SUMMARY BackgroundUntil recently only two therapeutic options have been available to control symptoms and the esophagitis in chronic gastro-oesophageal reflux disease (GERD), i.e. lifelong proton pump inhibitor (PPI) therapy or anti-reflux surgery. Lately, transoral incisionless fundoplication (TIF) has been developed and found to offer a therapeutic alternative for these patients.
The accuracy of two routine methods for the determination of urinary steroids – 17-ketosteroids (17-KS) and Porter-Silber chromogens – has been investigated by chromatographic separation and quantitative determination of individual 17-KS and Porter-Silber reacting steroids in 141 urine samples. For this purpose urine was submitted to enzyme hydrolysis and subsequent solvolysis. The pertinent steroids were separated by column chromatography into three groups, 11-deoxy-17-KS, 11-oxy-17-KS and Porter-Silber reacting steroids. The final separation was accomplished by paper chromatography.
As a mean, the urinary excretion of true 17-KS corresponded to about 40–50 per cent of the routine figures. Due to non specific chromogens, individual routine figures were completely unreliable and probably had no more significance than showing a difference between a high and a low urinary content of 17-KS A true figure, however, was never higher than that indicated by the routine method.
The routine method for determination of Porter-Silber chromogens also overestimated the urinary content of steroids, the true excretion of Porter-Silber steroids being, on an average, about 25 % lower. Again, the significance of individual determinations was low.
The determination of 17-KS and Porter-Silber steroids by column chromatography was found to be rather simple and reliable as only minor amounts of unspecific chromogens were included in the results. Moreover with this method, the 17-KS were separated into 11-deoxy-17-KS and 11-oxy-17-KS.
This is a case report of a woman, suffering from Cushing's disease, who conceived before treatment and who underwent successful adrenalectomy during pregnancy. The gestation continued normally until near term when symptoms of pre-eclampsia appeared on unchanged cortisone substitution. The urinary excretion of pregnantriol during the last trimester of pregnancy is described.
A four day ACTH-suppression test was performed in 58 patients showing symptoms often associated with hypercorticism and in 25 cases of Cushing's syndrome. The non Cushing patients suffered from obesity, hypertension, plethora, diabetes and mental disturbances in various combinations and/or conditions related to hypertrichosis and menstrual disorders. Some of them also showed an increased basal excretion of 17-ketosteroids.
Triamcinolone, in doses of 4 mg and 8 mg every six hours or 2 mg of dexamethasone every six hours, induced a good suppression of adrenocortical function in the non Cushing patients. This was demonstrated by chromatographic analysis of 24 different 24-hour urine samples collected on the third or fourth day of the test. In these cases – selected at random from the 58 non Cushing patients – the mean excretion of tetrahydroderivatives of cortisone and cortisol was < 0.3 mg/day (range 0.0–1.2 mg/day). Only traces of dehydroepiandrosterone and 11-oxy-17-ketosteroids were found.
In all cases, 17-ketogenic steroids, Porter-Silber chromogens and 17-ketosteroids were determined by routine methods and the results are discussed with regard to the presence of non specific chromogens. There was no difference in the urinary excretion of steroids during the administration of 16 mg and 32 mg respectively of triamcinolone and of 8 mg of dexamethasone daily.
In 9 of 11 cases of non-tumourous Cushing's syndrome, triamcinolone in a dose of 4 mg every six hours did not suppress the urinary excretion of 17-ketogenic steroids, Porter-Silber chromogens or 17-ketosteroids normally. In two cases, however, there was a normal suppression according to the criteria chosen. In one case of non-tumourous Cushing's syndrome, suppression could not be demonstrated during the administration of triamcinolone in a dose of 16 mg every six hours for four days.
Because of the varying degrees of suppression found in Cushing's syndrome, the diagnostic conclusions drawn from the ACTH-suppression test should be made with caution. Marked variation in the basal excretion of steroids adds to the difficulties as do the limitations of the test imposed by unspecificity of the methods used in evaluating the adrenocortical function.
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