Lipid abnormalities and acute pancreatitis.
Explore the source record for details and available documents.
Acute Disease↗
Biomedical subjects
J L Cameron
Publications and source records attributed to J L Cameron.
Primary common duct stones.
Thirty patients were identified as having primary common duct stones. Criteria for diagnosis included at least a two year symptom free interval following cholecystectomy; soft, light brown stones or sludge present in the common duct; and the absence of a long cystic duct remnant or a biliary stricture from the previous surgery. The average age of the 30 patients was 66 years. The interval between cholecystectomy and the diagnosis of primary common duct stones averaged 12 years. Acute cholangitis was a frequent mode of presentation. At the time of surgery the bile duct was often dilated out of proportion to the serum bilirubin. In only one of the 30 patients was ampullary stenosis present. Twenty-six of the 30 patients had only stone extraction and insertion of a T tube for treatment of their primary common duct stones. Twenty-two of the 26 were followed for an average of four years and nine months with no evidence of recurrent stones in 82% (18/22). Four developed recurrent primary common duct stones one, five, five, and 7 years later. It is concluded that most patients with primary common duct stones do well after stone extraction alone.
Aged↗
Aspiration pneumonia: beneficial and harmful effects of positive end-expiratory pressure.
With an ex vivo, isolated, ventilated, perfused canine pulmonary lobe, the effects of various levels of positive end-expiratory pressure (PEEP) were evaluated following acid injury. Following intrabronchial instillation of hydrochloric acid, eight lobes were ventilated with 5 cm of H2O of PEEP, 12 lobes with 10 cm of PEEP, and eight lobes with 15 cm of PEEP during a 4 hour perfusion period. Blood flow was kept constant in all preparations. Lobes with 5 cm of PEEP developed a 39% intrapulmonary shunt and increased their weight by 220%. When PEEP was increased to 10 cm, weight gain was similar (184%), but shunting decreased markedly, to 7%. When PEEP was increased further to 15 cm, shunting remained low (13%), but weight gain increased markedly, to 411% of the initial lobe weight. This study demonstrates the beneficial effects of PEEP in aspiration pneumonia, but it also points out that increasing levels of PEEP can magnify acid-pulmonary injury by causing a further increase in interstitial and intralveolar edema.
Animals↗
Acute pancreatitis with hyperlipemia: studies with an isolated perfused canine pancreas.
Clinical evidence suggests that in many settings hypertriglyceridemia can initiate an episode of acute pancreatitis. Hydrolysis of triglycerides by pancreatic lipase with the local release of large quantities of free fatty acids (FFAs) has been proposed as the pathogenetic mechanism. To gather information to evaluate this mechanism an isolated, ex vivo, perfused pancreatic preparation was used. Control preparations remained normal in gross appearance, gained little weight (18 gm), extracted oxygen and glucose and released carbon dioxide, and continued to secrete during a 4 hour perfusion period. Serum amylase remained normal (972 CU/100 ml) as did FFAs (1.11 mEq/liter). When triglycerides were added to the perfusate to increase the serum triglycerides to 1,600 mg%, the glands became edematous, hemorrhagic, and gained considerable weight (52 gm) during the 4 hour perfusion period. Serum amylase became markedly elevated (2,624 CU/100 ml), as did the serum FFA (29.19 mEq/liter). When FFAs were added directly to the perfusate, the glands became edematous, hemorrhagic, and gained weight (90 gm), but did so much more rapidly than when triglycerides were added. These studies add support to the concept that hypertriglyceridemia can initiate pancreatic injury. Furthermore, they suggest that the mechanism may be through the release of FFAs.
Acute Disease↗
Aspiration pneumonia; incidence of aspiration with endotracheal tubes.
Aspiration has been suggested as a source of pulmonary complications seen in patients with tracheal intubation. A previous study demonstrated that the high incidence of aspiration in patients with tracheostomies can be decreased by modification of the tracheostomy tube cuff design. In the present protocol, 100 patients with endotracheal tubes in place were studied to document the incidence of aspiration and to attempt to decrease the incidence by modification of cuff design. Utilizing an Evans blue dye test to detect aspiration, 27 of the 48 patients (56%) with standard low volume, high pressure cuffed tubes had positive tests. In 17 patients with modified standard cuffed tubes, the incidence of aspiration was decreased to 29% (5 patients). Aspiration was further decreased to 20% (7 patients) in the 35 patients with high volume, low pressure cuffed tubes. These results demonstrate that the incidence of aspiration in patients with endotracheal tubes can be decreased by modification of endotracheal tube cuff design.
Adolescent↗
Aspiration pneumonia: experimental evaluation of albumin and steroid therapy.
An experimental model using an ex vivo perfused ventilated canine pulmonary lobe was used to study aspiration pneumonia. After intrabronchial acid instillation, the lobe weight tripled, air way pressure and pulmonary artery pressure doubled, and intrapulmonary shunting increased from 5.5% to 53.4%. If large quantities of albumin were added to the lobe perfusate 5 minutes after intrabronchial acid instillation, weight gain, air way and pulmonary artery pressure, and intrapulmonary shunting were unchanged from control levels. If large quantities of steroid were added to the lobe perfusate 5 minutes after intrabronchial acid instillation, the lobe weight doubled but air way pressure and pulmonary artery pressure, and intrapulmonary shunting were not significantly different from control values. It is surmised that intrapulmonary acid aspiration causes an immediate and marked changed in pulmonary capillary permeability. Albumin administration by counteracting this permeability change, and steroid administration by modifying the permeability change, are both beneficial following acid aspiration.
Albumins↗
Long term transhepatic intubation for hilar hepatic duct strictures.
A technique for repairing benign hilar hepatic duct strictures using transhepatic intubation with a large bore silastic stent is described. This procedure has been used in 10 patients. In 9 instances the stricture involved the common hepatic duct, and in one patient the right and left hepatic ducts. Nine of the strictures followed cholecystectomy; one followed the primary repair of a gun shot wound to the hepatic duct. Hepaticojejunostomies were created and the transhepatic silastic stent was left in place for 6 months in one patient, and for 12 months in 8 patients. In one patient the silastic stents are still in place. There have been no treatment failures. All patients are healthy and at full activity from one year, 3 months to 6 years, 6 months from the time of repair (average 3 years, 5 months). In the 9 patients whose stents have been removed, the serum bilirubin levels are normal There have been no episodes of cholangitis following repair. This method of repair using long term transhepatic silastic stents is recommended for all high hilar hepatic duct strictures.
Adult↗
Internal pancreatic fistulas: pancreatic ascites and pleural effusions.
Thirty-four patients seen over a 10-year period with internal pancreatic fistulas are reported. In 22 patients the fistula was into the peritoneal cavity and they presented with pancreatic ascits. In 7 patients the fistula tracked up through the mediastinum into a pleural cavity, and they presented with pancreatic pleural effusions. Five patients presented with both pancreatic ascites and pancreatic pleural effusions. Diagnosis was made by finding a markedly elevated amylase and protein content in the ascitic and pleural fluids. Serum amylase was usually, but not always, elevated. Over one half of the patients had no history of inflammatory pancreatic disease. Initial treatment was non-operative using nasogastric suction, diamox, atropine, and multiple paracenteses or thoracenteses. This was successful in 48% (12/25). If non-operative therapy failed, surgery was performed to drain or resect the internal fistula. Surgery was successful in 82% (14/17). The internal pancreatic fistula was successfully demontrated in most instances by preoperative, operative, or postmortem pancreatography, or by gross observation at the time of surgery.
Adolescent↗
Clinical management of acute cholangitis.
In a series of 78 patients with acute cholangitis, 48 were associated with common duct stones, and in one-third of these, the stones were believed to be primary common duct stones. Even though the clinical presentation of acute cholangitis can be nonspecific with a remarkable absence of physical signs, almost all patients had elevations of serum bilirubin, transaminase and alkaline phosphatase levels, an indication of disease of the biliary tree. Initially, all of the patients were treated with antibiotics and most responded rapidly. Escherichia coli and klebsiella were the organisms involved in more than 85 per cent of the positive cultures, and penicillin and an aminoglycoside are recommended as the drugs of choice in acute cholangitis. Diagnostic procedures were then performed, and laparotomy was often not carried out for several days after admission. Eleven of the 78 patients died. Six of the 11 deaths in this series were from continuing or recurrent sepsis, and at postmortem examination, a retained stone or inadequately treated stricture was found. This points out the need for adequate diagnostic procedures prior to exploration.
Abdomen↗
The use of intramuscular propantheline in the short bowel syndrome.
A patient is presented with the short bowel syndrome who because of massive diarrhea was unable to maintain fluid and electrolyte balance with the aid of the usual antidiarrhea drugs. Her bowel remnant consisted of approximately 155 cm of proximal jejunum. Intramuscular propantheline has allowed this patient to function normally for the past 36 months. Balance studies are presented to document the benefit of this drug. Propantheline's effectiveness is probably secondary to its marked slowing of intestinal motility.
Adult↗
Successful long-term intravenous hyperalimentation in the hospital and at home.
Experience with long-term intravenous hyperalimentation in the hospital and at home in one patient over a 22-month period is reported. After multiple operative procedures the patient was left with only her stomach, duodenum, and 5 cm of the proximal part of the jejunum. During a 12-month period in the hospital, despite many life-threatening complications and with high-output intestinal fistulas, her weight increased from 40.7 kg (90 lb) to 70.1 kg (155 lb) on intravenous hyperalimentation therapy. During the past ten months, the patient has managed her intravenous feeding at home. A silicone elastomer catheter inserted into her superior vena cava through her facial vein has been used for the past ten months with no catheter sepsis. Although costly, home intravenous alimentation seems justifiable in selected patients because of the possible feasibility of bowel transplants in the near future.
Adult↗
Evaluation of prophylactic antibiotics in acute pancreatitis.
Explore the source record for details and available documents.
Abscess↗
Prevention of experimental postoperative adhesions by ancrod defibrinogenation.
Explore the source record for details and available documents.
Ancrod↗
Antibiotic therapy in acute pancreatitis.
Explore the source record for details and available documents.
Abscess↗
A test for patency of the cystic duct in acute cholecystitis.
A procedure was devised to quickly and reliably determine the patency of the cystic duct in patients suspected of having acute cholecystitis. First the gallbladder was stimulated to empty by a cholecystokinin injection. Thirty minutes later a radiolabeled biliary marker, either 150 muCi 131-I rose bengal or 2 mCi 99-mTc dihydrothioctic acid, was injected, and the accumulation of radioactivity in the liver and gallbladder regions was monitored by external gamma emission imaging and recording devices. The images of diagnostic importance were obtained between 60 and 90 minutes after injection of the tracer. Thirty-nine patients with acute abdominal pain were studied. Ten patients who had acute cholecystitis failed to show gallbladder accumulation of radioactivity, reflecting the cystic duct obstruction that initiates this disease. Twenty-nine patients having a variety of other diseases all showed gallbladder accumulation of activity, indicating in each patient that the cystic duct was patent. No significant adverse effects were noted. We conclude that the procedure is a useful adjunct to the clinical and roentgenographic evaluation of patients with acute abdominal pain.
Acute Disease↗
Septic complications following endoscopic retrograde cholangiopancreatography.
In four patients, septic complications developed following endoscopic retrograde cholangiopancreatography which required surgical intervention. The pathogenesis involves stasis in the pancreatic or biliary tree, but the source of infection is unclear. Prompt recognition and early surgical intervention should decrease the seriousness of these complications.
Adult↗
Observations by a James IV traveler on British surgical centers.
In Great Britain and Ireland there were many well-trained, technically excellent, clinical surgeons practicing the art of surgery in a system that guarantees an equitable and even distribution of quality care. University departments tended to be small but were very effective and stimulating units without the administrative and clinical burdens of a large teaching hospital. Surgical training programs were superb, but long, and continued to be molded by service requirements. Clinical research protocols were everywhere in evidence and were patient oriented, well controlled, and of the highest quality. Although there are several new impressive clinical plants, hospitals tended to be old and facilities somewhat dated. There are fewer intensive- and critical-care units than we have become accustomed to. As hosts, the British and Irish are unsurpassed as the most gracious, interesting, and educated people I know.
Education, Medical↗
A pathogenesis for alcoholic pancreatitis.
Twelve patients with prior episodes of alcoholic pancreatitis and hyperlipemia were admitted to a metabolic ward during a quiescent period. By lipid feeding (316 to 894 Gm. per day), significant hypertriglyceridemia (greater than 600 mg. per 100 ml.) was induced in 11 of the 12 patients. Seven of the 11 patients with hypertriglyceridemia developed abdominal pain similar to but not as severe as that experienced during prior attacks of pancreatitis. Four of the seven patients with abdominal pain developed serum amylase elevations, and, of the remaining three, one had a serum lipase elevation and one a urinary amylase elevation. Alcohol ingestion is known to increase serum triglyceride levels in many individuals. A prior study demonstrated that 41 percent of the patients presenting to our hospital with alcoholic pancreatitis had serum triglyceride elevations. The data from the present study suggest that increased serum triglycerides act as an important intermediary in the pathogenesis of acute pancreatitis in some alcoholic patients.
Adult↗