Showing papers on "Abdominal pain published in 1997"

Sclerosing mesenteritis, mesenteric panniculitis and mesenteric lipodystrophy: a single entity?

Abstract: We reviewed 84 cases coded as mesenteric lipodystrophy (ML), mesenteric panniculitis (MP), or retractile mesenteritis and sclerosing mesenteritis (SM), grading fibrosis, inflammation, and fat necrosis, and evaluating clinical subgroups. There was no gender or racial predominance. Patient age range was 23-87 years (average 60). Patients most often presented with abdominal pain or a palpable mass. A history of trauma or surgery was present in four of 84 patients. The most common site of involvement was the small bowel mesentery as a single mass (58 of 84) with an average size of 10 cm, multiple masses (15 of 84), or diffuse mesenteric thickening (11 of 84). All patients had some degree of fibrosis, chronic inflammation, and fat necrosis. Although a few patients showed a sufficient prominence of fibrosis, inflammation, or fat necrosis to permit a separation into SM, MP, or ML, respectively, in most patients these three components were too mixed for a clear separation. The clinical, demographic, and gross features did not help in defining these three entities. Contributors diagnosed 12 as sarcoma. Of 39 patients followed beyond the postoperative period, none died of these lesions. We conclude that SM, MP, and ML appear to represent histologic variants of one clinical entity, and in most cases "sclerosing mesenteritis" is the most appropriate diagnostic term.

Development and validation of the pain response inventory for children.

Abstract: The Pain Response Inventory (PRI) was developed as a multidimensional instrument to assess children's coping responses to recurrent pain. The PRI assesses 3 broad coping factors—Active, Passive, and Accommodative—each with subscales representing specific strategies for coping with pain. Confirmatory factor analysis was used to derive and cross-validate the factor structure of the PRI in 3 different samples of children and adolescents: school children, abdominal pain patients, and former abdominal pain patients. The subscales were found to be internally consistent and reasonably stable. Validity of the subscales was assessed by examining the relations of particular coping strategies to various outcome indicators, including functional disability, somatization symptoms, and depressive symptoms. Results indicated that different types of health outcome were predicted by different patterns of PRI coping strategies, thus supporting the utility of a multidimensional approach to the assessment of coping responses to pain. With the formulation of the gate-control theory of pain (Melzack & Wall, 1965), it became generally recognized that the experience of pain is not a purely sensory phenomenon related to tissue damage. Rather, it is also influenced by cognitive, behavioral, and emotional factors. This model suggests that effective pain management cannot rely solely on interventions directed at the source of tissue damage but also must include interventions designed to modify psychosocial factors that affect nociceptive processing (McGrath & Hillier, 1996). This multidimensional model of pain has been the impetus for the rapid growth in behavioral science research on pain in the past two decades. Cognitive and behavioral responses to pain, often studied under the rubric of "coping with pain," are of particular interest because they may be amenable to change through interventions by health professionals. Moreover, such coping responses may significantly lessen pain and associated disability and thereby complement and even decrease the need for more invasive pharmacological or surgical interventions. Studies of adult pain patients suggest that certain coping strategies (typically ' 'passive'' strategies, such as taking to bed, restricting one's activities, or

Stress-induced Visceral Hypersensitivity to Rectal Distension in Rats: Role of CRF and Mast Cells

Abstract: BACKGROUND Psychological factors have long been implicated in the aetiology of irritable bowel syndrome often associated with abdominal pain. This work was designed to study, in rats, the influence of partial restraint stress on the abdominal cramps induced by rectal distension and to determine the role of corticotropin releasing factor (CRF) and mast cells degranulation in this response. METHODS Abdominal contractions were electromyographically recorded. Thirty minutes after stress or intracerebroventricular CRF, rectal distension was performed by inflation of a balloon (0.4-1.2 mL). alpha-helical CRF9-41 or doxantrazole were administered centrally (15 min) and intraperitoneally (30 min), respectively, before stress. Histamine release and the number of mast cells were determined in colonic pieces from stressed and control rats. RESULTS Stress and CRF enhanced the number of abdominal cramps evoked by rectal distension without affecting rectal compliance. alpha-helical CRF9-41 and doxantrazole antagonized the stress and CRF-induced enhancement of abdominal cramps. Stress increased the colonic histamine content whereas the number of colonic mast cells was unchanged. CONCLUSIONS Stress enhances abdominal contractions in response to rectal distension in rats via pathways involving central CRF and intestinal mast cells.

Clinical characteristics of chronic idiopathic intestinal pseudo-obstruction in adults

Abstract: Background —Chronic idiopathic intestinal pseudo-obstruction, a syndrome of ineffectual motility due to a primary disorder of enteric nerve or muscle, is rare. Aims —To determine the clinical spectrum, underlying pathologies, response to treatments, and prognosis in a consecutive unselected group of patients. Methods —Cross sectional study of all patients with clinical and radiological features of intestinal obstruction in the absence of organic obstruction, associated with dilated small intestine (with or without dilated large intestine), being actively managed in one tertiary referral centre at one time. Results —Twenty patients (11 men and nine women, median age 43 years, range 22–67) fulfilled the diganostic criteria. Median age at onset of symptoms was 17 years (range two weeks to 59 years). Two patients had an autosomally dominant inherited visceral myopathy. Major presenting symptoms were pain (80%), vomiting (75%), constipation (40%), and diarrhoea (20%). Eighteen patients required abdominal surgery, and a further patient had a full thickness rectal biopsy. The mean time interval from symptom onset to first operation was 5.8 years. Histology showed visceral myopathy in 13, visceral neuropathy in three, and was indeterminate in three. In the one other patient small bowel motility studies were suggestive of neuropathy. Two patients died within two years of symptom onset, one from generalised thrombosis and the other from an inflammatory myopathy. Of the remaining 18 patients, eight were nutritionally independent of supplements, two had gastrostomy or jejunostomy feeds, and eight were receiving home parenteral nutrition. Five patients were opiate dependent, only one patient had benefited from prokinetic drug therapy, and five patients required formal psychological intervention and support. Conclusions —In a referral setting visceral myopathy is the most common diagnosis in this heterogeneous syndrome, the course of the illness is usually prolonged, and prokinetic drug therapies are not usually helpful. Ongoing management problems include pain relief and nutritional support.

Enteric-coated peppermint-oil capsules in the treatment of irritable bowel syndrome: A prospective, randomized trial

Abstract: To determine the efficacy and tolerability of an enteric-coated peppermint-oil formulation (Colpermin), we conducted a prospective, randomized, double-blind, placebo-controlled clinical study in 110 outpatients (66 men/44 women; 18-70 years of age) with symptoms of irritable bowel syndrome. Patients took one capsule (Colpermin or placebo) three to four times daily, 15-30 min before meals, for 1 month. Fifty-two patients on Colpermin and 49 on placebo completed the study. Forty-one patients on Colpermin (79%) experienced an alleviation of the severity of abdominal pain (29 were pain-free); 43 (83%) had less abdominal distension, 43 (83%) had reduced stool frequency, 38 (73%) had fewer borborygmi, and 41 (79%) less flatulence. Corresponding figures for the placebo group were: 21 patients (43%) with reduced pain (4 were pain-free), 14 (29%) with reduced distension, 16 (32%) with reduced stool frequency, 15 (31%) with fewer borborygmi, and 11 (22%) with less flatulence. Symptom improvements after Colpermin were significantly better than after placebo (P < 0.05; Mann-Whitney U-test). One patient on Colpermin experienced heartburn (because of chewing the capsules) and one developed a mild transient skin rash. There were no significant changes in liver function test results. Thus, in this trial, Colpermin was effective and well tolerated.

Ultrasonography and computed tomography reduce unnecessary surgery in abdominal rectus sheath haematoma.

Abstract: Background Rectus sheath haematoma is a rare cause of abdominal pain. If accurately diagnosed, surgery can be avoided in most cases. This study assessed the role of ultrasonography and computed tomography (CT) in the diagnosis of rectus sheath haematoma. Methods Thirty cases of rectus sheath haematoma diagnosed over 18 years were reviewed. Mean patient age was 59 years; there were 20 women and ten men. The results of imaging investigations were reviewed to determine their efficiency. Ultrasonography was performed in 21 patients and CT in nine. Results Arterial hypertension, anticoagulant therapy and strained coughing were the most frequent predisposing factors. The most common clinical manifestation was abdominal pain with a palpable mass. Leucocytosis occurred in 18 patients and the haematocrit fell in 13 patients but markedly in seven. Ultrasonography was diagnostic in 15 of 21 patients imaged, and CT was diagnostic in all nine. Treatment was conservative in 22 patients. Eight patients required surgery: four for diagnosis and four for treatment. Conclusion Surgery can be avoided in most patients with rectus sheath haematoma. Although the numbers were small, CT appeared to be more accurate than ultrasonography in facilitating the diagnosis.

The Treatment of Chronic Constipation in Adults

Abstract: To evaluate whether laxatives and fiber therapies improve symptoms and bowel movement frequency in adults with chronic constipation. English language studies were identified from computerized MEDLINE (1966-1995), Biological Abstracts (1990-1995), and Micromedex searches; bibliographies; textbooks; laxative manufacturers; and experts. Randomized trials of laxative or fiber therapies lasting more than 1 week that evaluated clinical outcomes in adults with chronic constipation Two independent reviewers appraised each trial's characteristics including methodologic quality. There were 36 trials involving 1,815 persons from a variety of settings including clinics, hospitals and nursing homes. Twenty-three trials were 1 month or less in duration. Several laxative and fiber preparations were evaluated. Twenty trials had a placebo, usual care, or discontinuation of laxative control group, and 16 directly compared different agents. Laxatives and fiber increased bowel movement frequency by an overall weighted average of 1.4 (95% confidence interval [CI] 1.1-1.8) bowel movements per week. Fiber and bulk laxatives decreased abdominal pain and improved stool consistency compared with placebo. Most nonbulk laxative data concerning abdominal pain and stool consistency were inconclusive, though cisapride, lactulose, and lactitol improved consistency. Data concerning superiority of various treatments were inconclusive. No severe side effects for any of the therapies were reported. Both fiber and laxatives modestly improved bowel movement frequency in adults with chronic constipation. There was inadequate evidence to establish whether fiber was superior to laxatives or one laxative class was superior to another.

Gut stromal tumors and their clinical behavior

Abstract: Background Gut stromal tumors (GST) are a group of intramural intestinal tumors formerly known as leiomyoma and leiomyosarcoma. To improve the understanding of GST behavior, we posed the following questions: What are the clinical sequelae? Do size and symptoms correlate? What are the indications for excision? Methods A retrospective analysis (1988 to 1996) of the clinical course for GST patients was completed including long-term follow-up. Results We found 39 patients with GST during the last 8 years. Their average age was 65 years and 59% were male. Tumors were found in the small bowel or stomach in 95% of cases. All patients were treated by surgical excision. Histologic grading yielded a benign diagnosis in 77%. Tumors were found incidentally at laparotomy in 41% and had an average size of 1.5 cm. In contrast, 59% of GST patients were symptomatic and the average size was 6 cm. In these 23 symptomatic patients, gastrointestinal bleeding occurred in 70%, of which acute hemorrhage was seen in 69–82% of them required transfusion and half required emergent operation. Additional findings in the symptomatic group included abdominal pain (57%), bowel obstruction (30%), and perforation (9%). An average long-term follow-up of 2.5 years was obtained in all patients (n = 34, 5 had died of other causes). Local recurrence was seen in 2 patients, metastatic disease in 2 other patients, and 30 (88%) were disease free. No patient with a GST discovered incidentally has had it recur. Conclusion Gut stromal tumors are uncommon yet cause significant patient morbidity. Small GST (2 cm) were asymptomatic but larger GST were usually symptomatic. Most GST behaved in a benign fashion after local resection. Due to the frequency of serious complications in symptomatic patients, complete excision is recommended for GST, even if incidentally discovered.

The use of analgesics in patients with acute abdominal pain

Abstract: Analgesics in patients with acute abdominal pain are often withheld for fear that they may change physical examination findings and thus may be unsafe. We conducted a randomized, prospective, placebo-controlled trial to investigate changes in physical examination following the administration of placebo, 5 mg, or 10 mg of morphine to 49 patients with acute abdominal pain. One patient was withdrawn secondary to inadequate documentation. Of the 48 patients who completed the trial, a statistically significant change in physical examination was noted in both groups receiving analgesics, but not in the placebo group. No adverse events or delays in diagnosis were attributed to the administration of analgesics. We conclude that physical examination does change after the administration of analgesics in patients with acute abdominal pain and that a larger study is needed to evaluate analgesic safety in this subpopulation of emergency department patients.

The acute abdomen in the pregnant patient. Is there a role for laparoscopy

Abstract: Background: The acute abdomen in the pregnant patient poses a difficult diagnostic and therapeutic challenge to the surgeon. Appendicitis, cholecystitis, and bowel obstruction account for the majority of the abdominal pain syndromes which require surgical intervention. Laparoscopy is being used increasingly in the diagnosis and operative management of these disorders.

Current Results of Surgical Therapy for Chronic Mesenteric Ischemia

Abstract: Background: Although recognition of chronic mesenteric ischemia has increased in recent years, this disorder has continued to present diagnostic and therapeutic challenges. Objective: To examine the modern results of surgical revascularization for chronic mesenteric ischemia. Design: Retrospective review. Setting: University medical center. Patients: The management of 24 consecutive patients (mean±SEM age, 58±3 years; 5 men, 19 women) who were undergoing surgical treatment of chronic mesenteric ischemia between 1986 and 1996 was reviewed. Intervention: Surgical mesenteric revascularization. Main Outcome Measures: Postoperative course, long-term graft patency rate, and long-term symptom-free survival rate. Results: The most frequent presenting symptoms were postprandial abdominal pain (18 patients [75%]) and weight loss (14 patients [58%]). Less specific complaints included nausea and vomiting (8 patients [33%]), diarrhea (7 patients [29%]), and constipation (4 patients [17%]). Atherosclerotic risk factors were common, including tobacco use (20 patients [83%]), coronary artery disease (10 patients [42%]), and hypertension (10 patients [42%]). The cause was identified as atherosclerosis in 21 patients, median arcuate ligament compression in 2 patients who were monozygotic twins, and Takayasu arteritis in 1 patient. Lesions were localized to all 3 major visceral vessels (celiac artery, superior mesenteric artery [SMA], and inferior mesenteric artery) in 8 patients, celiac artery and SMA in 13, SMA alone in 2, and SMA and inferior mesenteric artery in 1. Seventeen patients underwent antegrade reconstructions from the supraceliac aorta to the SMA and/or celiac artery; 7 patients underwent revascularization by use of a retrograde bypass that originated from the infrarenal aorta or a prosthetic graft. There were no perioperative deaths although 1 patient died in the hospital 6 weeks after early graft failure and sepsis (overall in-hospital mortality, 4%). Follow-up ranged from 3 months to 10 years (median, 2.4years). The mean±SEM 5-year primary graft patency rate, as objectively documented by use of contrast angiography or duplex scanning in 19 of 24 patients, was 78%±11%. Primary failure was documented in 3 patients (at 3 weeks, 5 months, and 7 months). Two patients required a thrombectomy; 1 of these patients subsequently died of an intestinal infarction. The mean±SEM 5-year survival rate by use of life-table analysis was 71%±11%. No patient with a patent graft experienced a symptomatic recurrence. Conclusions: Chronic mesenteric ischemia is usually a manifestation of advanced systemic atherosclerosis. Symptoms almost always reflect midgut ischemia in the distribution of the SMA. An antegrade bypass from the supraceliac aorta can be performed with acceptable operative morbidity and is currently the preferred reconstructive technique. Surgical revascularization affords long-term symptom-free survival in a majority of patients with chronic mesenteric ischemia. Arch Surg. 1997;132:613-619

ABC of palliative care: Constipation and diarrhoea

Abstract: #### Constipation ##### Definition ##### Associated symptoms ##### Symptoms of complications Constipation can be defined as the passage of small hard faeces infrequently and with difficulty. Constipation is more common in patients with advanced cancer than in those with other terminal diseases, and many of the associated symptoms may mimic features of the underlying disease. About half of patients admitted to specialist palliative care units report constipation, but about 80% of patients will require laxatives. ### History Assessment of constipation must include establishing in what way the present pattern of bowel movements is different from the normal pattern and a physical examination, including general observation, abdominal palpation, and rectal or stomal examination An accurate history is essential for effective management. Inquiry should be made about the frequency and consistency of stools, nausea, vomiting, abdominal pain, distention and discomfort, mobility, diet, and any other symptoms. In patients with a history of diarrhoea, care should be taken to distinguish true diarrhoea from overflow due to faecal impaction. Careful questioning about access to a toilet or commode is important. Limited mobility may mean that using the toilet or commode is avoided. Other issues, such as lack of privacy or the need for nurses or carers to help with toileting, can exacerbate constipation. ### Examination A constipated patient may have malodorous breath, or the smell of faecal leakage may be obvious. Bacterial degradation of hard stools can result in leakage, of which the patient has no warning. General observation may reveal that a patient is in pain, confused or disorientated, or unable to reach the toilet. Abdominal distension, visible peristalsis, and borborygmi can suggest obstruction. Radiograph of constipated patient showing stool masses and trapped gas Palpation may reveal an easily palpable colon with indentable and mobile (and rarely tender) …

A longitudinal study of pain: reported pain from middle age to old age.

Abstract: OBJECTIVE Describe patterns of pain reporting over a span of 24 years. DESIGN Individuals were interviewed on four occasions (1968, 1974, 1981, 1992). PARTICIPANTS Representative sample (n = 321) of the Swedish population aged 53-63 at baseline. MEASURES Self-reported pain in the chest, abdomen, and musculoskeletal system (back or hips, shoulders, hands, elbows, legs, or knees). RESULTS Less than 1% reported chest or abdominal pain on all four occasions. Whereas 21.8% of the sample reported musculoskeletal pain on all four occasions. More than half of the sample reported some kind of pain on three or four occasions. Women reported more severe and more persistent pain compared with men. There were more people who developed pain during the 24-year period than there were who became pain free. An increase in pain was equally common for chest and musculoskeletal pain, but a decrease in pain was much more common for musculoskeletal pain than chest pain. CONCLUSIONS Cross-sectional studies have shown differing age patterns in pain. This longitudinal study demonstrates different patterns for men and women and for different pain localities.

Splenic Abscess: Another Look at an Old Disease

Abstract: Objective: To study the changes in the incidence, causes, bacteriologic profile, and management of a splenic abscess. Design: Retrospective case study. Setting: Tertiary, university referral center. Patients: Thirty-nine patients with a splenic abscess. Interventions: None. Main Outcome Measures: Demographics, signs and symptoms, causes, risk factors, diagnostic methods, bacteriologic profile, treatment, and outcome. Results: Patients presented at a mean age of 43 years (range, 2-83 years), after a mean symptomatic period of 16 days, with fever (69%), abdominal pain (56%), nausea and vomiting (38%), and splenomegaly (31%). The majority of abscesses represented metastatic infection (n= 19), and 11 were secondary to immunosuppression. Twelve patients had human immunodeficiency virus disease and 9 used intravenous drugs. In patients who underwent computed tomography, all had abnormal scans (n=33), with a well-defined abscess(es) in 28. Nine abscesses were polymicrobial; monomicrobial isolates included gram-positive organisms (23%), gram-negative organisms (31%), fungi (23%), and mycobacteria (23%). Patients presenting before 1989 (1981-1988) (n=15) and those presenting after 1989 (1989-1996) (n=24) differed in risk factors (intravenous drug abuse, 0% vs 47% [P=.02]; hematologic malignancy, 43% vs 9% [P=.04]) and gram-positive isolates (18% vs 64%;P=.06). Patients underwent splenectomy (n= 18), open drainage (n=4), medical therapy (n= 10), or percutaneous drainage (n=5) with respective survival rates of 94%, 50%, 70%, and 100%. Conclusions: In 1996, splenic abscesses are increasingly common. Intravenous drug abuse and human immunodeficiency virus disease are significant risk factors, and the diagnosis should be considered in a patient with fever and abdominal pain who uses intravenous drugs. Antimicrobial agents should be broad since 36% of abscesses were polymicrobial, and should include coverage of gram-positive organisms. Arch Surg. 1997;132:1331-1336

CT findings at lupus mesenteric vasculitis.

Abstract: Purpose: To describe the spectrum of early CT findings of lupus mesenteric vasculitis (LMV) and to assess the utility of CT in the management of this uncommon entity.Methods: Abdominal CT was performed within 1–4 days (average 2.2 days) of the onset of severe abdominal pain and tenderness in 15 women with systemic lupus erythematosus. Prompt high-dose i.v. corticosteroid was administered in 11 patients after the CT diagnosis of LMV was made. CT was performed after abdominal symptoms subsided.Results: Eleven cases revealed CT features suggestive of LMV including conspicuous prominence of mesenteric vessels with palisade pattern or comb-like appearance (CT comb sign) supplying focal or diffuse dilated bowel loops (n=11), ascites with slightly increased peritoneal enhancement (n=11), small bowel wall thickening (n=10) with double halo or target sign (n=8). Follow-up CT before high-dose steroid therapy revealed complete or marked resolution of the abnormal CT findings.Conclusion: CT is helpful for confirming ...

Do patients with irritable bowel syndrome in primary care really differ from outpatients with irritable bowel syndrome

Abstract: Background —Little is known about the comparability of outpatients with irritable bowel syndrome (IBS) and patients with IBS in primary care with regard to severity of complaints, perceived limitations, other aspects of the complaints, and sex differences. Aims —To compare outpatients with IBS with primary care patients with IBS. Patients —One hundred and nine patients with IBS were recruited from general practices in Amsterdam and 86 patients with IBS were recruited from the outpatient clinic of the Department of Internal Medicine of the University Hospital in Nijmegen. Methods —Each patient completed a questionnaire on demographic variables, abdominal complaints, related complaints, and attributed causes of their abdominal complaints. The scores of the two groups were compared by univariate and multivariate analysis. Results —The outpatient group contained significantly more men, reported more severe abdominal pain, more frequent complaints, more interference with daily activities, and a higher degree of avoidance of activities (p Conclusions —Female outpatients consider their complaints to be more serious and interfering than do patients with IBS in primary care. Male outpatients were comparable to primary care patients with IBS. More research needs to be done into sex specific differences in IBS and into the factors that influence the decision to refer a patient with IBS.

Constipation-related symptoms and bowel program concerning individuals with spinal cord injury

Abstract: Purpose. To determine the prevalence of constipation-related symptoms in individuals with chronic spinal cord injury (SCI), to describe the bowel program as reported by patients and including use of bowel medications and evacuation techniques, and to examine the clinical, functional and pharmacological risks of difficulty with evacuation. Patients and Methods. This is a cross-sectional study of all in-patients at least 3 months beyond acute injury, on the West Roxbury/Brockton VAMC SCI Service, during a 10 month period (n=197). Clinical, functional, and medication data were abstracted from medical and nursing records. Individual interviews were conducted with all available participants (n=161, 82%) regarding bowel-related symptoms and treatment over the previous 1 month period. The study definition of difficulty with evacuation was spending more than 1 h per episode of bowel evacuation. Results. Forty-one percent of the 161 interview responders spent more than 1 h on bowel evacuation, 50% reported abdominal distension and 38% reported abdominal pain, 27% reported headaches or sweats relieved by having a bowel movement, and 33% reported fecal incontinence at least once a month. The bisacodyl suppository was the most commonly used laxative agent, while docusate was the most popular oral agent. Subjects with difficulty with evacuation (n=66) were compared with those who spent less than 1 h on evacuation (n=95). Factors associated with difficulty with evacuation were tetraplegia, Frankel grade A/B, laxative use, polypharmacy, previous urinary outlet surgery, and symptoms of abdominal pain and distension. Conclusion. Constipation-related symptoms are highly prevalent in individuals with spinal cord injury, despite considerable laxative use. Our findings suggest that difficulty with evacuation can be predicted on the basis of a patient's clinical profile.

Segmental arterial mediolysis studied by repeated angiography.

Abstract: Segmental arterial mediolysis (SAM) is a rare disease of unknown aetiology. We report the fourteenth case of SAM, but the first to demonstrate serial changes on arteriography. A 65-year-old woman with abdominal pain underwent laparotomy with resection of an abnormally beaded and narrowed segment of the right branch of the middle colic artery. Characteristic pathological findings of lysis of the arterial media with dissecting haematomas were present. Other than some post-prandial pain, the patient's post-operative course was uneventful. Serial arteriography showed various abnormalities in the trunk and branches of the superior mesenteric artery. Changes in the vessels consisted of three phases, i.e. dilatation, beading with narrowing and restoration of the smooth wall, with various modifications such as aneurysmal enlargement and occlusion.

Efficacy of diclofenac in lateral epicondylitis of the elbow also treated with immobilization. The University of Montreal Orthopaedic Research Group.

Abstract: Objective To evaluate the efficacy of an oral nonsteroidal anti-inflammatory drug in the treatment of lateral epicondylitis. Design Multicenter double-blind randomized controlled trial in which the following hypothesis was tested: whether diclofenac sodium provided a 20% or greater improvement over rest and cast immobilization in the response rate to treatment of lateral epicondylitis beyond and over rest in an experimental group compared with a control group after 4 weeks of treatment. Setting Recruitment from urban general practices and referrals to 4 university hospitals. Subjects and methods During a 1-year period, 206 subjects aged 18 to 60 years with lateral epicondylitis were recruited from the clientele treated by family physicians. Thirty subjects refused to participate and 47 presented with exclusion criteria, leaving 129 subjects who entered the study. One subject withdrew after 21 days. Interventions The experimental group was treated with a daily dose of diclofenac sodium (150 mg) for 28 days, while the control group received a placebo during the same period. In addition, both groups were immobilized in a cast for 14 days and were told not to perform repetitive movements of the involved limb for 21 days. Main outcome measures Measuring instruments consisted of grip strength measurements with a squeeze dynamometer, a visual analog pain scale, a visual analog function scale, and an 8-item pain-free function index. Results A statistically and clinically significant reduction of pain was associated with treatment with diclofenac, but no clinically significant difference in grip strength or functional improvement could be detected between the 2 groups. Secondary effects (diarrhea and abdominal pain) were significantly more frequent in the diclofenac-treated group. Conclusion Taking into account the limited improvement noted over rest and cast immobilization and the number of associated adverse events, it is difficult to recommend the use of diclofenac in the treatment of lateral epicondylitis at the dosage used in this study.

Emergency department evaluation of geriatric patients with acute cholecystitis.

Abstract: Objective: To estimate the frequency of abnormal clinical symptoms, laboratory tests, and diagnostic imaging studies in the ED assessment of elderly (≥65 yr) patients with acute cholecystitis, and to compare these factors in the young-old (65–74 yr), middle-old (75–84 yr), and old-old (≥85 yr) population groups. Methods: A retrospective, cross-sectional study was performed by review of ED records, hospital charts, and surgical operative reports of consecutive elderly ED patients determined at surgery to have acute cholecystitis. Records were reviewed between April 1990 and April 1995 at a large Midwestern tertiary care facility with 65,000 annual ED patient visits. Clinical signs and symptoms were compared in the young-old, middle-old, and old-old population groups. Results: Of the 168 patients reviewed, 141 (84%) had either epigastric or right upper quadrant abdominal pain, and 8 (5%) had no pain whatsoever. Only 61 patients (36%) had back or flank pain radiation. Ninety-six (57%) experienced nausea, 64 (38%) had emesis, and 13 (8%) had visible jaundice. Ninety-four (56%) patients were afebrile and 69 (41%) had no increase of white blood cell count. Twenty-two (13%) patients had no fever and all tests were normal. No statistical difference was noted in any symptom or laboratory factor for the 3 age groups, except jaundice was more common among the patients aged ≥85 years. Ultra-sonography was diagnostic for 91%, and CT was beneficial for only 1 patient. Eight patients had normal results on their ultrasonographic and CT studies. Conclusion: Classic symptoms and abnormal blood test results are frequently not present in geriatric patients with acute cholecystitis. Increasing age does not appear to affect the clinical and test markers used by clinicians to diagnose this illness. A high degree of awareness is essential for correct diagnosis of acute cholecystitis in geriatric patients.

Double‐blind study of the effect of cisapride on constipation and abdominal discomfort as components of the irritable bowel syndrome

Abstract: Aim: To study the effect of prokinetic treatment with cisapride in patients with constipation-predominant irritable bowel syndrome. Patients and methods: Ninety-six patients were randomly assigned to treatment with either cisapride 5 mg three times daily or placebo three times daily for a period of 12 weeks. The dosage could be doubled after 4 weeks. Presence of the target symptoms abdominal pain, constipation and abdominal bloating was an obligatory criterion for inclusion in the study. Results: After 12 weeks of treatment, 31%, 56% and 27% of the cisapride treated patients were found to be without the three target symptoms (P<0.05). The corresponding percentages for the placebo-treated patients were 31%, 58% and 19%, respectively, (P<0.05). The visual analogue scale (VAS) symptom scores assessed by the patients for global rating of bowel disease, general well-being and frequency of stool passage improved significantly within each treatment group (P<0.05). Evaluation of efficacy parameters using intention-to-treat analysis showed no statistically significant differences between the groups. Using efficacy analysis, the difficulty of stool passage showed a significantly higher improvement with cisapride (P0.05). Conclusions: These results indicate that cisapride is not superior to placebo in the treatment of constipation and abdominal discomfort as components of irritable bowel syndrome. It may, hovever, be of use in improving the difficulty of stool passage.