Biomedical subjects
Publications and source records attributed to P F Hagihara.
We report a case series of patients with significant recurrent gastrointestinal bleeding. All forms of nonoperative investigation, diagnostic celiotomy, and even resection of portions of the gastrointestinal tract were used unsuccessfully to find the lesions. Using a modification of Bowden's technique of intraoperative endoscopy with transillumination, the nonpalpable lesions were identified and treated successfully.
Up to 1 percent of renal transplant recipients have been reported to develop ischemic colitis. Immunosuppressive agents and uremia have been implicated in the development of this complication, but their exact relationship remains unclear. A rat model was developed to determine the effects of uremia alone and in combination with immunosuppression on the development of ischemic colitis. Seventy-six animals were included in the study. Uremia and ischemic colitis were induced surgically. The immunosuppressive agents azathioprine and methylprednisolone were administered for 72 hours after a colonic segment was devascularized in chronically uremic rats. One-way analysis of variance (ANOVA) showed that uremia potentiates colonic ischemia significantly (4.09 cm2 vs 1.25 cm2, P less than 0.03). The addition of parenteral steroids (methylprednisolone) or azathioprine alone and in combination did not potentiate or reduce this ischemic process in uremic animals. Each of these factors alone is commonly present in the renal transplant population and can contribute to the development of potentially fatal ischemic colitis.
The incidence of ischemic colitis in renal transplant recipients approaches 1 percent. The mortality in these patients with ischemic colitis is nearly 70 percent. Immunosuppressive agents have been implicated in the development of ischemic colitis. To study the effect of immunosuppressive agents on ischemic colitis, a 4-cm segment of the colon was devascularized in 27 male Fischer rats. The animals were divided into one control and two treatment groups. One treatment group received methylprednisolone and the other, azathioprine, in doses similar to those of renal transplant recipients. Both experimental groups, either separately or combined, showed significantly greater areas of colonic ischemic changes than did the control group. This study demonstrates that systemic administration of immunosuppressive agents may augment the development of ischemic colitis.
From 1962 through 1983, 1,869 appendectomies were performed at our institution. Careful review disclosed 11 patients (0.6 per cent) who had an appendectomy for recurrent pain in the right lower abdominal quadrant not associated with other classical symptoms of appendicitis. Seven patients had an urgent diagnostic barium enema during the course of the episode of pain for which they had an appendectomy and six of the seven were abnormal. All of the patients exhibited gross abnormality of the appendix, such as fecalith (four), torsion or kinking of the appendix (three), narrowed lumen (three) and purulent material in the lumen (one). However, three specimens were thought to be histologically normal. In a follow-up study of ten of 11 patients for two weeks to 20 years, there has been no recurrence of the abdominal pain in all but one patient.
We have described a patient who had an acutely ischemic hand after brachial artery puncture in the antecubital fossa. Because of the anatomy of the forearm, hematoma formation and compression of the brachial artery and median nerve are poorly tolerated and predispose to irreversible ischemia or neuropathy. We recommend that brachial artery puncture in the antecubital fossa be avoided.
A new colon cancer antigen is reported. It is designated as COTA, Colon-Ovarian Tumor Antigen, because it is found in mucins produced by both tissues during malignancy. The new antigen was identified by making antibodies against human colon cancer tissue in goats. The antisera were exhaustively absorbed with lyophilized extracts of normal colon, lung, liver, spleen, kidney, plasma, and the well-known colon tumor antigen, carcinoembryonic antigen (CEA). The new antigen was identified by immunodiffusion. Studies of 28 malignant tissue extracts, 10 ovarian adenocarcinoma cyst fluids, 43 normal tissues, and 5 plasma samples revealed that this antigen is found only in colon tumors and mucinous ovarian adenocarcinomas. The antigen was not detected in serous adenocarcinoma of the ovaries, extracts of adenocarcinoma of lung, breast, kidney or stomach nor in the extracts of normal tissues. Other tests show that this antigen is not CEA, Ca 19-9, or CSAp. It is stable to heating at 65 degrees for 5 minutes; it elutes from an ion exchange matrix (DEAE) with 0.3-0.5M NaCl; it migrates to the alpha-2 region on immunoelectrophoresis; and its size, by exclusion chromatography on Sepharose 4B, is 3-15 million daltons. Anti-COTA stains colon cancer tissue sections indicating that COTA is present in goblet-cell mucin.
To study the effect of acetic acid colitis on 1,2-dimethylhydrazine-induced colon tumorigenesis, fischer 344 male rats, 10 weeks of age, were divided into three groups: one receiving 5% acetic acid enema (subgroup 1a); one receiving 10% acetic acid enema (subgroup 1b); and one not receiving acetic acid enema (group 2). Colitis developed in rats in groups 1a and 1b, resulting in early death in some cases. Rats of all three groups received the same subcutaneous dose of dimethylhydrazine given once a week for 20 weeks starting at 11 weeks of age; they were killed at 31 weeks after the first dimethylhydrazine injection. The percentage of animals having tumors in the large bowel was greatest in subgroup 1b and least in group 2. The mean number of large-bowel tumors per animal in which large-bowel had developed was determined in each group. The mean number of subgroup 1 was greater than that of group 2 and also greater than that of groups 1a and 2 combined. The results of the study suggest that colonic mucosal injury may render the colonic epithelium susceptible to tumor induction by carcinogens in the fecal stream.
Left-sided ischemic colitis was induced in 44 inbred Male Fischer rats of the same age by a standardized devascularization procedure. Fifteen animals had nothing else done (Group I). Twenty-nine animals had feces evacuated from the left colon and received an enema just before the procedure; 14 had a sterile-water enema (Group II), and 15 had a 1 per cent hydrocortisone enema (Group III). At sacrifice, 72 hours after the surgical procedure, the mucosal surface grossly involved in ischemic changes was measured. The mean area of ischemic changes in a Group I was significantly greater than that of either Group II or Group III (P less than .05). The incidence of circumferential changes was highest in Group I and lowest in Group III; the difference between Group I and Group III was marginally significant (P = .06).
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Fourteen patients with massive colonic bleeding underwent preoperative evaluation including visceral angiography and/or colonoscopy. Segmental for subtotal colectomy was performed in each case. The freshly excised colonic specimen was opened and washed clean, and the mucosal surface was closely examined by manually compressing the specimen segment by segment in order to detect the minute bleeding site(s), which were then marked with a suture for histologic sectioning. This maneuver was successful in 13 instances. In 11 of these, histologic identification was made; seven were cases of vascular malformations, and four were cases of diverticular bleeding. In 5 of these 11 cases, colonoscopy and/or visceral angiography failed to localize the bleeding sites; four were cases of bleeding of diverticular origin. Of the two patients in whom histologic identification was not made despite suture identification, one underwent a second colonic resection in which bleeding sites were histologically identified; the bleeding was not caused by vascular malformations or diverticula. The method of examining the freshly excised specimen described is useful for accurate histologic identification of the cause of colonic bleeding, particularly for diverticular bleeding. The method is also useful for immediate assessment of adequacy and appropriateness of surgical resection.
Pseudolymphoma is an uncommon benign lesion of the stomach that poses a difficult problem in diagnosis and management. The clinical manifestations and endoscopic, radiologic, and biopsy findings are not generally helpful in making this diagnosis preoperatively. Histologic examination of the lesion is the only reliable method that distinguishes pseudolymphoma from true lymphoma. Distinguishing histologic features of pseudolymphomas are (1) formation of true germinal centers, (2) presence of a polymorphous inflammatory infiltrate, and (3) absence of lymph nodal involvement by lymphoma. We report four cases and review the literature to illustrate the features of pseudolymphoma. Subtotal gastric resection is done for diagnostic as well as for therapeutic purposes. Distinction of these benign lesions from malignant lymphomas is important so that unnecessary radical surgery and postoperative radiation therapy or chemotherapy are avoided.
The value of biliary scintigraphy was studied in 180 patients with suspected biliary tract disease. Scintigraphy was performed after intravenous injection of technetium-99m labelled (1) N-substituted iminodiacetic acid derivative (HIDA) in 91 patients, and (2) butyl derivative of iminodiacetic acid (BIDA) in 89 patients. Most of the patients were investigated additionally by conventional techniques such as cholecystography, cholangiography and ultrasonography. It is concluded that biliary scintigraphy is a simple and safe technique for visualization of the biliary tract. It is particularly useful in the evaluation of acute cholecystitis, in patients with iodine sensitivity requiring imaging of biliary tract, and in the differentiation of obstructive from nonobstructive jaundice. Its value in kinetic disturbances of the gallbladder and in quantitative evaluation of hepatobiliary function needs further study.
Subcutaneous injections of the carcinogen dimethylhydrazine in inbred Fischer 344 male rats induced squamous-cell carcinomas in the ear canal, adenocarcinomas in the small bowel and duodenum, and adenomas and adenocarcinomas in the large bowel. The incidences of the tumors induced in the large bowel and ear canal were dose-related. As for tumors of the large bowel, the average size of adenomas was less than that of adenocarcinomas with massive infiltration beyond the muscularis mucosa. The average size of early adenocarcinomas was greater than that of adenomas but less than that of adenocarcinomas with massive infiltration beyond the muscularis mucosa.
The incidence of ischemic colitis following abdominal aortic reconstruction was determined by postoperative colonoscopy during a three year period. The over-all incidence of colitis was 11 of 163 patients who underwent elective or urgent reconstruction of the abdominal aorta for aneurysmal and occlusive diseases. The incidence of ischemic colitis for patients who survived resection of ruptured abdominal aortic aneurysms was higher, although the colonoscopy rate was lower. The incidence might have been even higher if all patients surviving resection of ruptured abdominal aneurysms had undergone colonoscopy.
Fifty-two patients undergoing nonemergent abdominal aortic aneurysmectomy were prospectively studied to determine when the inferior mesenteric artery (IMA) could be ligated without subsequent development of ischemic colitis. Cannulation of the severed distal IMA for blood pressure measurement (IMA stump pressure) before and after aortic reconstruction was attempted in all and possible in 39 individuals. In 13 the IMA was thrombosed precluding pressure measurement. Prereconstruction and postreconstruction mean IMA stump and systemic arterial blood pressure measurements were computed and mean IMA/systemic pressure ratios were calculated. All patients underwent postoperative colonoscopy. One patient developed postoperative ischemic colitis. Her postreconstruction ratio was 0.37 and her postreconstruction mean IMA blood pressure was 33 mmHg, the only individual with a ratio and pressure less than 0.40 and 40 mmHg, respectively. Internal iliac arterial pulsations could not be restored in two patients. Although postresection indices were less than preresection indices in both, postresection indices were greater than 0.40 and 40 mmHg. In this study, if the IMA was thrombosed or if postresection pressures and ratios measured greater than 40 mmHg and 0.40 respectively, ischemic colitis did not develop following abdominal aortic aneurysmectomy. This simple test may prove useful in identifying patients at risk for developing postoperative ischemic colitis or if IMA revascularization is required.
Eighteen cases of spontaneous ischemic colitis are reviewed. The diagnosis was established according to the following criteria: 1) clinical background, 2) clinical characteristics, 3) morphologic characteristics, and 4) clinical and morphologic course. The last three constituted the diagnostic criteria. The cases were divided into mild-to-moderate, moderate-to-severe, and gangrenous categories. Although data on clinical background did not establish the diagnosis of spontaneous ischemic colitis, they were essential in strict diagnosis. Patients who had histories of Crohn's disease, chronic ulcerative colitis, and recent antibiotic administration were excluded from consideration. Appropriate stool examinations obtained in all of the mild-to-moderate and all except two of the moderate-to-severe cases excluded colitis due to pathogenic bacterial organisms or parasites. Spontaneous ischemic colitis generally occurs in older individuals; the average age in our patients was 60 years. Twelve of the 18 patients had at least some evidence of major cardiovascular disease.
Arteriovenous malformations have become recognized as a major cause of massive bleeding of the colonic origin. Although an arteriographic unit capable of serial magnification is ideal for detecting arteriovenous malformations in the bowel, the diagnosis may still be made by a combined approach of conventional arteriography, colonoscopy and operative juddment. the final diagnosis rests on gross and histologic demostration of vascular malformations in the excised specimen.
A 3-layer immunoperoxidase technique was used to demonstrate carcinoembryonic antigen (CEA) in colonic polyps from patients with or without previous or concurrent malignancy. CEA was demonstrated in a higher percentage of the polyps received as fresh specimens that were rapidly frozen and fixed in ethanol, than in formalin-fixed, paraffin-embedded sections. Tissue CEA content of both colonic carcinomas and polyps was determined by radioimmunoassay, and it was found that benign colonic tumours had levels of tissue CEA comparable to colonic cancer, indicating that CEA concentration in a tumour does not reflect its grade of malignancy. In fact, in one case in which both colonic cancer and polyps were removed, the polyps had the higher quantities of tissue CEA. Further, tissue CEA concentration of a polyp was not dependent on its size or location. Studying the titres of circulating CEA in these patients revealed an elevation of plasma CEA in one-third of the patients with only colonic polyps, whilst the patients with cancer all had increased titres.