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OBJECTIVES: The effectiveness of the association of lactulose with neomycin in the treatment of acute hepatic encephalopathy has never been assessed. The aim of this study was to compare the effects of lactulose-neomycin combination versus placebo in acute hepatic encephalopathy. METHODS: Eighty patients with cirrhosis were randomly treated for 5 days with placebo (n = 40) or with lactulose-neomycin (n = 40). Both groups were similar for all variables. RESULTS: The course of encephalopathy was similar in both groups. In the lactulose-neomycin group: 26 PATIENTS recovered, 3 remained unchanged, 3 worsened, 6 died, 2 were lost to follow-up. In the placebo group: 28 recovered, 2 remained unchanged, 2 worsened, 6 died, one was lost the follow-up, one dropped out of the study. Lactulose-neomycin treatment was not well tolerated in a significant number of patients. CONCLUSION: Lactulose-neomycin combination should not be used in the treatment of acute hepatic encephalopathy.

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A population of non ulcer dyspepsia outpatients with a normal gastroscopy was assessed. Clinical complaints, the type of the gastritis, its activity and bacterial density were evaluated. Helicobacter pylori (HP) was sought by histology, urease test and culture, on 3 distinct locations. HP was found in 62 p. cent of the patients, always in association with gastritis. Urease test and histology had the same sensitivity in the detection of HP. A randomized double blind study with amoxicillin vs placebo was carried out in 23 patients. At the end of 4 week treatment, a gastroscopy with biopsies was performed. The amoxicillin treated patients were significantly cured or improved. HP was undetectable or the bacterial density was decreased in this group. After amoxicillin, urease test was more sensitive than histology. HP might be involved in the pathophysiology of non ulcer dyspepsia in patients where HP was found.

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Among the various treatments of ruptured oesophageal varices two seem to be effective: oral propranolol therapy and ligation of the oesophagus on clip. In this controlled study these two methods were compared in a series of 55 patients hospitalized for ruptured oesophageal varices. After haemodynamic stability was obtained, the patients were allocated at random to either propranolol therapy (n = 28) or surgery (n = 27). Twenty-one per cent of these patients belonged to group C of Child's classification and 54 per cent to group A. The parameters studied were similar in both groups. Five patients were excluded from the study: 2 in the medical group when it appeared that propranolol was contra-indicated and 3 in the surgical group who died before the operation; however, these 5 patients were taken into account in a second statistical evaluation. Nineteen out the 26 patients under propranolol (73 per cent) had rebleeding (within the first 10 days in 3 cases). In the surgical group recurrent bleeding was observed in 4 out of the 24 patients (17 per cent), and 4 other patients died post-operatively. The difference in favour of the surgical group was highly significant (P less than 0.001), and it remained significant (P less than 0.05) when the 5 patients who could not be treated were included into the calculations. Cox's multivariate analysis showed that patients in Child's C group had a poorer prognosis.

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The aim of this study was to define an other cause of idiopathic constipation with a mathematic automatic classification Fifty patients were studied by colonic transit time, anorectal manometry and defecography. Three classical causes were found: 12 patients had hypertonic upper anal pressure; 8 patients had abnormal rectonanal inhibitory reflex and 12 patients had anatomic conditions reducing stool frequencies Automatic mathematic classification coming from optimised bowls technic has led to the characterization of a new cause. Eight young women (mean age 33 years) with hypertonic striated pelvic muscles on straining were identified. Three items were significantly different: defect of sphincteric relaxation without high sphincteric pressure; closure or non opening anorectal angle, hypertonic levator ani on straining. There was a significant high frequency (p less than 0.05) of urinary disorders in this new group. All abnormalities occurred during defecation. This group can be studied with other methods: balloon expulsion, anal electromyography. Clinical identity with urinary pathology may be explained by common neurologic disorders of pelvic striated muscle innervation.

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The aim of this work was to study retrospectively the survival of 164 patients with cancer of the pancreas diagnosed in a gastroenterological unit from 1975 to 1984, according to the therapeutic procedure: 50 patients have not been operated, 12 have undergone an exploratory laparotomy, 72 patients a biliary bypass, 13 patients had undergone a pancreato-duodenectomy, 15 patients a total pancreatectomy, and 2 a caudal pancreatectomy; 9 patients inoperable had benefit from endoscopic biliary drainage. The survival was not statistically different in the 4 groups of patients. Today with a 2 year's follow-up, all patients have died. In the homogeneous group of 80 patients having a tumor of the head of the pancreas, the survival of the unoperated patients (72 +/- 19 days) is statistically lower than that of the patients having a biliary by-pass (187 +/- 28 days) (p less than 0.02). According to the Cox model, the variables age, sex, tumor localization and diagnosis delay did not influence the survival time. In conclusion, the results of this study confirm the severity of the cancer of the pancreas, whatever the therapeutic procedure used. Because of lack of controlled studies, it is impossible to codify the therapeutic procedure of cancer of pancreas.

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Gastro-esophageal reflux (GER) is often associated with other functional digestive manifestations. The subjectivity of these manifestations permits an in-depth study of the personality of these patients as compared to a regional reference population with the use of the Minnesota multiphasic personality inventory. In these patients suspected to have a gastro-esophageal reflux, the means to the scales are modified except for that of the psychopathy scale, which is reassuring considering its severity. However, no personality profile may be exteriorized. The difference between patients with GER certified or not by pH measurement rests on the predominance of neurotic scales in the group presenting a gastro-esophageal reflux certified by pH measurement. This results appears to be due to the disease itself rather than to the conditions of performance of the MMPI during pH measurement. Only a pre- and post-therapeutic study will enable to confirm these data.

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Anorectal manometry was used in the training by biofeedback of children with idiopathic constipation. Fourteen children 7 to 12 years old with outlet obstruction due to sphincteric disorders were submitted to a biofeedback session. There was a good improvement in 10 of the 12 children who accepted this treatment. This result is in agreement with the data published in literature. This complementary treatment appears useful when it is well accepted by the parents and the child and when the manometric signal is well understood by the child who must be also able to apply the technique at home.

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Fifty-five adults with asthma were explored by gastroesophageal scintigraphy (GES) and pH monitoring (3 postprandial hours, 12 nocturnal hours). For their asthma, all patients received theophylline twice a day. Associated digestive symptomatology led to investigations for gastroesophageal reflux (GER). Twelve hours pH monitoring, the reference method, was validated in 13 normal volunteers. During 12 hr pH monitoring, 4 criteria were studied: number of GER, percentage of time at pH 4, number of GER longer than 5 min and longest GER. Acid reflux occurred in 69 p. 100 of cases. Three hours postprandial pH monitoring and GES showed a GER in 40 and 47.5 p. 100 of cases (p greater than 0.05). GES revealed pulmonary aspiration in almost a quarter of asthmatic adults. Detection of a 30 p. cent increment of nocturnal GER by long pH monitoring could explain that results may differ with various techniques. Pulmonary aspiration was more frequent after longer and deeper GER. The mean duration of GER was more than 9 min but it was not significantly different from GER without pulmonary aspiration. GES may be helpful after 12 h pH monitoring because it can prove pulmonary aspiration. Its association with long and intense GER at 12 h pH monitoring suggests definitive surgical treatment of GER in asthmatic patients.

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The hepatorenal syndrome is considered to be a functional renal failure due to active renal vasoconstriction. The purpose of this work was to study the urinary elimination of prostaglandins and the plasmatic polyunsaturated fatty acid precursors of prostaglandins. The urinary elimination of PGE2 was not significantly different in the groups of patients studied: controls, group I (193 +/- 42 ng/24 h), cirrhotic patients without ascites, group II (274 +/- 43 ng/24 h), cirrhotic patients with ascites, group III (269 +/- 41 ng/24 h). The urinary elimination of PGE1 and PGF2 alpha varied in the same way as PGE2. In cirrhotics with hepatorenal syndrome (group IV) the urinary elimination of vasodilating prostaglandins was greatly decreased (p less than 0.001); PGE2 (53 +/- 16 ng/24 h), PGE1 (65 +/- 11 ng/24 h). The urinary elimination of PGF2 alpha was also decreased (293 +/- 75 ng/24 h). On the other hand, the urinary elimination of thromboxane, a vasoconstrictor, increased progressively from group I (287 +/- 75 ng/24 h) to group IV (980 +/- 266 ng/24 h) (p less than 0.05). Plasmatic arachidonic acid was significantly decreased in group IV (5.0 +/- 0.6 p. 100) compared to group I (10.0 +/- 0.6 p. 100) (p less than 0.001), to group II (10.3 +/- 0.5 p. 100) (p less than 0.001), and to group III (8.5 +/- 0.7 p. 100) (p less than 0.05). In conclusion, in hepatorenal patients, urinary excretion of a vasoconstricting prostaglandin (thromboxane) is increased while urinary excretion of vasodilating prostaglandins is decreased. This decrease could be secondary to a lack of plasmatic arachidonic acid, precursor of prostaglandins.

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As theophylline is known to stimulate lipolysis and lipid mobilisation, plasma concentrations of malonyl dialdehyde were studied in asthmatic patients being treated with sustained release theophylline. Malonyl dialdehyde was assessed as malonyl dialdehyde like material (MDA-LM) by the thiobarbituric acid assay. In a kinetic study (eight patients) plasma MDA-LM concentrations were found to be significantly higher after 30 than after eight days' treatment or before treatment, but not significantly different after 90 than after 30 days. In a comparative study (29 patients and 29 healthy volunteers) the mean plasma MDA-LM concentration was shown to be very significantly higher in the asthmatic group. The results are probably explained by an effect of theophylline on lipid peroxidation, and the effect of long term treatment on plasma MDA-LM merits further investigation.

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