Showing papers in "Journal of Clinical Gastroenterology in 1984"
•
TL;DR: It is suggested that patients with IBD who receive therapy during pregnancy are at greater risk of fetal complications than the average population, but that disease activity is more likely to be responsible for this risk than drug treatment.
Abstract: The influence of inflammatory bowel disease (IBD) and its therapy upon pregnancy is a frequent consideration before and after conception. We looked at the influence of disease activity and drug therapy during pregnancy on fetal outcome in 147 pregnancies in 124 women. Patients were divided into two groups; 46 (28 ulcerative colitis, 18 Crohn's disease) who received drug treatment during pregnancy, and 101 (42 ulcerative colitis, 59 Crohn's disease) who received no treatment. The frequency of fetal complications was higher than in the general population in the "treated" patients, but was not higher than in patients with IBD who received no drug treatment. Active IBD was present in 43% of the treated patients whose pregnancies resulted in fetal complications. Of patients with Crohn's disease whose pregnancies resulted in fetal complications, active IBD was present in 62.5%. Thus, our experience suggests that patients with IBD who receive therapy during pregnancy are at greater risk of fetal complications than the average population, but that disease activity is more likely to be responsible for this risk than drug treatment. This risk is much more evident in active Crohn's disease than in ulcerative colitis.
168Â citations
•
TL;DR: Direct access to the gallbladder may lead to: 1) bettergallbladder visualization at time of ERCP, 2) retrieval of pure gallbladders bile for culture and sensitivity on chemical analysis, and 3) gallstone dissolution or extraction.
Abstract: Although the cystic duct can sometimes be cannulated at ERCP, no one has attempted a prospective study of how often this can be done, nor have the potential indications been evaluated. Accordingly, 50 consecutive patients with a variety of pancreaticobiliary conditions were studied prospectively. In 86% of the patients, free cannulation of the common bile duct was accomplished; in 74%, the cannula could be inserted selectively into the cystic duct. Such direct access to the gallbladder may lead to: 1) better gallbladder visualization at time of ERCP, 2) retrieval of pure gallbladder bile for culture and sensitivity on chemical analysis, and 3) gallstone dissolution or extraction.
72Â citations
•
65Â citations
•
TL;DR: Ranitidine 150 mg b.i.d. is recommended for the relief of symptoms and improvement in the endoscopic appearance of the esophagus and may be continued for up to a year if the patient's symptoms persist or return.
Abstract: We undertook a multicenter double-blind study comparing ranitidine to placebo in 73 patients with symptomatic gastroesophageal reflux ranging in age from 22 to 80 years (mean 49). Initially, all patients had moderate to severe symptoms associated with abnormal endoscopic and/or microscopic appearance of the mucosa. After six weeks, 46% of ranitidine-treated patients had a one-grade improvement in their symptom of regurgitation, as compared with 19% treated with placebo (p less than 0.01); ranitidine was no better than placebo in the improvement of pain or dysphagia. Endoscopic improvement occurred in 61% of ranitidine- and 48% of placebo-treated patients (p less than 0.05). Histological improvement occurred in a similar and small portion of patients treated with ranitidine and placebo; there was no correlation between clinical, endoscopic, and histological improvement. Antacid consumption was only half as great in the ranitidine as in the placebo group. Therapy with ranitidine was maintained for up to 12 months. The patients remained free of regurgitation or pain and there was a trend towards further improvement in the endoscopic or histopathologic appearance of the esophagus. Ranitidine 150 mg b.i.d. is recommended for the relief of symptoms and improvement in the endoscopic appearance of the esophagus. Treatment should be for a minimum of 6 weeks, but may be continued for up to a year if the patient's symptoms persist or return.
55Â citations
••
TL;DR: Improvement in Crohn's disease after drug therapy was evaluated in 38 patients with evidence of rectal disease at sigmoidoscopy in whom the rectum later appeared normal and histological evidence of activity persisted in one-third of the patients.
Abstract: Improvement in Crohn's disease after drug therapy was evaluated in 38 patients with evidence of rectal disease at sigmoidoscopy in whom the rectum later appeared normal. Rectal biopsies taken before and after therapy were examined histopathologically. Cell counts of the lamina propria connec
50Â citations
•
TL;DR: The mechanism of chylous ascites in cirrhosis is probably portal hypertension causing lymphatic rupture; however, the fact that serum-to-ascites albumin gradients were similar in the two groups, indicating similar degrees of portal hypertension, suggests that other factors also play a role.
Abstract: The spontaneous development of chylous ascites in patients with cirrhosis is documented, but its clinical features are not well defined. The incidence of this complication of chronic liver disease was 0.5% in ascitic patients in our liver unit. These patients were older than a control group with nonchylous cirrhotic ascites and, despite better liver tests, appeared to have a higher diuretic requirement. Several had disabling, recurrent spontaneous encephalopathy. The mechanism of chylous ascites in cirrhosis is probably portal hypertension causing lymphatic rupture; however, the fact that serum-to-ascites albumin gradients were similar in the two groups, indicating similar degrees of portal hypertension, suggests that other factors also play a role. Spontaneous transformation of previously clear ascites appeared to be associated with a poor prognosis. In contrast, the appearance of chylous ascites de novo in a cirrhotic patient appeared to have a more favorable outcome. Conservative management is recommended for most patients, as the degree of their liver disease appears to be the most important factor determining prognosis.
49Â citations
•
TL;DR: A patient with cheilitis is presented which preceded the recognition of colonic and perianal Crohn's disease by 7 years, and was unaffected by oral prednisone, sulfasalazine, azathioprine, and metronidazole.
Abstract: Oral lesions occur in an impressive number of patients with Crohn's disease. The lesions often precede the intestinal symptoms, and follow a variable course from asymptomatic to severe. They are important because of their association with Crohn's disease and the possibility that they could lead to an earlier diagnosis of Crohn's disease. We present a patient with cheilitis which preceded the recognition of colonic and perianal Crohn's disease by 7 years. The cheilitis responded to injection of steroids into the lips, but was unaffected by oral prednisone, sulfasalazine, azathioprine, and metronidazole.
49Â citations
••
TL;DR: Noncolonic AD in the elderly may be acquired during life, as in the classic situation in the right colon, but may be difficult to distinguish clinically and pathologically from the vascular lesions of hereditary hemorrhagic telangiectasia.
Abstract: The predominant site of bleeding intestinal angiodysplasia in elderly patients will be the cecum or ascending colon, but recent experience in the Yale-Affiliated Gastroenterology Program in 1 year indicates that elderly patients may have bleeding acquired angiodysplasia (AD) confined to the small intestine only. A review of the literature confirms that symptomatic small intestinal AD is infrequent and occurs at an average age of 32 years in some series. Five patients with symptomatic small intestinal AD diagnosed during 1981 at Yale were older, with an average of 62 years. Three of the five cases (all female) had lesions in the duodenum, with two (males) having lesions in the ileum. Noncolonic AD in the elderly may be acquired during life, as in the classic situation in the right colon, but may be difficult to distinguish clinically and pathologically from the vascular lesions of hereditary hemorrhagic telangiectasia.
45Â citations
•
TL;DR: The impact of chronic lactulose therapy on mental function in cirrhotics without overt encephalopathy appears to be limited, and improvements in psychomotor performance tests are limited.
Abstract: Thirty-two alcoholic cirrhotics without clinical evidence of encephalopathy were randomized to lactulose or sucrose treatment in order to evaluate the effects of chronic lactulose therapy on five psychomotor performance tests. Statistically significant improvement was seen in three of the five tests in the lactulose-treated group, while no significant improvement in any test was noted in the sucrose group. However, because of the limited extent of improvement in the lactulose treated group, problems with medication intolerance, and lack of improvement in complex psychosocial behavior, the impact of chronic lactulose therapy on mental function in cirrhotics without overt encephalopathy appears to be limited.
43Â citations
••
TL;DR: The authors' observations suggest that whenever intrahepatic stones are encountered in patients over 50 years of age with a long history of recurrent cholangitis and intractable pain, further examination incuding echo-guided aspiration cytology, liver scanning, and peritoneoscopy should be performed to rule out a coexisting Cholangiocarcinoma.
Abstract: During the period 1979-1982, 10 cases of cholangiocarcinoma associated with hepatolithiasis were seen. We report the clinical features of 10 cases of cholangiocarcinoma in association with hepatolithiasis, along with detailed histopathology from the four resected specimens. Our observations suggest that whenever intrahepatic stones are encountered in patients over 50 years of age with a long history of recurrent cholangitis and intractable pain, further examination incuding echo-guided aspiration cytology, liver scanning, and peritoneoscopy should be performed to rule out a coexisting cholangiocarcinoma.
42Â citations
•
TL;DR: It is concluded that histologic gastritis is associated with GER disease; and slowing of gastric emptying can be significantly correlated with increased severity of histologic gastroesophageal reflux in GER patients.
Abstract: The aims of this study were to: 1) investigate the incidence of histologic gastritis in patients with gastroesophageal reflux (GER); 2) ascertain if gastritis in GER patients could be correlated with impaired gastric emptying; and 3) determine if the presence of histologic antral gastritis correlated with other parameters of esophageal and gastric function. Twenty-three GER patients, mean age 53.3 years (range 28-68 years) with subjective and objective evidence for GER; and 20 normal subjects (13 males and seven females), mean age 28.7 years (range 19-46 years), underwent upper gastrointestinal endoscopy. Antral biopsies obtained from the greater curvature were graded as: 0 = normal; 1 = chronic gastritis; 2 = chronic active gastritis; and 3 = chronic atrophic gastritis. All patients underwent a gastric emptying study using an isotope-labeled semisolid meal. Eighteen of the 23 GER patients (78%) had histologic gastritis compared to two (10%) of the normals. No subject had endoscopic evidence of gastritis. Gradings of histologic gastritis were significantly (p less than 0.05) correlated with delayed gastric emptying. Twelve GER patients had severe gastritis (grades 2 or 3) and their gastric emptying, 79.7% +/- 5.8 (mean +/- S.E.M.) retention of isotope at 90 minutes after the meal, was significantly slower (p less than 0.01) than the 11 GER patients with either grade 0 or 1 gastritis, 56.1% +/- 5.9 retention, or the normal subjects, 51.8% +/- 1.7. We conclude that: 1) histologic gastritis is associated with GER disease; and 2) slowing of gastric emptying can be significantly correlated with increased severity of histologic gastritis in GER patients.
••
•
TL;DR: Serum levels of albumin and seromucoids provide the essential data to determine disease activity at routine follow-up of inflammatory bowel disease or to indicate the success or failure of therapeutic regimens, overriding any arbitrary clinical assessment.
Abstract: To provide a stronger relationship between clinical assessment of disease activity and laboratory measurements, we studied hemoglobin concentrations, sedimentation rates, and the serum levels of albumin and of seromucoids in 86 patients; first when seriously ill with either ulcerative colitis or Crohn's disease, and then again when they were well. Only albumin and seromucoids were separated clearly in the two states: hemoglobin and sedimentation rates showed significant overlap. Paired correlation tests between 10 laboratory variables in 149 patients with Crohn's disease of varying severity revealed a highly significant correlation between seromucoids and albumin (r = 0.71). Both variables correlated with six others, but at lower levels. Processing the correlation matrix by factor analysis suggested that the serum levels of albumin and seromucoid are indicators of the same effect--disease activity. A simple index using only hemoglobin, albumin, and seromucoid values, was derived from this analysis, positive values indicating health and negative ill health. Serum levels of albumin and seromucoids provide the essential data to determine disease activity at routine follow-up of inflammatory bowel disease or to indicate the success or failure of therapeutic regimens, overriding any arbitrary clinical assessment.
••
TL;DR: The drug is capable of producing hepatic injury, particularly when given in nonstandard doses intravenously, and reproducible with rechallenge of the drug (Ritalin).
Abstract: Methylphenidate-induced hepatic injury was documented by abnormal liver function tests including a markedly elevated serum bilirubin, serum glutamic oxaloacetic transaminase, and serum glutamic pyruvic transaminase. Liver biopsy confirmed portal inflammation and hepatocellular disarray. Enzyme changes were reproducible with rechallenge of the drug (Ritalin). The drug is capable of producing hepatic injury, particularly when given in nonstandard doses intravenously.
•
TL;DR: The overall risk is considered with emphasis on specific manifestations of Crohn's disease which predispose to malignancy so that the surveillance might be given special direction.
Abstract: Carcinomas of the ileum and colon in patients with Crohn's disease are being reported with such increasing frequency as to raise the question of a surveillance program to find dysplasia or the carcinoma itself at the earliest possible time. Accordingly, we consider the overall risk with emphasis on specific manifestations of Crohn's disease which predispose to malignancy so that the surveillance might be given special direction. Two more cases of carcinoma in Crohn's disease are reported, one in association with a long-standing fistula, the other with synchronous, metachronous, and multifocal lesions, and both with dysplasia.
••
TL;DR: In the authors' experience, the readier acceptance by patients of a continent internal reservoir over an external fecal-filled appliance has led to the performance of proctocolectomies for ulcerative colitis at an earlier stage of the disease.
Abstract: The conventional Brooke ileostomy is performed far more frequently than the Kock continent ileostomy. To determine the relative satisfaction with these operations, patients whose Brooke ileostomy had been converted to a Kock pouch were questioned about changes in their life-styles. Data were obtained from 80 patients who had worn an external appliance from 4 months to 33 years before the change-over to a Kock pouch. Improvement was reported in social activities (96.2%), athletic endeavors (87.5%), and sexual relations (76.2%). Patients spent less time caring for the stoma (92.5%) and wore street and beach attire with greater ease (97.5%). An average reduction of 75% was noted in ileostomy maintenance costs. The overall patient satisfaction with the Kock pouch was 98.7% despite an appreciable incidence of pouchitis and revisional operations. In our experience, the readier acceptance by patients of a continent internal reservoir over an external fecal-filled appliance has led to the performance of proctocolectomies for ulcerative colitis at an earlier stage of the disease.
••
TL;DR: A follow-up, available in 13 patients, reveals a low likelihood of malignant transformation or recurrence after surgical removal of granular cell myoblastoma.
Abstract: Granular cell myoblastoma, a rare, but generally benign tumor, is being encountered with increasing frequency in the digestive tract. Seventy-two cases have been described in the esophagus; we report two additional cases. A follow-up, available in 13 patients (including ours), reveals a low likelihood of malignant transformation or recurrence after surgical removal. Guidelines for the management of these tumors are presented.
•
TL;DR: Hirschsprung's disease should be considered in all adult patients who have had severe constipation since birth, especially if they are male.
Abstract: The natural history of adult Hirschsprung's disease was reviewed in 22 patients (four from our hospital and 18 from the literature). The diagnosis in nearly half the patients was made before age 30, and the oldest patients were 69 years of age. Male to female ratio was 4:1. Almost all patients had severe constipation since birth. Barium enema showed rectal narrowing in 77%, and colonic dilation in 100%. Anorectal manometry was performed in only four patients; three showed no relaxation with rectal distention. In all patients, rectal biopsy showed no ganglion cells. Appropriate operation for Hirschsprung's disease improved symptoms in over 80% of patients. Hirschsprung's disease should be considered in all adult patients who have had severe constipation since birth, especially if they are male.
••
TL;DR: Although nonspecific, these radiographic abnormalities are highly suspicious for Kaposi's sarcoma, particularly in patients with or at high risk for AIDS, especially homosexual men.
Abstract: About one-third of all patients with the acquired immunodeficiency syndrome (AIDS) have Kaposi's sarcoma. Gastrointestinal involvement has been noted in 50% of homosexual men with cutaneous Kaposi's sarcoma and AIDS. We report the abnormalities on barium studies of nine homosexual men from the San Francisco bay area who have AIDS and documented gastrointestinal Kaposi's sarcoma. Submucosal nodularity and infiltrative irregularity were the most frequently noted findings and were demonstrated in the stomach, duodenum, small bowel, and colon. The duodenum was the most frequent site of abnormality. Coalescent plaques, some with umbilications, were seen in the colon. Although nonspecific, these radiographic abnormalities are highly suspicious for Kaposi's sarcoma, particularly in patients with or at high risk for AIDS, especially homosexual men.
•
TL;DR: It is suggested that the association between major side effects, hypoalbuminemia, and hyperbilirubinemia in patients with chronic active hepatitis is attributable to increased serum unbound prednisolone caused by: 1) limited availability of binding sites (hypo albuminemia), or 2) displacement of bound steroid by competition (hyperbilirubsinemia).
Abstract: The response of serum prednisolone to a single oral dose of 30 mg of prednisone was studied in 12 patients with chronic active hepatitis taking prednisone, and in six healthy volunteers. Five of the 12 patients developed major side effects with prednisone, and seven showed less or no side effects. The patients with major side effects generally had higher serum bilirubin and lower serum albumin levels than the others. Prednisolone peak levels were similar in the three groups. Unbound (free) serum prednisolone was higher at 2, 3, 4, and 8 hours, in patients with chronic active liver disease and major side effects, than in the other two groups. Studies in vitro showed that protein binding of prednisolone increased with increasing albumin concentrations, and that bilirubin could displace some bound prednisolone. We suggest that the association between major side effects, hypoalbuminemia, and hyperbilirubinemia in patients with chronic active hepatitis is attributable to increased serum unbound prednisolone caused by: 1) limited availability of binding sites (hypoalbuminemia), or 2) displacement of bound steroid by competition (hyperbilirubinemia).
•
••
TL;DR: Isospora belli is a cause of protracted diarrhea in immunocompromised patients with acquired immunodeficiency syndrome and has been reported only once in this group, it is reported.
Abstract: Isospora belli is a cause of protracted diarrhea in immunocompromised patients. Acquired immunodeficiency syndrome (AIDS), seen mostly in homosexual men and narcotic addicts, predisposes affected persons to a number of opportunistic infections. As Isospora belli has been reported only once in this group, we report Isospora belli in an AIDS patient with chronic diarrhea.
••
TL;DR: It is suggested that lymphomas are more common among gastric neoplasms than reported in the past, and this may be due to the decline in gastric carcinoma or to a true increase in incidence.
Abstract: Primary gastric lymphoma comprised 20% of 119 patients with gastric malignancy seen at our hospital between 1975 and 1980, even when strict criteria were applied to exclude systemic lymphoma patients with gastric involvement. Of the 24 patients with gastric lymphoma, 16 had disease confined to the stomach and contiguous nodes. Eight with massive stomach involvement, but also evidence of distant disease were classified as "probable" primary gastric lymphoma. Symptoms, physical findings, and laboratory studies in the lymphoma patients were similar to those of carcinoma patients. Radiography was more likely to suggest benign conditions in cases with lymphoma. While endoscopy suggested malignant disease in over 80% of lymphoma patients, histologic diagnosis of lymphoma was made first by endoscopy in only 38%. Our data suggest that lymphomas are more common among gastric neoplasms than reported in the past. This cannot be accounted for by referral patterns or by improvement in diagnostic techniques. Although lymphomas appear to be more common, this is not necessarily due to a rise in their incidence. The proportionate increase in lymphomas may be due to the decline in gastric carcinoma or to a true increase in incidence.
•
TL;DR: A middle-aged woman with recurrent fever and a clinical diagnosis of hepatic abscess who proved at laparotomy to have adenosquamous carcinoma of the liver arising in a biliary cystadenocarcinoma is described.
Abstract: Primary biliary cystadenoma, cystadenocarcinoma, squamous carcinoma, and adenosquamous carcinoma of the liver are rare tumors. We describe a middle-aged woman with recurrent fever and a clinical diagnosis of hepatic abscess who proved at laparotomy to have adenosquamous carcinoma of the liver arising in a biliary cystadenocarcinoma. The pathologic features of the tumor and findings on ultrasonography, angiography, and computed tomography are described in detail. The pathogenetic relationships of this unusual tumor to chronic biliary inflammation, biliary cystadenoma, and cystadenocarcinoma and to bile duct malformations (von Meyenburg complexes) are considered.
••
TL;DR: Evidence suggests that this fibrous band in the lower rectal neck submucosa of all hemorrhoid patients and in only one control subject is the anorectal band which is an embryonic vestige.
Abstract: The role of the anorectal band in the genesis of hemorrhoids is studied. The anorectal band is a fibroepithelial tube which is a remnant of the anorectal sinus. Seventy-six hemorrhoid patients and 32 controls were studied. Rectal neck pressure recording was done for all subjects. Two biopsie
••
••
TL;DR: Dysphagia decreased in all patients and reflux symptoms were well-controlled in most patients with an antireflux regimen of elevation of the head of the bed, antacids, and cimetidine.
Abstract: Although recommended for patients requiring frequent dilations in whom surgery is not feasible, self-bougienage for benign esophageal stricture has not been examined critically. Thirteen patients performing self-dilations over a mean period of 4.8 years were evaluated. Dysphagia decreased in
••
TL;DR: Data indicate that changes in the concentration of some of the aromatic amino acids and branched chain amino acids are helpful in the diagnosis, evaluation of the severity of the hepatic morphologic changes, and prognosis of the type of liver disease.
Abstract: The diagnosis, prognosis, and treatment of various liver diseases are still frequently equivocal despite the various liver function tests and invasive procedures presently available to the clinician. The introduction of the Beckman Amino Acid Analyzer Model 119 Cl, greatly facilitated the determination of the individual amino acids in serum and cerebrospinal fluid, and the data thus obtained seem to help in the differentiation of some of the commoner types of liver disease. These data indicate that changes in the concentration of some of the aromatic amino acids (AAA) and branched chain amino acids (BCAA) are helpful in the diagnosis, evaluation of the severity of the hepatic morphologic changes, and prognosis of the type of liver disease. Moreover, the ratio between the AAA and the BCAA seems to be indicative of certain liver diseases. We describe the alterations in the amino acid patterns which may help in the diagnosis, prognosis, and treatment of patients with certain types of liver disease.
••
TL;DR: Treatment with antithyroid medication reversed the manifestation of all the symptoms, including dysphagia, which was accompanied by nasal speech, nasal regurgitation of food, weakness, and wasting of the proximal muscles of the upper and lower girdles.
Abstract: A 69-year old woman suffered from severe dysphagia, abdominal pain, and weight loss. The dysphagia was accompanied by nasal speech, nasal regurgitation of food, weakness, and wasting of the proximal muscles of the upper and lower girdles. Laboratory data revealed T3 sephadex uptake 65.2%; T4
•
TL;DR: Desensitization to sulfasalazine was successful in patients with IBD who previously had hypersensitivity reactions and the course of IBD was subsequently favorable in 35/40 (87%) for extended periods including 17/17 (100%) with ulcerative colitis.
Abstract: Desensitization to sulfasalazine was successful in 40/47 (85%) patients with IBD who previously had hypersensitivity reactions. The desensitization with sulfasalazine was well-tolerated with no serious complications in short- or long-term follow-up. The course of IBD was subsequently favorable in 35/40 (87%) for extended periods including 17/17 (100%) with ulcerative colitis. Desensitization should be attempted in patients who have had typical hypersensitivity reactions to sulfasalazine.