During a period of 24 months 693 consecutive patients with symptomatic gall bladder stones (526 males, 167 females; mean age 51 years, range 18-89) were treated by extracorporeal shock wave lithotripsy with a Piezolith 2300. The procedure was carried out on an outpatient basis without analgesics or sedatives. Concomitant chemolitholytic treatment (ursodeoxycholic and chenodeoxycholic acid 7-5 mg/kg/day each) was administered until three months after total fragment clearance for a maximum therapy period of 1.5 years. In 601 patients with radiolucent stones complete clearance of all fragments was obtained after three, six, 12, and 18 months in respectively 20, 41, 64, and 78%. Actuarial analysis of the subgroups according to the stone mass (size and number) selected an ideal patient population with solitary stones less than 20 mm diameter (84% stone free after one year). The results are significantly less good when the greater the number of stones or their maximal diameter increases. Treatment was interrupted in 3.6% of the patients. In 90 sludge or fragments remain present. Twenty five patients were lost to follow up for non-biliary reasons. Stone recurrence was 5.7% at one year and was observed both in patients with solitary and multiple stones. A cost effectiveness analysis suggests that laparoscopic cholecystectomy is the most effective and economic solution, although extracorporeal shock wave lithotripsy for solitary radiolucent stones less than 2 cm is cheaper than conventional cholecystectomy. Extracorporeal shock wave lithotripsy for multiple stones is the most expensive and least effective option.

Intramucosal 5-aminosalicylic acid (5-ASA) and acetylated 5-ASA (Ac-5-ASA) concentrations were determined in ileocolonic biopsy specimens from 61 patients with irritable bowel syndrome treated for one week with near equimolar doses of different slow release preparations of 5-ASA (Claversal, Asacol, or Pentasa) or azo-bound drugs (Salazopyrin, Dipentum). The transit time in these patients was accelerated by a laxative, metoclopramide, and colonic lavage. The presence of 5-ASA in the mucosa was confirmed by autofluorescence. The highest concentrations of 5-ASA were obtained after Asacol (mean (SEM), 298.5 (37.3) ng/mg wet wt), followed by Claversal 500 mg (108.8 (11.7) ng/mg wet wt) and Pentasa (25.7 (2.2) ng/mg wet wt). Very low concentrations only were observed after Claversal 250 mg (0.3 (0.03) ng/mg wet wt), Salazopyrine (1.2 (0.1) ng/mg wet wt), and Dipentum (11.0 (3.2) ng/mg wet wt). The results for Ac-5-ASA were similar but the concentrations were generally lower. Serum concentration-time curves over eight hours were obtained from 34 healthy volunteers after a single oral dose of 400 to 500 mg of the different drugs. For the slow release forms, an apparently inverse relationship was found between the area under the curve of the serum concentrations and the intramucosal concentrations, supporting the importance of the local availability of the drug. This inverse relationship was absent for the azo-bound drugs. Colonic washout induced mechanical removal of intraluminal 5-ASA with a secondary disturbance in absorption resulting in a rapid decline in the serum concentrations. However, only for Dipentum did this result in significantly lower 5-ASA mucosal concentrations. This is the first reported attempt to evaluate the mucosal availability of 5-ASA after different oral preparations. It shows that where transit time is accelerated higher mucosal concentrations occur after slow release preparations (except for Claversal 250 mg) than after azo-bound drugs. Additional studies are necessary to correlate these concentrations with clinical effects.

ageal dysmotility.We did find balloon distention to provoke chest pain in one half of our patients tested, irrespective of whether or not they had microvascular angina, esophageal motility dysfunction or positive Bernstein testing.We and others (5) have noted that patients with chest pain and angiographically normal coronary arteries also have a painful sensitivity to catheter manipulation within the heart, a response rarely seen in patients with coronary artery disease or valvular heart disease.These observations of abnormal esophageal and cardiac sensory perception suggest to me that a fundamental problem in patients with chest pain and normal coronary arteries may be abnormal afferent sensory pain receptor activity and nociception, with the perception of visceral sensations that would otherwise go unnoted in most individuals.However, regardless of the etiology, demonstrable or not, it is my experience that the majority of these patients, who I believe share many similarities, will continue to have chest pain.The real solution to everyone's dilemma may be an understanding of pain itself in these patients and its peculiar perception and propagation.

A prospective endoscopic and histologic study of terminal ileum and colorectum in 211 patients with seronegative spondylarthropathy revealed macroscopic inflammatory lesions varying from erythema to superficial erosions in 30% of the patients and microscopic inflammation in 61%. Two types of inflammation were observed: an acute inflammation resembling an infectious enterocolitis and a chronic inflammation. In idiopathic reactive arthritis both types of inflammation were equally present, whereas chronic inflammation predominated in patients with ankylosing spondylitis. In 32% of patients with chronic inflammation, the lesions particularly resembled early Crohn's disease. Repeat ileocolonscopy on 19 patients demonstrated a parallel evolution of joint symptoms and histologic lesions. All patients with acute inflammation went into clinical and histologic remission, whereas lesions persisted in patients with Crohn-like inflammation. In patients with chronic inflammation, remission and persistence were observed equally. This study identified a group of patients with seronegative spondylarthropathy which, even in the absence of gastrointestinal symptoms, showed evidence of gut inflammation, probably inducing an increased gut permeability with transgression of the oral tolerance and absorption of provocative antigens into the circulation. It is also possible that both diseases reflect a common underlying process.

A prospective study was conducted in 224 patients to determine the clinical significance of esophageal colonization with yeasts under different conditions. In accordance with the results of direct smear microscopic examination and culture of esophageal brushings, patients were divided into three groups: positive, negative, and the patients, in whom saprophytic forms were detected. A higher prevalence of positive findings was noted in patients with predisposing factors for yeast invasion than in patients free of underlying disease. Eleven percent of patients with an endoscopically normal appearing esophagus were positive. We have the impression that this situation may represent a preclinical condition of fungal esophagitis. Patients treated with H2-blocking agents showed a significantly higher incidence of positive findings, than did those without such treatment. Whether patients suffering from a refluxesophagitis resistant to long-term treatment with H2 blockers, but with a significant colonization by yeasts, could benefit by an additional treatment with antimycotics remains a controversial issue and should be studied in a controlled way.

Endoscopic sclerotherapy in active variceal bleeding stopped bleeding in 48 out of 67 patients (72%). Survival of the acute bleeding episode was related to liver function: 6% mortality in Child A patients vs. 48% mortality in Child C. Comparing two treatment modalities: 24 h Linton balloon tamponade followed by sclerotherapy vs. sclerotherapy alone, our results in comparable groups slightly, although not significantly, favor tamponade-sclerotherapy treatment: 75% survival vs. 71%. As this treatment modality is more convenient and helps to avoid dangerous aspiration pneumonia, we advocate balloon tamponade prior to sclerotherapy in acute variceal bleeding. In maintenance treatment 65 patients were treated until eradication of varices. The rebleeding risk was 0.034% per patient per month, with 64% of the rebleeding within the 2 first months before complete eradication of the varices. The long-term survival depends largely on liver function: one year survival of 88% in Child A vs. 30% in Child C. Using Aethoxysklerol 1% in intravariceal injection, no stricture occurred. Using a sterile injection needle and a glutaraldehyde-disinfected endoscope, no infectious complications directly related to the procedure occurred, and all hemocultures remained negative.

Rectosigmoidal varices are a extremely uncommon manifestations of portal hypertension but can cause massive hematochezia. Rectal varices occur as submucosal anastomoses between the superior rectal veins of the inferior mesenteric system and the middle and inferior rectal veins of the iliac system. In portal hypertension there is an increased flow and pressure through these anastomotic channels. Rectal varices are so rare beause in most people the rich coronary azygos system is better developed and thus shunts more blood. Because of congenital or anatomic variations, the rectal anastomosis are better developed in some people and will shunt more blood, causing rectal varices.

We report the clinical features of 7 men (mean age 22 years, range 7–53 years) with congenital hepatic fibrosis (CHF). Five patients presented with variceal bleeding and/or hepatosplenomegaly due to portal hypertension. Cholangitis was the presenting symptom in the other 2 cases. Diagnosis was established by histological examination of a surgical wedge biopsy (4 patients) or needle biopsy (3 patients). A portal-systemic shunting was performed in 6 patients, three times prophylactically. None of the 5 survivors developed chronic hepatic encephalopathy. Recurrent bouts of cholangitis with septicemia and hepatic abscesses were a major complication in 5 patients with a fatal outcome in 2 cases. Six patients had associated small and large cysts in the cortex of both kidneys, compatible with adult-type polycystic disease. One patient developed terminal renal insufficiency. In 3 patients kidney function remained normal at a mean follow-up time of 7.5 years (range 1–18 years). In 2 families (4 cases) an autosomal dominant inheritance of renal disease was suggested. This study demonstrates that CHF is a rare cause of portal hypertension in late childhood and in adults. Cholangitis is a severe and frequently fatal complication. Association with a variety of congenital renal abnormalities is very frequent. However, the association with adult-type polycystic disease as reported in 4 cases is very rare.

SummaryPlatelet counts, coagulation and fibrinolysis tests were done before, 10 min. 1, 3 and 24 hr after the performance of 24 sessions of injection Serotherapy with Polidocanol 1 % of oesophageal varices in 16 patients with liver cirrhosis. Thrombocytopenia was often present no significant changes occurred after sclerotherapy. The APTT and PT values did not change. The levels of F II. F V. F VII-X, F VIII F IX. and F X remained in the same range. Also the fibrinogen and plasminogen values did not change after the selerotherapy session. A rise in the scrum fibrin/fibrinogen degradation Products was not found, levels of antithrombin protein C, x antiplasmin and t-PA antigen femaincd stable. The absence of any change in the clotting parameters measured is in accordance with the clinical safety of the injection sclerotherapy of aesophageal varices in patients with liver cirrhosis.

The acoustic attenuation coefficient slope (beta) of liver was estimated in vivo from the spectral difference of returned echoes. beta of normal young subjects was lower than that of older subjects (mean: 0.340 vs 0.418 dB/cm.MHz). Limited fluid withdrawal from the body by haemodialysis did not affect beta. In alcoholic liver disease beta was related to the amount of fat and of fibrous tissue in liver biopsy specimens. High values of beta were observed as soon as the degree of steatosis exceeded 5 vol%. There was a similar increase of beta in the presence of fibrous interlobular septa. In normal liver beta was related to the amount of triglycerides in the liver specimen.

Chez 10 patients, nous avons procédé à la mise en place ďune endoprothèse biliaire type Huibregtse diamètre 10 F comme traitement définitif de cholédocholithiases impactées.

The aim of this clinical trial was to compare the frequency of duodenal ulcer healing under omeprazole therapy, giving 30 mg/day or 60 mg/day.