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Nonoperative direct examination of the pancreaticobiliary system with an ultrathin fiberoptic endoscope was compared to endoscopic retrograde cholangiopancreatography (ERCP). Thirty-one patients were examined by both techniques. Direct examination of the biliary system was successful in 12 patients, seven of whom had had previous endoscopic sphincterotomy. In two patients it revealed stones missed on ERCP. In none of the patients was an examination of the pancreatic duct possible. ERCP visualized the biliary system in 28 patients and the pancreatic duct in 30 patients. In one patient the ERCP revealed a stone missed by the peroral choledochoscopy. Peroral choledochoscopy is complementary to ERCP and should be reserved for patients with probable pathology of the biliary tract and normal ERCP.

Bromsulfophthalein (BSP) clearance and aminopyrine breath tests were performed in 13 patients with Gilbert's syndrome (GS) and six healthy volunteers. The BSP clearance was significantly lower in the GS patients (1.28 +/- 0.37 dl/min) than in the healthy volunteers (1.98 +/- 0.45 dl/min). The difference in clearance was not due to a significant difference in volume of distribution. The 13 patients with Gilbert's syndrome could be divided into three groups according to their BSP disappearance curves: in 7 the curves were normal; another 3 patients the disappearance rate of BSP was normal at the beginning, but became abnormally low later on; and in the last 3 patients, an abnormal BSP disappearance rate was observed during the whole experiment. Kinetic analysis of these BSP disappearance curves indicated increased regurgitation of BSP from the liver to the blood in the second group and defective hepatic BSP uptake in the third group. The aminopyrine breath test also demonstrated heterogeneity among the GS patients. There was no correlation between the impaired BSP clearance and the aminopyrine breath test.

To evaluate the role of the sympathetic nervous system in modulating esophageal motility, esophageal manometry was performed on two groups of patients who underwent upper dorsal sympathectomy for relief of palmar hyperhydrosis. In six patients sympathectomy was done by the supraclavicular approach, with removal of T2 and T3 ganglia. Manometry was performed before the operation and three weeks after it. In seven other patients sympathectomy was done by the axillary approach, with removal of T2-T4 ganglia. Manometry in this group was performed 28.4 +/- 22.4 months after the operation. Fifteen individuals with an intact sympathetic system served as controls. Manometric parameters evaluated were esophageal contraction amplitude and duration and lower esophageal sphincter pressure. The difference between the results obtained in the pre- and postoperative periods in the first group was not statistically significant. The differences between the two patient groups and between the patient groups and the control group were not statistically significant either. We conclude that upper dorsal sympathectomy does not affect esophageal motility in man.

Documented typhoid fever in a 26-year-old patient was complicated by acute hepatitis with unusually profound jaundice. Liver biopsy revealed focal cell necrosis, mononuclear cell infiltration. Kupffer cell proliferation, and mild cholestasis. Immunofluorescent studies of the liver biopsy revealed deposits of IgG, IgA, IgM, and C3 in the bile canaliculi, suggesting a role for damage by immune complexes in typhoid hepatitis.

In order to determine the composition of "normal" ascitic fluid, the results of analysis of the first paracentesis on 347 consecutive cirrhotic patients with ascites at the West Haven Veterans Administration Hospital between 1955 and 1976 were examined. The ascites was considered "normal" in 259 patients. Bacterial peritonitis was present in 51, malignant ascites in 18, pancreatitic ascites in 15, and ascites of other types in 4 patients. Normal ascites is sterile, usually clear, and contains 281 +/- 25 leukocytes/mm3 (mean +/- SEM), 27 +/- 2% of which are polymorphonuclear. In spontaneous bacterial peritonitis the fluid is usually cloudy, contains 6084 +/- 858 white blood cells/mm3, 77 +/- 4% of which were PMN and culture is positive for a single bacterial species, usually enteric in origin. Malignant and pancreatitis ascites are sterile, often cloudy, and contain an average of 696 +/- 273 and 1821 +/- 833 leukocytes/mm3, respectively, about half of which are polymorphonuclear. Amylase activity is increased in pancreatitic ascites, but not in other types of ascites. Stained smears of sediment for bacteria are often positive in bacterial peritonitis, but not in the other categories. Neither the specific gravity, protein concentration, nor glucose level is useful in the differential diagnosis of ascites. Based on the critical number of leukocytes alone, (500/mm3), one can accurately differentiate infected from uninfected fluid in over 90% of ascitic patients.

We studied gastric emptying of solid food, using a radionuclide technique, in 18 patients with chronic renal failure patients on hemodialysis: nine with nausea and vomiting or postprandial bloating and nine without. Both groups were compared with a group of normal subjects. Gastric emptying was consistent with a linear elimination in all groups. The regression coefficients of the symptomatic, asymptomatic, and control groups were -0.48 +/- 0.1%, -0.5 +/- 0.14%, and -0.58 +/- 0.15% min, respectively. These were not statistically different. Half-emptying times were 116.4 +/- 7.1 min, 97.8 +/- 13.7 min, and 98.7 +/- 5.6 min, respectively. These also were not statistically different. Values of percentage retention at 2.5 hours for the same groups were 31.6 +/- 5, 24.8 +/- 6.4, and 18.6 +/- 4.4, respectively, again with no statistical difference. Patients with chronic renal failure on hemodialysis, symptomatic or asymptomatic, have no obvious impairment of gastric emptying of solids.

A 71-year-old female with symptomatic colonic lipoma is described. An uneventful colonoscopic removal of the lipoma was performed. Colonoscopic removal of symptomatic pedunculated submucosal colonic lipoma may be recommended.

A patient with hyperparathyroidism and corneal calcifications is reported. The calcifications appeared following phosphate treatment and persisted for 31/2 years, despite local instillation of EDTA. Local application of EDTA after mechanical removal of the corneal epithelium completely eliminated the corneal deposits.

A 64-yr-old woman with ERCP manometry proven papillary dysfunction is described. This patient responded to nitrate therapy with disappearance of the pain and decrease in both basal and phasic sphincter activity. It is suggested that nitrate administration should be used to distinguish between patients with functional and organic pathology of the sphincter of Oddi. Nitrate therapy should be tried in patients with papillary dysfunction and only if this fails, should endoscopic sphincterotomy be considered.

A 50-year-old female with a giant duodenal polyp is described. An uneventful endoscopic removal of the polyp was performed. An aggressive endoscopic approach to such tumors seems to be justified regardless of their size.

Short-term duodenojejunal manometry, using a multilumen perfused tube, was performed in 12 patients with symptoms of motor dysfunction, 6 patients with irritable bowel syndrome and predominant diarrhea and 6 patients with chronic constipation. Ten healthy individuals served as controls. The durations, in minutes, of the various phases of the migratory motility complex in the three groups were: phase I: 24.4 +/- 22.1, 26.9 +/- 17.3, and 27.2 +/- 18.5; phase II: 86.7 +/- 25.2, 132 +/- 93, and 73.1 +/- 40.8, and those of phase III: 6 +/- 2.5, 6.8 +/- 5, and 6.4 +/- 1.7, respectively. The differences between patients and controls were not statistically significant. Variables of contractions of phase III in the different groups were: frequency (per minute): 10.9 +/- 0.8, 10.7 +/- 0.4, and 11.3 +/- 0.4; Summation of amplitudes per minute: 205.2 +/- 55.7, 288 +/- 57.9, and 337.8 +/- 76.5; Mean amplitude (mm Hg): 19.1 +/- 4.2, 28.6 +/- 5, and 33.5 +/- 7.1, respectively. Results in the patient groups were not significantly different from controls. Short-term duodenojejunal manometry was normal in patients with irritable bowel syndrome and in those with chronic constipation.

In a double-blind, randomized trial, we tested the effectiveness of metronidazole (0.6 g/day) against sulfasalazine (2 g/day) in the maintenance of remission in patients with ulcerative colitis. The patients were in remission for 1-11 months at entry to trial, which lasted for 12 months. Forty patients entered the trial and 33 completed it. Metronidazole was found to be slightly more effective than sulfasalazine, a difference statistically significant only at 12 months. Six patients also completed a crossover trial. Remission was maintained for 12 months in 3 patients by metronidazole and in none of the 6 by sulfasalazine. No significant side effects were noted, and in particular, no paresthesias were reported. This trial, as well as our previous one, suggests that metronidazole may be useful in the maintenance of remission in patients with ulcerative colitis, but that it is ineffective in the therapy of the acute attack.

The clinical significance of unexplained dilation of the common bile duct (CBD) seen at endoscopic retrograde cholangiopancreatography (ERCP) in non-jaundiced patients with abdominal pain, was studied in a group of 14 patients. A CBD diameter of more than 15 mm was associated with choledocholithiasis (29%), periampullary carcinoma (14%), papillary stenosis (14%), or no definite pathology (43%) during a follow-up of 20 months. Dilation of the CBD exceeding 20 mm, was associated with periampullary carcinoma or papillary stenosis in 80% of the patients. It is recommended that such a group of patients be followed very closely, and the ERCP examination repeated within a few months.

A population study of Crohn's disease (CD) during the years 1970-1980 was performed in a defined area in central Israel with 1,400,000 inhabitants. Three hundred and sixty-five patients with definite CD were identified, and a complete follow-up was obtained with particular attention to intestinal cancer. The mean follow-up time was 9.95 years (range, 1-49 years). Forty-four per cent of the patients were operated on, but only a few had total colectomy or bypass operations. Only one patient developed colorectal cancer after 7 years of disease. The observed to expected ratio for this cancer was 1.14 at 10 years of disease and 0.73 at 20 years of disease. The incidence of colorectal cancer was not significantly different from the expected in the population. None of the patients developed small-bowel cancer. At least five patients had extraintestinal malignancies. A review of the literature showed conflicting results with regard to cancer risk in CD. The risk was not significantly increased in the two existing population studies, including the present one.

An acute myocardial infarction was observed in a 62-year-old patient with hemophilia A, as well as myxedema, hypertension, obesity, hypercholesterolemia and angina pectoris. The occurrence of myocardial infarction in hemophiliacs is rare, and, to the best of our knowledge, this patient represents the fourth documented case in the literature.

Tc-HIDA cholescintigraphy in Dubin-Johnson syndrome (DJS) demonstrates intense prolonged homogeneous visualization of the liver, together with delayed visualization of the gall bladder and extrahepatic ducts. Such a cholescintigram has not been described for any other hyperbilirubinemic state. Because it is a noninvasive and easy technique, it is recommended for the evaluation of children suspected of having DJS.

A patient is described in whom CML first presented as blastic crisis. The diagnosis of CML was based upon the findings of Ph(1) chromosome in the bone marrow, basophilia in the peripheral blood, absence of NAP activity in the leukocytes, elevated serum vitamin B(12) and an enlarged firm spleen. CML with blastic crisis as its first expression is relatively rare, as compared to CML in which blastic crisis appears as a phase of prolonged clinically manifest disease.

The antisedative effect of flumazenil, a benzodiazepine antagonist, was studied in a double-blind placebo controlled trial in 61 patients who underwent upper gastrointestinal endoscopy and sedation with benzodiazepines. The efficacy of flumazenil in reversing the effect of both benzodiazepines, diazepam and midazolam, was significantly higher than placebo (p less than 0.0001). The effect of flumazenil was prompt and was clearly noticed at the first assessment, 5 min after its administration. In none of the patients was a relapse of the sedative effect of the benzodiazepines noticed. The administration of flumazenil was free of major side effects. Flumazenil administration permits an earlier discharge of patients following endoscopy. Its availability in the endoscopy suite may improve the outcome of serious but rare side effects related to benzodiazepines.

Two patients with spontaneous bacterial peritonitis caused by Neisseria meningitidis are described. In both cases immediate diagnosis was possible by examination of the ascitic fluid. Meningococcal peritonitis supports the hypothesis that the hematogenous spread of bacteria into the ascitic fluid may be one of the mechanisms of spontaneous bacterial peritonitis.