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Biomedical subjects

D B Sachar

Publications and source records attributed to D B Sachar.

At least 73 records · Page 4Linked to original sources
PubMed1989

Gastric fistulas in Crohn's disease. Report of cases.

Nine cases of gastric fistula occurring in patients with Crohn's disease were treated at The Mount Sinai Hospital over the past three decades. Six cases were found in a review of 1480 patients with Crohn's disease admitted between 1960 and 1983. Three others seen at this institution outside the time frame of the author's study have also been included. Among six new cases, five with cologastric fistula occurred among 907 patients with Crohn's disease involving the colon (0.6 percent), while only one with ileogastric fistula was encountered among 1211 patients with ileal disease (0.08 percent). Fistulas between the stomach and colon always originated in an area of colitis, usually passing from distal transverse colon to greater curvature, but occasionally from midtransverse colon to antrum. The only pathognomonic clinical features were feculent vomiting, eructations, or odor. Diagnosis usually was made by barium enema or, less frequently, by upper gastrointestinal series; rarely, the gastric fistula was found unexpectedly at surgery. The conventional and recommended therapy is colectomy with wedge excision of the stomach. Medical treatment with 6-mercaptopurine has been completely successful in one patient and intermittently successful in a second patient.

Adult↗
PubMed1989

Of mice and men: lessons on Crohn's disease and the spirit of scientific inquiry.

Over the past 10 years, Kiron Das and his associates have developed an animal model for the study of a putative Crohn's disease (CD)-specific antigen. Athymic T-cell deficient nu/nu mice inoculated with intestinal and lymph node tissue filtrates from patients with CD sometimes develop lymphomas and/or lymph node plasma cell hyperplasia. Patients with CD often have an antibody that reacts with an antigen contained in these murine lymphomas and hyperplastic lymph nodes. This antibody is found in the sera of about one-third to one-half of CD patients, but it is rarely found in ulcerative colitis (UC) patients and almost never in other controls. This issue of the Journal of Clinical Gastro-enterology contains Das's most recent clinical study on the subject, indicating that this serum antibody was present in 11 of 29 CD patients (38%), in only 4 of 25 UC patients (16%), and in almost no disease controls or normal subjects. Das's immunofluorescent assay is not yet sufficiently sensitive, specific, or convenient to be widely applicable as a routine serodiagnostic tool in clinical practice, but it could be enormously important if it proved in fact to be a marker for a CD-specific antigen. Other laboratories, however, have sharply questioned the specificity of this antigen, whose pathogenetic significance therefore remains controversial.

Animals↗
PubMed1989

Sera-reactivity in inflammatory bowel disease: frequency of recognition of Crohn's disease tissue primed nude mouse lymphoid tissue in an interinstitutional blinded study.

We used a double-blinded interinstitutional study with an indirect immunofluorescence assay to evaluate the immunoreactivity of Crohn's disease (CD) sera against hyperplastic and malignant lymph nodes from nude mice primed with CD tissue filtrates. We assessed the reactivity for potential usefulness as a serodiagnostic test by using sera from different clinical subgroups of patients with inflammatory bowel disease. The immunoreactivity of 86 coded sera from ambulatory patients treated at the Mount Sinai Medical Center were examined-29 from patients with CD, 25 from patients with ulcerative colitis (UC), 21 from disease controls, and 11 from normal controls. Each serum was tested at the Albert Einstein College of Medicine against lymph nodes from at least two of six nude mice inoculated with CD tissue filtrates or CD filtrate-induced lymphoma. There was positive immunofluorescent staining in 11 of 29 (38%) CD patients, 4 of 25 (16%) UC patients, 1 of 21 (4.8%) disease controls, and 0 of 11 normal volunteers. Statistically significant differences in immunoreactivity were seen between CD patients compared to non-inflammatory-bowel-disease controls (p = 0.007) and to normals (p = 0.02).

Animals↗
PubMed1988

Perforating and non-perforating indications for repeated operations in Crohn's disease: evidence for two clinical forms.

The surgical indications in 770 patients with Crohn's disease undergoing intestinal resection at The Mount Sinai Hospital from 1960-83 have been reviewed. Surgical indications were divided into two principal categories: 375 cases with perforating indications and 395 cases non-perforating. Among 292 patients who underwent second operations for recurrent Crohn's disease, the indications for second operation were closely dependent on the indication for primary resection. Second operations were undertaken for perforating indications much more often among cases where the initial indication had been perforating, than among those whose initial indications had been non-perforating (73% v 29%, p less than 0.00001). This trend to similarities in the indications which bring patients to surgery was maintained within each anatomical category of Crohn's disease and even between second and third operations (p less than 0.001). Operations for perforating indications were followed by reoperation approximately twice as fast as operations for non-perforating indications, whether going from first to second operation (perforating 4.7 v non-perforating 8.8 years, p less than 0.001), or from second to third (perforating 2.3 v non-perforating 5.2 years, p less than 0.005). Crohn's disease thus seems to occur in two different clinical patterns, independent of anatomic distribution. These are a relatively aggressive perforating type and a more indolent non-perforating type, which tend to retain their identities between repeated operations and to influence the speed with which reoperation occurs.

Adult↗
PubMed1988

Olsalazine in the treatment of ulcerative colitis among patients intolerant of sulphasalazine: a prospective, randomized, placebo-controlled, double-blind, dose-ranging clinical trial.

Sixty-six outpatients with active ulcerative colitis who were intolerant of sulphasalazine were treated in a double-blind randomized trial with placebo or olsalazine in daily doses of 0.75, 1.5, or 3 g. Overall, 35% of patients receiving olsalazine improved clinically, compared to 16% of patients receiving placebo. Statistically significant or nearly significant improvement was demonstrated in colitis activity by the end compared to the beginning of the study within the combined olsalazine group and within patient groups receiving olsalazine at daily doses of 1.5 g and 3 g. There were no differences between the treatment and placebo groups for any of the reported adverse effects or laboratory variables. The data suggest that olsalazine is effective for the treatment of ulcerative colitis and is well tolerated among patients intolerant to sulphasalazine.

Administration, Oral↗
PubMed1988

Extraintestinal manifestations in patients with diverticulitis.

Three patients had diverticulitis and extraintestinal manifestations of arthritis and pyoderma gangrenosum. In each, a mistaken diagnosis of idiopathic inflammatory bowel disease was first made because of extraintestinal complaints associated with the gastrointestinal symptoms of diverticular disease. The joint and skin manifestations were refractory to various treatments, including oral and intradermal steroids, immunosuppressive agents, and hyperbaric oxygen. Segmental resection of the involved colon promptly and completely resolved all symptoms, without recurrence 26 to 38 months after surgery. Microscopic examination of the resected specimens showed only diverticulitis without any evidence of chronic idiopathic inflammatory bowel disease. Patients with diverticulitis may have extraintestinal manifestations as do patients with other inflammatory diseases of the colon. The failure to recognize this relationship may result in misdiagnosis and prolonged medical therapy, whereas segmental colonic resection may be curative.

Aged↗
PubMed1988

The safety of sulfasalazine: the gastroenterologists' experience.

Although the incidence of side effects associated with sulfasalazine is in the range of 20%, most of the common side effects, including gastrointestinal reactions and headache, can be managed by dosage adjustment. In patients who experience allergic reactions of rash, fever, and arthralgia, therapy can usually be resumed after a program of desensitization. The risks associated with chronic low-grade hemolysis can be avoided by careful monitoring and, when necessary, folic acid supplementation. Certain idiosyncratic reactions to sulfasalazine do, however, represent absolute contraindications to further use of the drug. Sulfasalazine may cause reversible male infertility, but it is entirely safe for use during pregnancy and lactation. Overall, sulfasalazine has a long and impressive safety record, provided the drug is used with an awareness and appreciation of its potential pitfalls.

Drug Hypersensitivity↗
PubMed1987

Free perforation due to cancer in Crohn's disease.

Free perforation of cancer in Crohn's disease is exceedingly rare. Three cases were found among 1010 patients admitted to Mount Sinai Hospital between 1960 and 1980. Free perforation of cancer occurs late in the course of Crohn's disease between the second and third decades of disease, whereas spontaneous free perforation usually occurs within the first 5 years. Cancer-related perforation is associated with weight loss, mass and fistula, and carries a poor prognosis.

Adenocarcinoma↗
PubMed1987

Olsalazine sodium in the treatment of ulcerative colitis among patients intolerant of sulfasalazine. A prospective, randomized, placebo-controlled, double-blind, dose-ranging clinical trial.

Sixty-six outpatients with active ulcerative colitis who were intolerant of sulfasalazine were treated in a double-blind randomized trial. They received placebo or olsalazine sodium in daily doses of 0.75, 1.5, or 3 g. Overall, 35% of patients receiving olsalazine improved clinically, compared to 16% of patients receiving placebo. When the colitis activity at study entry was compared with that observed at the completion of the study period, statistically significant or nearly significant improvement was demonstrated within the combined olsalazine group (p = 0.01) and within patient groups receiving olsalazine at daily doses of 1.5 g (p = 0.04) and 3 g (p = 0.055). A dose-response relationship was suggested because 16%, 29%, 27%, and 50% of patients improved in the placebo and 0.75-, 1.5-, and 3-g olsalazine groups, respectively, (p = 0.04). A similar pattern of improvement was seen when sigmoidoscopic criteria were used, although a dose-response relationship was not demonstrated. There were no differences between the treatment and placebo groups for any of the adverse effects or laboratory variables reported at baseline or during the trial period. Four patients were withdrawn because of adverse reactions: 2 developed a skin rash while receiving olsalazine and 2 had diarrhea, one while on olsalazine and the other while on placebo. The data suggest that olsalazine is effective for the treatment of ulcerative colitis and is well tolerated among patients intolerant to sulfasalazine.

Adolescent↗
PubMed1987

Spontaneous free perforation and perforated abscess in 30 patients with Crohn's disease.

Spontaneous free perforation is an uncommon event in the natural history of Crohn's disease. It occurred in 21 of 1415 patients (1.5%) admitted with Crohn's disease to The Mount Sinai Hospital between 1960 and 1983. The mean duration from onset of Crohn's disease to occurrence of perforation was 3.3 years. Ten patients had small bowel perforation, ten patients had large bowel perforation, and one patient had simultaneous perforation of both ileum and cecum. The incidence of perforation in disease segments of small bowel was 1.0% (jejunum 6.0%, ileum 0.7%), and in the colon, 1.3%. Besides the 21 patients with spontaneous free perforation, an additional nine patients had spontaneous free rupture of an abscess into the peritoneal cavity. The mean duration from onset of Crohn's disease to rupture of abscess was 8.5 years. All 30 patients had surgery within 24 hours of perforation or rupture. All 21 patients with spontaneous free perforations survived, as did all but one of the nine patients with perforated abscess. The cornerstone of the treatment of ileocolonic lesions perforating into the general peritoneal cavity is proximal diversion with delayed reconstruction of intestinal continuity whenever possible. With perforation of the small bowel, primary reanastomosis is possible in selected patients.

Abscess↗
PubMed1987

Duodenal fistulas in Crohn's disease.

Of 1,480 patients with Crohn's disease admitted to The Mount Sinai Hospital between 1960 and 1983, eight (0.5%) had duodenal fistulas (DF), all originating from diseased small or large bowel and not from primary disease of the duodenum. The extent, duration, and major clinical features of Crohn's disease did not differ between patients with DF and those with other fistulas. Six of the patients underwent surgery for refractory disease or abscess formation and two patients were treated medically. All improved and were able to maintain an adequate oral intake after treatment. At follow-up 3-10 years later, the surgically treated patients were well but both medically treated patients had died, one from a probably unrelated brain tumor 7 years after discharge and one from necrotizing pancreatitis 10 years later. Our experience suggests that the presence of a DF is not an absolute indication for early surgery. The initial therapeutic management of such patients should be determined by the nature and severity of the underlying Crohn's disease rather than the presence of a DF. The late pancreatic complication in a patient with a chronic DF, however, raises the question of an association between the two.

Adult↗
PubMed1987

Levamisole in Crohn's disease: a randomized, double-blind, placebo-controlled clinical trial.

To evaluate the efficacy of levamisole in the treatment of Crohn's disease, 19 patients were entered into a long-term, randomized, double-blind, placebo-controlled clinical trial. Seventeen patients (eight in the levamisole group and nine in the placebo group) completed the initial treatment arm of the study. Assessments made at 4- and 12-month intervals failed to show any statistically significant difference between the two groups. Sixteen patients embarked on the second segment of the study; six were continued on the same initial therapy while the remaining 10 were crossed over to the alternate treatment. Again, analysis of the clinical scores did not reveal any beneficial effect of levamisole; in fact, all three patients who remained on levamisole for a period of 12 months after cross-over showed deterioration. The overall dismal results have provided no basis for enthusiasm for levamisole in the treatment of Crohn's disease.

Adolescent↗
PubMed1986

Free colonic perforation without dilatation in ulcerative colitis.

Free perforation occurred in only 7 of 702 patients with ulcerative colitis (1 percent) without toxic dilatation seen at The Mount Sinai Hospital from 1960 to 1981; however, these seven patients represented 30 percent (7 of 23) of all colonic perforations seen in patients with ulcerative colitis in our institution during the same period. Classic physical signs of peritonitis (silent, rigid abdomen and rebound tenderness) were absent in six of the seven patients, but all had a marked deterioration in general condition after perforation. Other signs included a sudden increase in severity of abdominal pain (three patients), marked abdominal distention (four patients), and a sharp decrease in frequency of bowel movements (six patients). Mortality was high (four of seven patients, 57 percent) and characterized by comparatively longer patient histories of colitis, longer current attacks, slightly greater delays between presumed perforation and operation, much higher transfusion requirements, and a 100 percent incidence of coagulopathy (thrombocytopenia and increased prothrombin time in three of four patients, and increased partial thromboplastin time in all four patients). The possibility of free perforation in ulcerative colitis must be considered in fulminating cases, even in the absence of colonic dilatation. Careful clinical monitoring and early surgical intervention may be the keys to reducing mortality.

Adult↗
PubMed1986

A comparison of multiple synchronous colorectal cancer in ulcerative colitis, familial polyposis coli, and de novo cancer.

Multiple synchronous colorectal cancer (MSCC) among 1537 patients (69 with familial polyposis coli (FPC), 780 with ulcerative colitis (UC), and 685 with de novo colorectal (DNC) cancers) admitted to The Mount Sinai Hospital between 1945 and 1981 was tabulated. MSCC occurred in five of 24 cancer patients with FPC (21%), in 12 of 65 cancer patients with UC (18%), but in only 17 of 685 DNC patients (2.5%). The proportions of MSCC cases with more than two synchronous tumors were also much greater in the former two groups (UC 6/12 = 50%, FPC 3/5 = 60%) than in DNC (0/17 = 0%). Multiplicity of cancers is thus a distinguishing feature of UC and FPC. MSCC differed from solitary cancers by association with older age and more advanced stage at diagnosis in patients with FPC and by a rightward shift in anatomic distribution in all patients, especially those with FPC and UC.

Adult↗
PubMed1986

Erythrocytic sedimentation rate as a measure of clinical activity in inflammatory bowel disease.

To assess the reliability of the erythrocytic sedimentation rate (ESR) as a measure of clinical activity in inflammatory bowel disease, we analyzed the correlations of ESR with a global assessment of clinical activity in 77 patients with varying extents of Crohn's disease and ulcerative colitis. Analysis of all 141 ESR determinations in all 77 patients showed a highly significant correlation between mean ESR and clinical activity score (r = 0.54, p less than 0.001). Analysis of 133 ESR determinations in these 77 patients when their disease activity was either mild, moderate, or severe showed some significant differences among certain disease categories. The highest mean ESRs were in patients with the most extensive colon involvement (Crohn's colitis 40.7 +/- 3.3, universal ulcerative colitis 31.0 +/- 3.9), whereas the lowest mean ESRs were in patients with the most limited disease (ulcerative proctitis and proctosigmoiditis 19.2 +/- 2.1). The rate of increase in ESR with progressively increasing clinical activity from mild to moderate was the same in all disease categories, with the exception of Crohn's disease limited to the small bowel (ileitis or jejunoileitis), in which the ESR was relatively unchanged in a small sample of patients. By the time clinical activity became severe, however, patients in all disease categories manifested similarly high ESRs, with the exception of ulcerative proctitis in which the ESR remained low in the single patient tested.(ABSTRACT TRUNCATED AT 250 WORDS)

Blood Sedimentation↗