Showing papers in "Journal of Clinical Gastroenterology in 1985"

Hiccups: causes and cures.

Abstract: Hiccups result from a wide variety of conditions that act on the supraspinal hiccup center or that stimulate or disinhibit the limbs of its reflex arc. While scores of hiccup remedies have been reported over the centuries, no single "cure" stands out as being the most effective. Measures that stimulate the uvula or pharynx or disrupt diaphragmatic (respiratory) rhythm are simple to use and often help to speed the end of a bout of otherwise benign, self-limited hiccups. Such manueuvers may also terminate persistent hiccups. Drug therapy usually becomes necessary for more intractable hiccups; chlorpromazine and metoclopramide being two of the most widely employed agents for this purpose. Physical disruption of the phrenic nerve, hypnosis, and acupuncture are other modes of therapy that have been used in severe cases. Because so many reports of hiccup "cures" are based on anecdotal experience rather than controlled clinical studies, I review the available treatments to provide a rational approach for the management of hiccups.

Outcome of toxic dilatation in ulcerative and Crohn's colitis.

Abstract: A review of 1,236 patients admitted to The Mount Sinai Hospital with inflammatory bowel disease between 1960 and 1979 yielded 75 cases (6%) with toxic dilatation of the colon. There were 61 cases among 613 patients (10%) with ulcerative colitis (UC), and 14 of 623 (2.3%) with Crohn's disease (CD). Fifty-nine of the 75 patients (79%) underwent surgery during their hospitalization with toxic dilatation. Twelve of the 75 patients (16%) died. Both UC and CD groups had similar mean ages at onset of colitis (32 years and 31 years, respectively) and at development of toxic dilatation (37 years); similar durations of overall disease (4.8 and 5.9 years) and of toxic dilatation prior to surgery (11 days and 13 days); and similar anatomic distributions of disease. Both UC and CD also had similar mortality rates (16% and 14%). Mean duration of presenting attack up to onset of toxic megacolon was longer in CD than in UC (62 days versus 31 days) and in unoperated versus operated cases (64 days versus 37 days), but was not significantly different between survivors and mortalities (43 days versus 39 days). Mortality rates were also unaffected by total duration of inflammatory bowel disease, first attack versus relapse (14% versus 18%), or medical versus surgical therapy (13% versus 17%). Factors which affected mortality included age (30% for patients over 40 years old, versus 5% for those younger than 40), sex (21% in women versus 13% in men), and especially the occurrence of colonic perforation (44% for cases with perforation versus only 2% in those without). Of the 12 patients who died, 11 had suffered colonic perforation.(ABSTRACT TRUNCATED AT 250 WORDS)

The superior mesenteric artery syndrome. The disease that isn't, or is it?

Abstract: Intestinal obstruction of the duodenum by entrapment between the aorta and the superior mesenteric artery (SMA) is an uncommon cause of megaduodenum. Despite many case reports, acceptance of the SMA syndrome as a clinical entity has been controversial on account of its confusion with other c

Effect of metoclopramide in diabetic gastroparesis.

Abstract: The aims of our study were to: determine the effect of metoclopramide parenterally and orally on delayed gastric emptying of a radionuclide test meal in symptomatic patients with diabetic gastroparesis not explained by ulceration or other mechanical problems; and evaluate in a double-blind crossover fashion the efficacy of metoclopramide in relieving the symptoms of diabetic gastroparesis. Thirteen patients with subjective evidence of gastric stasis had delayed gastric emptying of an isotope-labeled semisolid meal which was significantly accelerated (p less than 0.05) after 10 mg of metoclopramide parenterally. Patients then received metoclopramide 10 mg and placebo before meals and prior to retiring for 3 weeks in a randomized double-blind crossover design. During metoclopramide therapy nausea, vomiting, anorexia, fullness, and bloating were significantly (p less than 0.05) ameliorated compared to placebo with an overall mean symptom reduction of 52.6%. Gastric emptying studies after completion of the trial is seven patients, subjectively improved and receiving open-labeled metoclopramide, showed significantly less gastric retention. Individual improvements in gastric emptying after parenteral or oral metoclopramide, however, could not be correlated with symptom change during the treatment trial. We conclude that metoclopramide is an important therapeutic adjunct in the management of diabetic gastroparesis and its therapeutic effects are mediated through its prokinetic properties as well as centrally mediated antiemetic actions.

Angina-like Esophageal Pain: Differentiation from Cardiac Pain by History

Abstract: Consecutive patients coming as an emergency with chest pain due to myocardial ischemia or esophageal disease were interviewed on admission to the hospital, before they had been fully investigated. Classical features of angina pectoris were equally common in both groups and “crescendo angina”

Early and late onset ulcerative colitis: distinct clinical features.

Abstract: A review of 93 patients with ulcerative colitis revealed that in 47 (50.5%) symptoms first appeared between 21 and 30 years of age--"early-onset"--and in 26 (27.9%) at the age of 51 years or above--"late-onset." Proctocolitis was more common in late-onset patients (p = 0.077) and in males of both age groups (p = 0.002). Extensive colitis was significantly more common in females (p = 0.002). Patients with late-onset proctocolitis had more bowel movements/day and liver involvement than patients with early-onset disease. The first episode of proctocolitis was more protracted and the ensuing remission of shorter duration in late-onset patients. Most patients with early-onset disease improved on steroid enemas, whereas most patients with late-onset disease required systemic corticosteroid therapy (p = 0.0028). Female patients with early-onset proctocolitis tended to be more severely afflicted than males, with an increased incidence of weight loss, leukocytosis, increased erythrocyte sedimentation rate (ESR), and need for systemic corticosteroid therapy. We conclude that late-onset ulcerative colitis is distinct from early-onset disease in its relative refractoriness to therapy and its predilection for distal colonic involvement.

Marked elevation of serum transaminase activity associated with extrahepatic biliary tract disease

Abstract: Nine patients with choledocholithiasis or cholelithiasis developed transient elevations of serum glutamic oxalacetic transaminase (SGOT) levels of greater than 600 units. Awareness of such transient biliary disease will prevent an unnecessary evaluation of a primary hepatocellular disorder. In our study, we concluded that 1) The SGOT level rose and fell rapidly within a 24- to 72-hour period. 2) Higher SGOT levels were seen in patients with choledocholithiasis in whom the gallbladder had been removed. 3) In patients with choledocholithiasis a fall in SGOT level did not necessarily mean the stone had passed.

Final report on the United States Multicenter Trial comparing ranitidine to cimetidine as maintenance therapy following healing of duodenal ulcer.

Abstract: Patients with recently healed duodenal ulcers were enrolled at 14 participating centers in a 12-month study comparing the effectiveness of ranitidine and cimetidine, two H2-receptor blockers, for maintenance therapy. Patients were randomly assigned to take bedtime doses of 150 mg of ranitidine (n=60) or 400 mg of cimetidine (n=66). Endoscopic examinations were scheduled at baseline and after 4, 8, and 12 months of therapy, or when symptoms compatible with active ulcer disease developed. Life-table analysis indicated a relapse rate of 16% for the ranitidine subjects and 43% for the cimetidine subjects during the 12-month period (p=0.01). Therapy was discontinued in one ranitidine subject and two cimetidine subjects for adverse events considered drug-related. There were no drug-related laboratory abnormalities in either treatment group. No significant drug-related adverse effects were seen with either drug during this 1-year trial. At the doses prescribed, ranitidine was superior to cimetidine as maintenance therapy in duodenal ulcer disease.

The fate of the rectal segment after diversion of the fecal stream in Crohn's disease: its implications for surgical management.

Abstract: Diverting the fecal stream has been considered to benefit the course of Crohn's disease. Clinical signs and symptoms have not, however, been distinguished previously from the objective inflammatory changes in the distal segment. We reviewed the course of 16 consecutive patients with Crohn's disease in whom sigmoidoscopy showed normal mucosa at the time of diversion and who underwent an ileostomy or colostomy, the rectal segment being left in place. As early as 3 months after diversion, all 16 patients showed progressive friability, ulceration, and exudation in the retained rectum. Stricture occurred in four and lead to abdominoperineal resection in three. Four of eight patients with only moderate inflammation on sigmoidoscopy underwent reanastomosis which was followed by a return to a normal-appearing rectal mucosa. The rectal segment inflammed after diversion rarely shows the histological characteristics of Crohn's disease when resected. This leads us to suspect that the disorder of nonspecific "diversion colitis" might account for this phenomenon entirely, or at least it may accelerate the Crohn's disease process. Continuity of the intestinal tract should be maintained in the course of Crohn's disease surgery if feasible. If a diversion is clinically warranted, reanastomosis should be considered as early as possible despite progressive inflammation of the rectal mucosa.

Endoscopic sensitivity in the detection of esophageal strictures.

Abstract: Endoscopy was compared in 90 patients with a radiographic diagnosis of peptic esophageal stricture. Retrospectively, 78 strictures were classified as valid diagnoses giving a positive radiographic predictive value of 87%. Endoscopy diagnosed 74 (95%) of the 78 peptic strictures, detecting all 45 strictures under 10 mm in caliber, but failing to detect four (12%) of 33 broader strictures. Nine (75%) of the 12 radiographic false-positive errors involved misinterpretation of muscular or mucosal rings of the lower esophagus. We conclude that endoscopy and radiology are equally effective and complementary methods for evaluating patients with suspected peptic stricture.

Intralesional steroid therapy of pyoderma gangrenosum.

Abstract: Treatment of pyoderma gangrenosum complicating ulcerative colitis has in the past been frustrating and usually unsuccessful, frequently resulting in colectomy. Intralesional steroid therapy has been used off and on in a few patients, but the treatment is not widely known to gastroenterologists. We report two patients successfully treated for early pyoderma gangrenosum by intralesional injection of triamcinolone acetonide (Kenalog, 40 mg injection) together with conventional doses of systemic steroids. A single series of injections was sufficient to bring about healing of the lesions in both patients. The treatment permitted early discharge of patients from the hospital, and the skin lesions were completely healed within 2 months. The lesions have not recurred in follow-up examinations of 11/2 and 21/2 years, respectively. We hope that other physicians will find this approach equally effective.

Delayed gastric emptying in children with Crohn's disease.

Abstract: To evaluate the role of delayed gastric emptying in the decreased nutritional intake and growth retardation of some patients with Crohn's disease, we looked at four groups: 1) Crohn's disease with growth retardation; 2) Crohn's disease with malnutrition or acute weight loss; 3) Crohn's disease without growth retardation or malnutrition; and 4) normal controls. Gastric emptying was measured by a test meal incorporating 99mTc sulfur colloid-labeled chicken liver as the solid phase marker and 111In-labeled water as the liquid phase marker. The percent of each isotope retained in the stomach over 120 minutes was compared among the groups and correlated with established nutritional parameters, caloric intake, and disease activity. Gastric emptying of the liquid component was the same in all groups, and emptying of solids in patients with Crohn's disease and growth retardation was not significantly different from controls. However, gastric emptying of solids was delayed in five of seven patients in the malnourished group; the mean emptying rate of all seven patients was significantly slower compared both to the normals (p less than 0.01) and the Crohn's patients without growth disturbances (p less than 0.05). This delay was correlated with caloric intake, but not with disease activity or any individual nutritional parameter except arm muscle area (p less than 0.01). Multiple regression analysis revealed that 54% of the variation in the emptying of solids could be accounted for by nutritional factors. Fifty-seven percent of patients with delayed gastric emptying had radiologic and/or endoscopic evidence of nonconstrictive involvement of the duodenum with Crohn's disease, while 80% of patients with such involvement had delayed gastric emptying. These results help explain the decreased caloric intake observed in Crohn's disease patients and support the role of liquid caloric supplements.

Extrahepatic portal venous thrombosis: frequent recognition of associated diseases.

Abstract: Twelve patients with obstruction of the extrahepatic portal venous system were seen at the Tufts-New England Medical Center between 1970 and 1979; a cause for the portal vein thrombosis was detected in 11. These included pancreatic disease (4); hematologic disorders (2); postoperative complications of laparotomy (3); transhepatic gelfoam embolization of the portal vein (1); and exchange transfusion via the umbilical vein (1). Clinical features included frequent self-limited episodes of bleeding from esophageal or gastric varices; and no characteristic or clinically helpful laboratory findings. The diagnosis was usually made in patients by identifying clots in the portal vein on selective angiography of the celiac and/or superior mesenteric arteries in which the venous phase was examined. Attempts at surgical correction were largely unsuccessful. Further thrombotic episodes occurred in three patients, and led to death in one. Two patients were given chronic anticoagulation with Coumadin and Persantin for 1 and 11/2 years, respectively without further thrombosis or gastrointestinal bleeding. However, it not yet possible to assess the risks and benefits of such therapy.

Enhanced toxicity of acetaminophen in alcoholics: report of three cases.

Abstract: Severe intoxication from excessive acetaminophen without suicidal intent occurred in three patients, all alcohol abusers, one with evidence of underlying cirrhosis. Apparently, acetaminophen toxicity may be enhanced by alcohol. Language: en

Guillain-Barré syndrome: a possible extraintestinal manifestation of ulcerative colitis.

Abstract: In two elderly patients with ulcerative colitis, acute Guillain-Barre syndrome developed while the inflammatory bowel disease was in remission. The patients were treated with corticosteroids and recovered. Since both disorders are relatively uncommon, we suggest that the Guillain-Barre syndrome may have been causally related to the preexisting chronic inflammatory bowel disease. Guillain-Barre syndrome may be regarded as a possible extraintestinal complication of chronic ulcerative colitis.

Filiform polyposis: an unusual complication of inflammatory bowel disease.

Abstract: Filiform polyposis is an unusual form of inflammatory polyposis which complicates inflammatory bowel disease. Recognition of this variant is important in that its radiographic and endoscopic picture may mimic villous adenoma or adenocarcinoma. Filiform polyposis may precipitate obstruction by stricture formation or give rise to major hemorrhage. We report five patients with inflammatory bowel disease complicated by asymptomatic filiform polyposis to emphasize the pathology of this lesion. We also review the literature regarding this topic.

Salmonella infections complicating inflammatory bowel disease.

Abstract: One hundred and five of 267 patients with inflammatory bowel disease at a community hospital had recorded diarrhea, but only one had Salmonella (0.9%). Two additional patients, one from another institution, are also reported. A literature review disclosed only 37 cases, 18 of which were adequately defined clinically. Patients with IBD may not be at an increased risk for Salmonella infection. Salmonella infection may increase the severity of IBD, and therefore antibiotics may be necessary.

Small intestinal permeability as an indicator of jejunal mucosal recovery in patients with celiac sprue on a gluten-free diet

Abstract: Lactulose/mannitol excretion ratios were measured in 13 patients with celiac disease at diagnosis and after 5-8 months on a gluten-free diet. Jejunal biopsies were assessed histologically at diagnosis and during treatment. The excretion ratios in untreated patients were significantly higher than in 25 normal controls (P less than 0.01). On the diet, the excretion ratios fell in every patient, but in only eight did the ratio return to normal. There was a good correlation between the ratio and jejunal histological grading. During treatment, the ratios significantly inversely correlated with jejunal villous height/mucosal thickness ratios (P less than 0.001). Therefore, excretion ratios provide a well-tolerated noninvasive means of assessing the jejunal mucosa in patients with celiac disease on a gluten-free diet.

Gastroesophageal scintigraphy: is it a sensitive screening test for gastroesophageal reflux disease?

Abstract: Dynamic radionuclide imaging potentially offers a convenient, noninvasive technique for detecting gastroesophageal (GE) reflux disease Initial studies suggested a high degree of sensitivity, although subsequent reports have been less encouraging We sought to clarify this controversy by assessing the sensitivity of GE scintigraphy in 15 patients with severe esophagitis at endoscopy and 15 health volunteers After acid loading, scintigraphy was performed in the basal state and after maneuvers (Valsalva, abdominal compression) which provoke GE reflux Computer analysis permitted calculation of a reflux index for each maneuver An index greater than 4% was considered a positive test We found that the mean reflux index for the patients was significantly greater (p less than 001) than the healthy volunteers; 455 +/- 175% versus 042 +/- 011%, means +/- SEM Only 30% of the patients had a reflux greater than 4% Using data from our healthy volunteers, we redefined an abnormal reflux index as greater than 17%, but that only improved the test sensitivity to 60% and the specificity to 100% Scintigraphy for reflux is primarily limited by the short duration of imaging We cannot recommend GE scintigraphy as a useful screening test for reflux

Computed tomography in the evaluation of cirrhosis and portal hypertension.

Abstract: Patients with cirrhosis present a continuing diagnostic and therapeutic challenge. The status of their disease frequently changes, necessitating intensive serial evaluation. CT is an invaluable tool in the management of these patients because it can noninvasively provide vital information concerning liver size, contour, and occasionally hepatic parenchyma. More importantly, CT can demonstrate superficial and deep varices, assess the patency of the extrahepatic portal system, and detect other complications including ascites, hepatic steatosis, hemochromatosis, and hepatocellular carcinoma.

Primary biliary cirrhosis and chronic pancreatitis in a patient with ulcerative colitis.

Abstract: A 65-year-old Japanese woman had primary biliary cirrhosis (PBC) and chronic pancreatitis associated with ulcerative colitis. The association of PBC and ulcerative colitis may prove to be valid.

Ogilvie's syndrome associated with herpes zoster infection.

Abstract: Acute colonic pseudo-obstruction that occurs in the setting of an underlying medical condition is known as Ogilvie's syndrome. The etiology of Ogilvie's syndrome is unknown, and associated medical illnesses are varied and often extra-abdominal. While herpes zoster infection has been reported to cause constipation and hypomotility, the association with massive colonic distention has not so far been described. We present a patient with Ogilvie's syndrome in the setting of herpes zoster infection. There was no evidence of other active illnesses, and the patient has continued to do well since the resolution of the zoster. We believe that this is the first reported association of Ogilvie's syndrome and herpes zoster infection.

Colonic varices: a rare, but important cause of gastrointestinal hemorrhage.

Abstract: The diagnosis of colonic varices, a rare cause of gastrointestinal hemorrhage, may be exceedingly difficult. If this entity is not considered, a rectal or colonic biopsy may lead to brisk and dangerous bleeding, as in our patient on two separate occasions. Once the diagnosis is made, appropriate surgery will prevent future bleeding episodes.

The variable appearance of distal common bile duct stenosis in chronic pancreatitis.

Abstract: Cholangiograms of 15 patients with stenosis of distal portion of common bile duct due to chronic alcoholic pancreatitis were critically evaluated for stricture shape, length, and maximal diameter of the common bile duct. In these cholangiograms, different shapes of strictured segments were present, including the smooth tapering variety in eight, "funnel shape" in three, and "rat tail," "bent knee," "hourglass," and complete obstruction in one case each. The length of strictured segment ranged from 16 to 57 mm with a mean (+/- S.E.) of 40.7 +/- 4.1 mm. The mean (+/- S.E.) maximal diameter of the dilated portion of common bile duct was 18.9 +/- 1.3 mm with a range of 13-28 mm. There is a wide variety in the shape and length of the stenotic segments of the distal common bile duct in chronic alcoholic pancreatitis. Moreover, a particular radiologic configuration of common bile duct stricture is not helpful in predicting the nature of the underlying process in this group of patients.

Acute colonic pseudo-obstruction: a possible role for the colocolonic reflex.

Abstract: In diverse clinical settings, injury or impairment of the peripheral autonomic nervous system may cause acute co- Ionic pseudo-obstruction. The mechanism has remained elusive since Ogilvie's original description. In classic Ogilvie's syndrome, colonic pseudo-obstruction is associated with malignant invasion of the prevertebral ganglia, and may be mediated through the colocolonic reflex, described in a guinea pig model. We have treated three patients with acute colonic pseudo-obstruction due to: 1) malignant invasion of the prevertebral plexus (classic or true Ogilvie's syndrome), 2) clonidine, and 3) herniorrhaphy under epidural anesthesia. In this paper, we discuss the possible role of the colocolonic reflex in the pathophysiology of acute colonic pseudo-obstruction, and the delineation of true Ogilvie's syndrome from the other many causes of acute colonic pseudo-obstruction.

Imaging guided percutaneous hepatic biopsy: diagnostic accuracy and safety.

Abstract: During the 3-year period from May 1981 to June 1984, 145 patients with hepatic abnormalities demonstrated by computed tomography (CT) or ultrasonography (US) underwent 1S1 imaging guided percutaneous hepatic biopsies. These biopsies were performed with needles ranging in size from 21-gauge aspiration to 14-gauge cutting type. Histologic and cytologic results were correlated with subsequent surgical, autopsy, and clinical follow-ups ranging from 2 months to 3 years. The overall accuracy for imaging- guided biopsies was 92.1% and 98% for diagnosis of malignant lesions. Our complication rate of 1.3% is comparable to that reported in other studies. We discuss indications, techniques, and risks for imaging-guided percutaneous hepatic biopsy.

Colonic lymphoma in ulcerative colitis.

Abstract: Only rarely has lymphoma been associated with ulcerative colitis. We report a 25-year-old man with an 8-year history of ulcerative colitis, who developed diffuse large cell lymphoma (histiocytic) of the colon. We review 17 previously reported cases and discuss the risk of lymphoma, diagnostic clues, prognosis, and the evidence for a relationship between ulcerative colitis and lymphoma.

Massive bleeding due to arterial-enteric fistula from an ingested toothpick.

Abstract: A 62-year-old man developed massive lower gastrointestinal tract bleeding. Upper endoscopy and superior mesenteric arteriography initially failed to disclose a cause of bleeding. On rebleeding, intra-arterial vasopressin infusion during repeated arteriography caused reflux of dye into the iliac vessels to allow visualization of an arterial-enteric fistula. Exploratory laparotomy subsequently revealed perforation of the small bowel and common iliac artery by a toothpick which had been swallowed.

Adhesion-related colonic varices.

Abstract: Most colonic varices are attributable to portal hypertension. Intra-abdominal adhesions have been incriminated as the cause of intestinal varices only in association with portal hypertension. We present the first well-documented occurrence of adhesion-related colonic varices in the absence of portal hypertension or other known associated conditions. It is important to delineate the mesenteric vascular anatomy in order to select the appropriate surgical procedure.

Primary biliary cirrhosis and Graves' disease.

Abstract: We describe a patient with primary biliary cirrhosis associated with Graves' disease and discuss the possible autoimmune connections between the two disorders.