Biomedical subjects

P C Rantis

Publications and source records attributed to P C Rantis.

7 recordsLinked to original sources

PubMed1997

Chronic constipation--is the work-up worth the cost?

BACKGROUND: Chronic constipation can be a disabling condition that may require colectomy. Evaluation has been included as a way to select appropriate patients for colectomy and may also be extensive, unrevealing, and costly. AIMS: This study was undertaken to determine the cost and use of evaluation and outcome of patients with chronic constipation. METHODS: Patients with chronic constipation were reviewed for severity of symptoms, diagnostic studies performed, treatment, and outcome. The costs of the diagnostic studies were determined at our institution. Fifty-one patients were identified with chronic constipation; all were referred by other physicians. Mean age was 54 (range, 21-81) years; 59 percent were females. Average number of bowel movements per week was two (range, 0-4), and average duration of symptoms was five years (range, 1-20). Forty-three of 51 (84 percent) colonoscopies or barium enemas were normal. Thirteen of 51 (25 percent) colonic transit studies were abnormal. Twenty-six of 51 (51 percent) patients underwent defecography; 12 (46 percent) were abnormal. Thirty-seven of 51 (74 percent) underwent anal manometry; 5 (14 percent) were abnormal. One of 18 (6 percent) rectal biopsies demonstrated Hirschsprung's disease. Overall, 8 patients (16 percent) were diagnosed with outlet obstruction, 12 (24 percent) with colonic inertia, and 31 (61 percent) with constipation of unclear etiology. Overall mean cost of diagnosis was $2,752 (range, $1,150-$4,792). Fiber, cathartics, or biofeedback therapy was successful in 33 of 51 (65 percent) patients. Among the remaining 18 patients, 12 underwent surgery, of which 10 were successful. The remaining eight patients were constipated, despite treatment. CONCLUSION: A cost of $140,369 was expended on extensive diagnostic tests, from which 12 of 51 (23 percent) patients benefited. Exhaustive diagnostic evaluation of constipation is costly, and its benefits are unclear.

Adult↗

PubMed1996

Colonoscopic perforations. Etiology, diagnosis, and management.

Since its introduction into clinical medicine, flexible fiberoptic colonoscopy has had a great impact on diagnosis and management of diseases of the colon and rectum. There are three mechanisms responsible for colonoscopic perforation: specifically, mechanical perforation directly from the colonoscope or a biopsy forceps, barotrauma from overzealous air insufflation, and, finally, perforations that occur during therapeutic procedures. Perforation of the colon, which requires surgical intervention more frequently than bleeding, occurs in less than 1 percent of patients undergoing diagnostic colonoscopy and may be seen in up to 3 percent of patients undergoing therapeutic procedures such as polyp removal, dilation of strictures, or laser ablative procedures. Management of colonic perforation secondary to colonoscopy remains a controversial issue in that it can be effectively managed by operative and nonoperative measures. If a perforation does occur, signs and symptoms that the patient will experience will be related to both the size and site of the perforation, adequacy of the bowel preparation, amount of peritoneal soilage, underlying colonic pathology (where a thin walled colon from colitis or ischemia, for example, may result in a larger perforation than a healthy colon), and, finally, overall clinical condition of the patient. Radiology often establishes diagnosis. Plain films of the abdomen and an upright chest x-ray may reveal extravasated air confined to the bowel wall, free intraperitoneal air, retroperitoneal air, subcutaneous emphysema, or even a pneumothorax. A localized perforation may demonstrate lack of pneumoperitoneum. Some surgeons recommend surgery for all colonoscopic perforations; however, there does appear to be a role for conservative management in a select group of patients such as those with silent asymptomatic perforations and those with localized peritonitis without signs of sepsis that continue to improve clinically with conservative management. Finally, conservative management works well in those patients with postpolypectomy coagulation syndrome. Surgery is most definitely indicated in the presence of a large perforation demonstrated either colonoscopically or radiographically and in the setting of generalized peritonitis or ongoing sepsis. The presence of concomitant pathology at time of colonoscopic perforation such as a large sessile polyp likely to be a carcinoma, unremitting colitis, or perforation proximal to a nearly obstructing distal colonic lesion may force immediate surgery. Finally, in the patient who deteriorates with conservative management, one should proceed to surgery.

Algorithms↗

PubMed1996

Collagenous colitis: pathogenesis and management.

INTRODUCTION: Collagenous colitis is a rare disease of unknown etiology that primarily affects middle-aged women. It presents with chronic watery diarrhea and thickening of the subepithelial collagen layer of the colonic mucosa in the absence of endoscopic abnormalities. PURPOSE: This study was undertaken to review the current literature on clinical course, pathology, diagnosis, and current management of collagenous colitis. RESULTS: Collagenous colitis is an inflammatory disease of the colon, clinically characterized by a waxing and waning course of watery diarrhea, an inflammatory infiltration of the colonic mucosa, and a thickening of the subepithelial collagen layer. Its pathogenesis remains unclear, but there is evidence for an inflammatory process triggered possibly by an uncommon luminal agent. Diagnosis is established by colonic biopsies; in the setting of normal colonic mucosa, the disorder is primarily managed medically with virtually no role for surgery. CONCLUSIONS: Pathogenesis of collagenous colitis remains unclear. Current data favor an inflammatory etiology, possibly involving an initiating luminal insult. Guidelines for diagnosis are being established, and medical treatment options are variably effective in the majority of cases. Very unusual refractory cases may benefit from surgical management.

Biopsy↗

PubMed1995

Technetium-labelled red blood cell scintigraphy: is it useful in acute lower gastrointestinal bleeding?

Radionuclide scintigraphy is commonly utilized as a screening examination before performing more invasive procedures in the work-up of patients with lower gastrointestinal (GI) bleeding. We reviewed our institutional experience with technetium-labelled red blood cell scintigraphy (TRCS) in detecting and localising acute lower GI bleeding. The study group included 72 patients who had 80 red cells scans over a five year period. Thirty-eight scans were positive (47.5%), and 42 were negative (52.5%). Sites of lower GI bleeding were confirmed by endoscopy, arteriography, surgery and/or pathology in 22 of the 38 positive scans. There were four false-negative scans (9.5%). The overall sensitivity and specificity of TRCS in detecting lower GI bleeding was 84.6% (22/26) and 70.4% (38/54), respectively. The accuracy of localization of bleeding sites in the patients with confirmed positive scans was 72.7% (16/22). Thirty mesenteric arteriograms were performed on patients in this series. Eleven arteriograms were performed after negative TRCS; one was positive. Technetium-labelled red blood cell scintigraphy appears to be a useful screening examination for patients with lower GI bleeding who are hemodynamically stable. This may avoid the potential morbidity of arteriography in patients who are not actively bleeding.

Acute Disease↗

PubMed1995

Neck radionuclide scanning: a pitfall in parathyroid localization.

UNLABELLED: Radionuclide parathyroid scans are widely used to localize abnormal parathyroid glands. They are especially valuable for identifying ectopic glands, including those in the mediastinum. Two patients with hyperparathyroidism who had mediastinal glands that were not identified because only the neck was scanned prompted our review of the technique of parathyroid scanning at hospitals in our region and of the frequency of mediastinal parathyroid glands identified by scanning at our own institution. The nuclear medicine departments at 72 area hospitals were surveyed. Parathyroid scans were performed at 51 of these hospitals but only 13 (25%) routinely scanned the mediastinum and chest. At our institution 480 parathyroid scans were performed during a 9-year period. Twenty-six mediastinal parathyroid glands were identified by routine scanning of both the neck and mediastinum. Most of these glands could be removed through a cervical incision. However, four required formal thoracotomy and two thoracoscopy. CONCLUSIONS: A radionuclide parathyroid scan limited to the neck is an incomplete study. Scans that do not include the thorax will miss mediastinal glands that occurred in 5 per cent of the patients in our series. Despite this, radionuclide parathyroid scanning was limited to the neck in 75 per cent of surveyed hospitals. This practice increases the chance for failed surgical exploration and increases potential patient morbidity.

Adenoma↗

PubMed1994

Successful treatment of prolonged superior vena cava syndrome with thrombolytic therapy: a case report.

Superior vena cava (SVC) syndrome is most commonly due to direct compression of the SVC by a tumor. Recently, there has been an increase in the number of cases of SVC syndrome associated with chronic indwelling central venous catheters. We present a case history of a patient with prolonged symptoms of SVC syndrome that was successfully treated with catheter-directed (intraclot) infusion thrombolytic therapy with urokinase. The treatment, prevention, and incidence of SVC syndrome caused by thrombosis associated with catheters is discussed.

Aged↗

PubMed1993

Laparoscopic cholecystectomy bile duct injuries: more than meets the eye.

Laparoscopic cholecystectomy (LC) has rapidly become standard treatment of symptomatic cholelithiasis. Its advantages are well known, while its risks have not been well defined. The most common major complication of LC is bile duct injury. Over the past year, we have treated six patients for this problem. Injuries included: one partial laceration of the common bile duct; one partial laceration of the common hepatic duct; three complete common hepatic duct transections at the bifurcation, and one clip obstruction of the right hepatic duct. Intraoperative cholangiography was performed in two of six patients. Injury was recognized in these two cases, which were converted to celiotomy for immediate repair. One was repaired primarily; the other required a hepaticojejunostomy. Injuries were not identified at LC in four. Three of the four patients required biliary-enteric reconstruction procedures. With a mean follow-up period of 13 months, four of six patients remain symptomatic. LC does carry a real risk of bile duct injury. Routine intraoperative cholangiography may decrease this risk or at least allow early recognition and repair when it has occurred. Conversion to an open procedure is not a complication of LC but rather a sign of good surgical judgement. Patients not following the routine postoperative course must be evaluated for a possible bile duct injury to prevent the morbidity of delayed diagnosis.

Adolescent↗