The effect of oral decontamination with clindamycin palmitate on the incidence of bacteremia after esophageal dilation: a prospective trial.

BACKGROUND: Antibiotic prophylaxis to prevent bacterial endocarditis is recommended in high-risk patients undergoing esophageal dilation, a high-risk procedure. Some studies suggest that the oropharynx is the source of bacteremia. A topical antibiotic mouthwash, which reduces bacterial colonization of the oral flora, might decrease bacteremia rates and would be an attractive alternative to systemic administration of antibiotics. METHODS: Adults undergoing outpatient bougienage for a benign or malignant esophageal stricture were randomized in a clinician-blinded fashion to either pre-procedure clindamycin mouthwash or no treatment. Subjects were stratified by type of dilator used. Blood cultures were obtained immediately after the first esophageal dilation and 5 minutes after the last dilation. RESULTS: Fifty-nine patients were enrolled: 30 in the treatment arm and 29 in the no-treatment arm. There were 7 positive blood cultures: 5 in the treatment arm and 2 in the no-treatment arm. The identified organisms were Streptococcus viridans (2), Staphylococcus mucilaginous (2), Lactobacillus (2), and Actinomyces odontolyticus (1). Patients with bacteremia reported greater subjective difficulty with dysphagia (p = 0.01) irrespective of stricture diameter, procurement of biopsies, or dilator type. CONCLUSIONS: The percentage of cases with bacteremia for all dilations performed in this manner was 12% (95% CI [5.3, 23.6]), much lower than previously cited. All organisms in this study were oral commensals. There appears to be no effect of a clindamycin mouthwash on reducing bacteremia after esophageal dilation.

Incidence of stool guaiac conversion following extracorporeal shock wave lithotripsy.

OBJECTIVES: To study, in a prospective fashion, acute traumatic effects on the gastrointestinal tract of patients treated by extracorporeal shock wave lithotripsy (ESWL). METHODS: Stool samples from each of 54 patients were tested before and after ESWL for conversion to hemoccult positive. A minimum of one negative pre-ESWL stool guaiac test was required for inclusion into the study. A minimum of two stool guaiac tests were done after ESWL to verify negativity. Patients who converted to a positive hemoccult test after ESWL were then evaluated by colonoscopy for the source of bleeding. RESULTS: Fifty patients completed the study. A single patient (2.0%) converted to a positive post-ESWL hemoccult test and was evaluated with colonoscopy. This patient was found to have two benign adenomatous polyps in the sigmoid and descending colon after treatment for a left renal pelvis calculus. An additional patient with a slightly positive post-ESWL conversion refused further evaluation. The overall post-ESWL conversion rate to guaiac positive, therefore, was less than 4% (2 of 51 patients). CONCLUSIONS: There is no evidence of significant trauma or detectable bleeding in the normal gastrointestinal tract caused by ESWL as measured by postprocedure stool guaiac testing. Guaiac testing of the stool after ESWL may unmask pre-existing gastrointestinal disease. Therefore a positive guaiac test after ESWL warrants further evaluation. This study reaffirms that ESWL is a safe, minimally invasive technique for the treatment of urolithiasis, without significant adverse side effects on the gastrointestinal tract.

Acute pancreatitis associated with continuous infusion cytarabine therapy: a case report.

BACKGROUND: While acute pancreatitis is a recognized complication of numerous drugs, cytarabine's role in causing this complication is controversial. Approximately 15 cases have been reported to the Food and Drug Administration linking cytarabine with pancreas-related toxicities. Previous case reports have been complicated by comorbid illnesses and the coadministration of other drugs associated with acute pancreatitis. METHODS: This report describes the clinical course of a patient with acute myelogenous leukemia (AML) who developed recurrent pancreatitis associated with cytarabine therapy. RESULTS: A male age 36 years with French-American-British M5B acute myelogenous leukemia received induction cytarabine (200 mg/m2/day) by continuous infusion for 7 days, and subsequently developed acute pancreatitis. The patient was rechallenged with intermittent, bolus, high dose cytarabine (HDAC) (3 g/m2bid administered over 3 hours) during the following intensification treatment, but did not develop clinical acute pancreatitis. Retreatment with continuous infusion cytarabine at a later time resulted in recurrence of acute pancreatitis. CONCLUSIONS: This case illustrates that cytarabine treatment may cause acute pancreatitis, and that this toxicity may be schedule dependent. In those with known sensitivity to cytarabine, altering the administration technique may avoid this complication.

Recurrent abdominal pain from abdominal adhesions in an endurance triathlete.

Abdominal adhesions have been described as developing postoperatively and as developing "spontaneously" in patients over 60 yr old. To our knowledge, abdominal adhesions have not been described as an etiology of recurrent abdominal pain in young endurance athletes, without prior history of abdominal surgery. We present a 28-yr-old endurance triathlete with recurrent abdominal pain in which multiple diagnostic imaging studies were unable to diagnose the etiology. Diagnostic laparoscopy revealed adhesions between the ascending colon and the anterior abdominal wall. Laparoscopic adhesiolysis was performed successfully and the athlete resumed his training several weeks post-laparoscopy without symptoms. One year later, the athlete remains pain free.

Gastrointestinal bleeding and the athlete.

GI bleeding occurs with prolonged exercise and is probably mediated by visceral ischemia. It may produce acute hemorrhage, more chronic symptoms with anemia, or result in guaiac-positive conversion with little clinical disease. Hemorrhagic gastritis and colitis are the most frequently recognized lesions, and are usually transient and reversible. Acid suppression with cimetidine may be effective in selected patients with recurrent HG, but effective therapy for most patients with this form of GI bleeding is still uncertain. Awareness of the association between GI bleeding and exercise should stimulate further investigations into the pathophysiology and therapy.

Chronic multivitamin-mineral supplementation does not enhance physical performance.

The effects on physical performance of 90 d of supplementation with a high potency multivitamin-mineral supplement were studied in a double-blind, placebo-controlled design. Twenty-two healthy, physically active men were randomly assigned to a supplement (S) or placebo (P) group; both groups had similar physical characteristics. Performance was assessed from maximal aerobic capacity, endurance capacity, and isokinetic tests. Supplementation did not affect maximal aerobic capacity: pre and after approximately 12 wk of supplementation values for maximal oxygen consumption (48.5 +/- 1.3 vs 46.2 +/- 1.1 ml.kg-1.min-1), maximal heart rate (186 +/- 2 vs 187 +/- 2 beats.min-1) or treadmill time (19.96 +/- 0.48 vs 19.99 +/- 0.37 min) did not differ in the S group; similar findings were noted in the P group. Performance during the 90-min endurance run, as assessed from heart rates, rectal temperatures, and plasma glucose, lactate and adrenocorticotropin values, was not affected by treatment. Similarly, muscle strength and endurance were not affected. Thus, supplementation did not affect physical performance in well-nourished men who maintained their physical activity.

Plasma zinc uptake from a supplement during submaximal running.

The uptake of zinc (Zn) into the plasma after the ingestion of 25 mg of Zn from multivitamin-mineral supplement was studied in 10 men during running (R) and control (C) conditions; the R was for 2 h at 60-65% of their maximal oxygen uptake. Subjects took the supplement with 200 ml of deionized water before the R or C (0-time). Blood was drawn before the Zn load and every 30 min for 3 h. By 2 h, plasma Zn concentrations had risen to values that were 151 +/- 7% and 149 +/- 5% of (0-time) R and C concentrations, respectively. Furthermore, the average rates of Zn uptake into the plasma did not differ between the R and C (4.4 vs 3.8 mumol.l-1.h-1) conditions. Finally, areas under the curve were not different (R: 13.2 +/- 1.8 mumol.l-1.3h-1; C: 11.5 +/- 1.5 mumol.l-1.3h-1). In summary, submaximal endurance running did not affect plasma Zn uptake and therefore absorption of Zn from a supplement taken just prior to exercise. The effect of chronic exercise on Zn absorption remains to be determined.

Hormonal responses to ingesting water or a carbohydrate beverage during a 2 h run.

Ingestion of fluids providing carbohydrate and electrolytes extends endurance times during prolonged exercise. To understand the contribution of these factors, we examined hormonal, physiologic, and metabolic responses to ingesting water (W) or a 7% glucose polymer/fructose/electrolyte solution (GPFE) in 10 men (age: 30 +/- 2 yr, VO2max: 57.4 +/- 3.2 ml.kg-1.min-1) who ran on a treadmill for 2 h at 60-65% of their VO2max. Subjects drank 200 ml of W or GPFE at 0-time and every 30 min while running (30,60, and 90 min). Changes in serum sodium, potassium, and osmolality; heart rate; plasma lactate and glucose; and serum insulin and plasma norepinephrine were similar for both fluid treatments. In contrast, changes in serum free fatty acids (FFA), plasma cortisol, and arginine vasopressin (AVP) differed across fluid treatments: with GPFE, exercise abolished the rise in plasma cortisol, and attenuated the rise in both AVP and FFA. The observed suppression of cortisol and AVP was not related to changes in any of the parameters examined, but were strongly correlated with each other. These findings suggest that adding carbohydrate and electrolytes to fluids ingested during prolonged exercise decreases activation of the hypothalamic-pituitary-adrenal axis, a potentially beneficial change. However, mobilization of FFA was also decreased. The mechanism by which they occur remains elusive.

Vitamin and mineral status in physically active men: effects of a high-potency supplement.

Changes in nutritional status during supplementation with a high-potency multivitamin-mineral supplement were examined in 22 physically active men randomly assigned to take a supplement (n = 11) or placebo (n = 11) for approximately 12 wk. Four-day dietary intakes, blood concentrations, and urinary excretions of selected vitamins and minerals were measured before, during (approximately 6 and 12 wk), and after supplementation. No changes were observed in blood concentrations of vitamins A and C and measures of zinc, magnesium, and calcium status; the supplement provided less than 300% of the recommended dietary allowance (RDA) of these nutrients. In contrast, blood concentrations of thiamin, riboflavin, vitamins B-6 and B-12, pantothenate, and biotin increased significantly (P less than 0.05) by 6 wk to values that were maintained until the end of the supplementation. These vitamins were provided in amounts that ranged from 396% (biotin) to 6250% (vitamin B-6) of the RDA. Urinary excretions of these vitamins also increased during supplementation and both blood and urine values returned to presupplementation concentrations at approximately 13.5 wk postsupplementation.

Squamous cell carcinoma of the esophagus. Natural history, incidence, etiology, and complications.

In an attempt to improve the dismal outcome of patients with esophageal squamous cell carcinoma, attention has recently focused on suspected causes and other known influences on the course of this disease. This article reviews recent literature regarding the natural history, incidence, etiology, and complications of squamous cell cancer of the esophagus.

Effect of cimetidine on marathon-associated gastrointestinal symptoms and bleeding.

Occult gastrointestinal bleeding occurs in 8-30% of marathon runners. We hypothesized that cimetidine would decrease bleeding by reducing acid-mediated injury and conducted a blinded, placebo-controlled prospective trial to determine the impact of cimetidine on gastrointestinal symptoms and bleeding during a marathon. Thirty participants in the 1989 Marine Corps or New York City marathons completed pre- and postrace: (1) a questionnaire evaluating demographic, medication usage, training history, and gastrointestinal symptoms; (2) three consecutive stool Hemoccult (HO) cards; and (3) a stool Hemoquant (HQ). Fourteen runners (CR) took 800 mg of cimetidine by mouth 2 hr before the start and 16 runners (PR) took placebo. Three subjects were HO+ prerace and were not analyzed. Three subjects failed to take drug as directed and were analyzed as PR. Five of 14 PR and two of 13 CR were HO+ postrace (P greater than 0.05). Prerace HQ values (PR: 1.49 +/- 0.6 and CR: 0.60 +/- 0.1 mg hemoglobin/g stool) were not significantly different from postrace HQ values (PR: 0.73 +/- 0.2 and CR: 0.86 +/- 0.2 mg Hgb/g stool). Despite postrace HO+ conversion, no individual postrace HQ became abnormal. The frequency of gastrointestinal symptoms was similar for CR and PR, as well as HO- and HO+ individuals. Cimetidine did not significantly affect occult gastrointestinal bleeding as measured by HO or HQ results. This suggests that marathon-associated gastrointestinal symptoms and bleeding may be due to lesions other than acid-mediated disease or hemorrhagic gastritis.

Suture granuloma masquerading as malignancy of the biliary tract.

Eighteen years after having a duodenal leiomyosarcoma resected, a patient presented with weight loss, pruritus, and abdominal pain. ERCP was consistent with a cholangiocarcinoma with proximal hepatic duct stricture and nonfilling of the cystic duct. CAT scan revealed no extrinsic masses compressing the gallbladder or biliary tract. At surgical exploration, the patient was found to have a suture granuloma with surrounding fibrosis within the common bile duct. There was no evidence of malignancy.

Cimetidine reduces running-associated gastrointestinal bleeding. A prospective observation.

A prospective observational study was undertaken to compare the effect of cimetidine usage immediately before and during a 100-mile running race on the frequency of detectable gastrointestinal bleeding and to relate these data to the frequency and intensity of gastrointestinal symptoms and to training data collected from pre- and postrace questionnaires. Nine of 25 runners in the 1989 Old Dominion 100-mile Endurance Race took 800 mg of cimetidine 1 hr before the start and at 50 miles. Sixteen other runners acted as controls and were not different in age, gender, or training data. All runners also submitted three stool specimens from the week before the race and from the first three bowel movements after the race on standard Hemoccult cards. All runners were Hemoccult negative before the race. One of the 9 (11%) cimetidine runners and 14 of the 16 (87.5%) control runners were Hemoccult positive afterwards (P less than or equal to 0.05). Nausea and vomiting were less in those runners taking cimetidine (P less than or equal to 0.05). There was no difference in the race performance as related to the ability to finish or in the number of miles run during the race. This study may help to define the etiology of this common gastrointestinal bleeding in these ultradistance runners and may be useful in preventing some of the symptoms associated with long-distance running.

Chronic beta-carotene supplementation does not alter the gastric mucosal response to acute aspirin ingestion.

Carotenoids and retinoids have been reported to reduce gastrointestinal mucosa damage from a variety of irritants. We performed double-blind, placebo-controlled endoscopic trial to evaluate the effect of chronic beta-carotene supplementation upon the gastric mucosal response to acute aspirin injury. Six subjects taking chronic beta-carotene and six taking placebo each ingested 650 mg of aspirin after an endoscopy confirmed normal gastric mucosa. Three hours later, mucosal lesions were counted at repeat endoscopy. beta-Carotene did not prevent acute mucosal injury better than placebo.

Dietary patterns, gastrointestinal complaints, and nutrition knowledge of recreational triathletes.

Dietary habits, nutrition knowledge, and gastrointestinal complaints were evaluated in 21 female and 50 male triathletes; 30 completed hemoccult slides to determine the frequency of gastrointestinal bleeding. Triathletes trained 11 h/wk with weekly distances of 5.3, 116.5, and 40.9 km for swimming, biking, and running, respectively. Mean daily energy intake averaged 9058 and 11,591 kJ for women and men, respectively; 53.8% of the energy was from carbohydrates. Mean intakes of vitamins and most minerals exceeded the Recommended Dietary Allowances (RDAs), but many had intakes below RDAs for some nutrients; greater than 60% had low zinc and copper intakes. Because 39% took a daily multivitamin-mineral supplement, some had intakes 200-600% above the RDA. Although there were notable misconceptions about nutrition, nutrition knowledge was high. Upper-gastrointestinal complaints, reported by 50%, included bloating and abdominal gas; the incidence of positive hemoccult slides was 27%. The relation among performance, dietary patterns, nutrition knowledge, and gastrointestinal function remains to be established.

The effect of exercise on the gastrointestinal tract.

Surveys of athletes, primarily runners, have shown that digestive disorders are common, associated both with training and racing. Women, in particular, seem to suffer most commonly. Nearly half have loose stools and nausea and vomiting occur frequently after hard runs. Diarrhoea, incontinence and rectal bleeding occur with surprising frequency. Runners may use medications prophylactically to minimise some of these symptoms. Upper digestive symptoms seem to occur more commonly in multisport events such as triathlons or enduro. The published literature is difficult to analyse and the basic intestinal physiology not well studied. Most gastroenterologists are accustomed to evaluating the fasting patient at rest and exercise physiologists are seldom experienced with digestive techniques. Digestive symptoms occurring with exercise referable to the oesophagus include chest pain, gastro-oesophageal reflux symptoms, or symptoms related to alterations in motility. While little is known of the oesophageal physiology during exercise, it is believed that only minimal changes occur in most subjects. Gastro-oesophageal reflux occurs more frequently with exercise than at rest and may produce symptoms of chest pain suggestive of ischaemic disease. Acid exposure may be reduced by pretreatment with histamine H2-receptor antagonists. Oesophageal symptoms, though common, are rarely disabling to the athlete, and the clinical importance lies in confusion with ischaemic disease. Cases of acute gastric stasis following running have been reported and gastric physiology during exercise, particularly bicycling, has been more actively investigated. Gastric emptying during exercise is subject to a number of factors including calorie count, meal osmolality, meal temperature and exercise conditions. However, it is generally accepted that light exercise accelerates liquid emptying, vigorous exercise delays solid emptying and has little effect upon liquid emptying until near exhaustion. Gastric acid secretion probably changes little with exercise although some have postulated that ulcer patients may increase secretion with exercise. Some exercise-associated digestive symptoms, such as diarrhoea and abdominal pain, have been attributed to changes in intestine function. Small bowel transit is delayed by exercise when measured by breath hydrogen oral caecal transit times and motility may be reduced as well. Intestinal absorption during exercise has not been well evaluated but probably changes little in ordinary circumstances. Passive absorption of water, electrolytes and xylose are not affected by submaximal effort. Colonic transit and function is even more difficult to evaluate and published results have been conflicting. However, it is likely that many of the lower digestive complaints of runners such as diarrhoea and lower abdominal cramps are due to direct effects of exercise upon the colon.(ABSTRACT TRUNCATED AT 250 WORDS)

Gastrointestinal bleeding during an ultramarathon.

A prospective study was undertaken to determine the frequency of detectable gastrointestinal bleeding in participants of a 100-mile running race. Pre- and postrace questionnaires were utilized to determine training data, gastrointestinal symptoms, diet, and the use of medications during training and during the race, prior known gastrointestinal disease, and 100-mile race experience. Three prerace and the first three postrace stools were sampled for blood using the standard Hemoccult method in 35 runners: 85% of the participants who were Hemoccult negative before the race converted to positive in their postrace samples. Runners with the postrace Hemoccult-positive stools had more frequent and intense nausea, diarrhea, abdominal cramping, and bloating (P less than 0.05) during the race. Lower gastrointestinal symptoms correlated with Hemoccult positivity (P less than 0.05), whereas upper gastrointestinal symptoms did not. The majority of participants showed evidence of gastrointestinal bleeding after the race. Digestive symptoms are common and lower gastrointestinal symptoms correlate with gastrointestinal bleeding.