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UNLABELLED: To determine the aetiology and outcome of pneumonia in human immunodeficiency virus (HIV)-infected children, we prospectively investigated 250 children hospitalized with pneumonia who were known or clinically suspected to be HIV-positive, or who required intensive care support in Cape Town, South Africa. Blood culture, induced sputum or bronchoalveolar lavage, nasopharyngeal aspirate and gastric lavage were performed. Of the total, 151 children (60.4%) were HIV-infected. Pneumocystis carinii pneumonia (PCP), occurring in 19 (7.6%) children (15 HIV-positive), was the AIDS-defining infection in 20.3%. The incidence and type of bacteraemia (14.3%) were similar in HIV-positive and HIV-negative patients; S. pneumoniae (5%) and S. aureus (2%) were the predominant isolates. Sputum or BAL cultures yielded bacteria in 145 of 243 (60%) specimens; viruses were cultured in 37 (15.2%). Bacterial prevalence (including M. tuberculosis in 8%) and anti-microbial resistance did not differ by HIV status except for S. aureus which was more common in HIV-infected children. Thirty-one (20%) HIV-positive and 8 (8%) HIV-negative children died [RR 1.16 (95% CI 1.05-1.28), p=0.008]; using multiple logistic regression, PCP was the only risk factor for mortality (p = 0.03). CONCLUSION: In South Africa, PCP is an important AIDS-defining infection in children; bacterial pathogens occur commonly and with a similar prevalence in HIV-positive and HIV-negative children hospitalized for pneumonia. HIV-infected children with pneumonia have a worse outcome than HIV-negative patients.
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The aim of this study was to determine the role of fiberoptic bronchoscopy (FB) in pulmonary tuberculosis in children. We assessed bronchoscopic findings of 36 procedures performed in 30 children who presented the following abnormalities on chest films: lobular or segmentary atelectasis (17), paratracheal or parahilar adenopathies (14), parenchymatous consolidation (9) and localized hyperinflation (5). Premedication for FB included intravenous atropine and diazepam plus ketamine for sedation, as well as lidocaine 2 and 5% in aerosol form for topical anesthesia. FB results showed that involvement was endobronchial in 29 patients. In the 18 patients with X-rays suggestive of endobronchial tuberculosis (EBT), the diagnosis was confirmed by FB. Significantly, EBT was found by FB in 11 (36.6%) patients with no clinical or radiological signs of such involvement. EBT was in the early stages in 3 (10%) patients and was advanced in 8 (26.6%). M. tuberculosis was isolated in 9 (30%) of the 30 patients. Culture was of bronchoalveolar lavage in three, of gastric lavage in four and of endobronchial biopsy in two. We conclude that FB is a safe, important tool for the confirmation of EBT in the management of pulmonary tuberculosis in children. It serves as a guide for the start of steroid treatment, especially in children with no radiological suggestion of EBT.
Mycobacterium malmoense was isolated from sputum and gastric lavage from a 68-year-old man with gastric adenocarcinoma. The patient meets the criteria for diagnosis of pulmonary mycobacteriosis. The cultural, physiological and biochemical properties of the isolates were compared with other slowly growing mycobacterial species. Fatty and mycolic acid analyses revealed the presence of 2-methyleicosanoic and 2,4,6-trimethyltetracosanoic acids and alpha-, alpha'-and ketomycolates, all regarded as typical for M. malmoense. The possible origin of M. malmoense infections and methods for laboratory diagnosis are discussed. This is the first case of documented infection due to this organism in Belgium.
Therapy based on the protective passive immunity of Hyperimmune Bovine Colostrum (HBC) (raised against Cryptosporidium parvum in dairy cows immunized during gestation) was tested for heterologous efficacy in subclinical and clinical infections of 12 captive snakes with C. serpentis. Six gastric HBC treatments of 1% snake weight at 1-week intervals each, have histologically cleared C. serpentis in three subclinically infected snakes, and regressed gastric histopathological changes in one of these snakes. In all snakes, each subsequent HBC treatment significantly decreased the number of oocysts recovered in gastric lavage eluants (P < 0.03). The treatments induced oocyst-negative gastric eluants and stools in all snakes, and improved clinical signs of infection. Clinically infected snakes displayed severe histopathological changes in the gastric region; however, the numbers of developmental stages of C. serpentis were moderate. Considering the severity of pathology, much lower than expected pathogen numbers were observed, and it is believed that clinically infected snakes did not have enough time to repair tissue damage that had occurred over the years of infection. As the HBC treatment was safe and highly efficacious, it is recommended to gastrically administer the HBC therapeutically to snakes that are clinically or subclinically infected with C. serpentis. Hyperimmune bovine colostrum can also be used in snake supportive therapy or prophylaxis.
Due to conflicting reports on the role of CEA measurement in the gastric juice of patients with gastric malignancy, we have assessed gastric CEA levels in a variety of both nonmalignant and malignant lesions of the stomach. The average gastric CEA levels were higher in patients with gastric ulcer and gastric cancer than in healthy subjects and those with duodenal ulcer. In addition, the frequencies of abnormally high values were significantly (P less than 0.001) higher in gastric ulcer or gastric cancer than in healthy or duodenal ulcer groups, whereas there was no difference between gastric ulcer and gastric cancer groups. The evaluation of gastric CEA levels in relation to gastric inflammatory changes leads us to suggest a close relationship between gastric CEA values and the degree of gastric inflammation. Gastric lavage cytology did not provide a sensitive tool for detection of gastric disorders. This study suggests little value for gastric CEA determination in gastric cancer detection. However, we believe the association of rising gastric CEA levels with various types of gastritis justifies measuring gastric CEA to recognize "precancerous" mucosal changes of the stomach.
A prospective, randomized, single-blind study was carried out to determine whether gastric content is forced into the small bowel when gastric-emptying procedures are employed in self-poisoned patients. They were asked to swallow barium-impregnated polythene pellets, immediately prior to either gastric lavage or ipecacuanha-induced emesis. A second group of patients, who did not require treatment, were used as controls. Sixty patients were recruited to the study. The data show a significant difference in the number of residual pellets in the small bowel of the treated group (n = 40), when compared with the control group (P less than 0.0001). There was no statistical difference in the number of pellets in the small bowel when the treated groups were compared with each other. In addition, the inefficiency of gastric-emptying procedures is highlighted; 58.5% of the total number of pellets ingested were retained in the gastrointestinal tract of the ipecacuanha-treated group, while 51.8% of total pellets ingested were retained in the gastric lavage-treated group.
X-irradiation was shown to cause a 2-3-fold increase in the excretion of intravenously administered 1% neutral red and endogenous ammonia. It is suggested that elimination of excreta from the stomach may change the course of radiation sickness. The postirradiation gastric lavage alleviates the clinical picture of the disease, increases the survival rate and protects the gastric mucosa from "poisoning".
Primary detoxication by ipecac-induced emesis or gastric lavage is incomplete. In mild to moderate childhood poisoning administration of activated charcoal alone without gastric emptying is often more effective, because it binds toxins promptly. In-vitro and in-vivo studies of many substances have shown good adsorption to activated charcoal (e.g. digitalis, beta-blocking agents, phenobarbitone, carbamazepine, theophylline). If in-vitro adsorption is moderate to poor, administration of activated charcoal might nevertheless prove clinically valuable by altering the severity of symptoms such as has been shown with acetaminophen, salicylates or organophosphate insecticide intoxications. Possible risks are shown and dosage regimens of activated charcoal are given alongside an evaluation of additional cathartics in the initial treatment of childhood poisonings. The role of repeated doses of activated charcoal as a method of secondary detoxication in comparison with hemoperfusion techniques and its significance in clinical routine is pointed out. General conclusion: In mild to moderate childhood poisoning early administration of activated charcoal alone after consultation of pediatrician and/or poison center specialists is an adequate therapy.
Stress ulcer prophylaxis diminishes but does not eliminate the risk of severe bleeding from this complication. In 70-80% of the cases the source of bleeding is hemorrhagic gastritis. No controlled studies exist which have in particular investigated conservative therapy in patients with stress-induced hemorrhage. Even effective measures to suppress gastric acid secretion or to reduce splanchnic blood flow are ineffective in 10-40% of intensive care unit patients with stress-induced bleeding. In these cases total gastrectomy has so far often been the only therapeutic approach. We report our experience with a new approach in treating severe stress-induced hemorrhagic gastritis after ineffective primary treatment with H2-receptor antagonists, pirenzepine and somatostatin. Continuous gastric lavage with 5-10 l ice-cold Ringer's solution was used until complete cessation of bleeding, as evident from clear lavage. Repeated administration of 12 g sucralfate (60 ml) at 2-h intervals for 24 h through a gastric tube was used to prevent recurrence of bleeding and to promote healing. Sucralfate was reduced on the 2nd and 3rd day to 20 ml 2-hourly and later to 10 ml 4-hourly. In four patients this treatment was used as an ultima ratio when the patients were already scheduled for total gastrectomy. A total of 23 patients were treated during a 7-year period; all of them responded successfully, and no patient required surgery.
Procedures to reduce the absorption of ingested poisons have been employed widely for decades in the management of intoxicated patients. However, evidence of substantial clinical benefit to the majority of patients undergoing such treatments is lacking. Volunteer studies suggest that activated charcoal is generally more effective than either syrup of ipecacuanha or gastric lavage, though lavage may be more effective than syrup of ipecacuanha. Studies in poisoned patients have shown that although lavage is more effective than syrup of ipecacuanha, it led to a better outcome in comatose patients only if performed less than one hour after overdose. Syrup of ipecacuanha did not alter the outcome beneficially in those who were alert on presentation and is known to produce significantly more complications than charcoal alone even in patients who are awake with a gag reflex. A recent study suggests that activated charcoal may be superior both to lavage and syrup of ipecacuanha. Based on these studies it would seem reasonable to recommend that 50 to 100 g activated charcoal be administered to patients who have taken a substantial amount of a toxic substance less than one hour previously. This may be done conveniently by using an orogastric tube, which would also allow lavage to be undertaken with possible additional benefit.
Gastric bezoar formation is an uncommon sequela of gastroduodenal surgery or unusual eating habits. Because they generally produce severe symptoms, their removal is always necessary. Previously, this required surgical extirpation or slow enzymatic dissolution. We present here an endoscopic procedure for bezoar removal utilized successfully in five patients with vegetable-mucus bezoars. This technique employs a jet spray of water under direct vision to mechanically disrupt the bezoar, which may then be removed using a large gastric lavage tube. This procedure is simple, safe, and rapid and is therefore recommended as an alternative to surgical removal or enzymatic dissolution of gastric bezoars.
A 56-year old man suffered severe gastrointestinal tract bleeding five days following an anterior myocardial infraction. Nonoperative treatment consisting of gastric lavage, selective angiographic procedures on the gastric arteries with intra-arterial vasopressin injection (Pitressin), and massive blood replacement over a five-day period failed to halt hemorrhage. Institution of intra-aortic balloon pumping reversed the patient's hemodynamic deterioration and made possible a definitive operation. The successful outcome in this patient suggests that counterpulsation may play a useful role in lowering the formidable surgical mortality observed in patients with acute myocardial injury who require emergency noncardiac operations.
Secretagogue-stimulated gastric acid output is reduced when gastric mucosal blood flow is below normal. We tested the hypothesis that the reduction in acid secretion associated with reduced mucosal blood flow was due to a decrease in the delivery of the secretagogue. Gastric acid output was determined by continuous gastric lavage with 0.15 M NaCl, and gastric corpus mucosal blood flow was measured by hydrogen gas clearance in anesthetized, pylorus-ligated rats before and during a period of hypovolemia-induced reduction in mucosal blood flow. A linear correlation between pentagastrin- and histamine-stimulated gastric acid output and gastric corpus mucosal blood flow during hypotension over a range of mucosal blood flow rates was found, and each was expressed as a percentage of the plateau values before hemorrhage. When the dose of pentagastrin was doubled or tripled, or when the stimulation of gastric acid secretion was vagus nerve stimulation, a stimulant of acid secretion that is independent of blood flow for secretatogue delivery, the reduction in gastric acid output by hypotension was not reversed. We conclude that stimulated gastric acid secretion during hemorrhagic hypotension is blood flow-limited and not related to inadequate delivery of secretagogue to parietal cells.
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