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Rapid solid phase gastric emptying (SPGE) resulting in decreased satiety is postulated to be a contributing factor to obesity. Twenty-six morbidly obese patients with a weight range of 189-523 lb were entered into the Garren-Edwards gastric bubble program. SPGE studies were performed pre-bubble implantation and repeated within 2 wk after bubble implant. There was no significant difference between study patients pre-bubble insertion emptying time and the normal population curve. Emptying time was found to be significantly increased, post-bubble implant, compared with pre-bubble implant over five time periods of testing. The Garren-Edwards gastric bubble has been used as a method for inducing early satiety for the morbidly obese patient. It has been postulated that delay of SPGE would be associated with satiety. Our patients experienced satiety despite their more rapid SPGE. Thus, the satiety which was experienced by our subjects was not on the basis of delayed SPGE, as previously thought.

The effect of SMS 201-995, an analogue of somatostatin, on pancreatic exocrine secretion was investigated in both interdigestive and digestive states in dogs. In four dogs with gastric and Thomas duodenal cannulas, the pancreatic juice was collected by direct cannulation of the main pancreatic duct. SMS 201-995 was infused intravenously at doses of 0, 15, 30, 60, and 120 ng/kg/hr for 2 to 3 hours in the following experimental conditions: (1) interdigestive pancreatic secretion, (2) pancreatic secretion stimulated by the intravenous infusion of both secretin, 0.06 CU/kg/hr, and cholecystokinin octapeptide (CCK8), 0.03 microgram/kg/hr, and (3) pancreatic secretion after ingestion of a test meal. Pancreatic juice was analyzed for volume and outputs of bicarbonate and protein. Plasma levels of motilin, pancreatic polypeptide (PP), CCK, and secretin were determined by radioimmunoassay. SMS 201-995 inhibited significantly the pancreatic secretion and release of hormones, including secretin, CCK, PP, and motilin, in all three experimental conditions. The inhibitory action of SMS 201-995 on pancreatic secretion and hormone releases was dose dependent.

In this case study of upper gastrointestinal bleeding, a problem-solving question-and-answer format is used and is accompained by referenced discussion. The clinical area covered is one in which endoscopic and angiographic tools are available for diagnosis and tamponading devices and angiographic perfusion techniques exist for mangement. Of course, many varibles affect diagnostic and therapeutic decisions, but logic often dictates directions in management. The availability of skilled endoscopists and angiographers is an important factor in the optimal management of the patient with upper gastrointestinal bleeding in whom the source of bleeding is unknown.

A patient with a pancreatic cutaneous fistula subsequent to laparotomy was unresponsive to medical management including intravenous hyperalimentation. Radiation therapy resulted in progressive diminution of volume from the fistula with subsequent complete closure. Radiation thus offers another therapeutic modality for pancreatic fistulas.

Unlabelled: The pre-operative diagnosis of a pancreatic abscess was not considered in a comprehensive review in 1972. However, advances in technology (Ultrasound--US, Computed Tomography--CT) has allowed guided percutaneous needle aspiration (PNA) of suspected pancreatic lesions. The purpose of this study was to evaluate the safety and diagnostic ability of PNA to differentiate acute pancreatic inflammatory masses from pancreatic abscess (PA). Thirteen patients underwent PNA after US or CT revealed an acute pancreatic inflammatory mass (12/13 cystic). One patient underwent a second aspiration. Clinical features T degrees--101.3 degrees F mean (13/13), leukocytosis 14,400 cu/mm (11/13). Aspirated material was gram-stained and examined for bacteria and leukocytes and cultured., Results: PNA was accomplished successfully in all patients. Aspirate revealed bacteria in nine and pancreatic abscess was confirmed at surgery (8) or post-mortem exam (1). Four of five patients in whom no bacteria were visualized had medical resolution, the fifth had continued T degree and underwent a second aspiration which diagnosed a PA. PA contained moderate to large number of PML via aspiration., Conclusions: PNA provides a potentially important and safe diagnosis adjunct to earlier accurate differential diagnosis of pancreatic inflammatory masses from pancreatic abscess.

This review briefly outlines the gastrointestinal manifestations of diabetes mellitus. Usually, gastrointestinal abnormalities are asymptomatic. Severe gastrointestinal dysfunction may be quite debilitating, however. Gastrointestinal symptoms that are a consequence of diabetes may be confused with other primary gastrointestinal disorders. We attempt to provide a clinical approach to differentiating the basis of symptoms and outline the therapeutic plan that we generally employ. Much additional research is necessary to clarify our understanding of the pathophysiology of the gastrointestinal complications of diabetes and to develop improved therapeutic strategies.

CEA levels and their rate of change in 41 patients with pancreatic carcinoma following surgery, chemotherapy and radiation therapy were determined. Surgical resection, though not curative, was associated with a decrease in CEA level, with approximately half these levels returned to normal. No correlation with survival was noted. CEA levels are increased by obstructive jaundice. Radiation alone or in combination with 5-Fluorouracil did not change CEA levels in patients with locally unresectable pancreatic carcinoma. CEA levels progressively increased in patients with widespread metastatic pancreatic carcinoma, who expired from their disease.

The purpose of this prospective study was to evaluate the effect of compliance versus noncompliance with a behavior modification program (BMP) for 35 patients who underwent implantation of 51 Garren-Edwards gastric bubbles (GEGB). Criteria for morbid obesity was met by every patient. Two patient groups were formed by self-selection. Compliant patients (group I) attended 75% or more of the BMP. Group II consisted of noncompliant patients, and was divided further into partially complaint and totally noncompliant. A significant difference was found in both loss of weight and loss of body mass index (BMI) between the complaint and noncompliant groups, with no significant difference in weight loss between the partially and totally noncompliant groups. Patients' compliant or noncompliant behavior had a significant effect on changes in weight (p = 0.007) and body mass index (p = 0.005). Sixteen patients had two consecutive bubble implants. The rate of compliance was significantly higher during the first implant program, with a significantly greater loss in both weight and BMI for compliant patients. Follow-up data for 28 of 35 patients revealed a continued, albeit small, average weight decrease. In summary, weight loss does not result from the gastric bubble alone. Our study demonstrates that the key factor is compliance with a behavior modification program.

The sensitivity and specificity of ERCP for the diagnosis of suspected pancreatic ductal rupture was prospectively studied. Fourteen consecutive patients who were referred for abdominal pain and hyperamylasemia subsequent to abdominal trauma underwent ERCP, the majority within 24 hours of admission. Twelve of these also underwent abdominal CT, and 7 had peritoneal lavage. Four patients were found to have ductal rupture at ERCP. This was confirmed at laparotomy. Three additional patients who underwent laparotomy were found not to have a ductal rupture, although one had a pancreatic capsular laceration. The remaining 7 had clinical resolution. ERCP was 100% sensitive and specific in the diagnosis of pancreatic ductal rupture, whereas no combination of serum amylase, CT scan, and peritoneal lavage was equally effective.

Twenty-four patients with colorectal carcinoma and one patient with a recurrent, transitional-cell, vesical tumor invading the rectum but not amenable to surgical resection underwent neodymium-YAG laser therapy. There were 16 men and nine women with an average age of 75.6 years (range, 35 to 93 years). There were 14, 6, 1, 1, and 3 tumors found in the rectum, rectosigmoid colon, transverse colon, descending colon, and ascending colon, respectively. Symptoms consisted of bleeding or partial obstruction. Twelve patients were high-risk surgical candidates, 11 patients had widespread disease, and two patients had another primary tumor not controlled by a previous surgical procedure. The tumor was eradicated in two patients. There were two complications, namely, a perforation and a rectovaginal fistula. Thirteen patients died from their disease. The remaining patients have been kept free from obstruction and bleeding.

Esophageal obstruction secondary to recurrent breast carcinoma is not widely recognized. Frequently, the esophageal narrowing is attributed to a benign process, resulting in delays of diagnosis and treatment. Such a case prompted this report and review of the literature.

A prospective study was carried out in 60 patients to determine the efficacy of 99mTc-PIPIDA scintigraphy in differentiating biliary pancreatitis from nonbiliary pancreatitis. Forty patients were classified as having biliary pancreatitis and 20 patients as having the nonbiliary type. Scintigraphic scans were divided into five main types according to the time to visualization of the gallbladder and the time to excretion of 99mTc-PIPIDA into the intestinal tract. Normal scans were obtained on 95% of patients (19/20) with nonbiliary pancreatitis; 22.5% of patients (9/40) with biliary pancreatitis had normal scans. It is concluded that elevated amylase levels together with an abnormal biliary scan, as defined by the criteria presented here, indicate biliary pancreatitis, while a normal scan largely excludes such diagnosis.

Hypercalcemia may be associated with neoplastic disease, either as an epiphenomenon resulting from tumor-produced humoral substances or as a direct consequence of bone involvement. Endoscopic procedures are occasionally performed in this group of patients for both diagnostic and therapeutic purposes. This report reviews the interaction of hypercalcemia and sedative hypnotic drugs and suggests that hypercalcemia might be a risk factor for those patients undergoing endoscopy.

The most common causes of acute pancreatitis are biliary tract disease and alcoholism, but other causes account for about 10% of cases. Acute pancreatitis can be divided clinically into mild and severe (necrotic) disease. Risk of complications and death varies with the etiology, severity, and number of episodes and is highest in severe cases and biliary tract-related disease. Amylase determination is the best diagnostic serum screening test. Ultrasonography, computed tomography, and endoscopic retrograde pancreatography are also extremely useful in diagnosis. Treatment of acute pancreatitis usually consists of supportive measures; the roles of peritoneal lavage and surgery remain controversial. Pseudocysts occur in about 25% of patients but can be treated successfully with appropriate therapy.

Age has been assumed to be an independent risk factor in patients undergoing colonoscopy. However, this has never been specifically studied. We evaluated 302 patients 65 yr old or older, to determine the incidence of complications. We found that the risk is comparable to that of the heterogeneous patient population previously reported, except for a slightly increased incidence of delayed bleeding subsequent to polypectomy. In addition, the presence of cardiac, pulmonary, liver, or kidney disease was not found to be associated with an increased incidence of complications. Neither was there an increased risk of complications in patients undergoing colonoscopy, who had previously undergone abdominal or pelvic surgery. In summary, older patients experience the same risks as younger patients, except for post-polypectomy delayed bleeding, which may be related to atherosclerosis of the blood vessels, and appears to be more common in elderly patients.

Circulating CEA levels were determined in 102 patients wtih histologically proven pancreatic carcinoma and 26 patients with chronic pancreatitis. In the group with pancreatic carcinoma eleven patients had resectable tumors, the mean CEA in the nonjaundiced patients was 10 +/- 5 ng/ml while the mean value in jaundiced patients in this group was 27 +/- 40. Thirty-four patients with nonmetastatic locally unresectable disease had a mean serum CEA of 25 +/- 52 with a range of 1 to 250 ng/ml. Twenty-one percent had values of 5 ng/ml or less. The mean value in 57 patients with metastatic disease was 97 +/- 194 with a range of 0.05 to 1000 ng/ml and 19 percent had values of 5 ng/ml or less. Survival of patients with locally unresectable or metastatic carcinoma was significantly longer in those patients who had a normal CEA at the time of diagnosis. Circulating CEA in the metastatic group was much lower in patients with nonhepatic metastases as well as in those with well differentiated adenocarcinoma histology. Twenty-three patients with chronic pancreatitis and normal serum bilirubin had a mean CEA value of 5.3 +/- 4 ng/ml with 65% of values being 5 ng/ml or less but the CEA ranged from 4.6 to 27 in three who were jaundiced.

The evaluation and management of esophageal strictures ordinarily involves the three procedures of endoscopy, biopsy, and dilation at different times. The safety of performing these procedures in a single sitting was evaluated. The study included 48 patients (ages 44-85) with radiographically confirmed esophageal strictures located in the upper third (3/48), middle third (18/48), and lower third (27/48) of the esophagus. The strictures were determined to be due to peptic esophagitis of varying severity (28/48) or carcinoma (20/48). Dilation immediately followed endoscopy and biopsy with an average of three mercury-weighted dilators passed at this sitting. The size and type of dilators were determined clinically by the endoscopic estimation of esophageal lumen diameter. Anesthesia included topical Cetacaine and intravenous diazepam (5-15 mg.). All patients experienced symptomatic improvement immediately following the procedures. No complications were encountered. These data indicate that endoscopy, biopsy and dilation of esophageal strictures may safely be performed in a single sitting. Other advantages may include shortened hospital stay, earlier diagnosis and relief of symptoms and increased cost effectiveness.

The effects on liver function tests of liver-directed radiation (RT) and systemic chemotherapy (CT) were examined at 6 months after initiation of treatment on two Gastrointestinal Tumor Study Group protocols. Data from patients on protocol GI 6175 (adjuvant CT or no adjuvant therapy) were used to evaluate the effect of CT alone, and data from patients on protocol GI 6179 (adjuvant CT plus liver directed RT or no adjuvant therapy) were used to evaluate the combined effects of CT and RT. Finally, data from patients on GI 6179 who received less than protocol specified RT doses were used to determine whether minor differences in dose are detectable via liver function tests. In 40 patients receiving CT, the serum level of alkaline phosphatase was not significantly increased (p = 0.14) compared to that of control patients whereas the level of serum glutamate oxoloacetate transaminase was significantly elevated (p = 0.03). In 31 patients receiving both CT and RT, both alkaline phosphatase and SGOT were significantly elevated (both p = 0.03). In addition, in 19 patients who received less than full RT doses, the changes in dose were not detectable from those patients who received full dose (all p greater than 0.10). In summary, CT alone may elevate hepatocellular enzymes, whereas a combination of CT and liver-directed RT is associated with a significant increase in both SGOT and alkaline phosphatase. Small alterations in the dose of volume of RT are not detectable by liver function test variations.

Ten patients were identified at Jackson Memorial hospital/University of Miami Hospitals and Clinics with enteric coccidial infection due to Cryptosporidium spp. or Isospora belli. All had the acquired immunodeficiency syndrome as manifested by Kaposi's sarcoma or multiple opportunistic infections, or both. They presented with profuse diarrhea associated with weakness, anorexia, and weight loss. Routine examinations of stools for eggs and parasites as performed by the hospital laboratory were negative in all patients. Sugar flotation and modified acid fast techniques were used in the Tropical Disease Laboratory to identify oocysts of Cryptosporidium spp. in stools of seven patients. Malabsorption, characterized by a low 5-hour D-xylose and positive fecal fat, was observed in 6/6 of these patients. In three other patients Isospora belli oocysts were identified in stool specimens or via a duodenal string test. Spiramycin was the only drug found to be effective in treating patients with cryptosporidiosis. Patients with Isospora belli responded to a prolonged course of trimethoprim-sulfamethoxazole.

Two cases of gastric outlet obstruction, secondary to a pseudocyst of the pancreas, are described. The striking radiologic pictures are shown. The pathogenesis of this complication is discussed and a greater awareness of this entity is stressed.

The intractable ulcer is usually complicated because of posterior penetration, obstruction, or postbulbar or channel location; or it is an atypical ulcer such as those occurring with the ZE syndrome, hyperparathyroidism, and the milk-alkali syndrome. The management of intractability depends upon finding the cause and initiating the appropriate therapy. Many abdominal diseases may masquerade as intractable ulcers, so every patient must be evaluated thoroughly to prove that his ulcer is indeed intracetable.

A patient, who developed carcinoma of the rectum nine years following therapeutic radiation for pelvic malignancy is presented. The relationship of radiation to carcinoma of the colon is reviewed. This relationship makes rigorous follow-up of patients with radiation induced chronic proctocolitis essential.

A retrospective review of endoscopic procedures using the Nd-YAG laser was carried out for patients treated between September 1984 and November 1986. Two hundred twenty two procedures were performed on 104 patients (58M:46W) during this 26 month period. The study encompasses a unique period of time in this center, as it includes the initial use of the endoscopic laser technique, the learning curves associated with its application, and finally, the time when its use became routine. Treatment of tumors was the indication in 47 per cent of the cases. Gastrointestinal bleeding of benign cause was the indication in nearly half of the patients; arteriovenous malformations were the most common causes of bleeding. Laser photocoagulation of hemorrhoids was performed in 11 cases. Upper endoscopy was the route in 33 per cent of procedures. Anoscopy, flexible sigmoidoscopy, and colonoscopy were the routes in the remainder. The time spent on the procedure and the energy delivered were found to be variables of the type of lesion and the endoscopic route. Nd-YAG laser endoscopy can be used safely and effectively for a variety of bleeding and obstructive gastrointestinal conditions. Appropriate certification for granting of privileges to laser endoscopists is of utmost importance.

The infrequency of reports demonstrating dilatation of the pancreatic ducts in patients with chronic pancreatitis by CT, despite its frequent demonstration on endoscopic retrograde cholangiopancreatography (ERCP), prompted a review of 500 cases performed at the University of Miami School of Medicine/Jackson Memorial Hospital for suspected pancreatic disease. Pancreatic duct dilatation was demonstrated in 10 patients. An equal occurrence was documented in patients with chronic pancreatitis and with carcinoma. Therefore, the presence of dilated pancreatic duct only confirms the presence of pancreatic disease. No etiology should be favored by the isolated finding of a dilated duct on CT scanning.

Four hundred fifty-two patients with surgically resected colon or rectal cancer were evaluated to determine the incidence of intraluminal recurrences and the utility of a routine endoscopy screening program for detecting such recurrences. At the time of analysis, recurrent disease was found in 86 of 380 colon cancer patients and 21 of 72 rectal cancer patients. Local recurrence, defined as tumor within 400 cm2 of the primary, was present in 38 of 86 colon, and 11 of 21 rectal cancer patients. Of those 49 local recurrences, 15 were intraluminal, 6 of which were initially detected by a follow-up endoscopy program. Time to diagnosis, stage of disease, and survival were similar for patients whose lesions were detected by routine endoscopy versus those found by other means. New primary (metachronous) lesions defined as an intraluminal lesion occurring at least 5 cm beyond the surgical anastomosis were identified in six colon cancer patients and no rectal cancer patients. Of these six lesions, four were discovered during routine endoscopy. Thus, a routine follow-up endoscopy program is an important tool for the detection of intraluminal recurrence of colon and rectal cancer in patients who have undergone curative resection. However, routine follow-up endoscopy should not be the sole method of follow-up, since the incidence of intraluminal recurrence is small, and may initially be detected by other means in the majority of cases.