Biomedical subjects
Publications and source records attributed to F Stadil.
From 1984 to 1986 The Medico-Legal Council was heard concerning four cases of iatrogenic lesions of the common bile duct during cholecystectomy. The Council's statements show that lesions of the common bile duct or the common hepatic duct during otherwise uncomplicated, elective cholecystectomy are considered surgical malpractice and not accidental mishaps.
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In the Zollinger-Ellison syndrome, symptoms and complications are due to hypersecretion of acid, and the first therapeutic step is to suppress the acid secretion. Long-term treatment with histamine H2-receptor antagonists was compared with omeprazole treatment. A total of 30 consecutive ZES patients were treated continuously with H2-receptor antagonists. During long-term treatment, a marked tachyphylaxis was noted, more than 50% of the patients had periods of dyspepsia, recurrent ulcers were found in 10 patients and in 16 a decline in the action of the H2-receptor antagonist required a change to omeprazole after a median duration of 36 months. A total of 22 patients were treated with omeprazole. During long-term treatment, the dose could be reduced slightly. Inhibition of acid secretion was maintained in all cases, and none had dyspeptic symptoms. The median duration of treatment was 18 months, with a range of 1-120 months (H2-receptor antagonists) and 27 months with a range of 1-66 months (omeprazole). No side-effects were seen with omeprazole.
During the last 17 years about 100 gastrinomas have been diagnosed in Denmark. With background of the Danish material and the literature the clinical features and pathology of gastrinoma are reviewed and its medical and surgical treatment discussed.
Serum concentration of gastrin was measured before and after renal transplantation in 97 consecutive patients in order to assess possible correlations to gastrointestinal bleeding, allograft function, or graft rejection. In patients with transient signs of allograft rejection (N = 29) or upper gastrointestinal bleeding (N = 12) there was a nonsignificant trend towards higher postoperative gastrin levels, and in patients in whom the graft was removed (N = 29), this tendency was more pronounced (p = 0.06). The study demonstrated that monitoring of serum concentrations of gastrin following renal transplantation is of little clinical value. However, increased gastrin levels in serum may indicate that graftectomy may be the ultimate result.
The functional role of the jejunum and ileum with regard to peripheral plasma levels of intact neurotensin and NH2-terminal immunoreactivity of neurotensin was studied by using jejunoileal bypass as a model. Plasma levels were measured by radioimmunoassay before and after jejunoileal bypass randomized to different jejunoileal ratios. Seven patients were studied before bypass surgery and 28 were examined after end-to-side jejunoileal bypass with 50 cm intestine in continuity and a 3:1 or 1:3 ratio between the length of the jejunal and ileal segments. Fasting levels of intact neurotensin were unchanged by surgery, whereas levels of NH2-terminal immunoreactivity were higher in bypass patients with a long ileal segment (37.5 cm) than in unoperated patients and in those with a short ileal segment (12.5 cm). Meal-stimulated levels of intact neurotensin were higher after 1:3 than 3:1 jejunoileal bypass. The levels of NH2-terminal immunoreactivity in patients with a short ileal segment and in controls were lower than in patients with a long ileal segment. The results show that postprandial levels of both intact neurotensin and NH2-terminal immunoreactivity are related to the length of the functioning ileum and that even a difference in length of 25 cm is reflected in the circulating levels of neurotensin.
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We have investigated the gastric endocrine cells in 19 patients with the Zollinger-Ellison syndrome. Six received a long-term treatment with omeprazole, 5 one with H2 receptor antagonists and 8 had no medical treatment. Fifteen patients (79%) had hyperplasia of the endocrine cells in the oxyntic mucosa independent of treatment. The hyperplasia involved both enterochromaffin-like (ECL) and D1 cells and was positively related to the duration of disease (p less than 0.05). The duration of hypergastrinaemia was longer in the omeprazole-treated patients, but the hyperplasia was not significantly more pronounced in these patients. Gastric carcinoid tumours consisting mainly of ECL cells are rare in man and are most often seen in states of hypergastrinaemia such as chronic atrophic gastritis. It has seldomly been reported in Zollinger-Ellison patients; but now, when potent antisecretory drugs make it possible to avoid total gastrectomy, a raised incidence might result, and an increased attention to this aspect seems appropriate.
Treatment with omeprazole was evaluated in nine patients with the Zollinger-Ellison syndrome, in whom the effect of H2-receptor antagonists had become inadequate. Treatment with 20-80 mg omeprazole daily reduced basal acid secretion by 77-100%. The effect persisted during a continuous treatment of up to 2 years. In five patients the initial dose could be reduced after some time of treatment. In eight patients the treatment promptly relieved all symptoms, and in the last patient, who had disseminated metastatic disease and large anastomotic ulcers, the symptoms disappeared gradually over a period of 10 weeks. No adverse events were seen. We conclude that omeprazole is an effective inhibitor of the acid hypersecretion in Zollinger-Ellison patients, also when H2-receptor antagonists have failed.
Plasma concentrations of pancreatic polypeptide (PP) and vasoactive intestinal polypeptide (VIP) were measured after a meal consisting of 11 ml meat extract and 40 ml of 20% soya oil in 11 patients before and 3 months after gastroplasty for morbid obesity. Gastroplasty results in a small proximal pouch with a narrow stoma allowing delayed emptying into the distal pouch, and consequently postprandial distension of the proximal pouch. Postprandial plasma PP increased significantly (P less than 0.01) independent of gastroplasty. PP is therefore not involved in the early satiety after gastroplasty. Postprandial plasma VIP increased significantly from fasting levels both before and after gastroplasty (P less than 0.05). Only 10 min after a meal, the median value of VIP was significantly higher after than before gastroplasty (P less than 0.02) and may be caused by distension of the proximal pouch.
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The relations of calcitonin concentrations to the presence of bone marrow metastases and to the concentrations of calcium, parathormone and gastrin in serum were investigated in 74 untreated patients with small cell carcinoma of the lung. Calcitonin concentrations were enhanced in two thirds of the patients, while serum calcium concentrations were normal in all. In 19 of 57 patients parathormone concentrations were slightly above the normal range, but the concentrations of parathormone and calcitonin were not correlated. Bone marrow metastases had no influence on the concentration of serum calcitonin. Finally, a small inverse correlation between the concentrations of gastrin and calcitonin in serum was observed. The results resemble those of the calcitonin-producing medullary carcinoma of the thyroid, supporting the suggestion of an ectopic source of hypercalcitoninemia in small cell carcinoma of the lung.
Enteroglucagon concentration in peripheral blood was determined before and after a test meal in 24 morbidly obese patients. Eighteen had jejunoileal bypass, 6 with a 3:1 and 12 with a 1:3 jejunoileal ratio of the functioning segment, and 6 were unoperated. All three groups exhibited an increment of enteroglucagon concentration after the meal. Both the fasting values and the postprandial integrated increments were higher in operated patients than in unoperated patients and higher after 1:3 bypass than after 3:1 bypass. The findings agree with the hypothesis that enteroglucagon secretion is stimulated by exposure of the lower bowel to upper-bowel content, and that the effect of enteroglucagon is, as seen after bypass operation, stimulation of growth and reduction of motility of the intestine.
Six duodenal ulcer patients were investigated before and after truncal vagotomy and pyloroplasty. Four doses of gastrin-17 were injected intravenously (15.625, 31.25, 62.5, and 125 micrograms/kg body weight); the gastric secretory response and the disappearance rate of gastrin were measured. After vagotomy the basal level of gastrin increased from 64 pg/ml to 106 pg/ml. When corrected for the basal levels of gastrin, the peak levels and disappearance rate of gastrin-17 were observed to be the same after vagotomy as before (half-life before vagotomy, 5.6 min; after, 5.8 min). This indicates that vagus does not influence the metabolism of exogenous gastrin-17. The gastric secretion of acid was reduced to 30% after vagotomy, which shows that there is a synergism between vagus and gastrin-17.
The median diagnostic delay in 32 patients with verified insulinomas was 2 3/4 years (range 1/4--18). The median delay in the 1939--1958 period was shorter (2 years, n = 17) than in the 1959--1978 period (3 years, n = 15). Thus, modern developments with insulin estimations were without noticeable effect upon the diagnostic delay. The findings can probably only be explained by a poor awareness of the insulinoma syndrome in the medical profession.
Eighteen patients with metastatic carcinoid tumours were admitted to surgical gastroenterological department of Rigshospitalet during the period 1974--1978. Thirteen had primary carcinoid tumours in the terminal ileum, two in the lungs, one in the pancreas, one in the testis, and one possibly in the retroperitoneum. All patients had distant metastases, 13 in the liver. Carcinoid syndrome with flusing and diarrhoea was present in 15 patients (83%). The time elapsing from onset of symptoms until diagnosis was on an average 2 1/2 years. The most valuable screening test for carcinoid syndrome was determination of the excretion of 5-hydroxy-indol- acetic-acid. The most sensitive investigation for determination of primary tumour and/or metastases was abdominal angiography, which was positive in all cases. Other radiological investigations were less sensitive.