Ultrasonic evaluation of gallbladder emptying with ceruletide: comparison to oral cholecystography with fatty meal

Assessment of gallbladder function is required prior to nonsurgical treatment of gallstones. In order to develop a practical and reproducible method of evaluation, gallbladder emptying was studied by ultrasound (US) in 55 gallstone patients after intramuscular administration of ceruletide (0.3 g/kg). In 27 of these subjects, the US procedure was compared to oral cholecystography (OCG) with fatty meal. Maximal percent gallbladder contraction was reached 30 min after ceruletide in all patients. Maximal percent contractions were 47.5±27.7 during US with ceruletide and 33.9±16.3 during OCG with fatty meal (p = 0.03). A significant linear relationship was found between the results obtained with the two different procedures (r=0.57; p = 0.002). Serial US determinations of gallbladder emptying were performed in 16 patients. Individual variation was below 20% in 11 subjects, and in five subjects it ranged between 20 and 40%. Minor, self-limiting side effects were observed in 13 patients. US determination of gallbladder emptying after ceruletide appears to be a practical and reliable method to assess gallbladder function.     

Delayed gastric emptying and gastric autoimmunity in type 1 diabetes

OBJECTIVE: Delayed gastric emptying and/or gastrointestinal symptoms occur in 30-50% of diabetic patients. Known contributing factors are autonomic neuropathy and acute hyperglycemia, but the role of gastric autoimmunity has never been investigated, although 15-20% of type 1 diabetic patients exhibit parietal cell antibodies (PCAs). We studied gastric motility in diabetes in relation to PCA status, autonomic nerve function, HbA(1c), thyroid-stimulating hormone (TSH), Helicobacter pylori (HP), acid production, and gastric histology. RESEARCH DESIGN AND METHODS: Gastric emptying of solids and liquids (measured by (13)C-octanoic acid and (13)C-glycine breath tests, respectively) was tested in euglycemic conditions in 42 type 1 diabetic patients (male/female: 29/13; 15 PCA+; mean age 40 +/- 15 years; mean HbA(1c) 7.8 +/- 0.9%). Gastrointestinal symptoms, autonomic nerve function (Ewing tests), PCA status (indirect immunofluorescence), gastric histology, and acid secretion (pentagastrin) were assessed. RESULTS: Solid gastric emptying was delayed in 40% and liquid emptying in 36% of patients. Gastric motility did not correlate with symptoms. PCA status, gastric morphology, and acid secretion were similar in those with and without gastroparesis. HbA(1c) level (beta = 1.34, P = 0.011) was the only risk factor for delayed solid emptying in a logistic regression model testing HbA(1c), autonomic nerve function, PCA, HP status, age, sex, diabetes duration, and TSH. Half-emptying time for liquids correlated with TSH level (r = 0.83, P < 0.0001) and autonomic neuropathy score (r = -0.79, P = 0.001). CONCLUSIONS: We found that approximately 50% of type 1 diabetic patients studied had delayed gastric emptying that did not correlate with symptoms. Gastric autoimmunity did not contribute to diabetic gastroparesis. Metabolic control was worse in patients with delayed solid emptying.     

B超检查糖尿病患者Caerulein负荷试验后胆囊功能的意义

Ｂ超检查了糖尿病患者Ｃａｅｒｕｌｅｉｎ负荷试验所致的胆囊功能的变化及与植物神经障碍的关系。７例健康人，２３例糖尿病患者，其中无植物神经障碍（ＤＭ）组８例，植物神经障碍（ＡＮ）组１５例。超声下沿右肋间斜切、右助下斜切求得平均胆囊截面积（ＧＢｓｉｚｅ），计算胆囊最大收缩率（ＭＣ），收缩速度（ＣＲ），恢复速度（ＲＲ）。结果：ＤＭ组ＧＢｓｉｚｅ明显大于正常人，且恢复速度低下。ＡＮ组的胆囊最大收缩率（ＭＣ）明显低于ＤＭ组（Ｐ值＜０．１），ＣＲ、ＲＲ也明显低于正常人。本结果提示植物神经功能障碍导致了胆囊功能的变化，此负荷试验可用于糖尿病患者胆囊功能的检查。     

Autonomic dysfunction and upper digestive functional disorders in untreated adult coeliac disease

There is recent evidence that upper-gut motor abnormalities may be present in coeliac disease. However, to date, the pathophysiological mechanisms responsible for the above have not been explored. The purpose of the present study was to investigate upper-gut motor activity in coeliac disease and explore the role played by the autonomic nervous system in motility disturbances. Thirty untreated adult coeliac patients were recruited into the study. Oesophageal manometry and cardiovascular autonomic tests were performed in all patients; oesophageal pH-metry was carried out in 20 patients, gastrointestinal manometry in eight and scintigraphic gastric emptying in 13. Oesophageal motor abnormalities were detected in about 50% of patients, pH-metry was abnormal in 30% of them, and up to 75% of coeliac patients displayed gastrointestinal motility alterations. Delayed gastric emptying was documented in about 50% of patients and was correlated with manometric post-prandial hypomotility. Autonomic tests were positive in 45% of patients as a group, and reached pathological score in 19% of them. Autonomic score correlated significantly with the percentage of bi-peaked waves and with the number of fasting intestinal clusters. This study confirms that upper-gut motor abnormalities are frequently present in adult coeliac disease. Extrinsec autonomic neuropathy may play a role, although other pathophysiological mechanisms are likely to occur.     

Natural history of diabetic gastroparesis

OBJECTIVE: The major aim of this study was to evaluate the prognosis of diabetic gastroparesis. RESEARCH DESIGN AND METHODS: Between 1984 and 1989, 86 outpatients with diabetes (66 type 1, 20 type 2; 40 male, 46 female) underwent assessment of solid and liquid gastric emptying and esophageal transit (by scintigraphy), gastrointestinal symptoms (by questionnaire), autonomic nerve function (by cardiovascular reflex tests), and glycemic control (by HbAlc and blood glucose concentrations during gastric emptying measurement). These patients were followed up in 1998. RESULTS: Of the 86 patients, solid gastric emptying (percentage of retention at 100 min) was delayed in 48 (56%) patients and liquid emptying (50% emptying time) was delayed in 24 (28%) patients. At follow-up in 1998, 62 patients were known to be alive, 21 had died, and 3 were lost to follow-up. In the group who had died, duration of diabetes (P = 0.048), score for autonomic neuropathy (P = 0.046), and esophageal transit (P = 0.032) were greater than in those patients who were alive, but there were no differences in gastric emptying between the two groups. Of the 83 patients who could be followed up, 32 of the 45 patients (71%) with delayed solid emptying and 18 of the 24 patients (75%) with delay in liquid emptying were alive. After adjustment for the effects of other factors that showed a relationship with the risk of dying, there was no significant relationship between either gastric emptying or esophageal transit and death. CONCLUSIONS: In this relatively large cohort of outpatients with diabetes, there was no evidence that gastroparesis was associated with a poor prognosis.     

慢性胆囊炎与胆结石形成关系的超声研究

目的 探讨慢性胆囊炎与胆结石形成的关系.方法 慢性胆囊炎、胆结石患者及正常人各20例采用超声法进行脂餐前后胆囊容积及排空率的测定.结果 结石组较对照组脂餐前、餐后各期胆囊容积增大,排空率降低(P＜0.05).慢性胆囊炎组餐后胆容积及排空率与对照组无显著性差异(P＞0.05),但空腹容积显著增大(P＜0.05).结论 慢性胆囊炎患者存在胆囊运动功能异常,这种异常可能是胆囊结石形成的原因之一.     

Abnormal diurnal urinary sodium and water excretion in diabetic autonomic neuropathy

1. Diurnal patterns of urine output and sodium and potassium excretion were studied in 10 diabetic patients with and 10 without autonomic neuropathy, and in 10 normal subjects. 2. The diurnal patterns of excretion in the diabetic patients with autonomic neuropathy differed significantly from the two other groups, as a smaller proportion of the 24 h output of urine, sodium and potassium was excreted during the day and a larger proportion was excreted at night. 3. Similar changes were noted in the diurnal patterns of urinary kallikrein excretion in diabetic patients with autonomic neuropathy, and urinary kallikrein output correlated significantly with urine volume but not with urinary sodium excretion. 4. The diurnal patterns of excretion of urinary prostaglandin E2 and 6-keto-PGF1 alpha were not significantly different in diabetic patients with autonomic neuropathy. 5. Nocturia was a common complaint in this group, and the number of nocturnal voidings correlated with night urine volume. There was no evidence of premature bladder emptying. 6. The changes observed in the day/night urine output and sodium excretion could not be explained by glycosuria, insulin regimens, impaired renal function or abnormal diurnal prostaglandin excretion; their possible relevance to the diurnal changes of urinary kallikrein excretion is discussed.     

A Difficult Differential Diagnosis of Acute Cholecystitis in a Patient With Steroid-induced Diabetes

An impairment of gallbladder motility due to autonomic neuropathy may cause cholestasis and result in gallbladder stone formation. Diabetes is one of risk factors for acute cholecystitis. Diabetes and steroid use are associated with the susceptibility to bacterial infections, we are apt to diagnose steroid-induced diabetic patients manifesting symptoms of cholecystitis as having acute bacterial infective cholecystitis. Here, we report a very rare steroid-induced diabetic patient complicated with gallbladder torsion-induced necrotizing cholecystitis due to a floating gallbladder. KEYWORDS: Cholecystitis; Diabetes; Floating gallbladder; Torsion.     

Role of the gastric phase in fat-induced gallbladder contraction and cholecystokinin secretion in humans

The present study was undertaken to investigate the role of the gastric phase of fat-induced gallbladder contraction and endogenous cholecystokinin (CCK) secretion in humans. Gallbladder emptying, measured by cholescintigraphy, and endogenous CCK secretion, measured by radioimmunoassay, were studied in healthy subjects after both intragastric and intra-intestinal administration of corn oil. In addition, patients with partial gastrectomy were investigated to study the effect of accelerated gastric emptying. In the healthy subjects, intragastric administration of fat resulted in a significantly (P less than 0.05) later increase in plasma CCK levels (20 +/- 2 min) compared to intraintestinal fat (5 +/- 1 min). Similarly, the onset of gallbladder emptying was significantly (P less than 0.05) delayed after intragastric fat (20 +/- 2 min) compared to intestinal fat (10 +/- 1 min). In the healthy subjects the integrated plasma CCK response to intragastric fat was significantly (P less than 0.005-P less than 0.01) reduced from 10 to 30 min. In the patients with partial gastrectomy the rise in plasma CCK (10 +/- 1 min) and the onset of gallbladder emptying (15 +/- 2 min) were in the same range after intra-intestinal and intragastric fat. No significant differences in plasma CCK levels, integrated CCK response or gallbladder emptying were found in the patients according to the site of fat application. It is concluded that endogenous CCK secretion and gallbladder emptying in response to intragastric fat are significantly delayed in healthy subjects but not in patients with partial gastrectomy, in whom gastric emptying is accelerated.(ABSTRACT TRUNCATED AT 250 WORDS)     

A 61-year-old woman with abdominal pain and urination disorders

The case of a 61 yo diabetic woman presenting with dysuria and lower abdominal pain is described. The incomplete resolution of the clinical picture after short antibiotic treatment and a strong suspect of autonomic neuropathy oriented to an anamnestic reevaluation that evidenced the presence of pneumaturia. The last was the key-symptom that guided to diagnostic imaging showing emphysematous cystitis while a gastroscopy confirmed the presence of autonomic neuropathy manifested by gastroparesis. Emphisematous cystitis is a characteristic infectious complication of diabetic patients induced by a persistent incomplete bladder emptying and bacterial glucose fermentation. The complete eradication of the infectious agent requires a long term antibiotic course and a prompt identification of this pathology.     

Impaired gastric emptying in diabetic patients with cardiac autonomic neuropathy

The aim of our study was to measure the gastric emptying rate for a solid meal in diabetic patients who had no gastrointestinal complaints with (group 1, n = 12) or without (group 2, n = 10) cardiac autonomic neuropathy and in normal controls comparable in age and sex (group 3, n = 10). Gastric emptying rate was assessed with a sequential scintiscanning method. The percentages of the initial isotope activity remaining in the stomach at different times (20, 40, 60, 80, 100, and 120 min) after the ingestion of a Tc-99m-labeled test meal and the emptying half-time were calculated. Cardiac autonomic neuropathy was determined by the beat-to-beat variations in heart rate during deep breathing. A significant reduction of the gastric emptying rate was observed in group 1. Indeed, at 80, 100, and 120 min the percentage of residual isotope activity was 73 +/- 4, 60 +/- 6, and 50 +/- 6% (mean +/- SE), respectively, in group 1 versus 61 +/- 3 (P less than .05), 45 +/- 4 (P less than .05), and 32 +/- 4% (P less than .02) in group 2. In group 3, residual isotope activity was 57 +/- 4 (P less than .05 vs. group 1), 41 +/- 4 (P less than .05), and 29 +/- 4% (P less than .02), respectively. Emptying half-time was also longer in group 1 (121 +/- 9 min) than in group 2 (95 +/- 6 min, P less than .05) or group 3 (90 +/- 4 min, P less than .02).(ABSTRACT TRUNCATED AT 250 WORDS)     

Disturbances of the alimentary tract motility and hypermotilinemia in the patients with diabetes mellitus

Lower esophageal sphincter pressure (LESP), gastric emptying, small bowel transit time and plasma motilin levels were measured in diabetics and normal subjects in order to investigate the disturbances of the alimentary tract motility and the participation of motilin in these motility disorders. Hypermotilinemia was observed in all diabetics with or without autonomic neuropathy. Low response of LESP to tetragastrin found in diabetics with autonomic neuropathy could not be explained by motilin. Gastric emptying was highly correlated with fasting plasma motilin levels and a significantly accelerated gastric emptying observed in diabetics without complications or diabetics with diarrhea was considered to be due to hypermotilinemia. On the contrary, no significant correlation was observed between small bowel transit time and plasma motilin levels, suggesting no participation of endogenous motilin in the regulation of small bowel transit.     

The role of cholecystectomy in reducing recurrent gallstone pancreatitis

BACKGROUND AND STUDY AIM: Endoscopic sphincterotomy (ES) or cholecystectomy can prevent recurrent acute pancreatitis (RAP) in patients with gallstone-related pancreatitis. However, it is unknown whether cholecystectomy after ES offers additional benefit in preventing RAP in these patients. This is a retrospective study to assess whether cholecystectomy can decrease the incidence of RAP in patients with gallstone-related pancreatitis. PATIENTS AND METHODS: Records from 139 patients with gallstone-related pancreatitis were analyzed. Of these, 58 patients had gallbladder stones with concomitant common bile duct (CBD) stones and 81 patients had gallbladder stones without CBD stones. Of the 58 patients who had both gallbladder and CBD stones, 37 (63.8 %) did not undergo cholecystectomy after ES (group 1) and 21 patients (36.2 %) did undergo cholecystectomy after ES (group 2). Of the 81 patients who had gallbladder stones but who did not have CBD stones, 54 (66.7 %) did not undergo cholecystectomy (group 3) and 27 (33.3 %) did undergo cholecystectomy (group 4). RESULTS: At the time of analysis, three patients (8.1 %) in group 1 and three patients (14.3 %) in group 2 developed RAP. There was no significant difference in the estimated probability of occurrence of RAP over time between group 1 and group 2 ( P = 0.41). However, there was a significantly higher probability of patients developing RAP over time in group 3 compared with group 4 (6/54 vs. 0/27 respectively, P = 0.04). CONCLUSION: In patients with gallbladder stones without CBD stones, cholecystectomy can decrease the incidence of RAP. In patients with both gallbladder and CBD stones, however, the risk of RAP was not further reduced by cholecystectomy after ES and complete removal of CBD stones.     

Evidence of Impaired Afferent Vagal Function in Patients with Diabetes Gastroparesis

Two patients, a 28-year-old male and a 70-year-old female, with chronic insulin dependent diabetes mellitus and evidence of autonomic neuropathy were studied using cortical evoked responses following esophageal balloon and electrical stimulation. Both patients had symptomatic gastroparesis, poor gastric emptying, and reduced gasfroduodenal motility including abnormal results of scintigraphy and manome-try. There was slowing of afferent vagal conduction but good evoked potential responses were recorded even though one patient could not feel electrical stimulation of either the proximal or distal esophagus. It is improbable that the gastric symptoms are due to an afferent autonomic neuropathy, but symptoms may well be related to impairment of motor vagal pathways. Nevertheless, afferent vagal pathways are involved in severe diabetes mellitus. The clinical significance of this delay in conduction velocity of afferent pathways remains to be established.     

实时超声对功能性消化不良患者的胃及胆囊运动的研究

１１３例功能性消化不良（ＦＤ）及１５名健康对照者，口服液体脂餐４００ｍｌ后，用Ｂ超测定胃及胆囊排空功能。结果显示：ＦＤ组中６９例（６１．０６％）有胃排空延迟，２８例（２４．７７％）有胆囊排空不足，其中１１例（９．７％）既有胃排空延迟，又有胆囊排空不足。４４例（３８．９３％）胃排空时间正常；８５例（７５．２２％）胆囊排空正常。液体脂餐后Ｂ超测定胃及胆囊排空为一方便、无创，准确之检测方法。     

胆结石患者胆囊排空功能的超声研究

６４例胆结石患者胆囊排空能力的超声研究结果表明，大多数胆结石患者空腹胆囊容积和脂餐后残余容积增大，胆囊排空功能减弱，当脂餐后６０分钟，刖囊排空率＜１２％时，提示胆囊颈或胆囊管梗阻。     

Gallbladder abnormalities in carcinoma of pancreatic head: findings on MR imaging

Background  Our objective is to study the gallbladder abnormalities on MR images associated with carcinoma of the pancreatic head. Methods  Thirty-six patients who had surgical resection of pancreatic head carcinoma were retrospectively analyzed regarding the appearance of the tumor and gallbladder on MR imaging performed within one month before surgery. The changes of the gallbladder wall, and the dimension of the gallbladder, cystic duct, pericholecystic region, and common bile duct (CBD) on MR imaging were noted. Results  About 92% (33/36) of patients had at least one gallbladder abnormality on MR imaging, including thickened gallbladder wall (58%), gallbladder wall striation (19%), gallbladder wall severe enhancement (44%), enlarged gallbladder (33%), gallbladder stone (19%), dilatation of cystic duct (67%), focally increased liver parenchymal enhancement adjacent to the gallbladder (19%), and pericholecystic fluid (11%). 64% of patients had dilated CBD. The diameter of the cystic duct was correlated with those of the CBD (r = 0.45, P < 0.01) and gallbladder (r = 0.56, P < 0.0001). Enlarged gallbladder, dilatation of the cystic duct, and CBD were correlated with chronic cholecystitis. Conclusion  Most patients with pancreatic head carcinoma show gallbladder abnormalities on MR imaging. Cystic duct dilatation follows CBD dilatation and is the primary cause for dilated gallbladder and chronic cholecystitis in carcinoma of pancreatic head.     

糖尿病自主神经病变病人眼底照相散瞳效果观察与意外伤害防范

目的:探讨糖尿病并发自主神经病变病人在眼底照相中的散瞳效果以及在散瞳恢复过程中减少发生意外伤害的方法。方法:将糖尿病无并发症病人与糖尿病并发自主神经病变的病人各50例进行组间比较,两组均采用复方托品酰胺眼药水给予散瞳。同时将糖尿病并发自主神经病变病人的双眼按左右眼进行自身对照,左眼1次1滴,右眼1次2滴,每5 m in 1次,共3次。从第一次给药开始计时,分别在20 m in,40 m in时用测瞳尺由同一护士测量瞳孔直径大小,并记录瞳孔散大及恢复的时间。结果:糖尿病无并发症病人与糖尿病并发自主神经病变病人瞳孔直径在散瞳后20 m in大小差异有统计学意义(P<0.01),40 m in大小差异无统计学意义(P>0.05)。加大剂量与常规剂量的瞳孔直径差异无显著性(P>0.05),而恢复时间差异性显著(P<0.01)。结论:糖尿病并发自主神经病变病人散瞳效果不佳,延长散瞳时间可增加散瞳效果。增加药物剂量对瞳孔的恢复时间影响有显著性差异,在护理上要对病人进行特别的关注。     

Impaired gallbladder and gastric motility and pathological gastro-oesophageal reflux in gallstone patients

Impaired gallbladder motility is common in gallstone patients and might be associated with other gastrointestinal defects. Twenty patients with small stones in an opacified gallbladder at oral cholecystography and 20 healthy subjects homogeneous for sex, age and body size were studied by ultrasonography to assess gallbladder and gastric emptying simultaneously in response to a standard liquid meal (120 kcal, 11 g fat, 200 mL). The same subjects underwent ambulatory 24-h gastro-oesophageal pH monitoring. Dyspeptic symptoms were specifically investigated using a questionnaire. Gallstone patients had a significantly larger fasting (P < 0.05) and residual (P < 0.005) gallbladder volume with slower (P < 0.05) and less complete (anova , 0.001 < P < 0.05) gastric emptying than healthy control subjects. The speed of antral emptying was significantly correlated with the speed of gallbladder emptying (n = 40, r = + 0.31, P < 0.05). Pathological gastro-oesophageal reflux was present in 75% and 15% of patients and control subjects respectively (P < 0.05). Overall, 95% of gallstone patients had abnormal pH profiles resulting from pathological gastro-oesophageal reflux and/or prolonged gastric alkalinization. The speed of post-prandial antral emptying was significantly correlated with the duration of the longest gastro-oesophageal reflux episode (r = + 0.30, P < 0.03) and duodeno-gastric reflux episode (r = + 0.80, P < 0.02). Best predictors for gastric alkalinization were the following indices of gallbladder function: large fasting volume (P = 0.03), large ejection volume (P = 0.009) and slower emptying (P = 0.032). Gallbladder and gastric motility were similar in patients with (n = 12) and without (n = 8) dyspeptic symptoms. Pathological gastro-oesophageal reflux was found in 83% of dyspeptic patients and in 25% of patients without dyspepsia (P < 0.01). When reflux was present, it was significantly less in asymptomatic than in dyspeptic patients [time at pH < 4, median (range): 6.4% (3.2–22.6%) vs. 47.8% (2.1–87%), P < 0.05]. This study shows that a subgroup of gallstone patients with small—mainly asymptomatic—stones have impaired gallbladder and gastric motility as well as abnormal gastro-oesophageal pH-profiles. These findings point to the existence of multiple functional defects of the upper gastrointestinal tract in gallstone disease.     

Reduced airway vagal tone in diabetic patients with autonomic neuropathy

1. Forced expiratory flow rates and specific airways conductance were measured before and after the inhalation of the atropine-like drug ipratropium bromide in 11 diabetic patients with autonomic neuropathy and a control group of 11 diabetic patients without autonomic neuropathy. Respiratory muscle function was assessed by recording maximal inspiratory and expiratory mouth pressures. 2. There was no difference between the two groups of diabetic patients in airway calibre before ipratropium bromide or in maximal mouth pressures. 3. Bronchodilatation after ipratropium bromide was greater in the control group than in the autonomic neuropathy group of patients. 4. It is concluded that, despite the lack of clinical evidence of respiratory involvement, patients with diabetic autonomic neuropathy have reduced airway vagal tone.