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Quality of life and proctocolectomy
GASTROENTEROLOGY
1992;102:2181-2193
CORRESPONDENCE Readers are encouraged to write Letters to the Editor concerning articles that have been published in GASTROENTEROLOGY. Short, general comments are also considered, but use of the Correspondence Section for publication of original data in preliminary form is not encouraged. Letters should be typewritten double-spaced and submitted in triplicate.
Quality of Life and Proctocolectomy Dear Sir: I read with interest the article by Kijhler et al.,’ puzzled that quality of life could be considered without reference to the number of stools passed, nocturnal incontinence, pouch infections, or the number of surgeries required, and the degree of influence of these on the life. Following “ileoanal pull-through,” all patients require a second operation to close the colostomy, and at least 30% are believed to face a third for dysfunction, adhesion, etc.: pouch inflammation will affect about 10% of patients; and nine stools a day (and night) are common in the first year, with six to seven thereafter; nocturnal fecal incontinence passes slowly. This should be compared with the rapid return to work after a Brooke ileostomy has been performed, ileostomy with bowel obstruction and revision occurring in about 5%-10%. I suppose that if one eliminated all of these problems and considered only the presence or absence of the appliance, one might write such an article, but it seems to me to be misleading. A. THOMAS MARUBBIO, M.D.
Fargo Clinic 737 Broadway Fargo, North Dakota 58123 1. Kijhler LW, Pemberton
JH, Zinsmeister AR, Kelly KA. Quality of life after proctocolectomy. Gastroenterology 1991;101:679684.
Gastric Secretion in Normal Subjects Dear Sir: In a recent studjr of healthy elderly subjects, Goldschmiedt et al.’ found an increase both in acid and pepsinogen secretion and in serum gastrin secretion. They thereby deduced that the parieta1 and chief masses were increased. However, the subjects they studied were rated healthy simply because they had no symptoms and no history of medical or surgical digestive tract disease. Among them were individuals who tested positive for Helicobatter pylori. In previous work of ours, the parietal cell mass was evaluated by means of a morphometric count expressed as a parietal index.’ The morphometric count decreased with age in healthy subjects having a histologically normal gastric mucosa after the age of 50. The increase was accompanied by a decrease in the functional expression, HCl. *,3 We found no significant variations in serum gastrin secretion after that age.2,3 The simultaneous decrease in acid secretion did not stimulate the antral G cells, stimulation of which is considered to occur at decidedly higher pH values? and only in the course of advanced chronic gastritis.’ In more recent work on gastric cytosecretory variations in normal subjects, we carried the investigation a stage further by evaluating the chief cell component,6 expressed as a zymogenous index (ZI), and by evaluating the corresponding functional datum, serum pepsinogen I concentration (PGI).7 After the age of 50, we found a decrease in the ZI and an equally significant decrease in the PGI leveL7 The percent decrease in chief cells was greater than that of the parietal cells, possibly because of decreased resistance to factors related to aging (i.e., wear and tear, circulatory changes] because they are more differentiated.“” Peptic activity in the gastric juice showed no significant changes in the elderly, but
this was because of the fact that pepsin secretion is an expression not only of chief cells but also of fundic-antral mucopeptic cells, which undergo no age-related changes.g The differences between our results and those of Goldschmiedt et al. are probably the result of the stricter criteria we adopted for the selection of normal subjects because acid and peptic secretion, in particular, may be affected by both exogenous and endogenous factors. In our study, in fact, to be classified as normal a subject had to be symptomless, have a normal endoscopic and histological pattern, be H. pylori negative, smoke no more than 10 cigarettes a day, have normal kidney and liver function, and be psychologically normal. Histological assessment of the gastric mucosa, both fundic and antral, is very important because it has been established that 50% of subjects with normal results of endoscopy may have histologically chronic gastritis.’ Thus, undiagnosed chronic superficial gastritis may, in varying percentages, involve increased acid secretion” and, in more than 90% of cases, increased serum concentrations of PGI and PGII,“~‘2 even if there are no quantitative changes in the parietaP and chief celP2 masses. An evaluation of kidney function should not be omitted because PGI is constantly excreted, without diurnal variations, through glomerular filtration. Hence, changes in kidney function are often present in the elderly and may be accompanied by an increase in serum PGI levels.‘3 Liver function must also be considered because it plays a part in the metabolism of pepsinogen. With regard to the effect of cigarette smoking, some studies have shown it can increase acid secretionI and peptic secretion.” Finally, psychological disturbances should not be ignored, for they may well have an important effect on acid and peptic secretion.‘6’8 Accurate measurement of H. pylori is essential because the presence of the bacterium in the mucosa of the fundus or antrum means an increase in PGI and PGII levels.6,‘9 Its effect on acid secretion is controversial. Some argue that it induces an increase2o,21 mediated by several factors capable of increasing gastrin and consequently increasing secretion of acid by the parietal cells (i.e., production of ammonia, release of cytochines, increased GRP). Be that as it may, one thing is certain: serological identification is not always enough to detect H. pylori. The presence of antibodies may be a sign of past infection or an occasional contact. It does not ensure that the bacterium is not present in the stomach. In our experience, to be certain of H. pylori positivity, at least a culture and a rapid urease test must be histologically positive. In view of these considerations and in order to be sure that any changes are really related to physiological aging, it is clearly necessary, when selecting healthy individuals, to exclude variables likely to affect gastric secretion. RODOLFO CHELI, M.D. GIANNI TESTINO, M.D.
Department of Gastroenterology San Martin0 Hospital Genoa, Italy Goldschmiedt M, Barnett CC, Schwarz BE, Karnes WE, Redfern JS, Feldman MF. Effect of age on gastric acid secretion and serum gastric concentrations in healthy men and women. Gastroenterology 1991;101:977-990, Giacosa A, Cheli R. Correlations anatomo-secretoires gastriques en fonction de l’age chez des sujets ayant une muqueuse fundique normale. Gastroenterol Clin Biol 1979;3:647-651.
1992;102:2181-2193
CORRESPONDENCE Readers are encouraged to write Letters to the Editor concerning articles that have been published in GASTROENTEROLOGY. Short, general comments are also considered, but use of the Correspondence Section for publication of original data in preliminary form is not encouraged. Letters should be typewritten double-spaced and submitted in triplicate.
Quality of Life and Proctocolectomy Dear Sir: I read with interest the article by Kijhler et al.,’ puzzled that quality of life could be considered without reference to the number of stools passed, nocturnal incontinence, pouch infections, or the number of surgeries required, and the degree of influence of these on the life. Following “ileoanal pull-through,” all patients require a second operation to close the colostomy, and at least 30% are believed to face a third for dysfunction, adhesion, etc.: pouch inflammation will affect about 10% of patients; and nine stools a day (and night) are common in the first year, with six to seven thereafter; nocturnal fecal incontinence passes slowly. This should be compared with the rapid return to work after a Brooke ileostomy has been performed, ileostomy with bowel obstruction and revision occurring in about 5%-10%. I suppose that if one eliminated all of these problems and considered only the presence or absence of the appliance, one might write such an article, but it seems to me to be misleading. A. THOMAS MARUBBIO, M.D.
Fargo Clinic 737 Broadway Fargo, North Dakota 58123 1. Kijhler LW, Pemberton
JH, Zinsmeister AR, Kelly KA. Quality of life after proctocolectomy. Gastroenterology 1991;101:679684.
Gastric Secretion in Normal Subjects Dear Sir: In a recent studjr of healthy elderly subjects, Goldschmiedt et al.’ found an increase both in acid and pepsinogen secretion and in serum gastrin secretion. They thereby deduced that the parieta1 and chief masses were increased. However, the subjects they studied were rated healthy simply because they had no symptoms and no history of medical or surgical digestive tract disease. Among them were individuals who tested positive for Helicobatter pylori. In previous work of ours, the parietal cell mass was evaluated by means of a morphometric count expressed as a parietal index.’ The morphometric count decreased with age in healthy subjects having a histologically normal gastric mucosa after the age of 50. The increase was accompanied by a decrease in the functional expression, HCl. *,3 We found no significant variations in serum gastrin secretion after that age.2,3 The simultaneous decrease in acid secretion did not stimulate the antral G cells, stimulation of which is considered to occur at decidedly higher pH values? and only in the course of advanced chronic gastritis.’ In more recent work on gastric cytosecretory variations in normal subjects, we carried the investigation a stage further by evaluating the chief cell component,6 expressed as a zymogenous index (ZI), and by evaluating the corresponding functional datum, serum pepsinogen I concentration (PGI).7 After the age of 50, we found a decrease in the ZI and an equally significant decrease in the PGI leveL7 The percent decrease in chief cells was greater than that of the parietal cells, possibly because of decreased resistance to factors related to aging (i.e., wear and tear, circulatory changes] because they are more differentiated.“” Peptic activity in the gastric juice showed no significant changes in the elderly, but
this was because of the fact that pepsin secretion is an expression not only of chief cells but also of fundic-antral mucopeptic cells, which undergo no age-related changes.g The differences between our results and those of Goldschmiedt et al. are probably the result of the stricter criteria we adopted for the selection of normal subjects because acid and peptic secretion, in particular, may be affected by both exogenous and endogenous factors. In our study, in fact, to be classified as normal a subject had to be symptomless, have a normal endoscopic and histological pattern, be H. pylori negative, smoke no more than 10 cigarettes a day, have normal kidney and liver function, and be psychologically normal. Histological assessment of the gastric mucosa, both fundic and antral, is very important because it has been established that 50% of subjects with normal results of endoscopy may have histologically chronic gastritis.’ Thus, undiagnosed chronic superficial gastritis may, in varying percentages, involve increased acid secretion” and, in more than 90% of cases, increased serum concentrations of PGI and PGII,“~‘2 even if there are no quantitative changes in the parietaP and chief celP2 masses. An evaluation of kidney function should not be omitted because PGI is constantly excreted, without diurnal variations, through glomerular filtration. Hence, changes in kidney function are often present in the elderly and may be accompanied by an increase in serum PGI levels.‘3 Liver function must also be considered because it plays a part in the metabolism of pepsinogen. With regard to the effect of cigarette smoking, some studies have shown it can increase acid secretionI and peptic secretion.” Finally, psychological disturbances should not be ignored, for they may well have an important effect on acid and peptic secretion.‘6’8 Accurate measurement of H. pylori is essential because the presence of the bacterium in the mucosa of the fundus or antrum means an increase in PGI and PGII levels.6,‘9 Its effect on acid secretion is controversial. Some argue that it induces an increase2o,21 mediated by several factors capable of increasing gastrin and consequently increasing secretion of acid by the parietal cells (i.e., production of ammonia, release of cytochines, increased GRP). Be that as it may, one thing is certain: serological identification is not always enough to detect H. pylori. The presence of antibodies may be a sign of past infection or an occasional contact. It does not ensure that the bacterium is not present in the stomach. In our experience, to be certain of H. pylori positivity, at least a culture and a rapid urease test must be histologically positive. In view of these considerations and in order to be sure that any changes are really related to physiological aging, it is clearly necessary, when selecting healthy individuals, to exclude variables likely to affect gastric secretion. RODOLFO CHELI, M.D. GIANNI TESTINO, M.D.
Department of Gastroenterology San Martin0 Hospital Genoa, Italy Goldschmiedt M, Barnett CC, Schwarz BE, Karnes WE, Redfern JS, Feldman MF. Effect of age on gastric acid secretion and serum gastric concentrations in healthy men and women. Gastroenterology 1991;101:977-990, Giacosa A, Cheli R. Correlations anatomo-secretoires gastriques en fonction de l’age chez des sujets ayant une muqueuse fundique normale. Gastroenterol Clin Biol 1979;3:647-651.