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PubMed1989

Ryle's tube drainage of afferent loop after partial gastrectomy and that of gall bladder after cholecystojejunostomy.

Ryle's tube drainage of the afferent loop effectively prevented duodenal blow-out or anastomotic leakage in 40 patients undergoing partial gastrectomy for recurrent peptic ulcer. Similarly the same procedure was adopted in 20 cases of cholecystojejunostomy. The tube prevented anastomotic leakage and decompressed the biliary tree by effective bile drainage from the very 1st day thus favouring the prognosis. There was no complication observed directly related to either procedure in the present series.

Adult↗

PubMed1990

Effect of loxiglumide, a cholecystokinin antagonist, on pancreatic polypeptide release in humans.

The purpose of this study was to determine the role of cholecystokinin in the regulation of postprandial pancreatic polypeptide secretion in humans. The pancreatic polypeptide responses to modified sham feeding and gastric instillation of a test meal were first compared with the response to oral ingestion of the same meal. The experiments were repeated under cholinergic (atropine) and cholecystokinin (loxiglumide) blockade. Atropine completely abolished the pancreatic polypeptide response to sham feeding and caused significant reductions after gastric and oral food intake. Loxiglumide, on the other hand, significantly reduced pancreatic polypeptide release to oral food (51% inhibition) without affecting the response to sham feeding. In separate experiments using a duodenal perfusion system, the effects of atropine and loxiglumide on intestinal phase-stimulated pancreatic polypeptide release were examined, and both cholinergic and cholecystokinin blockade induced complete suppression. It was concluded (a) that cholecystokinin is involved in postprandial pancreatic polypeptide response, especially during the intestinal phase stimulation, and (b) that the cholinergic system is crucial and superimposed on cholecystokinin in stimulating pancreatic polypeptide release.

Adult↗

PubMed2004

Transpyloric feeding tube placement in critically ill patients using electromyogram and erythromycin infusion.

STUDY OBJECTIVES: Transpyloric feeding is desirable in critically ill patients who often have gastroparesis; however, correct placement is difficult, requiring fluoroscopy, endoscopy, or time-consuming blind attempts. This study evaluated the success rate and time required to place transpyloric tubes using erythromycin infusion and GI electromyogram (EMG) signal. DESIGN: Observational trial. SETTING: University hospital medical ICU. PATIENTS: Thirty-nine patients receiving mechanical ventilation for respiratory failure (n = 13), pancreatitis (n = 9), ARDS (n = 8), neurologic disease (n = 4), major surgery (n = 3), and GI disease (n = 2) were enrolled (25 men and 14 women; mean age, 48.4 years; range, 21 to 82 years). INTERVENTIONS: Unweighted Flexiflo 10F feeding tubes were modified by the placement of an electrode 4 to 8 cm from the tip to record electromyogram (EMG) signals (Ross Products Division; Columbus, OH). Gastric signals are high amplitude with a frequency of 3 cycles per minute, while the duodenum and jejunum are low amplitude and 11 to 13 cycles per minute. Erythromycin was infused at a dose of 3 mg/kg to enhance gastric motor activity and emptying. The transpyloric tube was placed in the stomach, and its position was confirmed by EMG, then slowly advanced until duodenal EMG was detected. Tube position was determined by abdominal radiography. MEASUREMENTS AND RESULTS: Thirty-one of 39 placements were immediately successful (initial success rate, 80%), 23 jejunal and 8 duodenal, requiring an average 7.8 min (range, 3 to 31 min). Six attempts in five patients were initial failures but were repeated, reaching the duodenum in one patient and the jejunum in four patients. CONCLUSION: Erythromycin infusion and EMG guidance can facilitate rapid transpyloric feeding tube placement in critically ill patients at the bedside.

Adult↗

PubMed1993

The safety and clinical utility of esophagogastroduodenoscopy for acute gastrointestinal bleeding after myocardial infarction: a six-year study of 42 endoscopies in 34 consecutive patients at two university teaching hospitals.

The risks versus benefits of panendoscopy performed soon after myocardial infarction were studied. At Robert Wood Johnson University Hospital from January 1986 through December 1991 and at Princeton Medical Center from January 1990 through December 1991, 82 patients developed overt gastrointestinal bleeding (1.2% of all myocardial infarctions) and 14 patients developed occult gastrointestinal bleeding (0.2% of all myocardial infarctions) within 3 weeks after myocardial infarction. Thirty-four of the patients underwent 42 panendoscopies within 3 weeks of myocardial infarction. Indications for the initial endoscopy included hematemesis in 25, melena without hematemesis in four, red blood per rectum in three, and occult blood in the stool in two. The initial panendoscopy, on average, was performed 6.2 +/- 7.5 (SD) days after myocardial infarction. The 34 initial panendoscopies provided the diagnosis in 27 (79%), and clinically helpful information in four (12%). Common diagnoses were duodenal ulcer in 11, hemorrhagic gastritis in four, and hemorrhagic esophagitis in three. Three complications were due to the initial endoscopy, including fatal ventricular tachycardia, near respiratory arrest, and hypotension. These complications occurred in three (37.5%) of eight patients who were significantly unstable before endoscopy. No (0%) complications occurred in the 26 relatively clinically stable patients undergoing the initial endoscopy. This difference in complication rate was statistically significant (p < 0.01, Fisher's exact test). We conclude that recent myocardial infarction is not an absolute contraindication to panendoscopy. In this retrospective study, the benefits exceeded the risks of panendoscopy in medically stable patients with significant gastrointestinal bleeding. Panendoscopy should be performed with monitoring by electrocardiography and pulse oximetry after stabilization of vital signs, which may require transfusion of blood products, supplemental oxygen administration, endotracheal intubation, and mechanically assisted ventilation. Panendoscopy in highly unstable patients had a high complication rate in this study.

Aged↗

PubMed1974

Trypsin and chymotrypsin in duodenal aspirate and faeces in response to secretin and cholecystokinin-pancreozymin.

The secretion of trypsin and chymotrypsin into the duodenum in response to secretin and CCK-PZ has been compared with the faecal excretion of the enzymes following similar stimulation in 47 individuals undergoing clinical investigation. The faecal output of chymotrypsin correlated well, but trypsin less satisfactorily, with the secretion of the respective enzymes into the duodenum. The faecal excretion of chymotrypsin following stimulation with secretin and CCK-PZ can therefore be used as an index of pancreatic enzyme-secretory capacity.

Cholecystokinin↗

PubMed1987

Percutaneous endoscopic duodenostomy (PED). Case report.

Surgeons are increasingly using endoscopy to place transabdominal feeding tubes for enteral nutrition or gastric decompression. A possible extension for the application of this new technique is the direct placement of the feeding tube into the duodenal bulb. Two patients are presented in whom percutaneous endoscopic duodenostomy was successfully performed, although percutaneous endoscopic gastrostomy was not possible. It shows that this new method is technically possible. In both patients the positive influence of this technique on the patient's quality of life could be shown using the Spitzer Quality of Life Index and the Karnofsky Performance Status. Enteral nutrition was maintained for more than 6 weeks.

Aged↗

PubMed1979

[Interaction of dimethyl prostaglandin E2 and ethanol on the pancreatic secretion of the rat].

We have studied the action of 16,16-dimethyl prostaglandin E2 methyl ester (DiMePGE2) on pancreatic secretion in the unanesthetized rat with pancreatic and duodenal fistulae. DiMePGE2 inhibited volume, protein secretion and bicarbonate output. The inhibition of protein concentration is dose related (ED50 = 5.35 microgram/rat). DiMePGE2 was effective by the intraduodenal, intravenous, and intraperitoneal routes. Intraduodenal infusion of ethanol alone (2 mL 16% (v/v) in 1 h) strongly increased protein secretion (concentration, +30%; output, +69%) When 4 microgram DiMePGE2 was injected intraperitoneally just before the ethanol infusion, the secretory effect of ethanol disappeared and the inhibition was similar to that observed with DiMePGE2 alone.

Animals↗

PubMed1986

Duodenal diversion with vagotomy and antrectomy for severe or recurrent reflux oesophagitis and stricture: an alternative to operation at the hiatus.

In cases of mild symptomatic gastro-oesophageal reflux, standard antireflux surgery, such as fundoplication or the Angelchik prosthesis, produces satisfactory results. Duodenal diversion is recommended for use only in patients with severe oesophageal damage. This situation commonly arises where the gastro-oesophageal junction cannot be reduced into the abdomen, or where previous surgery has made reoperation at the hiatus difficult and hazardous. Fifty-seven patients with severe reflux oesophagitis have been treated by Roux-en-Y duodenal diversion and antrectomy. Thirty three patients had vagotomy in addition. Median follow-up after operation is 6.1 years. In 35 patients (61%), the technique was used as primary surgical treatment. These included 22 patients in a randomized trial of the method. Thirteen (23%) had previously had unsuccessful antireflux surgery. Nine (16%) had undergone previous operations for peptic ulcer or achalasia. There was no operative mortality. No patient in the series required stricture resection. Good or excellent overall results were achieved in 86% of patients. Eighteen of twenty seven patients with severe strictures required an average of three dilatations after operation before dysphagia was completely relieved. Heartburn was dramatically relieved and oesophagitis settled within an average period of 6 months. Poor or unsatisfactory overall results were observed in 8 (14%) patients. These included one tight fibrous stricture which required endoscopic intubation despite resolution of oesophagitis, and four patients who developed a stomal ulcer. No patients suffered from the dumping syndrome. Malignancy must be carefully excluded by biopsy in all cases of stricture.

Adult↗

PubMed1977

Pneumoperitoneum complicating mechanical ventilator therapy.

Subdiaphragmatic air arouses the clinical suspicion of a perforated intra-abdominal viscus. In patients with respiratory failure requiring mechanical ventilation, the retroperitoneal dissection of air from the mediastinum may give rise to radiologic evidence of subdiaphragmatic emphysema. The present report describes four patients with this syndrome. In three of them, a perforated gastric or duodenal ulcer was initially suspected. None of these three patients underwent surgery. Autopsy examinations in two patients revealed extraperitoneal subdiaphragmatic emphysema with secondary rupture into the free peritoneal cavity. The third patient had an uneventful recovery and was discharged from the hospital. In a fourth patient, signs of peritonitis prompted an exploratory laparotomy. No perforation of an intraperitoneal viscus was identified. Upper gastrointestinal contrast roentgenography and peritoneal lavage may help determine the etiology of subdiaphragmatic air in patients undergoing therapy with a mechanical ventilator.

Adolescent↗

PubMed1980

[Preoperative percutaneous transhepatic drainage of the biliary system (PTCD) in malignant obstructive jaundice (author's transl)].

Percutaneous transhepatic intubation and drainage of the biliary system were performed in 23 patients, 19 cases preoperatively because of malignant obstructive jaundice. With 12 days the bilirubin serum level went to normal values, and the patients general condition and liver function showed marked improvement. By preoperative PTCD the mortality of palliative procedures in pancreatic carcinoma decreased. Complications occurred in five cases and were easy to manage. Clinical aspects such as indication, optimal period of drainage, and value of other techniques in bile drainage are discussed.

Adult↗

PubMed1996

Nitric oxide mediates mechano- and chemoreceptor-activated intestinal feedback control of gastric emptying.

The effect of nitric oxide (NO) synthase inhibition on the gastric emptying of nutrient and nonnutrient meals was investigated in nine dogs. The inhibition of NO synthase delayed the gastric emptying time of both nutrient and nonnutrient meals, but the percentage delay of nutrient meals was significantly greater than that of nonnutrient meals. The inhibition of NO synthase during the emptying of nonnutrient meals enhanced mainly the amplitude of antral, pyloric, and distal duodenal contractions. However, NO synthase inhibition during the emptying of nutrient meals stimulated several spatial and temporal parameters of gastropyloroduodenal contractions. We conclude that NO is one of the neurotransmitters of intestinal feedback that regulates the gastric emptying of both nutrient and nonnutrient meals. The nature and intensity of intestinal feedback by the stimulation of both chemo- and mechanoreceptors by nutrient meals is different from that by the stimulation of mechanoreceptors only by the nonnutrient meals.

Animals↗

PubMed1995

Comparison of nasogastric tube securing methods and tube types in medical intensive care patients.

BACKGROUND: Nasogastric tube displacement can result in serious complications such as aspiration and inadvertent migration of the tube into the lungs. Replacement of the tubes is costly, time- and effort-intensive, uncomfortable for the patients, and potentially dangerous. OBJECTIVE: To determine the best of three methods for securing nasogastric tubes in a medical intensive care population and to identify variables related to the failure of tube securing methods. METHODS: A convenience sample of 103 patients requiring duodenal or standard gastric tubes for feeding, medication delivery, or decompression were randomly assigned to one of three taping methods: pink tape, clear tape, or "butterfly," for a total of 264 taping episodes. Data collection included the mean time until failure of the securing methods as well as variables such as patient alertness and mobility. RESULTS: The mean time until failure was 100 hours with pink tape versus 56 hours with clear tape and 30 hours with the "butterfly." Differences were significant. Duodenal tubes stayed secured longer than standard sump tubes (mean time until failure was 86 vs 41 hours) for all taping methods, but not significant relationship was demonstrated between mean time until failure and variables such as alertness, sedation, confusion, mobility, and the use of restraints. CONCLUSION: Our results showed that the pink tape method was superior. Nasogastric tube securing methods in adult critical care patients vary in efficacy and should be selected carefully.

Adhesives↗

PubMed1988

Erratic gastric emptying of levodopa may cause "random" fluctuations of parkinsonian mobility.

The pathogenesis of "random" fluctuations in parkinsonian mobility, which are not clearly related to the dosing schedule of levodopa, has not been determined. We rated parkinsonian mobility and assayed plasma dopa in one patient with clinically random fluctuations during two modes of administration of levodopa/carbidopa: (1) standard oral route and (2) direct duodenal delivery via nasoduodenal tube. During oral therapy, mobility varied unpredictably in relation to levodopa dosing, suggesting a clinically random pattern. During duodenal delivery, however, a predictable and dramatic pattern of recurrent end-of-dose deterioration was observed; each intraduodenal levodopa dose resulted in 60 to 90 minutes of benefit. Plasma dopa levels correlated closely with mobility ratings for both modes of administration. Our findings indicate that erratic gastric emptying of levodopa is responsible for apparently "random" oscillations in mobility in at least one patient with Parkinson's disease and probably in others.

Absorption↗

PubMed1975

The biliary excretion of cefazolin.

The biliary excretion of cefazolin was studied by perfusion of isolated rabbit livers. Under these conditions, 6.7 percent of the amount of cefazolin added to the circulating blood was excreted in bile, and concentrations of drug in bile were significantly higher than concentrations in serum. Biliary excretion of cefazolin was also studied in humans after the intravenous administration of 500 mg of the drug. In 10 normal subjects, maximal concentrations of cefazolin (17.10 plus or minus 8.5 mug/ml) in the fluid obtained by duodenal tubing were attained 1-2 hr after administration of cefazolin. Concentrations were similar in bile collected by external drainage from five cholecystectomized patients (maximal levels, 14.0 plus or minus 4.7 mug/ml) 1-2 hr after injection. Assays during cholecystectomy showed that 1 hr after injection, cefazolin levels were much higher in common duct bile (31 plus or minus 11 mug/ml) than in gallbladder bile (5 plus or minus 2 mug/ml).

Animals↗

PubMed1975

[Catheter embolisation of the splenic artery as treatment for acute bleeding from varices (author's transl)].

Embolisation of the splenic artery with fibrin foam, in order to stop acute bleeding from varices, was carried out in two patients. This was performed immediately after diagnostic arterial indirect demonstration of the portal vein; by this method it is possible to achieve at least a temporary cessation of bleeding from oesophageal or gastric varices. The procedure is indicated in desparate situations, if intubation has been unsuccessful or has had to be discontinued, when endoscopic sclerosis is contra-indicated or when an emergency shunt cannot be carried out because of poor liver function or the general condition of the patient. Permanent results cannot be expected and recurrence of bleeding cannot be avoided. The use of splenic embolisation depends on stopping the acute bleeding in order to obtain an interval during which liver function can be improved so that a decompressing shunt operation becomes possible subsequently.

Acute Disease↗

PubMed1976

Treatment of stress-induced upper gastrointestinal/hemorrhage with metiamide.

The H-2-blocking antihistamine metiamide was used to treat 14 episodes of bleeding from the stomach or duodenum in eleven patients. In 11 instances bleeding was due to erosive gastritis or duodenitis and bleeding promptly ceased after one or two doses of 300 mg at 6 h intervals and did not recur as long as the drug was continued. In the 2 instances in which bleeding continued, chronic ulcers had eroded into major blood-vessels. There were no complications from the drug even in five patients with severe bone-marrow suppression after renal transplantation. Metiamide seems to be a safe and highly effective agent in the control of bleeding due to erosive gastritis.

Adolescent↗

PubMed1995

Gastric but not duodenal motor effects of oral erythromycin are dose related.

There has been increasing interest in the potential use of erythromycin as a prokinetic agent, despite limited data on the effect of oral administration on gastrointestinal motility. We have now evaluated, in 15 conscious pigs fitted with strain gauges, the response of (i) basal gastric motility and (ii) gastric motility during inhibition with intraduodenal triglycerides infusion to increasing doses of oral erythromycin. In the basal state, erythromycin led to dose-dependent increases in both the amplitude (10-30 mg kg-1) and the frequency (10-55 mg kg-1) of gastric contractions. The corpus was more responsive than the antrum, with an increase in amplitude at lower doses. The amplitude of the duodenal contractions was also improved but not in a dose-dependent manner. Gastroduodenal coordination was unchanged regardless of the dose of erythromycin. Following inhibition of gastric motility, a dose of erythromycin below 45 mg kg-1 increased both the amplitude of gastric contractions and the gastroduodenal coordination, although individual doses produced smaller increases in amplitude than in the basal state. These results suggest that erythromycin has a different mechanism of action in the stomach compared with the duodenum. The reduced effectiveness of large doses of erythromycin has important therapeutic implications.

Animals↗

PubMed2000

[Ketorolac versus tramadol: comparative study of analgesic efficacy in the postoperative pain in abdominal hysterectomy].

OBJECTIVE: To compare the analgesic efficacy of tramadol to that of ketorolac trometamol administered intravenously and at fixed times over the 24 hours after abdominal hysterectomy. PATIENTS AND METHODS: This controlled, double blind, randomized clinical trial enrolled 76 women undergoing abdominal hysterectomies. Two treatment groups were formed: the TRA (Tramadol) group received 100 mg and the KET (Ketorolac) group 30 mg administered every 6 hours intravenously. Patients were ASA I-II and aged 35 to 65 years old. Patients were excluded from the study if hysterectomy was performed because of a tumor, or if there was a history of bleeding dyscrasias, of gastric or duodenal ulcers or of allergy to drugs in the study or if other analgesics had been used within 15 days of surgery. Analgesic efficacy was assessed using a visual analog scale (VAS) and a verbal response scale (VRS). Need for top-up analgesia was recorded, as were the number of patients withdrawing before the end of the study and the side effects attributable to treatment. RESULTS: The mean VAS score throughout the study was 3.6 for the TRA group and 4.4 for the KET group (non-significant, p = 0.05). Likewise, VRS scores were similar. In the first 12 h after surgery, VAS scores in the TRA group were statistically lower than those of the KET group (p < 0.05). Nine patients abandoned the study before it ended: 3 in group TRA and 1 in the KET group. Three withdrew in the TRA group (2 because of vomiting and 1 for administrative reasons). Six left the KET group (4 for uncontrolled pain, 1 for impossible intubation and 1 for administrative reasons. In the TRA group, 38% experienced vomiting whereas only 8% did so in the KET group. No serious postoperative complications were recorded. CONCLUSIONS: During the first 12 hours following surgery, a 100 mg dose of tramadol has been shown to provide more effective pain relief than 30 mg of ketorolac administered intravenously every 6 hours. The only drawback to administering the drug intravenously was the high incidence of postoperative vomiting.

Adult↗