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An adult cat with vague signs of gastrointestinal dysfunction was found to have a congenital portosystemic shunt. There were no signs of hepatoencephalopathy, which is in contrast to what has been reported in other cats with the disease.
Cholecystectomy will not always relieve the abdominal symptoms of the patient with gallstones. The functional effects of gallbladder removal in a patient with a patent cystic duct are not known in detail. Studies of the function of the gallbladder and pancreas have suggested feedback mechanisms for the release of cholecystokinin (CCK). A disturbed regulation of CCK release after cholecystectomy might induce pancreaticobiliary and gastrointestinal dysfunctions. In our study the concentrations of CCK in plasma were measured in 17 patients with gallstones. The measurements were taken with gallbladders opacified at cholecystography and with patent cystic ducts at the operation, in the fasting state, and during stimulation before and 17 weeks after the cholecystectomy. The CCK assay used measures sulfated CCK-8, CCK-22, and CCK-33 with equimolar potency but neither nonsulfated CCK nor any gastrins. Emtobil (containing peanut oil and sorbitol) was used for peroral stimulation of the CCK release. The basal concentration of CCK was 4 pmol/L and rose five times during a "test meal." No significant differences were seen in fasting or stimulated concentrations of plasma CCK before and after the cholecystectomy. Thus cholecystectomy in gallstone patients with functioning gallbladders does not seem to influence the regulation of CCK release.
Infants born to opiate-dependent women frequently have low birth weights and low 1- and 5-min Apgar scores. Significant postnatal problems, excluding neonatal withdrawal, can include jaundice, infection, aspiration pneumonia, transient tachypnea, and hyaline membrane disease. Neonatal abstinence may be severe and persist for as long as 3 months. Abstinence symptoms can include central nervous system hyperirritability, gastrointestinal dysfunction, respiratory distress, tremors, fever, high-pitched cry, increased muscle tone, uncoordinated sucking and swallowing reflexes, dehydration, and possible electrolyte imbalance. During the first week of life, increased respirations associated with hypocapnia and alkalosis may occur. The Brazelton Neonatal Behavioral Assessment Scale has been used to quantify the neurobehavioral effects on neonates of narcotics administered prenatally. A marked decline in mortality rates of infants born to opiate-dependent mothers is evident. In Philadelphia, infant morbidity has been related not only to the type of maternal narcotic dependence, but also to the amount of prenatal care. Infants whose mothers received prenatal care have been found to have higher birth weights similar to infants of control mothers. Although the newborn with intrauterine exposure to narcotic agents may appear normal at birth, the effects of the pharmacologic agent may not become apparent until later in development. To obtain a more favorable outcome for the high-risk mother and child involved in the problems of perinatal addiction, several recommendations are proposed.
Surgical procedures can be accomplished successfully in patients with uremia provided certain principles of perioperative management are observed. Preoperative dialysis minimizes the biochemical derangements and improves fluid balance, hypertension and hemostasis. Drug schedules are adjusted in consideration of abnormal metabolism in renal disease. Anesthetic management is modified in recognition of potentially adverse or altered activity of anesthetic agents and neuromuscular relaxants. The lightest plane of anesthesia consistent with expeditious operative technique is maintained, since adequate tissue oxygenation is dependent upon increased cardiac output in these invariably anemic patients. Intraoperative hyperventilation sustains the usual compensatory mechanism for uremic metabolic acidosis in the conscious patient, thereby averting increments in serum potassium levels associated with increasing acidosis. Postoperative morbidity may include shunt thrombosis, infection, impaired wound healing, bleeding, pericarditis, pleuritis and pancreatitis. Hypervolemia and hyperkalemia are best managed by early postoperative dialysis. A period of nutritional support using intravenous essential L-amino acids and hypertonic glucose appears promising, especially when gastrointestinal dysfunction exists.
Eighteen homosexual men who had had lymphadenopathy in two or more extrainguinal sites for more than 5 months but had no evidence of other illnesses or infections were studied. All had extreme malaise, and 90% had additional symptoms (fever, night sweats, weight loss or gastrointestinal dysfunction). They were compared with 10 healthy homosexual and 10 healthy heterosexual male controls. The mean numbers of circulating T8 (suppressor) lymphocytes were increased equally in the two homosexual groups, but the mean number of T4 (helper) lymphocytes was decreased only in the group with lymphadenopathy. The response to testing for recall anergy was diminished in both homosexual groups but was significantly lower in the group with lymphadenopathy. The serum immunoglobulin and complement concentrations and the numbers of circulating B lymphocytes were normal in each group. Seven of nine lymph node biopsy specimens showed characteristic hyperplasia and confluence of follicles. Thus, idiopathic persistent, generalized lymphadenopathy in homosexual men without opportunistic infections or malignant diseases appears to be a distinct syndrome; it may also be related to the acquired immune deficiency syndrome.
Contact urticaria is characterized by erythematosus whealing lesions after apposition of particular substances on the skin. Sometimes these substances are able to determine systemic reactions as rhinoconjunctivitis, bronchial asthma, gastrointestinal dysfunction and anaphylactic shock: these symptoms justify the denomination of contact urticaria syndrome. It can be classified as Immunological, not Immunological and Unidentified. Our cases show a sharp prevalence of contact urticaria caused by foods and especially by fruits and vegetables.
Three litters of pigs were weaned at 21 days of age, and 3 others were left with the sow. Pigs were killed at 21, 23, 28, or 39 days of age. Weaned pigs exhibited anxiety, gastrointestinal dysfunction, and decreased rate of body weight gain. Plasma glucose or liver glycogen concentrations were not decreased by weaning. Adrenal gland weights and tyrosine hydroxylase (EC 1.14.3a), dopamine beta-hydroxylase (EC 1.14.2.1), phenethanolamine-N-methyl transferase (EC 2.1.1), and monoamine oxidase (EC 1.4.3.4) activities were increased after weaning. Adrenal catecholamine and cortisol levels and dopa decarboxylase (EC 4.1.1.26) and catechol-o-methyl transferase (EC 2.1.1.6) activities were not significantly altered, although some increases were indicated. Cranial cervical ganglionic choline acetyltransferase (EC 2.3.1.6) and tyrosine hydroxylase activities were increased after weaning. Weaning of swine at 21 days of age is a stressful experience, and many effects persist for at least 18 days; however, growth was no longer impaired 18 days after weaning.
Achalasia is a disease of the esophagus characterized by incomplete relaxation of the lower esophageal sphincter, resulting in obstruction. Aperistalsis and dilation of the esophageal body occurs later, contributing to the esophageal dysfunction. Gastrointestinal bleeding in achalasia is an infrequent complication usually caused by stasis ulcer, esophageal varices, carcinoma, or pneumatic dilation of the sphincter. We describe here a patient with longstanding achalasia who bled vigorously from a proximal esophageal site that can be identified as arterial bleeding by endoscopy. Subsequent esophageal resection allowed detailed histological and immunohistochemical examination, which revealed a vascular ectasia. This lesion was associated with an unusually rich network of nerve fibers containing calcitonin gene-related peptide. Neuropeptide Y- and substance P-containing fibers were found to be decreased in this lesion as compared with controls. On the other hand vasoactive intestinal peptide- and nitric oxide synthase-containing fibers appeared quantitatively similar to those of controls. Calcitonin gene-related peptide is known to be involved in angiogenesis and may have played a causative role in the development of this lesion. Vascular ectasia may represent a hitherto unreported complication of achalasia.
BACKGROUND: Ascites is a common sequela of advanced or recurrent gynecologic malignancies, such as carcinoma of the ovary, fallopian tube, or endometrium. Symptomatic treatment with repeated paracentesis is the initial management after failure of chemotherapy. STUDY DESIGN: This study was done to evaluate the safety and effectiveness of a peritoneovenous shunt (PVS) in the palliation of these patients with recurrent ascites. A retrospective review of 25 patients having a PVS between 1982 and 1992 was performed. RESULTS: The 25 patients consisted of 21 patients with carcinoma of the ovary, two with primary carcinoma of the peritoneum, one with carcinoma of the endometrium, and one patient with carcinoma of the fallopian tube. The mean weight and abdominal girth decreased after shunt insertion (p < 0.001). Gastrointestinal dysfunction and dyspnea also improved with PVS insertion. There was no change in mean Karnofsky score after placement of a PVS. Two patients died within ten days postoperatively. The median survival period was 80 days and shunt occlusion occurred in four patients. CONCLUSIONS: The insertion of a PVS is effective in relieving refractory malignant ascites in gynecologic malignancies. The impact on quality of life requires further study.
Carcinoma of the pancreas has a poor prognosis with a short survival time. Despite diagnostic advances, diagnosis is often delayed because early symptoms are frequently vague and non-specific. Symptomatic treatment is the only possibility in the large majority of patients with pancreatic cancer since curative surgical excision of the tumor is only possible in few cases. Symptoms managed, in the aim to improve the quality of life, include weight loss and anorexia, abdominal pain, jaundice secondary to biliary compression and digestives consequences of pancreatic surgery. Anorexia is a frequent complaint in patients with pancreatic cancer, and contributes to decreased caloric intake, weight loss and malnutrition. Patients who are unable to eat, due to obstruction or dysfunctional gastrointestinal tract, may benefit from enteral or parenteral nutrition. Patients whose main reason to not obtain adequate food intake is anorexia may benefit from recently developed pharmacologic strategies. Megestrol acetate often produce an improvement in appetite and weight gain in patients with advanced cancer. Jaundice can be treated by surgical biliary drainage or better still by palliative biliary endoprosthesis. Percutaneous transhepatic or endocopic biliary drainage are now well established methods for decompressing malignant biliary obstruction. Pain occurs in 80-85% of patients with advanced disease. Abdominal pain should be treated by oral non-narcotic analgesics, or, if necessary, potent narcotic analgesics, and sometimes by percutaneous block of the celiac ganglion, splancnicectomy or abdominal radiotherapy. Celiac plexus block with alcohol is the most common and well described therapy for the specific pain from carcinoma of the pancreas. Digestive consequences of pancreatic surgery also require symptomatic treatment.
An open clinical trial was designed to examine the efficacy and safety of lobenzarit (CCA), a newly developed disease modifying anti-rheumatic drug, in combination with conventional treatment with prednisolone for patients with systemic lupus erythematosus (SLE). Fifteen patients with SLE were given CCA 40 mg b.i.d. for the first 2 weeks, 80 mg b.i.d. for the next 4 weeks, and 80 mg t.i.d. or b.i.d. until the end of the 12-month trial, in addition to prednisolone, whose doses were kept unchanged throughout the trial. The patients' clinical responses to CCA, including alterations in various laboratory parameters and the development of complications, were evaluated at the end of 12 months. Fourteen of the 15 patients completed the 12-month trial. Significant increases in the white blood cell count and CD4/CD8 ratio, as well as decreases in serum anti-DNA antibody, were noted after the trial. Five patients presented with adverse effects, including mild liver dysfunction, gastrointestinal symptoms and dizziness. Only one patient who developed dizziness withdrew at 9 months. Eleven patients could be reevaluated after discontinuation of CCA, and only 2 of them have experienced recurrence of active disease 6 months after discontinuation. In one additional patient who had not responded to prednisolone 35 mg daily, administration of CCA resulted in improvement of the disease activity. These results indicate that CCA in combination with corticosteroids is a useful adjunct in the treatment of SLE. A placebo-controlled study will be necessary to confirm these results.
BACKGROUND: The optimal treatment of patients with "high risk" cancer involving the uterine cervix has not been defined. These patients include those with "bulky" or barrel shaped cervical tumors, individuals with adenocarcinomas or sarcomas, and those who respond poorly to radiation. As these patients are at high risk of failure if treated with radiation, it has been proposed that radical hysterectomy be performed in combination with radiation to improve local control of disease. We review our recent experience with this combined modality approach. METHODS: We reviewed patients treated at UCLA Medical Center between 1982 and 1990. All patients had multiple risk factors for poor local control. Twenty patients underwent radical hysterectomy (12 (60%) class II, 5 (25%) class III, one (5%) class IV, 2 (10%) class V) after pelvic irradiation. Fifty percent had "bulky" (> 4 cm) Stage I cervical cancer, while 45% had Stage II and 5% Stage III. Fifty percent of the patients had an element of adenocarcinoma. Two patients (10%) had uterine sarcoma with cervical involvement. Thirty percent of the study group had a poor response to preoperative radiation. RESULTS: Seventy percent of patients had nodal metastasis. Post-operative morbidity included infections (50%), urinary retention (10%), and ileus (5%). Long term morbidity included ureteral obstruction (30%), small bowel obstruction (20%), chronic gastrointestinal dysfunction (10%), chronic pelvic pain (10%), urinary fistula (10%), and vault necrosis (5%). Morbidity was less if patients only received preoperative brachy or teletherapy alone. Sixty-five percent of subjects are alive without disease with a mean follow up of 26 months. CONCLUSION: Although limited by the number of patients, we conclude that radical hysterectomy after radiation is morbid but may be effective in treating patients with 1) large cervical tumors, 2) cervical cancer that responds poorly to radiation, 3) small recurrent cervical tumors, 4) patients unable to undergo brachytherapy for cervical cancer, and 5) uterine sarcomas involving the cervix.
We investigated the effects of various selective 5-hydroxytryptamine (5-HT)3 receptor antagonists, including GK-128 [2-[(2-methylimidazol-1-yl)methyl]benzo[f]thiochromen-1-one monohydrochloride hemihydrate], on colonic function. In conscious rats, 5-HT and a 5-HT3 receptor agonist, 2-methyl-5-HT, dose-dependently increased fecal pellet output, but another 5-HT3 receptor agonist, m-chlorophenylbiguanide, did not affect output. The selective 5-HT3 receptor antagonists GK-128, granisetron, ramosetron, azasetron and ondansetron depressed the increase in fecal pellet output caused by 2-methyl-5-HT and by wrap-restraint stress. However, the rank order of potency of antagonists in the two defecation models was not consistent with that for the von Bezold-Jarisch reflex. Although granisetron and ramosetron dose-dependently reduced the spontaneous excretion of fecal pellets, GK-128 did not affect it. These results suggest that GK-128 may be used for the treatment of stress-induced gastrointestinal dysfunction. Furthermore, the present results suggest that the 5-HT3 receptor involved in colonic motility may be different from the classically defined 5-HT3 receptor and/or that the regulation of colonic motility mediated by 5-HT3 receptors during stress may be different from normal physiological conditions.
The pathophysiology and clinical features of TA-GVHD are reviewed. Engrafted donor derived lymphocytes in TA-GVHD mainly target the immune system, i.e. myeloid and lymphoid as a result of recognition of "foreign" recipient transplantation antigens. The pathophysiology of acute GVHD has been described as a "cytokine storm" at the barrier of the immunobiological defence in the skin, liver, and intestine. TA-GVHD is mostly an acute syndrome, and predominantly associated with a pan-cytopenia, severe immunosuppression, a skin eruption, hepatitis, and gastrointestinal dysfunction, clinically manifested nausea, vomiting and diarrhea. The overall risk of TA-GVHD is unknown and is probably higher than the approximately 300-350 cases reported in the literature. TA-GVHD is often unrecognized in the setting of complex medical situations, where target organs are already dysfunctional. Furthermore, incomplete manifestations of the triad of GVHD may be present, or the syndrome may be mild or atypical. Finally, the potential diagnosis may be missed. We present an atypical case of fatal TA-GVHD in an immunocompetent diabetic patient after CABG operation, showing leukocytosis throughout the clinical course.
OBJECTIVE: To analyze the significance of cobalaminopenia (< 200 pmol/l) in patients with severe rheumatoid arthritis (RA). METHODS: We studied 42 patients with RA and cobalaminopenia (incidence 4%). Most patients had severe and longstanding disease. Concentrations of homocysteine, methylmalonic acid (MMA), gastrin, and pepsinogen 1 were analyzed in sera that had been stored frozen. A capillary gas chromatographic mass spectrometric technique was used to determine homocysteine and MMA. RESULTS: As a group, patients had significantly higher levels of serum homocysteine and serum MMA than laboratory reference probands (p < 0.0001 and p < 0.005, respectively). Individually, 20 of 39 patients had elevated serum levels of homocysteine (> 15 micromol/l). In 12 of 39 patients serum levels of MMA were elevated (> 0.37 micromol/l). Twenty of 42 patients had biochemical signs of disturbed gastric function. CONCLUSION: Our findings were compatible with the hypothesis that cobalaminopenia is one of several biochemical signs of gastrointestinal dysfunction in patients with severe RA. It is suggested that the hyperhomocysteinemia associated with vitamin B12 deficiency, folate deficiency, vitamin B6 deficiency, and impaired renal function may have a role in promoting high cardiovascular morbidity in patients with RA.
Gastrointestinal (GI) sensory-motor abnormalities are common in patients with diabetes mellitus and may involve any part of the GI tract. Abnormalities are frequently sub-clinical, and fortunately only rarely do severe and life-threatening problems occur. The pathogenesis of abnormal upper GI sensory-motor function in diabetes is incompletely understood and is most likely multi-factorial of origin. Diabetic autonomic neuropathy as well as acute suboptimal control of diabetes has been shown to impair GI motor and sensory function. Morphological and biomechanical remodeling of the GI wall develops during the duration of diabetes, and may contribute to motor and sensory dysfunction. In this review sensory and motility disorders of the upper GI tract in diabetes is discussed; and the morphological changes and biomechanical remodeling related to the sensory-motor dysfunction is also addressed.
The great majority of patients with duodenal ulcer (DU) given a single oral dose (50 mg) of dicetel (pinaverium bromide)--a selective blocker of calcium channels--showed optimization of vegetative reactivity and vegetative support of physical and mental activities. This contributes to relief of psychovegetative syndrome of the modulation of dysfunctions of proximal gastrointestinal tract (GIT). The addition of dicetel to combined treatment of PH shortened healing of DU, relieved pain, stopped gastric and intestinal dyspepsia, corrected motor-tonic defects of the proximal GIT caused by dysfunction of different links of the regulatory-adaptive system.
Autonomic neuropathy of the gastrointestinal tract may represent a primary disorder, but much more often it is secondary due to systemic disorders like diabetes mellitus. This review gives an overview about the common clinical manifestations and the principles and limitations in diagnostic work-up of autonomic dysfunction of the gastrointestinal tract. Diagnostic evaluation usually includes a combination of screening tests for autonomic neuropathy and specialized diagnostic procedures for the detection of sequela of autonomic neuropathy in gastrointestinal motility.