No abstract

This report describes two patients with esophageal columnar epithelium (Barrett's esophagus) in which microinvasive adenocarcinoma developed. Case 1 had multiple foci of carcinoma rn u!u contiguous with epithelium resembling gastric and intestinal mucosa. Case 2 had signet-ring type adenocarcinoma. Surveillance for malignant transformation in columnar esophageal epithelium should be routinely performed, and because of its focal nature, multiple biopsies and cytologic examination should be carried out. T h e presence of carcinoma 01 i r / t r should lead to consideration of excision of the affected esophagus.Cancer 41 CASE REPORTS Case 1A 47-year-old white male executive had a 20-year history of intermittent epigastric pain exacerbated by spicy foods ilnd recumbency and relieved by antacids. In Ilecembw 1973, his epigastric pain increased in intensity and duration, radiated to the back and awakened him from s1ec.p. L!pper gastrointestinal radiography revealed a sliding hiatal hernia with esophaqeal reflux and tertiary contractions. Antacid treatment was intensified and the head of his bed elevated, but minimal relief was obtained. In April 1975. fiberoptic endoscopy revealed a deep stellate 1.2 cm ulcer associated with edema and stiffening in the distal esophagus. Multiple biopsies revealed benign squamous epithelium. Since "Barrett's esophagus" was suspected, endosco:)y was repeated and biopsies were obtained at the ulcer site and proximally to the level of the aortic arch. Biopsies from the ulcer were processed for routine light-microscopic examination; the proximal biopsies were immediately placed in gluteraldehyde, pH 7.4, and processed for ultrastructural study as previously de~cribed.~Carcinoma ~n si!u was demonstrated at the ulcer site. Following refcrral to the Department of Surgery at the Llniversity of Chicago, esophageal manometry and pH measurements showcd a low distal esophageal sphincter pressure and free reflux in erect and supine positions. An esophageal acid-saline perfusion test was positive. A radical posterior medi;istinectomy was performed with resection of the distal 11.5 cm of the esophagus and the proximal half of the stomach. An isoperistaltic left colon segment was interposed between the normal esophagus and stomach, and a pyloroplasty was performed to facilitate gastric emptying.The proximal resected margin of the esophagus was lined by hyperplastic epithelium and contained foci of reflux esophagitis as described by Ismail-Beigi

Experimental diet-induced dog gallstones contained mainly protein, mucous substances, bile salts, bilirubin, an insoluble pigment which formed an insoluble black residue after acid hydrolysis, and only traces of cholesterol. Added dietary cholesterol was necessary to pigmented gallstone production and led to hypercholesterolemia. In bile, the ratio of cholesterol to bile salts was increased, but phospholipids were increased and cholesterol insolubility was not found. Dry weight, osmolality, and concentration of sodium and potassium in bile were reduced, but were not considered sufficient to influence micelle formation or lipid-pigment solubility. Taurine was reduced in serum and bile and unconjugated bile acids appeared in gallbladder bile; the pKa of these acids is near the pH of bile in these animals and may have caused precipitation of bile acids, accounting for their presence in the stones. Bile cultures were sterile. Total bilirubin content was unaltered but the methods used did not exclude the presence of unconjugated bilirubin as a potential cause of pigment precipitation in aqueous bile. Increased numbers of secretory vesicles occurred in gallbladder epithelium and large amounts of mucus were in the epithelial crypts. These observations suggest that bile proteins or mucous substances are important to lithogenesis in this model.

Pemoline, a central nervous system stimulant, has been used extensively in Great Britain and Europe for a variety of conditions including memory failure and depression. In the 10 years that the drug has been used no report of hepatotoxicity has appeared. A prospective study of efficacy and safety of pemoline was started in the United States approximately 3 years ago. This report describes two patients who developed reversible liver abnormalities while receiving pemoline during the study and following rechallenge with the drug.