Gallbladder Motility in Crohn Disease: Influence of Disease Localization and Bowel Resection

Background: Intrahepatic lithiasis still is a complicated disease and merits special attention during therapeutic intervention. Although resection of the affected liver lobe or segment is the best therapeutic option to completely remove the source of recurrent infection, the need for endoscopic treatment modalities is evident because hepatic resections are combined with a high morbidity and mortality rate. Methods: Over a 10-year period (1988-1997) 55 patients with intrahepatic stones that were not accessible to routine endoscopic extraction were treated at our department. These patients underwent either extracorporeal shock-wave lithotripsy (n = 27) or intracoporeal electrohydraulic (n = 12) or laser lithotripsy (n = 16). Results: Using these techniques, we achieved stone fragmentation in 33.3%, 41.6%, and 75%, respectively. With a combination of the different methods, more than 90% of intrahepatic stones could be removed endoscopically. Overall complication rate was 12.7%; complete recovery was achieved in all patients with conservative management. Conclusion: The endoscopic approach to intrahepatic lithiasis appears to be a useful alternative to surgery, with a lower morbidity and mortality. If endoscopic therapy fails, surgery is still possible.     

Effect of Amino Acids on Lower Esophageal Sphincter Characteristics and Gastroesophageal Reflux in Humans

The effect of a commercially available mixedamino acids solution, when given either intravenously orintragastrically, on lower esophageal sphincter (LES)pressure, frequency of transient LES relaxations (TLESRs) and gastroesophageal reflux (GER) wasinvestigated in six healthy volunteers. LES pressure andesophageal pH were simultaneously recorded on threeseparate occasions 1 hr before (basal) and 3 hr during intravenous or intragastric infusion ofamino acids (250 mg protein/kg/hr) or saline (control).No significant changes in LES pressure were seen in thecontrol experiment. Intravenous amino acids caused a rapid and sustained (P < 0.01)decrease in LES pressure whereas intragastric aminoacids decreased LES pressure only gradually andtemporarily (P < 0.01). In the three experiments nosignificant differences were observed in TLESR frequency,the number of GER episodes, the mechanism of reflux, orduration of acid exposure. In healthy subjects bothintragastric and, especially, intravenous infusion of amino acids significantly decrease LESpressure but do not affect the frequency of TLESRs orGER episodes during a continuous liquid gastricload.     

Delayed plasma cholecystokinin and gallbladder responses to intestinal fat in patients with Billroth I and II gastrectomy

This study was undertaken to examine the intestinal phase of cholecystokinin (CCK) secretion and gallbladder contraction in patients who had undergone partial gastrectomy. Plasma CCK concentrations, measured by radioimmunoassay, and gallbladder contraction, measured by cholescintigraphy, were studied after intestinal administration of fat. Fasting plasma CCK concentrations were in the same range in nine patients who had undergone Billroth I gastrectomy (1.0 +/- 0.2 pmol/L), in nine patients who had undergone Billroth II gastrectomy (1.4 +/- 0.2 pmol/L), and in nine normal subjects (1.5 +/- 0.4 pmol/L). The peak increments in plasma CCK after intestinal fat were significantly (p less than 0.05) lower in patients with partial gastrectomy (5.4 +/- 0.6 pmol/L) compared with normal subjects (7.9 +/- 0.8 pmol/L). The integrated plasma CCK secretion was significantly (p less than 0.01 to p less than 0.05) reduced during the first 30 minutes in patients after Billroth I (74 +/- 11 pmol/1.30 min) and Billroth II gastrectomy (51 +/- 11 pmol/1.30 min) compared with normal subjects (122 +/- 18 pmol/1.30 min). Similarly, the start of gallbladder emptying was significantly (p less than 0.05) delayed in patients after partial gastrectomy. After 1 hour, however, the integrated plasma CCK response and gallbladder emptying were in the same range in Billroth I patients (186 +/- 34 pmol/1.60 min, 60% +/- 7%), Billroth II patients (175 +/- 17 pmol/1.60 min, 63% +/- 7%) and normal subjects (190 +/- 18 pmol/1.60 min, 55% +/- 6%). It is concluded that in patients who have undergone partial gastrectomy plasma CCK and gallbladder responses to intestinal fat are significantly delayed but reach normal levels beyond 30 minutes.     

Lack of effect of the specific cholecystokinin receptor antagonist loxiglumide on cholecystokinin clearance from plasma in man.

Saline or loxiglumide (2.5 mg kg-1 in 10 min, followed by 5 mg kg-1 h-1 for 200 min) was administered intravenously in random order to six healthy subjects. After 60 min cholecystokinin (CCK-33) was infused (0.5 i.d.u. kg-1 h-1 for 1 h then 1.0 i.d.u. kg-1 h-1 for 1 h). Loxiglumide did not change basal levels of CCK and did not augment plasma CCK-immunoreactivity during CCK-33 infusion. After cessation of the CCK-infusion, plasma CCK concentrations decreased rapidly to basal values within 12 min, and the elimination half-life during loxiglumide infusion (4.8 +/- 0.8 min) was not significantly different from that during saline infusion (4.2 +/- 1.0 min). These results suggest that loxiglumide does not interfere with the distribution and metabolism of CCK.     

Efficacy of lower than standard doses of pancreatic enzyme supplementation therapy during acid inhibition in patients with pancreatic exocrine insufficiency

GOAL: To compare, during strong acid inhibition with omeprazole, the effect of 2 different doses of an enteric-coated pancreatic enzyme preparation on fecal fat excretion and abdominal symptoms in patients with exocrine insufficiency due to chronic pancreatitis (CP). BACKGROUND: Treatment with pancreatic enzymes reduces fecal fat excretion in patients with CP but is rather unsuccessful due to irreversible lipase inactivation at pH below 4. STUDY: Sixteen patients with CP (3 women, 13 men; age 53+/-3 y) participated in this randomized double blind 2-way cross over study. Fecal fat excretion and fat intake were measured and abdominal symptoms (visual analog scales) were scored during a 2 weeks control period, during omeprazole 60 mg+pancreatic enzymes 10,000 Fédération Internationale Pharmaceutique IU lipase tid (treatment A) for 2 weeks and during omeprazole 60 mg+pancreatic enzymes, 20,000 Fédération Internationale Pharmaceutique IU lipase tid (treatment B) for 2 weeks. RESULTS: During acid inhibition with enzyme supplementation fecal fat excretion was significantly (P<0.01) reduced compared with control: 18+/-7 and 18+/-5 g/24 h versus 36+/-8 g/24 h for treatment A, B, and control, respectively. Abdominal symptom score and general well being improved significantly (P<0.05) during treatments A and B versus control. No differences in fat excretion or symptoms scores between treatments A and B were observed. CONCLUSIONS: During strong acid inhibition, lower than recommended oral doses of pancreatic enzymes are therapeutically effective with respect to fat absorption and symptom reduction.     

Gallstone formation after pancreas and/or kidney transplantation: an analysis of risk factors

Pancreas and kidney transplantation (SPK) is the treatment of choice for patients with type 1 diabetes mellitus and end-stage renal failure. Gallstones are common after SPK transplantation but little is known about the true incidence and etiology of gallstones in this group. We therefore evaluated the incidence of gallstones and the presence of transplant-related risk factors in patients after SPK and kidney transplantation alone (KTA). Data were evaluated of 56 consecutive patients who underwent SPK transplantation and compared the results with those of 91 consecutive nondiabetic patients who underwent KTA transplantation at the Leiden University Medical Center between 1987 and 1994. Of the 58 evaluable KTA patients, 20.7% developed gallstones during 7.7 yr of follow-up and in the SPK group 43.9% of the 41 evaluable patients developed gallstones during 7.1 yr of follow-up. Postoperative weight loss and cyclosporin A-related hepatotoxicity correlated with gallstone formation both in SPK and KTA patients. In addition, the duration of postoperative fasting and autonomic neuropathy correlated with gallstones in SPK patients. It is concluded that both in patients after SPK transplantation and in patients after KTA transplantation, the risk to develop gallstones is significantly increased. Physicians should be aware of the high incidence of gallstones in SPK recipients.     

Clinical trial: short- and long-term benefit of relaxation training for irritable bowel syndrome

BACKGROUND: Psychotherapy is effective in treating irritable bowel syndrome, but the effect of relaxation training, a brief psychological group intervention, is not known. AIM: To determine the efficacy of relaxation training in a large cohort of irritable bowel syndrome patients. METHODS: Ninety-eight irritable bowel syndrome patients were included in this randomized controlled trial. Forty-six patients received standard medical care (CON) and 52 received four 90-min sessions of relaxation training in small groups in addition to standard medical care. Irritable bowel syndrome symptom severity, medical consumption and quality of life were assessed at baseline in patients and in 38 healthy controls and evaluated in patients at 3, 6 and 12 months after intervention. RESULTS: Irritable bowel syndrome symptom severity was significantly reduced in the relaxation training group compared to CON at 3, 6 and 12 months after treatment (time-by-treatment interaction, P = 0.002). The number needed to treat for long-term improvement was 5. Quality of life had improved (general health, P = 0.017; health change, P = 0.05). Frequency of doctor visits was reduced (P = 0.039). CONCLUSIONS: Relaxation training is a brief group intervention that significantly improves symptom severity, general health perception and medical consumption in irritable bowel syndrome patients immediately after, as well as 6 and 12 months after intervention.     

Effect of Somatostatin on Lower Esophageal Sphincter Characteristics in Man

Background: Data from previous studies on intestinal metaplasia at the gastroesophageal junction have been conflicting, which makes the diagnosis of Barrett's esophagus less obvious. This may partly be due to the lack of a reliable classification of the Z-line appearance. We previously proposed such a classification (the ZAP classification) that was shown to correlate with the prevalence of intestinal metaplasia. The use of different immunohistochemical techniques has increased in the study of intestinal metaplasia. In the present study our aim was to 1) evaluate the impact of different antibodies, namely cytokeratin (CK) 7, 13, and 20, CaCO3/73, and FBB2/29, in order to differentiate between Barrett's esophagus and cardia intestinal metaplasia, and 2) explore the staining patterns in different ZAP grades. Methods: Thirty-nine specimens with intestinal metaplasia were compared - 9 from Barrett's esophagus, 6 from cardia, and 24 from the Z-line. The Z-line specimens were evaluated with respect to ZAP grade. Results: No differences were encountered regarding staining patterns for CK13 and CaCO3/73 in Barrett's esophagus and cardia. The staining pattern of CK7/20 was significantly different between Barrett's esophagus and cardia. CK7/20 showed a rising frequency of Barrett's esophagus staining pattern with rising ZAP grade. Conclusion: CK7/20 is a feasible marker for Barrett's esophagus. Intestinal metaplasia in different ZAP grades differs regarding expression of immunohistochemical markers.