital for more than 21 days. Conclusion: Hepatic surgery for metastatic cancer can be performed with acceptable low perioperative morbidity and minimal mortality. Effect of erythromycin on gallbladder emptying in patients with antrectomy or truncal vagotomy. A.A.M. Masclee, M.L. Ledeboer, H.A.J. Gielkens, F.G.H. van der Kleij, C.B.H.W. Lamers. Department of Gastroenterology and Hepatology, University

Hospital,

Leiden,

Netherlands.

Erythromycin, as a motilin agonist, stimulates gallbladder contraction in healthy control subjects. Since the action of erythromycin is cholinergic-dependent and possibly related to premature Phase III MMC activity in the antrum we investigated the effect of erythromycin on gallbladder volume in 6 patients with truncal vagotomy and pyloroplasty (TV + P) with the antrum in situ (age 50-73 yr), 14 patients with antrectomy (Billroth I partial gastrectomy n = 6, age 34-65 yr; Billroth II partial gastrectomy n = 8, age 42-70 yr) and 8 control subjects (age 22-70 yr). Gallbladder volumes, measured with ultrasonography, were determined every 15 min for 1X0 min after erythromycin infusion (3 mg/kg i.v.). Results: Fasting gallbladder volumes were not significantly different between patients with TV + P (30 + 5 cm’), Billroth I anastomosis (26 f 4 cm3), Billroth II anastomosis (25 + 3 cm’) and control subjects (24+2 cm3). Erythromycin induced a significant reduction in gallbladder volume at a maximum of 46+6% in the controls (p < 0.05), 49$90/c in the patients with TV+ P (p < 0.05) and 38& 7% in the patients with Billroth I anastomosis (p < 0.05). However, no significant reduction in gallbladder volume in response to erythromycin was observed in the patients with antrectomy and Billroth II anastomosis. Conclusion: These results indicate that neither the longvagus nerve nor the antrum is essential for erythromycin-induced effects on the gallbladder. Since no reduction in galtbladder volume after erythromycin was observed in the patients with antrectomy and Billroth II anastomosis, we suggest that duodeno-jejunal anatomical integrity is essential for erythromycin-induced gallbladder contraction. Clinical relevance of three-dimensional (CT) reconstructions in liver surgery. A. Hennipman ‘, M.S. van Leeuwen ‘, J. Noordzij ‘, R.F. Schmitz ‘, H.G. Gooszen “, Th.J.M.V. van Vroonhoven a. Departments of a Surgery and b Radiology. University

Hospital,

Vtrecht,

Netherlands.

The most important complication when performing partial resections of the liver is severe loss of blood. Recently a 3-D display of CT and MR data has been used to study the anatomy of the liver. 3-D reconstructions accurately visualize

A36

Abstracts

/Netherlands

Journal

the intrahepatic vascular systems. Analysis of the vascular anatomy of the liver in 10 healthy volunteers demonstrated in 8 cases one or more differences when compared with the ‘standard’ anatomy that has been popularized by Coineaud. Most often the differences are found in the right hemiliver. It can be hypothesized that an improved understanding of the vascular anatomy leads to a more efficient use of the relatively avascular intersegmental or intersectoral planes, thus diminishing blood loss and preserving a better circulated parenchyma.

of Medicine

46 (1995)

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At present we are analysing the anatomy of the liver by way of 3-D (CT) reconstructions in patients with centrally located or multiple lesions in whom surgery is considered. In our first 10 patients we observed an anatomy different from the ‘Coineaud anatomy’ in 6. In 3 patients we decided to perform a type of resection different from that originally planned using 2-D images. Conclusion: 3-D reconstruction of 2-D imaging of the liver does contribute in a relevant way to the planning of partial resections.