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H. pylori is the cause of one of the most common infectious diseases worldwide. Infection with H. pylori leads to exaggerated synthesis of several inflammatory cytokines. Only a minority of infected patients develops peptic ulcer disease. H. pylori strains associated with peptic ulcer disease induce strong mucosal infiltration with inflammatory cells and increased expression of several cytokines. Cytokines may contribute to ulcer development by different mechanisms, including stimulation of gastrin and pepsinogen release, suppression of somatostatin synthesis and activation of inflammatory cells.

The administration of nonsteroidal anti-inflammatory drugs (NSAIDs) is frequently associated with injury to the gastroduodenal mucosa and leads in approximately 1.5% of patients to severe complications such as haemorrhage or perforation. The risk of serious upper GI complications is increased in patients > 65 years with a previous history of peptic ulcer disease or gastrointestinal haemorrhage, concomitant steroid use and significant cardiovascular comorbidity. Previous studies have shown that misoprostol is effective in reducing the incidence of gastric and duodenal ulcers as well as serious gastrointestinal complications. Recently, four large clinical trials have demonstrated that omeprazole is effective in preventing and treating NSAID-induced ulcers. Omeprazole when compared to misoprostol was equally effective in preventing gastric ulcers and more effective in duodenal ulcers. For treatment of gastric and duodenal ulcers, omeprazole was more effective than misoprostol and ranitidin. Prophylaxis of NSAID-induced ulcers should be administered in all patients with several risk factors for serious gastrointestinal complications.

"Digest" is a international effort to record the prevalence of digestive symptoms in the general population. The international questionnaire was tested in German translation for reliability and reproducibility. The questionnaire consists of 14 symptoms, which were investigated by standardized questions. Each symptom was described in 3 dimensions: frequency, severity and impact on daily activities. 127 successive patients referred for upper gastrointestinal endoscopy were interviewed twice by a young assistant and by an experienced gastroenterologist before the diagnostic work-up. A further 72 volunteers served as a control group. In these volunteers no upper gastrointestinal endoscopy was performed. Reliability and reproducibility were calculated by the Spearman rank test. The most frequent diagnoses were: organic diseases (oesophagitis [28], gastric ulcer/erosive gastritis [32] and duodenal ulcer [18]); functional diseases (dyspepsia [32] and irritable bowel syndrome [14]). Reproducibility was satisfactory by accepted standards (p > 0.7). Reliability was very good, with r-values for each symptom between p 0.96-0.99. The impact on daily activities was highest in the case of heart-burn or localized upper gastrointestinal pain, and lowest in the case of belching and fullness. The questionnaire can be easily administered by the non-specialist and the results discriminate well between functional/organic diseases and healthy people, thanks to excellent reproducibility and reliability.

Lithium clearance was used to investigate the effect of calcitonin on renal sodium excretion. Two sequential renal function tests, calcitonin and placebo treated, were performed in 6 healthy students. Intravenous administration of 0.5 mg human calcitonin (hCT) (Cibacalcin, Ciba-Geigy, Basel, Switzerland) significantly raised fractional excretion of sodium (FENa), from 1.73% (0.97%) to 3.63% (0.89%) (p < 0.001), and lithium clearance (Cli), from 35.1 (5.4) to 53.9 (8.5) ml/ min x 1.73 m2 (p < 0.01). By using inulin and lithium clearance we calculated proximal (PFR), distal (DFR) and total excreted sodium (TAN). Our results clearly demonstrate that hCT has a proximal diuretic effect in humans and that a calcitonin induced proximal sodium loss is compensated by increased sodium reabsorption within 80 minutes after hCT application. Calcitonin increases the excretion of lithium and has a potential to be used in lithium intoxication.

Radioopaque markers are well established tools to determine segmental and total colonic transit time. However, since no data are available on intraindividual reproducibility, in this study reproducibility was assessed in 14 health male and 12 healthy female volunteers. The mean segmental colonic transit and total colonic transit time were not significantly different for the two measurements. Colonic transit time was consistently shorter in males than in females. The menstrual phase did not show a significant influence in the latter. The intraindividual variations of the colonic transit times were acceptable with a reproducibility coefficient of 20 h.

Inflammatory bowel disease (IBD) is characterized by T-cell activation and mucosal influx of inflammatory cells partly mediated by increased local release of cytokines and chemokines. Increased levels of activated platelets are reported in IBD. Activated platelets induce endothelial cells in vitro to secrete several cytokines and growth factors and to express adhesion molecules. This study investigates the expression of interleukin-1 (IL-1), IL-8 and granulocyte-macrophage colony-stimulating factor (GM-CSF) receptors on circulating platelets from patients with IBD and healthy controls and assesses the in vitro effect of various concentrations of IL-1 beta, IL-8 and GM-CSF on platelet activation in healthy controls. Flow cytometry was performed to quantify the percentage of platelets binding phycoerythrin (PE) labeled recombinant human IL-1 beta, IL-8 and GM-CSF. Platelet activation was assessed using fluorochrome labeled anti-GMP-140, an activation-dependent antigen. Results are expressed as percentage cytokine receptor expressing platelets (median and interquartile range IQR). Platelets from patients with IBD expressed significantly more cytokine receptors compared to healthy controls: IL-1R [8.7% (5.5-18.2) vs 3.1% (2.4-4.8), p < 0.05], IL-8R [22.5% (18.1-27.9) vs 8% (4.5-9.2), p < 0.001)], GM-CSFR [25.9% (16.1-39.2) vs 3.9% (2.7-3.9), p < 0.001]. The percentage of activated platelets was significantly increased after in vitro stimulation with IL-1 beta, IL-8 and GM-CSF. We conclude that cytokines and chemokines modulate platelet activation through specific, functional receptors which are upregulated in IBD.

The purpose of this review is to summarize new developments in the surgical treatment of benign and malignant tumors of the rectum, focusing on oncological requirements and postoperative functional aspects which affect the quality of life. One of the developments is the transanal endoscopic microsurgical (TEM) approach to resection of adenomas and low risk early cancers in the rectum. Another focus is total rectum resection with colo-anal reconstruction with a colon pouch. This procedure reconstructs anorectal anatomy and provides nearly normal function. The reconstruction exists in two forms, (a) the colon-J-pouch and (b) the ileocecal interposition pouch (cecum pouch), which was developed at our institution. The review includes 33 consecutive patients with a rectum tumor. Standardized tumor-specific and functional staging determines which technique is used. 12 patients were operated on using the transanal endoscopic approach, 3 patients had a posterior proctotomy, another patient a transanal local excision and 17 patients total rectum resection with colon pouch reconstruction as described above.

Gastroduodenal ulcers are strongly associated with Helicobacter pylori (HP) infection. Successful eradication drastically diminishes ulcer recurrence. Most of the eradication schemes include metronidazole (Flagyl). The present study was designed to establish the metronidazole resistance rate in Switzerland. Antral biopsies were taken in 153 patients with suspected ulcers (115 men, 38 women, mean age 46 +/- 16 [SD] years) during upper endoscopy for bacteriological testing. Metronidazole resistance (> 8 micrograms/ml) was found in 47/153 (31%) of the isolates. Resistance was found in no case to amoxicillin (Clamoxyl) (0/104 = 0%) and only in 3% (2/66) to clarithromycin (Klazid). Metronidazole resistance of HP in a third of the isolates studied is comparable to numbers found in other European countries. These findings raise the question whether eradication schemes including metronidazole without prior sensitivity testing are justified. Amoxicillin and clarithromycin appear to be valid alternatives.

Although more than a fourth of the adult population reports dyspeptic complaints, little is known about the prevalence of clinically relevant UGI endoscopic findings in these patients in comparison with asymptomatic volunteers. This type of information is required in order to assess the relative risks of organic dyspepsia and the sensitivity and specificity of dyspeptic complaints for peptic lesions. In an attempt to fill this gap, the authors compared two trials carried out in the German-speaking part of Switzerland: (a.) 172 adult asymptomatic volunteers (age 20-78 years, 74 females, 98 males) participated in an epidemiological trial to measure the prevalence of positive CLO-urease tests and of upper GI-tract lesions. (b.) 119 patients (age 18-84 years; 68 females, 51 males) consulting their family doctor because of upper digestive symptoms of at least 1 month's duration (epigastric pain or discomfort, heartburn, acid regurgitation, early satiety, bloating, etc.) were referred for UGI endoscopy as a screening procedure; functional dyspeptics were thereafter randomized to a double blind drug trial (not reported here). In both trials the gastric presence of Helicobacter pylori was measured by means of the CLO-urease test. Prevalences of lesions and of positive urease-tests in the dyspeptic population were compared with the sex and age adjusted prevalences registered in the control population.(ABSTRACT TRUNCATED AT 250 WORDS)

Coloanal reconstruction is a sphincter saving operation following total rectal resection to treat rectal cancer 3 to 11 cm above the dentate line. Total rectal resection in this situation is justified from the oncological and surgical viewpoint because the local recurrence rate and morbidity are not different from the "gold standard", abdominoperineal resection sacrificing the anal sphincter. Although patients undergoing straight coloanal reconstruction preserve continence, they are often disturbed by high stool frequencies and imperative urge. We set out to establish whether construction of a colon-j-pouch could ameliorate the quality of defecation and thus prove useful. In this study the pre- and postoperative results of a pilot study with 4 consecutive patients following colon-j-pouch-anal reconstruction are presented. Perioperatively, 3 of 4 patients suffered from intermittent disturbances of urinary voiding. Sexual function was disturbed in 3 of 4 patients. All patients were completely continent. The preliminary results showed a decreased sphincter pressure at rest of 40 mm Hg (SD: 5) and a normal squeeze pressure. Endoanal ultrasound demonstrated a normal anal sphincter morphology. Pouch compliance yielded 4.7 ml/cm H2O and was better than after straight coloanal reconstruction in the control group (2.8 ml/cm H2O). The stool frequency at 6 months was 3/24 hours without imperative urge. The colon transit time lasted 49 hours and was in the normal range. No pouch evacuation disorders were observed. These results show a minimal morbidity in colon-j-pouch-anal reconstruction with preservation of complete continence in the follow-up time.(ABSTRACT TRUNCATED AT 250 WORDS)

The standard treatment for symptomatic cholecystolithiasis remains surgery, the present method of choice being laparoscopic cholecystectomy. Noninvasive treatment options are available, but should be restricted to selected cases. Extracorporal shock wave lithotripsy (ESWL) is an alternative to noninvasive treatment, provided the patients are carefully selected. The main disadvantages include prolonged administration of gall salts and the problem of stone recurrence.

The pathogenesis of peptic ulcer disease is complex. It is associated with a spiral organism, Helicobacter pylori, which induces chronic gastritis. The evidence for a causal association between H. pylori and peptic ulcer disease stems primarily from the observation that eradication therapy with bismuth and various antibiotics may produce normalization of gastritis and possible cure of ulcer disease. The prevalence of H. pylori infection and potential implications for therapy are discussed. Who should undergo eradication therapy, and how? The problem remains that--despite the fact that a cure is possible--no simple therapy is available.

Splenectomy intended to treat hypersplenism can, in the presence of portal hypertension (PTH), lead to extrahepatic portal and mesenteric vein thrombosis. The management of possible variceal bleeding in patients with extrahepatic portal vein occlusion following splenectomy in portal hypertension is a problematic and challenging undertaking. We report on the management of variceal bleeding in 2 noncirrhotic patients with PTH who developed portal vein thrombosis following ill-advised splenectomy. It must be stressed again that splenectomy alone intended to control hypersplenism in portal hypertension is to be avoided at all costs. Options for the treatment of portal and mesenteric vein thrombosis and variceal bleeding are proposed.

Use of radiopaque markers with a plain X-ray of the abdomen is a simple technique to measure mean segmental and total colonic transit time. We evaluated 128 healthy volunteers with a mean age of 40 years (range 20-81 years) from three different parts of Switzerland to assess age and sex specific normal transit times. In men and women colonic transit time was not influenced by age. The mean transit time was significantly shorter in men than in women (30 +/- 2 hours versus 41 +/- 3 hours: p less than 0.05). In men the transit time was also influenced by smoking. Non-smoking men had a significantly shorter transit time than smokers (26 +/- 2 hours versus 40 +/- 5 hours: p less than 0.05). In women, neither smoking nor the menstrual cycle influenced transit time. For normal colonic transit time we recommend up to 66 hours for smoking men, up to 44 hours for non-smoking men and up to 70 hours in general for women.

The efficacy of flexible sigmoidoscopy as a screening method for colorectal cancer is still undetermined, and a reduction in mortality due to this cancer by mass screening has not been demonstrated so far. An important precondition for the practicability of screening sigmoidoscopy is its acceptability by the persons to be screened. Acceptability was tested in 294 volunteers without abdominal symptoms from a general medical outpatients clinic. Mean age of participants was 58 years (45-86), 65% were men and 35% women. Sigmoidoscopy was judged harmless by 221 persons (75.1%), painful by 62 (21.1%), very painful by 11 (3.7%), and unacceptable by none. Every participant would have agreed to repeat the examination. In 36 patients 52 polyps were detected, comprising one carcinoma, 18 adenomas (in 15 patients), 32 hyperplastic polyps and one lipoma. We conclude that sigmoidoscopy was well accepted in this study and should be evaluated further as a mass screening method for colorectal cancer.

A simplified 13C-urea breath test (UBT) for detection of Helicobacter pylori (Hp) infection was evaluated in 50 patients. Following upper gastrointestinal endoscopy the patients received 100 ml of a liquid test meal with 100 mg 13C-urea. Breath samples were obtained at baseline and 30 minutes respectively. The UBT was positive (difference of 13CO2 enrichment exceeding 5%) in 33/35 patients with culture-proven Hp infection and negative in 14/15 patients in whom microbiological culture, histology and a urease test (CLO-test) were negative. We conclude that in view of its high sensitivity (94%) and specificity (93%) the UBT is useful for rapid, non-invasive diagnosis of Hp infection.

43 patients with symptomatic gallbladder stones were treated by extracorporeal shockwave lithotripsy and oral bile acids. In all patients the stones were successfully fragmented during the first lithotripsy session. 33 patients underwent 2-4 treatment sessions. In 16 out of 43 patients the stones disappeared within 7.9 months. The rate of stone dissolution was dependent on the number and size of stones. 3 patients required surgery because of frequent colic in one case, cholecystitis in one case and lack of cooperation in one case. No important side effects were noted except mild pancreatitis 3 weeks after lithotripsy in one patient. Results at this center of extracorporeal shockwave lithotripsy combined with oral bile acids indicate that this treatment may become an alternative to cholecystectomy in patients with a small number (less than 3) of stones not exceeding 30 mm in diameter.

Recent advances in knowledge of the hormonal control of exocrine pancreatic secretion are discussed in the light of two main mechanisms of action: first, the effect of the main regulatory peptides on the exocrine pancreas, and second, the inhibitory mechanisms which may affect pancreatic secretion. A synthesis of the regulatory principles controlling exocrine pancreatic secretion is attempted.

Feeding with nasally placed enteral feeding tubes is a method frequently used for long-term nutrition of patients with neurologically or mechanically induced swallowing disorders. Feeding tubes, however, may be unsatisfactory due to either esthetic considerations or complications such as esophagitis, bleeding or pulmonary aspiration. Recently, endoscopic techniques for placing of feeding gastrostomies without laparotomy have been introduced. We report on our experience with 46 endoscopically controlled percutaneous gastrostomies in 38 patients according to the method described by Russell. Cerebrovascular diseases and malignancies of the oropharynx were the 2 most common indications for creation of the gastrostomy. Endoscopically assisted gastrostomy was successful in 38 of 40 patients referred. One serious and two minor complications were encountered. Gastrostomy was in use for a median time span of 3 months (range 1-83 weeks). We conclude that endoscopically assisted percutaneous gastrostomy is a simple, safe, and effective means of providing enteral nutrition in patients requiring tube feeding.

Efficacy and side effects of lithotripsy of gallbladder stones with a piezoelectric lithotriptor are assessed. 16 treatments were performed in 8 patients (1-3 per patient). Patients required no premedication, analgesia, infusion or monitoring. Gallstone fragmentation was achieved with all treatments. Laboratory findings remained unchanged after treatment, with the exception of one patient with mild pancreatitis. With adjuvant oral bile acid treatment, 6 of the 8 patients were stone-free within 3 days to 3 months. Extracorporeal shockwave lithotripsy with piezoelectric shock waves provides painless and efficient gallstone fragmentation. Repeated treatments may speed complete fragment dissolution.

Dose response curves of the octapeptide of cholecystokinin (CCK-8) and 3 of its methoxinine analogues have been established in 4 conscious dogs with respect to gastric and pancreatic secretion. In the analogues the methionine was replaced by methoxinine in position 3 (B) and (D) or 6 (C). Of the 4 tested substances CCK-8 exhibited most activity with regard to pancreatic protein secretion, followed by B, C, and D. Analogue C had the strongest stimulating effect on gastric acid secretion, while its effect on pancreatic secretion was minor. Correlation of chemical structure with biological activity points to the importance of the methionine residue in position 6.

The pancreas has both exocrine and endocrine components. The exocrine component of the pancreas manufactures, stores, and packages digestive enzymes for digestion of food, whereas the endocrine secretes hormones that regulate the metabolism and utilization of the absorbed nutrient components. Both components are closely related, not only anatomically but also functionally. The available evidence to support the concept of a close interrelationship of endocrine and exocrine pancreatic function is summarized. It is shown that the endocrine part exerts a profound effect upon the digestive activities of the organ, and that impairment of endocrine function, such as diabetes, severely affects the exocrine component of the gland. Furthermore, dysfunction of the exocrine gland, as in chronic pancreatitis, progressively disturbs the function of the islet cell hormones. The interactions are governed by a complicated control system, the details of which are not yet clarified. As in any partnership, dysfunction of one partner severely affects the other and vice versa.

Vasoactive intestinal polypeptide (VIP), a basic polypeptide mainly found in neural tissue, has been associated with specific endocrine pancreatic tumors. In the present study, a sensitive and specific radioimmunoassay for VIP is described and its clinical application discussed.

In four healthy volunteers increasing doses of intravenous CCK-33 induced an increase in plasma PP concentration measured by RIA. PP concentration rose from a basal level of 67 +/- 15 pmol/l to 198 +/- 45 pmol/l with 2 IDU/kg/h (p less than 0.05). In four mongrel dogs equipped with Thomas cannulas, the same doses induced a more pronounced rise in plasma PP (p less than 0.01). It is concluded that intravenous CCK-33 induces the release of PP in man and dog in a dose-dependent manner.