Biomedical subjects
Publications and source records attributed to L J Brandt.
This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. The paper was approved by the committee on September 25, 1999, and by the AGA Governing Board on November 25, 1999.
BACKGROUND: Colon vascular ectasias are a common cause of lower intestinal bleeding among the elderly. The lesions may be difficult to diagnose at colonoscopy because they are small and their appearance may be influenced by the patient's blood pressure, blood volume, and narcotic sedation during the procedure. The purpose of this study was to determine whether naloxone influenced the appearance of colon vascular ectasias at colonoscopy. METHODS: One hundred forty-four patients older than 60 years undergoing complete colonoscopy participated in the study. Medications were given in the usual doses. After a 2-minute inspection of the cecum and ascending colon, naloxone was given, followed by another 2-minute observation period. Photographic documentation of areas of interest was obtained before and after administration of naloxone. RESULTS: One hundred fourteen patients (79%) had no ectasias before or after administration of naloxone. Fourteen (9.7%) initially had normal vessels, and the vessels became more prominent; 4 (2.7%) initially had no ectasias, but ectasias later developed. Four patients (2.7%) had ectasias before administration of naloxone that did not change; 8 (5.4%) had ectasias before administration of naloxone that increased in size (3 patients), number (7 patients), or both (2 patients). CONCLUSIONS: Naloxone can enhance the appearance of normal colonic vasculature and ectasias. Naloxone is an important adjunctive medication for patients undergoing examinations for lower intestinal bleeding.
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Perineal lesions are a frequent and troublesome complication of Crohn's disease. Although there are various surgical and medical therapeutic regimens available to treat these lesions, all have significant associated morbidity, mortality, and toxicity. Recently, the beneficial effects of hyperbaric oxygen therapy (HBOT) have been described in patients with severe or refractory perineal disease, but the role of HBOT in larger groups or less severely affected patients has not yet been studied, nor has the minimum number of treatments required for initial or complete healing of perineal disease in this population been described. This article reviews the known and theoretical tissue effects of HBOT and discusses its potential role in treating patients with perineal Crohn's disease.
Pneumatosis intestinalis (PI) is characterized by multiple gas-filled cysts or linear gas within the bowel wall. PI may be idiopathic (15%) or secondary (85%) to a variety of disorders. We report here the first otherwise healthy adult with C. difficile infection complicated by PI and review the possible mechanisms of this previously unrecognized complication of pseudomembranous colitis. With treatment of the underlying infection, the PI resolved within 6 days of presentation.
OBJECTIVE: It is widely believed that Clostridium difficile (C. difficile)-associated diarrhea is a more severe disease in the elderly than in the young, associated with increased morbidity and mortality. These beliefs are largely anecdotal, and there are few data supporting them. METHODS: We conducted an evaluation in an urban, tertiary care hospital of 89 inpatients in whom C. difficile-associated diarrhea was identified. These patients were evaluated prospectively, and the group was divided by age into those < 60 yr of age (younger) and those > or = 60 yr (elderly). RESULTS: There was no difference in mortality or morbidity in elderly individuals with C. difficile-associated diarrhea when compared with younger persons similarly infected. The response to standard treatment was similar in both groups. Older patients were more likely to have an elevated white blood cell count in association with C. difficile-associated diarrhea (60% vs 26%, p < 0.05), and were more likely to have acquired their infection in the hospital (89% vs 50%, p < 0.0001). CONCLUSIONS: In the elderly, C. difficile-associated diarrhea is almost always acquired in institutions, and may not be obvious among patients' other problems. The elderly do not seem to have an increase in C. difficile diarrhea-associated morbidity or mortality. There is no evidence that C. difficile-associated diarrhea is more severe in the elderly than it is in the young.
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Trichomonads are pathogens of the female genital tract and colonizers of the oropharynx. Gastrointestinal and pulmonary diseases have been reported in association with Trichomonas species, but a direct pathogenic effect of this organism in these organ systems remains controversial. Esophageal disease due to trichomonads has not been previously reported. A 43-yr-old man with acquired immunodeficiency syndrome (AIDS) with odynophagia and esophageal erosions was evaluated by endoscopy. Cytologic brushings from three of four sites in the esophagus were positive for trichomonads. Treatment with metronidazole resulted in clearance of the organism from the esophagus and improvement in clinical symptoms. We report esophageal trichomoniasis diagnosed on esophageal brush cytology in a man with AIDS. Clinical response was confirmed by cytologic studies and odynophagia improved with metronidazole treatment. Study of cytologic preparations was superior to biopsy for identification of this organism and was particularly useful in following the post-treatment course of disease.
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Colonic ischemia encompasses a wide clinical spectrum from mild, reversible disease to severe, irreversible injury. It is a frequent disorder of the large bowel in the elderly, and can mimic certain diseases such as inflammatory bowel disease and neoplasms. The clinical course is variable, but often includes crampy, lower abdominal pain and the passage of red or maroon blood mixed with stool. In most cases, management is expectant, with supportive care and attention for signs of complicated disease. Prognosis typically is favorable, with a majority of patients completely resolving their illness; a minority go on to develop irreversible injury including strictures and chronic segmental colitis. Successful management of a patient with ischemic colitis requires a high degree of clinical suspicion, early diagnosis, careful follow-up, and prompt recognition of persistent disease.
OBJECTIVES: Up to 20% of patients with AIDS have abnormal intestinal permeability (IP). Glutamine seems to play an important role in preventing the increase in IP and loss of intestinal mucosal mass associated with total parenteral nutrition, and may be superior to glucose for oral rehydration in the setting of intestinal infection. This study was designed to see if supplemental glutamine could alter the abnormal IP of AIDS. METHODS: Randomly chosen patients with AIDS from the Jacobi Medical Center human immunodeficiency virus (HIV) clinic underwent IP testing using lactulose and mannitol. Those with abnormal IP were enrolled. Duodenal biopsies were performed with a Crosby capsule and the patients were randomized in a double-blind fashion to receive placebo or glutamine (4 g/day or 8 g/day) for 28 days, after which intestinal permeability tests and duodenal biopsies were repeated. Intestinal morphology was graded by ratio of villus height to crypt depth, and by degree of inflammation. RESULTS: All patients complied with the therapy and there were no dropouts or reported side effects. The results showed less worsening of IP with the 4 g/day dose, compared with placebo. At the 8 g/day dose, there was stabilization of IP and improved absorption of mannitol. Intestinal morphology and inflammation did not change in any group. CONCLUSIONS: These results, although not significant, suggest a trend towards improved IP and enhanced intestinal absorption with glutamine. Glutamine doses of at least 20 g/day may be necessary to improve IP. We recommend further studies at higher doses and for longer durations.
OBJECTIVE: E. coli O157:H7 may cause hemorrhagic colitis resembling ischemic colitis. Diagnosis is usually made by finding sorbitol-negative colonies on MacConkey agar that react with O157 and H7 antisera. Most ischemic colitis is idiopathic, but some may be caused by E. coli O157:H7, inasmuch as this organism can produce fibrin thrombi in colon vasculature. The objectives of this study were to determine whether E. coli O157:H7 infection can be diagnosed retrospectively from paraffin blocks of colon sections and whether an association exists between E. coli O157:H7 infection and colonic ischemia. METHODS: Paraffin-embedded sections of normal colon (n = 2) and various colitides [ischemic (n = 11), E. coli O157:H7 (n = 2), IBD (n = 8) and pseudomembranous (n = 3)] were used. Sections were deparaffinized, rehydrated, incubated with 3% peroxide in methanol, rinsed, and incubated with peroxidase-labeled antibody isolated from goats immunized with whole E. coli O157:H7. Sections were stained with peroxidase chromagen reagent and counterstained with hematoxylin. Coarse, granular, orange-brown staining was considered positive. To determine the localization of the chromagen deposits, three cases that stained positive, including one of the culture-proved E. coli O157:H7 colitis and two of colonic ischemia, were processed for electron microscopy. RESULTS: Both cases (100%) of E. coli O157:H7 colitis and three of 11 (27.3%) cases of ischemic colitis stained positive by light microscopy. In one culture-proved case, electron microscopy demonstrated staining of bacillary structures; in two cases of colonic ischemia, extensive deposits of chromagen material were present that were associated neither with inflammatory cells nor with bacterial forms. CONCLUSIONS: Immunoperoxidase staining of archival sections may be used to diagnose E. coli O157:H7 infection. An etiological role for this organism is possible in some cases of colonic ischemia.
We report five AIDS patients who developed pneumatosis intestinalis and review the pertinent literature to clarify the contributory importance of underlying infections, to suggest a management plan, and to determine whether pneumatosis intestinalis alters prognosis. Of the five patients reported, three had concurrent infections including cryptosporidiosis (one patient), presumptive CMV (one patient), and toxoplasmosis of the central nervous system (one patient). One patient also had neutropenia. Another patient was immunosuppressed during treatment for lymphoma, and the fifth patient had been taking corticosteroids before the diagnosis of CNS lymphoma. In four of five patients pneumatosis involved the right colon. Pneumatosis was linear in all five patients and also was cystic in two of the five. All patients were followed conservatively without short term adverse events, despite the known association of linear pneumatosis with bowel necrosis. We advocate conservative management and an attempt to avoid surgery whenever possible.
Gastrointestinal (GI) bleeding is an uncommon manifestation of AIDS despite the frequent involvement of the GI tract by infections, malignancies, and a variety of other disorders. GI bleeding may occur from a variety of causes, some specifically associated with AIDS and others unrelated to immunocompromise; most patients with AIDS who have lower GI bleeding have causes attributable to AIDS-specific lesions. Just as in an incompetent patient, an aggressive approach to diagnosis and treatment of GI bleeding in AIDS patients is warranted.
This infection first surfaced as a U.S. public health problem in the early 1980s. The problem persists, in the United States and elsewhere. Illness may resemble that in other infectious colitides and should be considered in the differential diagnosis of ischemic colitis. Prompt diagnosis may be made by specific stool culture.
This article has traced the evolution of our knowledge of mesenteric ischemia from the initial stage of recognition of the condition and its manifestations, through the phase of treatment after the fact-resection of gangrenous intestine, to our present-day attempts to diagnose and treat the ischemic episode before death of the bowel and patient occurs. It is history from the authors' perspective, and because of limitations of space it is, perforce, highly selective. Hundreds of valuable contributions could not be included, and their omission in no way detracts from their importance. A number of surgeons, including Williams and Bergen in this country, Marston in England, Saegesser in Switzerland, and Kieny in France, have made mesenteric ischemia a major focus of their careers and have published extensively on it. The first book devoted to all aspects of mesenteric ischemia, Vascular Disorders of the Intestines edited by Boley, Schwartz, and Williams, was published in 1971. Since that time a number of books and monographs have chronicled progress in the field. Together these references make a good foundation for newly interested investigators in the subject. The results of diagnosis and management of mesenteric ischemia have improved significantly over the past 100 years but remain poor. The best part of the history of mesenteric ischemia remains to be written.
A 68-yr-old woman who had had a cholecystectomy and endoscopic sphincterotomy developed recurrent common bile duct obstruction. She had another ERCP with extension of the site of endoscopic sphincterotomy, and 3 days later biliary obstruction again developed, this time from a blood clot filling the common bile duct. The clot was removed by Fogarty technique, and the duct was irrigated with heparin; the obstruction resolved. Minor hemobilia (biliary tract hemorrhage without overt GI bleeding) may be confused with choledocholithiasis. When biliary obstruction follows endoscopic sphincterotomy, attempts at flushing the duct should precede empiric maneuvers for stone removal.
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