1018

responses (my italics) in disease represent specific absorptiondefects ". On such points both he and I clearly agree.My quote from Gasser (" you cannot determine a

process from a potential "), when read in its context, wasmeant to underscore the difficulty in determining a mech-anism from a single measurement of an intestinal P.D.-e.g., the usual polarity of lumen negative to blood could begenerated by anions moving from blood to lumen or

cations from lumen to blood or both.. The changes inhuman jejunal P.D. induced by glucose, however, are knownto be accompanied by enhanced absorption of sodium ionsin vivo 6-$and in vitro.9 9

Finally, Dr Wingate’s criticism that we " deduced " a" pathological diminution of glucose absorption fromvoltage data without supporting evidence " in the patientwith amyloidosis is invalid. We said that in this patient" both the apparent Km and P.D. max were significantlylower than normals reflecting an apparent increase in theaffinity of the active transport mechanism for glucose aswell as an apparent reduction in the P.D. max generated "-no more. It is unfortunate if we gave an impression thatthere was a direct, stoichiometric relation between P.D. maxand the chemical absorption of glucose. The task now isto forgo non-productive disputes and obtain, by electricaland chemical techniques, kinetic measurements of elec-trogenic active hexose transfer in various malabsorptivediseases. Only this can enable an objective assessment ofthe merits or demerits of electrical versus chemical data.

Department of Physiology,University of Sheffield,

Sheffield S10 2TN. R. J. LEVIN.

TRANSIENT BACTERÆMIA COMPLICATINGPERORAL JEJUNAL BIOPSY

SIR,-We wish to report an unusual complication ofperoral biopsy of the small intestine, which has not beenhitherto widely recognised.A 77-year-old man presented with watery malodorus stools

and weight loss. He had a history of subtotal gastrectomy withBillroth-n anastomosis and vagotomy for peptic ulcer. Investiga-tion revealed anasmia, erythrocyte-sedimentation rate 146 mm.in 1 hour, white cells 3000 per c.mm., serum-folate 10 ng.per ml., serum-carotene 36 .g. per 100 ml., and vitamin Bi,140 pg. per ml. Renal function studies were normal. Serum-

protein electrophoresis showed total protein 9-8 g. per 100 ml.(albumin 3-2, p-globulin 5-2, y-globulin 0-5, oci-globulin 0-3,and IX2-globulin 0-6). Serum-immunoglobulin assay showed anIgG of 590 mg. per 100 ml., IgA 3 g. per 100 ml., and IgM420 mg. per 100 ml. Agar immunoelectrophoresis demonstratedan IgA paraprotein with a 0 migration pattern, consisting ofKappa light chains. A bone-marrow biopsy showed morpho-logical changes consistent with a lymphocytic-plasmacyticmalignancy. A 25 g. d-xylose test showed an excretion of 2-4 g.in 5 hours (normal >5 5 g. in 5 hours). A 72-hour faecal fatdetermination on 100 g. of fat daily showed an excretion of60 g. in 72 hours or 20 g. per 24 hours (normal < 18 g. in 72

hours). A Schilling test with 6’Co vitamin B12 with intrinsicfactor (LF.) gave a 4% excretion in 24 hours (normal > 10%).Urinary indican excretion was 156 mg. in 24 hours (normal< 100 mg. in 24 hours).10 A barium swallow and small bowelfollow-through demonstrated a Billroth-n gastrojejunostomywith prominent gastric folds, but normal radiographic patternof jejunal and ileal mucosa.

-

Because steatorrhcea and malabsorption had developed in thepresence of malignancy, a small-bowel biopsy was performed todetermine whether an intestinal mucosal infiltrative processcould account for these manifestations. Following the positioning

6. Fordtran, J. S., Rector, F. C., Carter, N. W. J. clin. Invest. 1968,47, 884.

7. Sladen, G. E., Dawson, A. M. Nature, 1968, 218, 267; Clin. Sci.1969, 36, 119.

8. Modigliani, R., Bernier, J. J. Biol. Gastro-Enterol. 1972, 5, 165.9. Binder, H. J. Gastroenterology, 1974, 67, 231.

10. Neale, G., Tabaqchali, S. Gut, 1966, 7, 711.

of a multipurpose suction biopsy tube (Quinton) in the jejunum,four pieces of jejunal mucosa were obtained with a four-portcapsule. Patient tolerated the procedure well and did not com-plain of symptoms at the time of biopsy. Six hours later hedeveloper fever (396&deg;C), rigors, abdominal discomfort, andvomiting. There was no hsmatemesis, and stool examinationswere negative for occult blood. Six blood-cultures were obtainedduring the febrile period, but only one yielded a growth of

(x-streptococcus. He was treated with intravenous fluids, genta-micin, and clindamycin. Fever, abdominal discomfort, and

rigors subsided within 48 hours and did not recur during therest of his stay in hospital. Histological examination of jejunalbiopsy did not demonstrate any evidence of malignancy. Afterthe start of treatment with cyclophosphamide, prednisone, andvincristine, he was discharged. He also had a 2-week course oftetracycline, which resulted in striking improvement of diarrh=and steatorrhcea.

It is very likely that our patient had developed blind-loop syndrome with bacterial overgrowth related to pre-vious gastric surgery and gastrojejunostomy. Althoughduodenal aspirate and culture were not obtained, low

vitamin-B12 assay, abnormal Schilling test, and the sub-sequent response to tetracycline strongly suggest intestinalbacterial overgrowth which resulted in malabsorption andpostgastrectomy steatorrhoea. This is further substan-tiated by the rise in urinary indican excretion whichcharacterises malabsorptive disorders, such as coshacdisease, scleroderma, jejunal diverticulosis, and post-gastrectomy steatorrheea.1-1 Blind-loop syndrome is knownto be associated with steatorrhaea,3 vitamin-Bl2 mal-

absorption as evidenced by abnormal Schilling test 12 andlow d-xylose urinary excretion. 13

It is conceivable, therefore, that after jejunal biopsyluminal bacteria entered the blood. It is not clear whether(X-streptococcus can be incriminated as the causative

organism of bacteraemia or simply represents a contaminant.Bacterial flora in blind-loop syndrome usually consistsof bacteroides, anaerobic lactobacilli, coliforms, andenterococci. Bacteraemia after endoscopic procedures hasbeen long recognised as a complication, especially after

urological instrumentation.14 More recently, proctoscopicbiopsy of rectal polyps,15 sigmoidoscopy, 16 and liver biopsy 17have been associated with bactersemia. Small intestinal

biopsy, particularly in patients with evidence of bacterialovergrowth, is yet another procedure which carries a

definite risk of bacteraemia.

Department of Medicine,University of KansasSchool of Medicine,

Kansas City, Kansas 66103,U.S.A.

CONSTANTINE ARVANITAKISMAX S. ALLEN.

SI UNITS

SIR,-For several years we have used report forms onwhich the approximate normal range and local laboratoryerror of an estimation are printed below each reportedresult. This has proved particularly helpful on changingto SI units. Seeing the printed normal range helps theclinician to interpret the results, and knowledge of thelaboratory error removes any decimal-place problem. Allresults can be reported to three significant figures, themaximum number which technical errors in the clinical

laboratory ever permit.

11. Greenberger, N. J., Saegh, S., Ruppert, R. D. Gastroenterology.1966, 55, 204.

12. Donaldson, R. M., Jr. in Gastrointestinal Disease (edited by M. HSleisenger and J. S. Fordtran); p. 927. Philadelphia, 1973.

13. Goldstein, F., Karacadag, S., Wirts, C. W., Kowlessar, O. D

Gastroenterology, 1970, 59, 380.14. Slade, N. Proc. R. Soc. Med. 1958, 51, 331.15. Lal, D., Levitan, R. Archs intern. Med. 1972, 130, 127.16. Le Frock, T. L., Ellis, C. A., Turchik, T. B., Weinstein, L

New Engl. J. Med. 1973, 289, 467.17. McCloskey, R. V., Gold, M., Weser, E. Archs intern. Med. 1973.

132, 213.