Biomedical subjects
Publications and source records attributed to G Watkinson.
In a retrospective review of 85 patients with primary biliary cirrhosis (PBC), 10 (11.8%) were noted to have extrahepatic malignant neoplasm. In seven female patients the tumour developed within a mean of 3.5 yr after the clinical onset of PBC. This observed number of tumours, 3.5 times more common than the expected age-adjusted incidence, was statistically significant at the 0.5% level.
A survey of all patients in whom liver biopsy showed epithelioid granulomas was undertaken at two major teaching hospitals in Glasgow for the period 1970-1979. Seventy-seven patients with hepatic granulomas were studied retrospectively. In 53 cases (69 per cent) a clear-cut clinical diagnosis was established, which included sarcoidosis (eight cases), tuberculosis (eight), extrahepatic biliary obstruction (seven), primary liver diseases (11), neoplasm (six), bacterial infection (five) and miscellaneous (eight). In 24 patients (31 percent) no cause was found. Seventeen patients from this idiopathic group were studied prospectively and single examples of the following conditions were subsequently diagnosed; pulmonary tuberculosis, primary biliary cirrhosis, ulcerative colitis, adenocarcinoma of rectum, primary hepatocellular carcinoma, alpha-one antitrypsin deficiency and pulmonary fibrosis, sarcoidosis, pulmonary fibrosis alone, gallstones, rheumatic heart disease, unexplained hepatosplenomegaly and one death from mesenteric artery thrombosis. Only six cases remained truly idiopathic. Three of these patients recovered and in two liver biopsy became normal. The other three have persistent granulomas associated with continuing illness.
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A prospective survey of radiological bone and joint changes was undertaken in 42 patients with primary biliary cirrhosis (PBC) and 23 patients with alcoholic or cyptogenic cirrhosis who formed a control population. PBC patients were commonly found to have hypertrophic osteoarthropathy (38%), joint erosions (31%) and osteoporosis, these results being significantly different from the control group. Hypertrophic osteoarthropathy most frequently affected the first metacarpal and was rarely associated with finger clubbing or clinical symptoms. Joint erosions were most evident in the hands, often associated with a positive rheumatoid factor but only accompanied by symptomatic arthritis in four cases. Patients with PBC show a high prevalence of symptomless bone and joint changes which may become manifest clinically only as the disease progresses; radiography of the hands is recommended as a screening test for these changes.
Sperm analysis of 21 patients taking sulphasalazine for inflammatory bowel disease revealed that 86% had abnormal semen analysis and 72% had oligospermia.
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Patients with active rheumatoid arthritis frequently have hepatosplenomegaly and biochemical features of hepatic disease. A prospective study with liver biopsy has been carried out in a series of 31 rheumatoid arthritis patients with clinical and/or biochemical evidence of hepatic dysfunction. Four of the 31 (13%) were found to have definable chronic liver disease, normal hepatic histology or non-specific reactive changes being found in the remainder. In the large majority of patients the hepatic abnormality in rheumatoid arthritis remains functional and unexplained.
The clinical and radiological features of six cases of fat-encrusted colon are described. In patients with steatorrhoea, despite standard colonic preparation, fat may adhere to colonic mucosa and produce a radiological appearance that simulates the changes of inflammatory bowel disease. Steatorrhoea was due to coeliac disease in five patients, the sixth being a case of primary sclerosing cholangitis. The initial radiological diagnosis at barium enema in all six patients was of inflammatory bowel disease. On the basis of this appearance surgery was advised in three patients, one of whom proceeded to laparotomy with a view to colectomy. The correct diagnosis can be established by familiarity with the radiological appearance and confirmed by repeating the barium enema examination after 5 days of a fat-free diet, when the colonic mucosal pattern returns to normal.
The effects of azathioprine on the course of primary biliary cirrhosis were studied prospectively in a multinational, double-blind randomized clinical trial involving 236 patients, of which 124 received azathioprine and 112 placebo. No significant effects were seen on survival, clinical course, hepatic histologic features, hepatic tests, or immunologic abnormalities after a median follow-up period of 18 mo, but most of the trends observed were in favor of azathioprine. The results obtained so far indicate that the effect of azathioprine as a single treatment is limited and probably of little clinical importance, but more years of follow-up will be needed to provide a definite conclusion.
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Five patients with non-specific small intestinal ulceration and malabsorption are presented. Four of these patients had subtotal villous atrophy of jejunal mucosa but none showed a morphological improvement after gluten withdrawal from the diet. Intestinal ulceration caused the complications of melaena, intestinal obstruction and perforation which resulted in the death of three patients. A review of the English literature reveals twenty-seven similar cases for which the term idiopathic chronic ulcerative enteritis is recommended. The condition is of unknown aetiology, diagnosis only being firmly established by laparotomy and histological examination of resected bowel. The relationship of this syndrome to coeliac disease, intestinal lymphoma and Crohn's disease is discussed. Management is extremely difficult and the long-term prognosis poor. Gluten withdrawal should be tried in the presence of villous atrophy but the value of steroid therapy in unresponsive cases is unproven. Surgical excision of the worst affected segments of small bowel has so far proved to be the most effective course of action.
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A new cause of severe transient fitting polyarthritis is described in a patient with primary biliary cirrhosis. Hypercholesterolaemia is thought to provoke acute inflammatory periarthritis and peritendinitis. The clinical features are sudden onset of peripheral joint pain and effusion, with redness of the overlying skin, often precipitated by unusual exercise. Cholestyramine may help to prevent this form of arthritis.
Of 98 patients dying with primary biliary cirrhosis only four developed hepatocellular carcinoma. It is suggested that the development of hepatocellular carcinoma is uncommon in this type of chronic liver disease because of its known female preponderance, and the fact that cirrhosis develops late in the course of the illness.
Sera from patients with chronic liver disease were tested for antibody against hepatitis B surface antigen by radioimmunoassay. The antibody was found in 25% of patients with alcoholic cirrhosis and in 52% when alcoholic cirrhosis was associated with portal hypertension, these results being significantly higher than in a matched control population. Other forms of chronic liver disease did not differ from the control population. Hepatitis B virus infection might be a factor in determining which alcoholic patients go on to develop chronic liver disease and cirrhosis.
There has been a revival of interest amongst young people in the raw consumption of "wild" Psilocybin mushrooms, because of their hallucinogenic properties. Seven cases of mushroom overdosage are described. Whilst the hallucinogenic mushrooms are relatively harmless, the dangers from inadvertent ingestion of commonly occurring poisonous varieties are emphasised.