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Biomedical subjects

D K Rex

Publications and source records attributed to D K Rex.

At least 19 recordsLinked to original sources
PubMed1992

Chronic constipation with encopresis persisting beyond 15 years of age.

Childhood constipation with encopresis is a common malady. Previous reports suggest that essentially all patients either respond to standard treatments or have spontaneous recovery before 16 years of age. In this paper, we describe the results of anorectal function studies and treatment outcome in four patients in whom constipation and encopresis persisted beyond 15 years of age. Abnormalities in the ability to defecate water-filled balloons, in external sphincter relaxation with straining, in rectal sensation and development of the urge to defecate, and in maximum anal resting pressure were seen in some or all of these patients. In addition, two patients had impaired voluntary squeeze strength. Two patients responded to standard therapy; a colostomy was needed in one; and one failed therapy and has become a recluse.

Adolescent↗
PubMed1992

Combined anorectal manometry and defecography in 50 consecutive adults with fecal incontinence.

Fifty consecutive patients presenting with fecal incontinence were evaluated prospectively with anorectal manometry, defecography, and other tests of anorectal function to assess the clinical utility of defecography in fecal incontinence. Leakage of contrast at rest and failure to narrow the anorectal angle with pelvic squeezing were specific but not sensitive predictors of decreased sphincter pressures as determined by manometry. Thus, after manometry, defecography provided no additional information regarding sphincter strength. Retention of contrast in large rectoceles or incomplete rectal evacuation at defecography had excellent correlation with the presence of clinical symptoms of outlet obstruction constipation (present concurrently with incontinence) and indicated an etiology of outlet obstruction symptoms. Defecography may provide useful information in incontinent patients with outlet obstruction constipation symptoms but has little additive value to anorectal manometry in incontinent patients without such symptoms.

Adult↗
PubMed1992

Distal colonic hyperplastic polyps do not predict proximal adenomas in asymptomatic average-risk subjects.

The significance of distal colonic hyperplastic polyps was investigated in 482 asymptomatic average-risk subjects, aged 50-75 years, in whom fecal occult blood test results were negative and who underwent screening colonoscopy. The incidence of adenomas in the colon proximal to the sigmoid-descending colon junction in subjects with hyperplastic polyps distal to that point was 18% and was similar to the incidence of proximal colonic adenomas in subjects with no distal colonic polyps (15%). The incidence of proximal colonic adenomas in subjects with no distal colonic adenomas was 38% and was significantly greater than the incidence found in individuals with no distal colonic polyps or only hyperplastic polyps. Our data do not support distal colonic hyperplastic polyps as markers for proximal colonic adenomas in asymptomatic average-risk subjects.

Adenoma↗
PubMed1992

Recognizing acetaminophen hepatotoxicity in chronic alcoholics.

Serious hepatotoxicity may develop in chronic alcoholics while they are taking therapeutic doses of acetaminophen. The mechanism of increased susceptibility involves induction of isoenzymes of the cytochrome P-450 system by alcohol and depletion of hepatic glutathione reserves, both of which can result from chronic alcohol ingestion and both of which affect the metabolism of acetaminophen. Chronic alcoholics with acetaminophen hepatotoxicity usually seek help after jaundice and clinical liver disease have already developed. At presentation, the blood acetaminophen level is often low or unmeasurable. Features that should immediately suggest acetaminophen hepatotoxicity in a chronic alcoholic include an aspartate amino-transferase level of more than 1,000 IU/L and, sometimes, a very long prothrombin time. The diagnosis can be distinguished from that of suicidal ingestion or alcoholic hepatitis by means of routine laboratory tests and a carefully taken history.

Acetaminophen↗
PubMed1992

Post-cardiac surgery tamponade mimicking acute hepatitis. Report of two cases.

Two patients developed cardiac tamponade from delayed hemorrhage into the pericardial sac following open heart surgery. The initial clinical manifestations of tamponade included nausea and dramatic elevations of serum aminotransferases, simulating acute hepatitis. To our knowledge, this presentation of cardiac tamponade has not been previously reported.

Acute Disease↗
PubMed1992

Selection of constipated patients as subtotal colectomy candidates.

We evaluated 224 consecutive patients referred for severe constipation prospectively by strict criteria to determine their candidacy for subtotal colectomy. Eighteen patients had insufficient symptoms to warrant evaluation. Two hundred six patients had anorectal manometry and defecography, and 182 had colonic transit measurement. Forty-nine patients had normal or minimally abnormal studies. One-hundred twenty-nine patients had abnormalities such as outlet obstruction, mild colonic inertia, diffuse gut dysfunction, or combinations of factors not favoring subtotal colectomy. Twenty-eight patients had colonic inertia without outlet obstruction and with disabling symptoms; 19 of these patients underwent subtotal colectomy. Follow-up > or = 12 months was available in 14 patients from this group. Of these patients, 12 (86%) were clinically improved. Preoperative evaluation accurately predicted postoperative fecal incontinence and likely reduced postoperative constipation. Small-bowel obstruction occurred postoperatively in 4 patients (29%), and remains a major risk of subtotal colectomy even in carefully selected candidates.

Adult↗
PubMed1992

Gastroesophageal reflux disease in adults: pathophysiology, diagnosis, and management.

Gastroesophageal reflux disease (GERD) refers to symptoms or tissue damage that result from gastroesophageal reflux. Reflux esophagitis is a subset of GERD and implies the presence of esophageal inflammation, ie, esophageal erosions that are visible endoscopically, or nonerosive inflammation that can be documented by biopsies. Heartburn is the most common and specific symptom of GERD. In some patients, chest pain or respiratory symptoms may be the only presenting signs. In patients aged < 50 years with uncomplicated GERD, empiric therapy (typically with antacids or an H2-receptor antagonist) is appropriate. For older patients, those with complications, and those whose symptoms do not respond to empiric therapy, endoscopic evaluation is indicated. Many patients will improve with standard twice-daily dosing of an H2-receptor antagonist. However, GERD is generally more resistant to antisecretory pharmacologic therapy than is peptic ulcer disease. Those patients who fail to respond to standard dosing of an H2-receptor antagonist may get relief from high-dose H2-receptor antagonists or omeprazole therapy.

Adult↗
PubMed1992

A pharmacokinetic and endoscopic comparison of an oral and an experimental buccal piroxicam formulation.

We compared the endoscopic effects and pharmacokinetic profiles of an experimental buccal formulation of piroxicam to oral capsules in an attempt to determine whether nonsteroidal antiinflammatory drug-induced gastropathy is due to a local or systemic effect. Ten healthy subjects received 20 mg piroxicam daily in a double-blind, randomized, crossover, placebo-controlled study. Upper endoscopies were performed at the baseline and at the end of each 2-week dosing arm of the study. Pharmacokinetic data obtained included serum and gastric piroxicam concentrations and serum 5'-hydroxypiroxicam metabolite concentrations after the first dose and 2 weeks of dosing. No differences in endoscopy scores or patient symptom scores were noted between the two dosage forms after 2 weeks of dosing. Pharmacokinetic data of piroxicam and the metabolite revealed that the buccal formulation may not have been absorbed exclusively from the buccal mucosa.

Administration, Buccal↗
PubMed1991

Screening colonoscopy in asymptomatic average-risk persons with negative fecal occult blood tests.

Colonoscopy was performed on 210 asymptomatic average-risk persons, aged 50-75 years, who had negative fecal occult blood test results. Colonoscopy was complete to the cecum in 209 subjects. Fifty-three subjects (25%) had adenomas and two had cancer. All of the adenomas greater than or equal to 1 cm in size and both cancers occurred in subjects aged greater than or equal to 60 years. Fifty-one percent of subjects with adenomas and one with cancer had no neoplasms distal to the sigmoid-descending colon junction. One subject had a major postpolypectomy hemorrhage that stopped spontaneously. Screening colonoscopy, therefore, has a high yield for detection of neoplasms in asymptomatic average-risk persons aged greater than or equal to 60 years with negative fecal occult blood test results. The yield is low in persons aged 50-54 years and intermediate in persons aged 55-59 years.

Adenoma↗
PubMed1991

Endoscopic detection of a tiny cecal ulcer containing carcinoma in-situ.

A 3-mm cecal ulcer without any adjacent polypoid structure was detected in a 66-year-old asymptomatic man undergoing screening colonoscopy. Biopsies demonstrated carcinoma in-situ. The literature on tiny colonic carcinomas and carcinoma in-situ in the absence of any polyp is reviewed in this article.

Aged↗
PubMed1991

Barium enema use in Indiana.

All 118 hospital-based radiology departments in Indiana responded to a survey of barium enema (BE) use. The percentage of community hospitals in Indiana using barium enema, both single contrast (SCBE) and double contrast (DCBE) for various indications, was similar to that reported for major medical centers around the world. The use of SCBE and DCBE did not differ between small and large hospitals or between hospitals in small versus large communities. There was, however, wide variation among community hospitals in their overall use of either contrast technique. Barium enema usually was performed without antecedent sigmoidoscopy. However, 60% of Indiana hospitals perform BE on the same day as flexible sigmoidoscopy. The results indicate that the use of BE in community hospitals in Indiana is similar to that reported for major medical centers. Like major medical centers, there is no consensus regarding many issues in the performance of BE.

Barium Sulfate↗
PubMed1991

Radiographic evaluation of suspected small bowel obstruction.

Plain abdominal radiographs and enteroclysis studies were reviewed blindly in 117 consecutive patients undergoing enteroclysis for suspected small bowel obstruction. Plain radiographs were unreliably predictive of the presence of obstruction as determined by enteroclysis and surgery. Among patients with normal or abnormal nonspecific plain radiographs, varying degrees of small bowel obstruction were demonstrated by enteroclysis in 22%. Conversely, of patients with obstruction on plain radiographs, 42% had either normal enteroclysis studies or only minor adhesions. Enteroclysis correctly predicted the presence of obstruction in 100%, the absence of obstruction in 88%, the level (proximal vs distal) of obstruction in 89%, and the etiology of obstruction in 86% of operated patients. Enteroclysis is advocated as the definitive study in patients with clinical uncertainty about the diagnosis of small bowel obstruction.

Diagnosis, Differential↗
PubMed1991

Failure of physicians to recognize acetaminophen hepatotoxicity in chronic alcoholics.

We encountered six alcoholic patients with severe acetaminophen hepatotoxicity during a 2-year period. All patients had marked elevations of aminotransferases and sometimes remarkably high prothrombin times at, or shortly after, presentation. In five of six cases the diagnosis was missed by the physicians initially caring for the patient. The apparent reasons for the missed diagnosis were insufficient history regarding the use of acetaminophen, an inappropriate reliance on blood acetaminophen levels, and lack of knowledge regarding typical aminotransferase elevations in alcoholic hepatitis vs acetaminophen toxicity. The initial clinical presentation of acetaminophen hepatotoxicity in chronic alcoholics is easily recognized clinically and is distinct from acetaminophen hepatotoxicity in suicide ingestions and from alcoholic hepatitis. Internists and other physicians should be aware of this entity and rely on the clinical picture and the history of acetaminophen use to confirm the diagnosis.

Acetaminophen↗
PubMed1990

Association of anterior ectopic anus and partial absence of levator musculature in a woman with impaired defecation. Report of a case.

A 25-year-old nulliparous woman with adult onset constipation and slight anterior displacement of the anus underwent pelvic magnetic resonance imaging and was diagnosed with congenital hemiabsence of the levator ani sling. Impaired defecation was confirmed by anorectal function studies and defecography demonstrated an anterior rectocele, perineal descent at the upper limit of normal, and partial obstruction of defecation, which appeared related to the levator sling abnormality. To our knowledge, this combination of findings has not been previously described as a cause of adult onset constipation.

Adult↗
PubMed1990

Flexible sigmoidoscopy plus air contrast barium enema versus colonoscopy for suspected lower gastrointestinal bleeding.

A randomized, controlled trial was performed to compare the diagnostic yields and cost-effectiveness of two strategies for the evaluation of nonemergent lower gastrointestinal bleeding. Three hundred eighty patients aged greater than or equal to 40 yr were randomized to undergo initial flexible sigmoidoscopy plus air contrast barium enema or colonoscopy; 332 completed the initial studies. Initial colonoscopy detected more cases of polyps less than 9 mm in size, adenomas, and arteriovenous malformations but fewer cases of diverticulosis. No significant difference was found between strategies in the number of patients detected with cancers or polyps greater than or equal to 9 mm in size. In both strategies, cancers were more common in subjects aged greater than or equal to 55 yr (8% overall) than in those aged less than 55 yr (1%). Among patients aged less than 55 yr with suspected lower gastrointestinal bleeding, initial flexible sigmoidoscopy plus air contrast barium enema is a more cost-effective strategy for the detection of colonic neoplasms than initial colonoscopy. However, initial colonoscopy is more cost effective for those aged greater than or equal to 55 yr.

Barium Sulfate↗
PubMedDate not supplied

Performing screening flexible sigmoidoscopy using colonoscopes: experience in 500 subjects.

There is still controversy regarding the optimal length of flexible sigmoidoscopes. We performed screening distal colon examinations using 168-cm colonoscopes in 500 asymptomatic subjects who were unsedated and had sigmoidoscopy cleansing preparation. The mean depth of penetration was 66 cm and was similar in persons in whom the examination was discontinued because of poor preparation versus those with discomfort. Polyps were detected in 87 patients, but only 5 subjects had polyps detected above 60 cm. We conclude that in a group of unsedated subjects scheduled for flexible sigmoidoscopy after a sigmoidoscopy prep, the use of instruments longer than 60 cm gives very little additional yield.

Colonic Neoplasms↗
PubMedDate not supplied

Endoscopic ultrasonography as an adjunct to fine needle aspiration cytology of the upper and lower gastrointestinal tract.

Twenty consecutive patients with either extrinsic or submucosal masses or gastric ulcers suspicious for malignancy with previously negative conventional forceps biopsies and/or brush cytology underwent a combined approach of endoscopic ultrasound (EUS) followed by fine needle aspiration cytology. Diagnostic results were obtained in 17 of 20 patients. The three patients with indeterminate aspirates had EUS findings strongly supportive of the final diagnosis. EUS combined with fine needle aspiration cytology appears to be of value in the evaluation of extrinsic, submucosal, and ulcerative lesions of the gastrointestinal tract.

Biopsy, Needle↗