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Showing papers in "Journal of Clinical Gastroenterology in 1989"


Journal ArticleDOI
TL;DR: The analysis revealed that constipation is one of the most common chronic digestive disorders in the United States, affecting one of every 50 people, and the occurrence of constipation increased with advancing age, showing an exponential increase in prevalence after the age of 65.
Abstract: Using health statistics from the United States and England and Wales, we review the epidemiology of constipation and possible etiologies of this disorder as suggested by its epidemiologic distribution. The analysis revealed that constipation is one of the most common chronic digestive disorders in the United States, affecting one of every 50 people. The occurrence of constipation increased with advancing age, showing an exponential increase in prevalence after the age of 65. The age distribution of constipation was similar in both sexes, but overall constipation was three times more common in women than in men. Constipation more frequently affected nonwhites than whites, and people from families with low income or less formal education. The characteristic epidemiologic pattern of constipation suggests the influence of environmental factors. Insufficient dietary fiber is widely believed to be a major cause of constipation, yet it is difficult to devise a mechanism by which dietary fiber alone could produce the marked differences observed between gender, race, and socioeconomic status. Recent evidence suggests that disruption of neural regulation of colonic motility plays an important role in the development of chronic constipation. This loss of neural regulation may result from mechanical damage to the pelvic nerves due to childbirth or pelvic surgery, exposure to environmental toxins (e.g., organochlorine insecticides or heavy metals), or possibly exposure to an infectious agent. Other environmental factors that may play a role in the pathogenesis of chronic constipation have not yet been elucidated. Consequently, studies examining the epidemiology of chronic constipation are important for providing insight into potential environmental risk factors relevant to the etiology of this disorder.

219 citations



Journal ArticleDOI
TL;DR: Gastric motor dysfunction and concomitant gastric stasis have been implicated in the pathogenesis of nonulcer dyspepsia, but a cause-and-effect relationship is not established and delayed emptying was not associated with the occurrence of postprandial pain, belching, or nausea.
Abstract: Gastric motor dysfunction and concomitant gastric stasis have been implicated in the pathogenesis of nonulcer dyspepsia, but a cause-and-effect relationship is not established. Essential dyspepsia refers to a subgroup of nonulcer dyspepsia patients who have no evidence of irritable bowel syndrome, gastroesophageal reflux, or pancreaticobiliary disease. In 32 patients with essential dyspepsia, and 32 randomly selected dyspepsia-free community controls of similar age and sex, we measured gastric emptying of solids using Tc99m-Sulphur Colloid in a fried egg sandwich. Subjects with neuromuscular or other diseases that may alter gastric emptying were excluded. Symptoms were assessed by a standard questionnaire. Data processing was carried out "blinded" to the subjects' clinical status. Female patients took significantly longer to empty half the initial stomach activity (mean 90 min) than female controls (mean, 73 min; p = 0.02). The rate of emptying at 25 min was also significantly less in female patients than in controls. Female and male controls, and male patients, had similar emptying times. Delayed emptying was not associated with the occurrence of postprandial pain, belching, or nausea; there was a trend for the half-time rate of emptying to be greater in patients with abdominal distention. While gastric emptying of solids is slightly delayed in females with essential dyspepsia as a group, this may not explain their symptoms.

144 citations


Journal ArticleDOI
TL;DR: The most striking features in the production of the "pincher mechanism" of the duodenum were found to be a short aortomesenteric distance together with sagittal parallelism between aorta and superior mesenteric artery.
Abstract: A series of 18 patients underwent surgery for upper abdominal symptoms and signs of superior mesenteric artery syndrome (SMAS). The diagnosis was made by simultaneous arteriography and barium meal. Findings at operation confirmed SMAS in every patient, and a duodenojejunostomy was performed. Duodenal and jejunal wall biopsy from 13 patients revealed normal myenteric and submucous plexuses. A follow-up study of 16 patients was performed after 7 years. At follow-up, the weight loss seen preoperatively had been corrected. However, symptoms were essentially similar to those found at the original examination. Only the frequency of the most distressing symptom, vomiting, was significantly decreased (p less than 0.05). The most striking features in the production of the "pincher mechanism" of the duodenum were found to be a short aortomesenteric distance together with sagittal parallelism between aorta and superior mesenteric artery. In conclusion, we recommend a conservative attitude in the treatment of SMAS. Surgical treatment with duodenojejunostomy may be indicated only if vomiting is a predominant symptom and proper conservative treatment has failed.

141 citations


Journal ArticleDOI
TL;DR: The pooled estimate provides evidence of the short-term efficacy of both the antisecretory and gastrokinetic agents, whether considered as drug classes or as individual drugs, and confirms the importance of the placebo effect in FD.
Abstract: The results of therapeutic trials in functional dyspepsia (FD), a frequently encountered condition, are contradictory. Our aim, then, was to produce a pooled estimate, or meta-analysis, of a series of short-term randomized placebo-controlled clinical trials on the pharmacological treatment of FD with antisecretory and gastrokinetic drugs. We retrieved trials for analysis purposes by consulting computerized data bases and by scanning published reviews, Current Contents, and references cited in the individual studies. We also requested bibliographical updates from the medical departments of the manufacturers of the drugs used in the various trials. Of 74 trials retrieved by these means, 23 proved eligible for meta-analysis on the basis of six selection criteria defined a priori. Results were expressed in terms of "therapeutic success" (TS), which includes "symptom-free patients," patients with "significant improvement in symptoms," "excellent results," and so on. The differences in TS rates between the various drugs and placebo were calculated in each trial as the algebraic difference together with the respective 95% confidence interval (95% C.I.); the pooling of results of all eligible trials was done using Cochran's weighted method. With antisecretory drugs, the mean difference in TS rates versus placebo was +20% (95% C.I.: 14-24%). The therapeutic gain for the respective antisecretory agents was 25% (95% C.I.: 14-36%) in the case of pirenzepine and 18% (95% C.I.: 12-24%) in the case of H2 antagonists. Meta-analysis of trials with gastrokinetic drugs also showed superior efficacy of these agents compared with placebo, with a mean difference in TS rates of +46% (95% C.I.: 40-52%).(ABSTRACT TRUNCATED AT 250 WORDS)

117 citations


Journal ArticleDOI
TL;DR: In a double-blind trial 60% of acute variceal bleeding episodes were controlled with terlipressin (glypressin) compared with 37% in patients given placebo (NS).
Abstract: In a double-blind trial 60% of acute variceal bleeding episodes were controlled with terlipressin (glypressin) compared with 37% in patients given placebo (NS). Rebleeding was more common in the placebo group so that at 5 days bleeding remained under control in 54% of patients treated with terlipressin compared with only 19% after placebo therapy (p less than 0.025). Blood transfusion requirements were similar in the two groups. Terlipressin appeared to be the most effective in those patients with severe hepatic dysfunction.

106 citations


Journal ArticleDOI
TL;DR: Evaluated dyspeptic symptoms in 245 arthritic patients from the practices of two rheumatologists, finding no statistical association between any NSAID, or combination of NSAIDs, and the frequency of dyspepsia.
Abstract: Gastroduodenal intolerance is one of the major factors limiting the use of aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs) in patients with rheumatic diseases. We previously demonstrated that dyspepsia was not a marker for ulcer in NSAID users. We have now evaluated dyspeptic symptoms in 245 arthritic patients (receiving 13 different NSAIDs) from the practices of two rheumatologists. Fifty-seven patients (23%) gave a history of previous peptic ulcers. Heartburn, indigestion, or sour stomach at least once within the past year was present in 62.5%; 36.7% had experienced these symptoms within the previous 2 months and 28.6% within the previous week. Only 39 patients (15.9%) had experienced dyspepsia more than once daily within the previous month, and 8 (3.3%) had dyspepsia greater than 5 times/day. Thirty-four of the 39 patients with daily dyspepsia claimed to obtain relief with cimetidine or antacids (34 patients) or food (2 patients), whereas 3 had not discovered anything that provided relief. Women smokers were more likely than nonsmokers to experience dyspepsia (p less than 0.001). Neither men smokers nor those with a history of previous ulcer were more likely to have dyspepsia than nonsmokers or those without a history of ulcer (p greater than 0.5). We were not able to find a statistical association between any NSAID, or combination of NSAIDs, and the frequency of dyspepsia.

102 citations


Journal ArticleDOI
TL;DR: Some features uncommonly or never reported in benign recurrent intrahepatic cholestasis, including plasmapheresis seemed to diminish jaundice and improve biochemical disorders are emphasized.
Abstract: Benign recurrent intrahepatic cholestasis is characterized by attacks of cholestasis. The purpose of our study of 26 patients was to emphasize some features uncommonly or never reported in this disease: (a) in each patient, the attacks of cholestasis were stereotypic; (b) attacks of cholestasis were not associated with pruritus in 15% of our patients; (c) the occurrence of attacks of cholestasis during pregnancy or oral contraceptive use might be a fortuitous coincidence; (d) gallstones were found in several patients with benign recurrent intrahepatic cholestasis and might be present earlier than in the general population; (e) in some of our patients, during attacks of cholestasis, serum transaminases were very high, exceeding 15 times the upper limit of normal; (f) mild portal inflammatory infiltration was found in one third of our patients; (g) no treatment shortened the duration of cholestasis, and in a few patients, plasmapheresis seemed to diminish jaundice and improve biochemical disorders.

83 citations


Journal ArticleDOI
TL;DR: Patients can get and stay better with no "specific" therapy, and favorable predictive factors for continued remission included a normal rectal mucosa on sigmoidoscopy, limited extent of colitis, and remission recently achieved by active therapy or maintained by therapy for at least 1 year before study entry.
Abstract: We have attempted to elucidate the "natural history" of ulcerative colitis by studying the placebo groups of 11 controlled trials of 185 patients with active disease. Most (182) of the patients were mild to moderately ill, but 3 had severe colitis. They were studied by endoscopic, pathologic, and/or clinical criteria and followed for 15-42 days. Up to 52% improved clinically and 59% sigmoidoscopically. Relapses commonly occurred within 2 months of these "spontaneous" improvements. In another six trials of 174 patients in remission receiving only placebo therapy (134 followed for 6 months and 40 for 12 months), up to 51% remained in remission. Favorable predictive factors for continued remission included a normal rectal mucosa on sigmoidoscopy, limited extent of colitis, and remission recently achieved by active therapy or maintained by therapy for at least 1 year before study entry. Thus, patients can get and stay better with no "specific" therapy. We have clarified advantageous predictive factors.

79 citations


Journal ArticleDOI
TL;DR: All previous cases of Wilson's disease with this unusual complication are reviewed and the role of copper in hepatic oncogenesis as well as the alpha-naphthylannidase stain for the diagnosis of hepatocellular carcinoma is discussed.
Abstract: A 33-year-old man with Wilson's disease developed hemoptysis and radiographic evidence of nodular pulmonary infiltrates. A premortem diagnosis of hepatocellular carcinoma was made on the basis of alpha-naphthylannidase stains of pulmonary tissue obtained by open lung biopsy. We review all previous cases of Wilson's disease with this unusual complication and discuss the role of copper in hepatic oncogenesis as well as the alpha-naphthylannidase stain for the diagnosis of hepatocellular carcinoma.

78 citations


Journal ArticleDOI
TL;DR: Analysis of waiting time to conception showed that fecundability was not different in spouses of IBD patients and controls, and it is concluded that the overall reproductive capacity of men with IBD is not markedly diminished.
Abstract: We examined fertility in men with inflammatory bowel disease (IBD) to determine whether the reported deficit in pregnancies in their spouses was due to reduced reproductive capacity. The cases were 106 men with Crohn's disease and 62 with ulcerative colitis drawn from the rosters of North Carolina chapters of the National Foundation for Ileitis and Colitis. The 140 normal controls were neighbors identified by the cases. There were 186 pregnancies among the spouses of men with Crohn's disease, 110 among the ulcerative colitis group, and 300 among the controls. The mean number of pregnancies among the Crohn's disease patients (1.75 +/- 0.12) was significantly lower than the number for controls (2.14 +/- 0.11), p less than 0.02. The reduction in the mean number of pregnancies among patients with ulcerative colitis (1.77 +/- 0.18) was not significantly different from controls (p less than 0.07). Analysis of waiting time to conception showed that fecundability (the probability of pregnancy in a menstrual cycle) was not different in spouses of IBD patients and controls. We conclude that the overall reproductive capacity of men with IBD is not markedly diminished.

Journal ArticleDOI
TL;DR: Almost 30% of patients with essential dyspepsia, predominantly women, in whom statistical analysis failed to reveal any specific pattern of symptoms, had significantly delayed gastric emptying suggesting idiopathic gastric stasis.
Abstract: Gastric emptying, mouth-to-cecum transit (MCT), and whole-gut transit of a solid-liquid meal was measured in 30 control subjects and in 43 patients with essential dyspepsia, in whom organic digestive diseases and secondary disorders of gastric emptying had been excluded. The rate of gastric emptying was determined by an anterior gamma camera technique, MCT by the hydrogen breath test, and whole-gut transit by the first appearance of stool markers. Approximately 30% of patients with essential dyspepsia, predominantly women, in whom statistical analysis failed to reveal any specific pattern of symptoms, had significantly delayed gastric emptying suggesting idiopathic gastric stasis. Concerning MCT and whole-gut transit, significant differences between the control and study group could not be detected.

Journal ArticleDOI
TL;DR: At an appropriately selected cutoff level, amylase can be effectively used as the first-line test and isoamylase or lipase as adjunct tests for acute abdominal conditions.
Abstract: We evaluated the diagnostic value of serum amylase, isoamylase, and lipase for the diagnosis of acute pancreatitis from sera of patients with acute abdominal pain. Comparison was first made in condition A between 32 patients with image-proven pancreatitis and 414 patients with nonpancreatic acute abdomen (the control group), then in condition B, between 62 pancreatitis patients with or without image proof and the control group. We found (a) that patients with image-proven pancreatitis suffer a more severe clinical course than those without; (b) that the sensitivity, positive predictive value, and accuracy in condition B are higher than in condition A at any cutoff level; (c) that none of the enzyme assays is specific at the upper reference limit, but their diagnostic yields are much improved by raising cutoff levels to about three or four times the upper limit; and (d) that at these selected cutoff levels, amylase had a diagnostic value similar to p-isoamylase or lipase in both conditions (sensitivity 84% and 92% for amylase in conditions A and B, respectively; specificity 98% and 98%; positive predictive value 75% and 90%; negative predictive value 99% and 99%; accuracy 91% and 97%). In conclusion, at an appropriately selected cutoff level, amylase can be effectively used as the first-line test and isoamylase or lipase as adjunct tests for acute abdominal conditions.

Journal ArticleDOI
TL;DR: These histologic parameters appear to be diagnostically useful when applied in appropriate clinical settings and will require reevaluation when serologic tests for NANB hepatitis become available.
Abstract: We reviewed 40 liver biopsy specimens from 36 patients with non-A, non-B (NANB) hepatitis by light microscopy to characterize the histopathologic features associated with this condition. NANB hepatitis had been acquired from intravenous drug use (6 patients), transfusion (11 patients), sporadic (13 patients), and other routes (6 patients). The major pathologic diagnoses included acute hepatitis, chronic persistent hepatitis, chronic lobular hepatitis, chronic active hepatitis with or without cirrhosis, and hepatocellular carcinoma. Histopathologic changes seen in varied combinations in these specimens included acidophilic degeneration of hepatocytes (100%), fat (85%), formation of portal tract lymphoid aggregates or follicles (52%), bile duct damage (30%), and multinucleate giant hepatocytes (25%). Prominence of sinusoidal cells was variable, but often striking. Hepatocyte atypia (liver cell dysplasia) was noted in 17 specimens. These histologic parameters appear to be diagnostically useful when applied in appropriate clinical settings and will require reevaluation when serologic tests for NANB hepatitis become available.

Journal ArticleDOI
TL;DR: In selected patients with unexplained gastrointestinal symptoms but no objective features of gut disease, quantifiable gastric and small bowel motility parameters do not differ in the age groups 18-39 and 40-69 years.
Abstract: To test the hypothesis that age alters fasting and postprandial antral and intestinal motility in humans, we studied 23 patients, aged 18-39 years (median 28), and 13 patients, aged 40-69 years (median 49). All were having gastrointestinal symptoms, but in none was there objective clinical, radiologic, or endoscopic features of bowel disease, and manometry of the stomach and proximal small bowel was normal. We quantitated certain parameters of fasting intestinal motility and postprandial antral and jejunal motility. There were no significant differences in the interval between interdigestive motor complexes (IMC), duration, propagation velocity, or maximum number of contractions during phase III of the IMC, or postprandial antral and jejunal motility indices. The postprandial indices show a very similar distribution in each decade. Thus, in selected patients with unexplained gastrointestinal symptoms but no objective features of gut disease, quantifiable gastric and small bowel motility parameters do not differ in the age groups 18-39 and 40-69 years.

Journal ArticleDOI
TL;DR: The 10-year experience of a community teaching hospital with gastric epithelial polyps is reviewed and 121 polyps removed from 35 patients are analyzed, finding that all polyps were of the same histologic type.
Abstract: We have reviewed the 10-year experience of a community teaching hospital with gastric epithelial polyps and have analyzed 121 polyps removed from 35 patients. Hyperplastic polyps constituted nearly 75% of the polyps examined; fundic gland polyps constituted 17%, and adenomatous polyps were infrequent (8.6%). No clinical or endoscopic finding distinguished the variants of polyp before histologic examination. The majority of hyperplastic and fundic gland polyps were multiple. Whenever there were multiple polyps, all polyps were of the same histologic type. In no case did adenocarcinoma originate within a benign polyp. In only a single case was there an associated adenocarcinoma elsewhere in the stomach. None of the adenomatous polyps was linked with gastric adenocarcinoma.

Journal ArticleDOI
TL;DR: Successful therapeutic endoscopy is reported in eight cases of Dieulafoy's disease in a period of 20 months, with positive results for heat-probe thermocoagulation and hypertonic glucose solution.
Abstract: Dieulafoy's disease is an underdiagnosed cause of massive upper gastrointestinal bleeding. The mortality rate is extremely high and the diagnosis is usually made at autopsy. Operation has been deemed the treatment of choice for Dieulafoy's disease in the past decades. Here, however, we report successful therapeutic endoscopy in eight cases of Dieulafoy's disease in a period of 20 months. Six patients (75%) were in shock before therapy. Six received heat-probe thermocoagulation, one received pure alcohol (99.8%) injection and one received hypertonic glucose solution (50%) injection. No perforation or recurrent hemorrhage occurred in the following period of 11.2 +/- 3.4 months (SEM) in six patients. The other two died of unrelated illness. In the near future, therapeutic endoscopy may replace surgery in the management of Dieulafoy's disease.

Journal ArticleDOI
TL;DR: In American black patients with inflammatory bowel disease, the course of IBD was similar to that of white patients, although in Crohn's disease the reoperation rate and the rate of joint involvement were higher in black IBD patients.
Abstract: Sixty-four black patients with inflammatory bowel disease (IBD) were seen from 1960 to 1987 at the Medical College of Georgia, representing 22% of all patients with IBD: 38 of them had Crohn's disease (CD) and 26 had ulcerative colitis (UC). In those with CD, the small intestine alone was involved i

Journal ArticleDOI
TL;DR: The idea that putrefaction of the stools causes disease, i.e., intestinal autointoxication, originated with physicians in ancient Egypt and persists in the public mind, probably as an extension of the childhood habit of toilet training.
Abstract: The idea that putrefaction of the stools causes disease, i.e., intestinal autointoxication, originated with physicians in ancient Egypt. They believed that a putrefactive principle associated with feces was absorbed in to the general circulation, where it acted to produce fever and pus. This description of the materia peccans represented the earliest forerunner of our present notion of endotoxin and its effect. The ancient Greeks extended the concept of putrefaction to involve not only the residues of food, but also those of bile, phlegm, and blood, incorporating it into their humoral theory of disease. During the 19th century, the early biochemical and bacteriologic studies lent credence to the idea of ptomaine poisoning--that degradation of protein in the colon by anerobic bacteria generated toxic amines. Among the leading proponents of autointoxication was Metchnikoff, who hypothesized that intestinal toxins shortened lifespan. The toxic process, however, was reversed by the consumption of lactic acid-producing bacteria that changed the colonic microflora and prevented proteolysis. The next logical step in treatment followed in the early 20th century when surgeons, chief among them Sir W. Arbuthnot Lane, performed colectomy to cure intestinal autointoxication. By the 1920s, the medical doctrine fell into disrepute as scientific advanced failed to give support. However, the idea persists in the public mind, probably as an extension of the childhood habit of toilet training.

Journal ArticleDOI
TL;DR: After establishing criteria of patient selection, disease activity and, remission, lymphoplasmapheresis was performed in seven patients with severely active chronic Crohn's disease, achieving a statistically valid remission, lasting an average of more than 18 months, in 48 of them.
Abstract: After establishing criteria of patient selection, disease activity and, remission we performed lymphoplasmapheresis in seven patients with severely active chronic Crohn's disease. Five of the seven responded, but the results were unpredictable, not cost-effective, and had 100% morbidity. We then changed the protocol to selectively remove T-cells by differential ultracentrifugation. The initial goal was to remove 40 times 10(9) T-cells, but it was changed to 80 times 10(9) in order to increase the length of remission. We found that all patients with steroid-dependent chronically active Crohn's disease show evidence of protein calorie malnutrition. We used total parenteral nutrition with T-lymphocyte apheresis in the last 21 of 25 patients so treated. We have now completed a series of 54 patients, achieving a statistically valid remission, lasting an average of more than 18 months, in 48 of them. Criteria of remission included absolute zero steroid dosage. There has been no mortality or evidence of immunocompromise. The only morbidity (four patients) was the need for intravenous catheters during the apheresis procedure. This work has been confirmed elsewhere. Immune studies in active, untreated disease show low serum values of interleukin-2, as well as abnormalities of T-cell responsiveness to interleukin-2. The mechanism of how T-lymphocyte apheresis works is not clear, but it represents a promising new approach to the treatment of Crohn's disease.

Journal ArticleDOI
TL;DR: It is confirmed that intravenous sedation causes hypoventilation and hypoxemia during esophagogastroduodenoscopy and further arterial oxygen desaturation are caused by either the mechanical effect of the endoscope or a reflex stimulated by it.
Abstract: Hypoxemia during esophagogastroduodenoscopy (EGD), or panendoscopy has been generally attributed to sedation. We studied 49 patients ranging in age from 17 to 71 years with normal or nearly normal lung function undergoing EGD to determine the effects of sedation and the effects of the endoscope on arterial oxygen saturation (SaO2). All patients received intravenous diazepam and 41 also received meperidine. EGD was delayed 10.7 +/- 7.5 min after intravenous diazepam administration in the 42 group 1 patients. Seven patients underwent EGD within 2 min of receiving intravenous diazepam (group 2). Ventilation decreased after diazepam, recovered, then decreased immediately after endoscope insertion in the group 1 patients. Periods of hypopnea, up to 39 s long, were observed during EGD. The average decrease in SaO2 was 4.0% after diazepam (p less than 0.0001). SaO2 returned to the pre-EGD level, then decreased 2.4% during EGD (p less than 0.0005). Maximum SaO2 decrease occurred 27 +/- 6 s after insertion of the endoscope then rapidly recovered. There was a linear correlation between the duration of hypopnea and maximum SaO2 decrease (r = 0.84, p less than 0.001). All group 2 patients experienced a period of hypopnea (13.3 +/- 9.6 s) and SaO2 declined 9.0%. The SaO2 decline was significantly greater in the group 2 subjects (p less than 0.0001). Our results confirm previous findings that intravenous sedation causes hypoventilation and hypoxemia. Moreover, hypoventilation and further arterial oxygen desaturation are caused by either the mechanical effect of the endoscope or a reflex stimulated by it.

Journal ArticleDOI
Michio Shimizu1, J Miura, T Tanaka, H Itoh, Y Saitoh 
TL;DR: A case of porcelain gallbladder in a 67-year-old Japanese woman is reported and the literature describing its ultrasound appearance is reviewed, summarize, and tabulate.
Abstract: We report a case of porcelain gallbladder in a 67-year-old Japanese woman and review, summarize, and tabulate the literature describing its ultrasound appearance. We classify the ultrasound finding of porcelain gallbladder into two types: a complete type and an incomplete type. The relation between the type of porcelain gallbladder and pathological features is important because in the incomplete type the frequency of cancer was much higher than in the complete type.

Journal ArticleDOI
TL;DR: As immunosup-pressive therapy is a beneficial treatment of autoimmune chronic active hepatitis, an acute presentation of this liver disease should be considered as an alternative diagnosis to acute non-A, non-B hepatitis in patients with these clinical characteristics.
Abstract: An unusual clinical presentation of chronic active hepatitis is the abrupt onset of symptoms and jaundice, suggesting acute viral hepatitis. In this report, six patients had the acute onset of a severe liver disease. Five of the patients were female and ranged in age from 13 to 64 years. Marked elevations in the total bilirubin (17.1 +/- 11.4 mg/dl), AST (1,346 +/- 352 mIU/ml), and ALT (1,043 +/- 213 mIU/ml) were present (mean +/- SD). Negative serologies for hepatitis A and B were found. Liver histology showed severe hepatocellular injury. A diagnosis of autoimmune chronic active hepatitis with acute features was made on the basis of high titers of antinuclear antibody and smooth muscle antibody and the presence of hypergammaglobulinemia. As immunosuppressive therapy is a beneficial treatment of autoimmune chronic active hepatitis, an acute presentation of this liver disease should be considered as an alternative diagnosis to acute non-A, non-B hepatitis in patients with these clinical characteristics.

Journal ArticleDOI
TL;DR: It is suggested that metronidazole may be useful in the maintenance of remission in patients with ulcerative colitis, but that it is ineffective in the therapy of the acute attack.
Abstract: In a double-blind, randomized trial, we tested the effectiveness of metronidazole (0.6 g/day) against sulfasalazine (2 g/day) in the maintenance of remission in patients with ulcerative colitis. The patients were in remission for 1-11 months at entry to trial, which lasted for 12 months. Forty patients entered the trial and 33 completed it. Metronidazole was found to be slightly more effective than sulfasalazine, a difference statistically significant only at 12 months. Six patients also completed a crossover trial. Remission was maintained for 12 months in 3 patients by metronidazole and in none of the 6 by sulfasalazine. No significant side effects were noted, and in particular, no paresthesias were reported. This trial, as well as our previous one, suggests that metronidazole may be useful in the maintenance of remission in patients with ulcerative colitis, but that it is ineffective in the therapy of the acute attack.


Journal ArticleDOI
TL;DR: Achalasia remains an elusive diagnosis in current practice, and errors in diagnosis are related to delay in obtaining appropriate studies or misinterpretation of such studies, and this delay leads to persistent symptoms and ineffective and/or inappropriate therapies.
Abstract: An impression that achalasia remains an elusive diagnosis led us to review our recent experience From August 1, 1985 to March 31, 1987, we saw 25 patients with "previously untreated" achalasia for consultation and/or treatment Data was extracted from review of their records Achalasia was the initial diagnosis in only 12 patients The others were given diagnoses of gastroesophageal reflux (4), presbyesophagus (2), esophageal spasm (2), psychiatric disorders (2), and combination of various disorders (3) In the latter patients, various diagnostic studies were either inappropriately delayed or misinterpreted, so that incorrect diagnoses were given Errors in diagnosis led to further inappropriate testing and therapies We conclude that: (a) achalasia remains an elusive diagnosis in current practice, (b) errors in diagnosis are related to delay in obtaining appropriate studies or misinterpretation of such studies, and (c) this delay leads to persistent symptoms and ineffective and/or inappropriate therapies

Journal Article
TL;DR: The narcotic bowel syndrome is an often overlooked diagnosis in many clinical settings and its etiology, presentation, and treatment are reviewed.
Abstract: In this editorial, we review the narcotic bowel syndrome, its etiology, presentation, and treatment. We suggest this is an often overlooked diagnosis in many clinical settings.

Journal ArticleDOI
TL;DR: An enterovesical fistula in Crohn's disease rarely leads to serious complications and can often be treated successfully with medical therapy alone: by itself, it need not serve as an indication for surgery.
Abstract: We reviewed the course of 500 patients with Crohn's disease to document the incidence, the nature, and the results of management of fistulas to the bladder. Seventeen patients (14 men and three women) had developed enterovesical fistulas; 16 had pneumaturia. The barium radiographs demonstrated the fistula in only 37%. All had received sulfasalazine, and most were treated with corti-costeroids and antibiotics intermittently; two had successful control of their urinary symptoms on this regimen. Eight patients who received 6-mercaptopurine (6-MP) in addition tolerated the urinary fistula well, so that we encourage a trial of 6-MP for this complication of Crohn's disease. Six patients continue on medical therapy alone after a mean of 5.3 years. There were no instances of pyelonephritis during 60 patient years. Eleven patients eventually underwent bowel resection, but in only two was persistence of the enterovesical fistula the primary indication for elective surgery, and in both, it was the patient's choice. Visualization of the fistula on barium enema radiograph or presence of a connection between the sigmoid and the bladder were not associated with adverse outcome. An enterovesical fistula in Crohn's disease rarely leads to serious complications and can often be treated successfully with medical therapy alone; by itself, it need not serve as an indication for surgery.

Journal ArticleDOI
TL;DR: It is concluded that the hypertensive LES is a heterogenous disorder, despite abnormal LES parameters, most patients have normal esophageal function, and frequent psychological abnormalities may contribute to their report of symptoms.
Abstract: The hypertensive lower esophageal sphincter (LES) (mean LES pressure greater than 45 mm Hg; LES relaxation greater than 75%; normal peristalsis) is a poorly characterized motility disorder associated with chest pain and dysphagia. Therefore, we carried out a multidisciplinary study to assess esophageal pressures and function in 15 symptomatic hypertensive LES patients (3 men, 12 women; mean age, 53 years). On-line computer analysis showed a significant (p less than 0.05) increase in LES pressure (55.5 versus 14.9 mm Hg) and residual pressure (6.8 versus 1.1 mm Hg) as well as a decrease in percentage of LES relaxation (87 versus 93%) in patients compared with age-matched controls. All patients had normal peristalsis but 7 of 15 had nutcracker esophagus (mean distal amplitude, 216 mm Hg). No patient had evidence of impaired liquid transport on barium esophagram. The emptying of solids as assessed by radionuclide scans was normal in 14 of 15 patients. Of the 12 patients who completed both psychological inventories, nine had elevated scores on scales assessing anxiety and somatization. The heterogenous nature of this disorder is illustrated by a patient with a changeable narrowing in the distal esophagus associated with the transient impaction of a marshmallow. Dysphagia but not chest pain improved after pneumatic dilatation. We conclude that the hypertensive LES is a heterogenous disorder. Despite abnormal LES parameters, most patients have normal esophageal function, and frequent psychological abnormalities may contribute to their report of symptoms. A minority have abnormal esophageal transit.

Journal ArticleDOI
TL;DR: A recent patient is reported with a retrograde gastrojejunal intussusception, the most common of the four anatomic variants of jejunogastric intussUSception.
Abstract: Jejunogastric intussusception is a rare complication following gastrojejunostomy, Bilroth II partial gastrectomy, and Roux-en-Y gastrojejunostomy. We report a recent patient with a retrograde gastrojejunal intussusception, the most common of the four anatomic variants of jejunogastric intussusception. It may present acutely as a surgical emergency with ischemic small bowel or chronically, with severe postprandial discomfort. Surgical correction is mandatory although controversy exists as to the most appropriate corrective procedure.