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A duodenal tube was introduced into the duodenum of the fasted baboon via the nasal passage. After the application of vacuum for several minutes, the baboon received an intravenous injection of pancreozymin and cholecystokinin which caused contraction of the gall bladder. Aspiration of the bile sample was carried out via the duodenal tube.
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Perforated peptic ulcers are usually managed surgically after failure of more conservative medical treatment of ulcer disease. This case illustrates transnasogastric placement of a drainage catheter through a perforated ulcer, which was successful as definitive therapy.
Myasthenia gravis is the most common disorder of the neuromuscular junction. Myasthenia crisis, defined as respiratory failure requiring mechanical ventilation in myasthenia gravis, is a common life-threatening complication that occurs in approximately 15% to 20% of patients with myasthenia gravis. The advent of effective mechanical ventilation, specialized neurointensive care units, and the widespread use of immunotherapies have substantially altered the prognosis of myasthenic crisis. The authors recommend more liberal intubation of patients with myasthenia gravis crisis; early intubation and mechanical ventilation is perhaps the most important step in the management of myasthenia gravis crisis. The authors favor an orotracheal approach for intubation, and placement of small bore duodenal tubes that may help decrease the risk of aspiration and may be more comfortable than regular nasogastric tubes for the patient. Plasma exchange is more effective than intravenous immunoglobulin in the treatment of myasthenia gravis involving respiratory failure. A randomized trial is required to confirm the superior efficacy of plasma exchange compared with intravenous immunoglobulin. In the acute setting, the role of immunosuppression and intravenous or intramuscular pyridostigmine remains limited and at times controversial. The therapy should be tailored on an individual basis using the best clinical judgment.
Myasthenia gravis (MG) is the most common disorder of the neuromuscular junction. Myasthenia crisis, defined as respiratory failure requiring mechanical ventilation in MG, is a common life-threatening complication that occurs in approximately 15% to 20% of patients with MG during their life time. The advent of effective mechanical ventilation, specialized neurointensive care units and the widespread use of immunotherapies have substantially altered the prognosis of myasthenic crisis. Early intubation and mechanical ventilation is perhaps the most important step in the management of myasthenic crisis. The authors favor an orotracheal approach for intubation, and placement of small bore duodenal tubes that may help decrease the risk of aspiration and may be more comfortable than regular nasogastric tubes for the patient. Plasma exchange may be more effective than the intravenous immunoglobulin in the treatment of myasthenic crisis involving respiratory failure. A randomized trial is required to confirm the superior efficacy of plasma exchange compared with intravenous immunoglobulin. In the acute setting, the role of immunosuppression and intravenous/intramuscular pyridostigmine and the newer agents such as tacrolimus remains limited and at times controversial. The therapy should be tailored at an individual basis using best clinical judgment.
BACKGROUND: The upper small bowel is of pivotal importance for the stimulation of exocrine pancreatic secretion in response to a meal. We hypothesize that more distal delivery of nutrients into the small intestine will result in less activation of pancreatic secretion. MATERIALS AND METHODS: Eight healthy subjects (3 male, 5 female; age 23 +/- 1 years) participated in two experiments, performed in random order. Subjects were intubated with a 4-lumen tube. Duodenal outputs of pancreatic enzymes and bilirubin were measured by aspiration using a recovery marker. The distal opening was used for continuous administration of a mixed liquid meal and located at either the ligament of Treitz or 60 cm further distally. Gallbladder volume was measured and blood samples were drawn for determination of gastrointestinal hormones. The duration of each experiment was 4 h; with 1 h fasting and 3 h continuous administration of nutrients. RESULTS: During proximal jejunal feeding, pancreatic enzyme output increased significantly over basal levels. No significant increase over basal levels was observed during distal jejunal feeding. Bilirubin output and gallbladder contraction were significantly (P < 0.05) reduced during distal compared to proximal jejunal feeding. No significant differences were found in plasma levels of CCK, PYY and neurotensin between proximal and distal jejunal feeding. CONCLUSION: Continuous feeding in the distal jejunum does not stimulate exocrine pancreatic secretion but maintains gallbladder contraction, although to a lesser extent. These effects are not related to hormonal changes but probably reduced activation of the enteropancreatic reflexes.
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The use of therapeutic endoscopy in the complex of gastric and duodenal ulcer therapy permits to reduce the duration of patient's stay in the hospital 1.5-2 fold. A disadvantage of the method consists in the fact that it is hard for the patients (especially, the elderly) to endure the complete course of treatment. The authors have used a naso-duodenal polychlorvinyl tube of original construction for prolonged irrigation of an ulcer with drug solutions stimulating the reparative processes. In all the patients, a duodenal ulcer has epithelized within 18.3 days. The long-term results of treatment with the use of this method confirmed its high effectiveness (positive result was noted in 91.7% of cases).
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Thirty-nine patients with cholelithiasis were prospectively studied to evaluate the qualitative and quantitative differences between duodenal bile and gallbladder bile. Duodenal bile obtained before cholecystectomy by nasoduodenal intubation and ceruletide injection was qualitatively similar to gallbladder bile obtained during surgery. Microscopic cholesterol crystals as an indicator of cholesterol gallstones (n = 35) could be detected in 31 (89%) and 35 (100%; p = NS), respectively. Moreover, there was no difference in the molar percentage of three biliary lipids and the mean cholesterol saturation index (1.54 +/- 0.72 and 1.74 +/- 0.42; p = NS) of the two sources of bile. Duodenal bile was, however, dilute as compared with gallbladder bile, as evidenced by lower cholesterol crystal counts (167 +/- 247 versus 705 +/- 978; p < 0.01), lower total lipid concentration (5.8 +/- 2.7 versus 11.1 +/- 5.6 g/dl; p < 0.001), and lower concentrations (in mmol/l) of the three bile lipids--that is, total bile acids, phospholipids and cholesterol (p < 0.001). Good concentrated bile (total lipid concentration > or = 5 g/dl) could be obtained in 74% of duodenal bile samples, compared with 90% of gallbladder bile (p = NS). Our study shows that, although duodenal bile is dilute as compared with gallbladder bile, it is qualitatively similar to gallbladder bile and, because of the ease and safety of its collection, can be used to study serial alterations in biliary composition in individual subjects.
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Bicarbonate secretion by the stomach may play a role in gastric mucosal protection, and we have therefore examined bicarbonate secretion in the human stomach. Gastric bicarbonate production and contamination with salivary and duodenal bicarbonate was measured in healthy volunteers using an intubation technique. The stomach and duodenum were perfused with nonabsorbable markers and the pH, PCO2, marker, and amylase concentrations measured in 10-min gastric and duodenal aspirates. These measurements enabled calculation of gastric bicarbonate content and the amount of bicarbonate contributed by saliva and duodenogastric reflux. Acid secretion was suppressed by intravenous cimetidine. Validation studies demonstrated a good correlation between instilled and calculated recovered bicarbonate (r = 0.97, P less than 0.001, N = 6), and marker recovery was consistent in each subject. Over a 6-h period, gastric pH ranged from 6 to 7 and PCO2 from 20 to 40 mm Hg. Gastric bicarbonate output stabilized at 326--392 mumol/hr and mean bicarbonate concentration ranged from 2.3 to 20.0 mmol/liter. Approximately two thirds of this bicarbonate was free, 11% was derived from duodenogastric reflux, and 3% from swallowed saliva. This study demonstrates secretion of bicarbonate by the human stomach in vivo at a rate equivalent to 10--20% of basal acid secretion.
OBJECTIVE: To investigate the value of dynamic examination of duodenal fluid in the differential diagnosis of infantile hepatitis syndrome (IHS) and extrahepatic biliary atresia (EHBA). The aim of the study was to establish a simple, rapid and accurate diagnostic procedure for infantile cholestatic jaundice. METHODS: The authors developed a special duodenal drainage-tube and established a specific duodenal fluid drainage technique. The duodenal fluids were collected and the colors were documented. The bilirubin, gamma-glutamyltranspeptidase (gamma-GT) and bile acid concentrations in the duodenal fluids were measured. RESULTS: Duodenal fluid drainages were initially performed on 561 cases of infants with cholestatic jaundice. The yellow duodenal fluids were drained within 3-8 minutes after intubation in 342 cases. The yellow fluids were obtained in more patients after continuous drainage for 24 hours (21 cases) and 48-72 hours (16 cases), respectively. The duodenal fluids were light yellowish in 71 cases and white in 111 cases. The drainage techniques were subsequently performed in 182 infants with light yellowish or white duodenal fluids after conservative treatment. The duodenal fluids were yellow in 91 cases, white in 89 cases, and slightly yellowish in 2 cases. The increased levels of bilirubin (> or = 8.5 micromol/L), gamma-GT (> 20 IU/L) and bile acid (positive or 33-260 micromol/L) were observed in the yellow duodenal fluids. While the bilirubin levels were 0-2 micromol/L or 5-8 micromol/L in the white or slightly yellowish duodenal fluids, with gamma-GT levels at 0-5 IU/L and bile acid tested negative. According to the criteria set as bilirubin > or = 8.5 micromol/L, bile acid tested positive and gamma-GT > 20 IU/L in duodenal fluid, 470 infants were diagnosed as HIS; 91 cases were diagnosed as EHBA with duodenal fluid bilirubin < 8.5 micromol/L, bile acid tested negative and gamma-GT < 20 IU/L. The diagnoses of these patients were confirmed by surgical operation. CONCLUSION: Dynamic examination of duodenal fluid is a simple, rapid, safe and reliable method in the differential diagnosis of infantile cholestatic jaundice.