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Dysfunction of autonomic nervous system, accompanying different diseases of central and peripheral nervous system, is manifested by cardiovascular, gastrointestinal, genitourinary, thermoregulatory, respiratory and pupillary disorders. In the paper the methods of autonomic nervous system evaluation are reviewed, in particular the most popular cardiovascular and thermoregulatory tests.
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Hypercalcemia is a potentially lethal endocrine disorder occurring in 10% to 20% of cancer patients at some time during the course of their disease. Clinical manifestations vary in severity, depending on the degree and duration of hypercalcemia, rapidity of onset, patient's age, performance status, sites of metastases, previous antineoplastic therapy, and the presence of hepatic or renal dysfunction. The clinical features of hypercalcemia are protean and affect multiple organ systems, resulting most prominently in neurologic, gastrointestinal, renal, cardiovascular, and musculoskeletal morbidity. Recognition of the disorder requires a high index of suspicion because many of its symptoms, such as nausea, anorexia, weakness, fatigue, lethargy, and confusion, are non-specific and, in the patient with a malignancy, can result from other complications of the primary disorder. If identified appropriately as being related to hypercalcemia, such symptomatology is potentially reversible with treatment. Whereas in the ambulatory general medical population the most common cause of hypercalcemia is primary hyperparathyroidism, in cancer patients and hospitalized patients in general, the most common cause is malignancy. Hypercalcemia in cancer patients is, in most cases, due to advanced metastasized disease. Diagnostic tests are useful in the differential diagnosis of hypercalcemia, and such tests, together with an accurate history and careful clinical observation, permit the best therapeutic approach to an individual patient.
Gallbladder contractility was assessed using ultrasound in 111 patients with biliary pathology and 34 normal controls. The original and literature data show that food stimulus-induced contractility of the gallbladder is related to the pattern of gastric evacuation, duodenal mucosa status, nervous regulation, morphological inflammatory and sclerotic lesions in the gallbladder wall. Echographic evaluation of motor-evacuatory function of the stomach contributes to more accurate interpretation of the contractility. Hypotonic biliary dyskinesia is thought nonidentical to hypomotor dyskinesia. These disorders reflect different aspects of gallbladder dysfunction.
The author discusses morbid conditions of the upper digestive tract giving rise to dyspepsia, especially those involving gastric function. Several classifications are reported, as well as studies concerning gastric emptying. The effects of spa treatments with drinking of mineral waters is examined in relation to primary dysfunctions of the stomach and biliary passages.
Among 113 consecutive patients with disseminated intravascular coagulation (DIC), twenty cases who developed this condition under surgical intervention are the subject of this study. At the onset of DIC, fourteen cases were suffered from severe infection. Coagulation study in these patients revealed decreased platelet counts and prolonged prothrombin time. There was marked increase in fibrinogen degradation products and positive ethanol gelation test was frequently observed. These findings were analogous to those found in the more chronic presentations of DIC in the patients with neoplastic diseases, however, plasma concentration of fibrinogen was normal. Antithrombin III level was extremely low in the patients with surgical DIC. The patients with DIC in surgery took acute or subacute courses with very high incidence of major organ failure. The patients with dysfunction of more than three organs were seen in eight of 20 cases. The lungs, kidneys, liver and gastrointestinal tracts were involved in the descending order of frequency. Fourteen patients died and six of these were autopsied. All had multiple fibrin thrombi in more than two organs. The numbers and sites of microthrombi in the major organs were well matched with the clinical manifestations. These results suggested that DIC might be one of the precipitating factors of multiple organ failure.
A multi-center phase II clinical study with high dose cytarabine (NS-075) was conducted in adult patients with relapsed and/or refractory acute leukemia. 2 g/m2 cytarabine was given 12 times by 3-hour intravenous infusion every 12 hrs. 46 patients were registered, and 44 were evaluable: 35 with acute myeloid leukemia (AML) and 9 with acute lymphoblastic leukemia (ALL). There were 28 males and 16 females, with a median age of 37.5 years (range 15-68), including 6 of more than 60 years. Among 35 patients with AML, there were 16 (45.7%) complete and 2 (5.7%) partial remissions. Among 9 patients with ALL, there were 2 (22.2%) complete and 1 (11.1%) partial remissions. The major non-hematologic toxicities were gastrointestinal symptoms such as nausea/vomiting, anorexia and diarrhea, as well as fever, infection, conjunctivitis, alopecia, hepatic and renal dysfunctions. Central nervous system (CNS) toxicity was mild and reversible. Therapy-related death occurred in 5 patients resulting from prolonged pancytopenia, which suggests the necessity of strict countermeasures for infections as well as good patient care. These results indicate that high-dose cytarabine is a promising therapy for treatment of relapsed and/or refractory acute leukemia.
OBJECTIVES: To investigate the etiologies of urinary bladder involvement in patients with systemic lupus erythematosus (SLE), the clinicoradiologic features of gastrointestinal tract manifestations and clinical outcomes in patients with lupus cystitis accompanied by gastrointestinal manifestations. METHODS: We conducted a retrospective chart review on 413 patients with SLE. Patients were selected for review on the basis of lower urinary tract symptoms including urinary frequency, urgency and urinary incontinence. Radiologic studies were analyzed in patients with lupus cystitis. RESULTS: Ten consecutive patients, complicated with lower urinary tract symptoms, were identified. Underlying etiologies were as follows: lupus cystitis in five, neurogenic dysfunction secondary to transverse myelitis in three, cyclophosphamide-induced cystitis in one and tuberculous cystitis in one patient. All patients with lupus cystitis showed gastrointestinal manifestations, such as abdominal pain, nausea, vomiting and/or diarrhea during the periods of cystitis symptoms. In all patients with lupus cystitis, paralytic ileus was demonstrated on plain abdominal X-ray and ascites, bilateral hydroureteronephrosis and thickened bladder wall were identified on abdominal ultrasound or CT. Abdominal CT revealed bowel wall thickening in four of the five patients. The main sites of thickened bowel on abdominal CT were territory supplied by superior mesenteric artery. Two of five patients with lupus cystitis expired during the follow-up period. CONCLUSION: Diverse etiologies may cause lower urinary tract symptoms in patients with SLE. Lupus cystitis is strongly associated with gastrointestinal involvement and abdominal CT can be a useful radiologic tool to investigate the gastrointestinal tract involvement in patients with lupus cystitis.
A case of intestinal pseudo-obstruction in a 76-year-old man who presented with a six-year history of intermittent vomiting and abdominal pain and a 1(1/2)-year history of diarrhea is described. Investigation demonstrated aperistalsis of the lower esophagus and an unresponsive atonic small intestine. Marked malabsorption was present and appeared due to intestinal bacterial overgrowth consequent to the hypomotility. Autonomic nervous system testing failed to reveal any definite abnormality. Although this disorder is markedly similar to scleroderma involving the gastrointestinal tract, there was only minimal fibrosis of the bowel musculature evident at autopsy and the neural components appeared to be intact. These findings suggest that the basic disorder may be one of smooth muscle dysfunction. Other known causes of pseudo-obstruction could not be demonstrated.
Hirschsprung disease (HSCR) is a congenital disorder associated with the absence of intrinsic ganglion cells in the distal gastrointestinal tract. Recently, many missense, nonsense and frameshift mutations of the ret proto-oncogene were found in familial and sporadic cases of HSCR. Consistent with the view that the HSCR phenotype is the result of inactivation of Ret, the missense mutations detected in the tyrosine kinase domain were demonstrated to result in a marked decrease of the kinase activity of Ret. However, the effects of missense mutations found in the extracellular domain remain unknown. We now report that five mutations in the extracellular domain examined inhibit transport of the Ret protein to the plasma membrane. As a consequence, they significantly decreased the transforming activity of Ret with multiple endocrine neoplasia (MEN) 2A mutation for which cell surface expression is required. Our results also demonstrated that long segment HSCR mutations more severely impair transport of Ret to the plasma membrane than a short segment HSCR mutation, suggesting that the level of its cell surface expression may correlate to the HSCR phenotype.
Few studies describe patients' quality of life and their experienced symptoms during the recovery period after having undergone upper gastrointestinal surgery at 3 and 12 months. The aims of this study were to explore patients' quality of life and symptoms preoperatively and at 3 and 12 months following upper gastrointestinal surgery and to describe and compare patients' experiences of appetite, food intake, weight changes, tiredness and sleeping patterns. A descriptive and comparative quantitative design was used. Three instruments were used: the Gastrointestinal Symptom Rating Scale, the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire and the Eating Dysfunction Scale. A questionnaire was used to investigate symptoms such as mood, appetite, sleep, activities and well-being. Twenty-four patients were included in the study. The major results were that anxiety levels and global health status decreased and that patients felt more disappointed after 12 months compared with after 3 months. Four patients at 3 months after surgery and eight patients at 12 months regained their weight compared with the situation before surgery. The contribution of nursing care activities focusing on the importance of food intake and the patients' current and historical medical records in relation to their health status should continue to be examined and researched over a longer period of time.
BACKGROUND: Patients with multiple sclerosis (MS) may experience numerous symptoms, including spasticity, fatigue, cognitive dysfunction, depression, bladder dysfunction, bowel dysfunction, sexual dysfunction, and pain. OBJECTIVE: This article reviews the pharmacologic and nonpharmacologic interventions used to manage the symptoms of MS and discusses how interventions for a particular MS symptom may have an impact on other symptoms. METHODS: The English-language literature was reviewed through November 2005 using MEDLINE and the Cochrane Database of Systematic Reviews, with no restriction on year. The search terms included multiple sclerosis, disease-modifying therapies, adverse events, and combinations of multiple sclerosis with terms such as spasticity, fatigue, depression, mood disorders, pain, bladder dysfunction, bowel dysfunction, sexual dysfunction, cognitive dysfunction, and quality of life. RESULTS: The numerous options for the treatment of MS symptoms have shown varying degrees of efficacy and tolerability. Certain symptoms, if left untreated, may precipitate exacerbation of others. For example, spasticity may lead to pain and bladder and bowel dysfunction, whereas fatigue can compromise cognitive function. Similarly, the adverse effects of treatments for certain symptoms may further compromise other aspects of function. For example, the use of antidepressants may lead to sexual dysfunction, and treatments for spasticity and pain may cause sedation, which can worsen fatigue, cognitive dysfunction, and depressed mood. CONCLUSIONS: MS is associated with numerous symptoms that can be adversely affected by each other and by therapeutic interventions. Careful clinical monitoring and individualization of pharmacologic and non-pharmacologic therapies are recommended to manage the symptoms of MS, with the goals of improving or maintaining function and preserving the patient's quality of life.
PURPOSE: The bowel and sexual function of colorectal cancer patients undergoing either sphincter-saving or sphincter-sacrificing surgical procedures may be impaired. A legitimate question is how these different surgical techniques affect the patients' quality of life. METHODS: Seventeen studies were identified that compared at least one of four aspects of patient functioning (i.e., physical, psychologic, social, and sexual) between stoma patients and nonstoma patients. RESULTS: Although the literature does not yield entirely consistent findings, some long-term effects of surgery can be identified: 1) both patient groups are troubled by frequent or irregular bowel movements and diarrhea; 2) stoma patients report higher levels of psychologic distress than do nonstoma patients; 3) although both stoma patients and nonstoma patients report restrictions in their level of social functioning, such problems are more prevalent among patients with a colostomy; 4) sexual functioning of male and female stoma patients is consistently more impaired than that of male and female patients with intact sphincters. Results of the current review were compared with those of other, related areas. CONCLUSIONS: Although nonstoma patients generally fare better than do stoma patients, they also suffer from physical impairments induced by sphincter-saving procedures (e.g., impaired bowel and sexual function). These impairments may become more prevalent as ultralow anastomosis is more frequently applied, resulting in bowel and sexual dysfunction and related psychologic distress. Well-designed studies are needed that examine whether quality-of-life benefits are to be gained by use of ultralow anastomosis compared with colostomy.
Hemorrhage is a prominent feature of hemorrhagic fever with renal syndrome (HFRS) in China. It occurs in all phases of the disease and is an important cause of death. Petechiae involving skin and oropharyngeal mucosa are the commonest manifestation of hemorrhage, occurring in more than 90% of patients. Gastrointestinal hemorrhage is the next commonest manifestation, occurring in approximately 50% of patients. Suggested mechanisms of hemorrhage include vascular injury, thrombocytopenia and platelet dysfunction, disseminated intravascular coagulation, circulating heparin-like activity, and uremia. Controlled trials of treatment regimens for hemostatic impairment in HFRS have not been performed. Support of blood pressure can lessen hemorrhage by limiting the adverse consequences of hypotension and shock. Dialysis is of benefit in patients with hemorrhage and significant renal failure.
This study was undertaken to ascertain whether clinical and endoscopic factors can predict the outcome in patients with acute upper gastrointestinal hemorrhage. A total of 185 patients admitted with hematemesis over a 4-year period were studied. Clinical evidence of shock and hepatocellular dysfunction and hemoglobin level were noted on admission. Endoscopy was performed within 48 hours of admission to look for the site and number of lesions, and stigmata of hemorrhage. On analysis, age, clinical evidence of shock, hepatic dysfunction and hemoglobin less than 8.0 g/dl (80 g/L) were found to be significant in prediction of risk of further hemorrhage. Similarly age, past history of jaundice, previous bleeding episodes and clinical evidence of hepatic dysfunction were statistically significant predictors of mortality. Bleeding from varices and peptic ulcer was associated with a worse prognosis than acute mucosal lesions. It is concluded that clinical and endoscopic factors can be used to identify a group of patients at high risk of further hemorrhage and mortality.
Decompensated liver disease was investigated in 94 unselected Filipino patients sequentially hospitalized with Schistosoma japonicum infection. Liver damage was objectively scored from 3 (none) to a maximum of 10 (severe damage with encephalopathy) using a modified Pugh-Child grading system. Liver parenchymal dysfunction occurred in 52% of patients and was severe in 21% (hepatic encephalopathy or markedly prolonged prothrombin time). Severity scores were higher in patients with previous gastrointestinal bleeding (7.3 vs. 5.1; P less than .001) and were inversely correlated with admission hematocrit (r = -.60; P less than .001). Ultrastructural analysis revealed abnormalities of Disse's space--the site of blood-hepatocyte exchange. Praziquantel achieved 100% parasitologic cure, but none of the 27 patients followed up for a mean of 9.6 months after receiving it had resolution of liver damage. Liver parenchymal dysfunction is a common problem in hospitalized schistosomiasis patients and persists after parasitologic cure.
Vasoactive intestinal peptide (VIP) and the newly discovered pancreatic polypeptide (PP), both having been proposed as pathogenetic factors in the watery diarrhea syndrome (WDRA), were intravenously infused into rats in order to study the effect on small bowel propulsion. Simultaneously with the infusion of hormone, radioactive test substance was continuously infused into the duodenum of the conscious animal through a permanent catheter. By recording the distribution of radioactivity along the excised gastrointestinal tract, analyses of small bowel propulsion were possible. After infusion of VIP small bowel transit time was significantly prolonged, and the local propagation velocity was retarded both in the proximal and the distal part of the small bowel. PP did not alter small bowel populations. The heavily retarded transport rate after VIP is a propulsive dysfunction and not inconsistent with the clinical sign of diarrhea.
Although the incidence of significant complications occurring during endoscopic procedures that require sedation are low, it has been demonstrated that they are usually related to cardiovascular system dysfunction. Such complications are a manifestation of cardiac hypoxia and are a function of the arterial oxygen desaturation. A practical method of monitoring such patients includes continuous oxygen saturation measurements and EKG monitoring. From October, 1987 to July, 1989, a total of 730 endoscopic examinations were performed using a combination of meperidine and midazolam as an intravenous (IV) bolus for sedation. Supplemental nasal oxygen was routinely given at 2 L per minute and real-time monitoring was performed with electrocardiograph and continuous pulse oximeter. There were no deaths and only four untoward events related to medication that altered the course of the examination. Transient hypoxemia that responds to gentle stimulation and bradycardia resolving with cessation of endoscope advancement are viewed as physiologic responses and not complications. All occurrences were immediately identified and corrected appropriately, and no morbidity resulted. With proper monitoring of oxygen saturation, pulse, and cardiac rhythm in a patient with nasal oxygen, IV bolus administration of meperidine and midazolam is a safe and adequate sedation even in the elderly and debilitated patient.