Watery diarrhoea: an unusual manifestation of breast cancer.

Analysis of an 83-year-old male presenting with diarrhoea showed secretory diarrhoea. serum levels of gastrin and pancreatic polypeptide were elevated. Somatostatin-receptor scintigraphy revealed a hot spot in the left thoracic wall and subsequently, breast adenocarcinoma with neuroendocrine differentiation was diagnosed. Postoperatively, the patient made an uneventful recovery. The relationship between the clinical picture, the results of pathological examination and hormonal analysis is discussed and put into perspective.

Hepatocholedochal cysts. A rare cause of obstructive jaundice.

The case history is described of a 21-year-old woman who, after analysis because of jaundice and pain in the upper abdomen, was diagnosed as having hepatocholedochal cysts Type IV-A. Surgery was performed. In connection with this case history the literature on hepatocholedochal cysts is reviewed.

The endoscopic spectrum of colonic mucosal injury following aortic aneurysm resection.

Ischemic colitis is a serious complication of aortic aneurysm resection. A knowledge of the endoscopic appearance and the clinical course of various forms of colonic mucosal injury is important for the clinician who has to decide which patient should be carefully monitored after aneurysm resection. This article reports on 48 patients with colonic mucosal injury, subdivided into non-specific lesions and ischemic colitis. Details are given of the endoscopic picture and the clinical course. It is concluded that only the gangrenous form of ischemic colitis is of clinical significance, and is related to bowel perforation and late stricture formation.

Organic personality disorder after traumatic brain injury: cognitive, anatomic and psychosocial factors. A 6 month follow-up.

OBJECTIVE: The purpose of the study is to describe psychosocial adjustment in patients who present Organic Personality Disorder (OPD) after TBI in relation to patients with TBI without OPD. METHOD: The group included patients who were admitted as inpatients in the Neurology Service. Exclusion criteria were: previous personality disorders; previous alcohol and drugs addiction, history of head injury and other neurological diseases. For this purpose, a semi-structured interview based on the ICD-10 was applied to the patient or significant other during the 1st or 2nd week after the accident. Selected patients were evaluated with psychological and psychosocial tests and questionnaires 6 months after head injury, among them: WAIS, Benton Test, Rey Osterrieth Test, Wisconsin Cards, Psychosocial Scale and Neurobehavioural Rating Scale (NRS-27). RESULTS: No significant differences were observed in relation to demographic characteristics, type of head injury, GCS, or psychometric results. Significant differences were found in the answers to neurobehavioural and psychosocial questionnaires, showing more impairment in patients with OPD. CONCLUSIONS: The results show that, in this group, patients with OPD after TBI present more psychosocial adjustment and emotional problems than patients with TBI without OPD diagnosis. The difference found is independent of cognitive impairments.

Ischaemic disease of the colon and rectum after surgery for abdominal aortic aneurysm: a prospective study of the incidence and risk factors.

In a prospective study of 100 patients operated on for an infrarenal localised aortic aneurysm, routine postoperative colonoscopy revealed ischaemic colonic disease, defined as ulceration or necrosis of different degrees in three of 66 patients (4.5%) operated on electively or semi-acute, and in six of 34 patients (17.6%) operated on for a rupture of their aneurysm. Colonoscopic findings were interpreted as transmural gangrene in three patients, extensive superficial necrosis in one, and ulceration in five. Exploratory laparotomy, however, led to a definite diagnosis of transmural gangrene in only one patient. This patient was the only one whose death was directly related to this complication, notwithstanding timely surgical intervention. Four patients had severe and protracted diarrhoea, while four others exhibited no clinical symptoms at all. Ischaemic colonic lesions were found more often in patients who had been exposed to a period of preoperative shock, than in those who were operated on in a stable circulatory state (20.7 vs. 4.2%; P less than 0.05). It was also more common in patients in whom the patency of at least one hypogastric artery could not be preserved (36 vs 5.6%; P less than 0.02). Ligation of a patent inferior mesenteric artery was not in this study related to the development of ischaemic colonic disease, nor was a period of prolonged (greater than 1 h) cross clamping of the aorta. Postoperative diarrhoea was an early warning sign of ischaemic colonic disease in five of nine patients. Other clinical symptoms or signs were of no value at all in this respect.(ABSTRACT TRUNCATED AT 250 WORDS)

No beneficial effect of low-dose fetal intravenous gammaglobulin administration in combination with intravascular transfusions in severe Rh D haemolytic disease.

Recent observations have shown that treatment with high-dose intravenous gammaglobulin (IVIgG) given to the mother may improve fetal outcome in cases of severe Rh D alloimmunization. Unfortunately, the costs of this new method of treatment are too high for routine use. Therefore, we decided to apply this treatment to the fetus and to investigate whether the effect of IVIgG might be attributable to blockade of the fetal mononuclear phagocyte system. We have performed a randomized study in which 20 fetuses with severe Rh D-haemolytic disease (HDN) were treated with intrauterine intravascular red cell transfusions (IUT). In 10 of these 20 cases transfusions were followed by administration to the fetus of low-dose IVIgG (85.7 +/- 11.6 mg/kg by ultrasound-estimated fetal weight because of fetal vascular volume considerations). We compared the number of IUTs, postnatal exchange transfusions, haematocrit (Ht) and haemoglobulin (Hb) values before and after transfusion (s) needed by the newborns of the two groups. No significant differences in the transfusion requirements of the fetuses and in the clinical outcome could be demonstrated. However, the 95% confidence interval for the difference in the improvement of cord blood Ht was too wide for any conclusions. The 95% confidence interval for the difference in the improvement of Hb levels suggests that any clinically relevant advantage of IVIgG on Hb is unlikely.

Olsalazine as an alternative therapy in a patient with sulfasalazine-induced eosinophilic pneumonia.

A man with Crohn's colitis developed eosinophilic pneumonia after treatment with sulfasalazine. Challenge with sulfapyridine revealed that this component of sulfasalazine was the likely causative agent. Treatment with olsalazine, a 5-aminosalicylic acid compound (disodium-azodisalicylate), was well tolerated without recurrence of pulmonary symptoms.

The efficacy of laboratory diagnosis of Helicobacter pylori infections in gastric biopsy specimens is related to bacterial density and vacA, cagA, and iceA genotypes.

A total of 500 consecutive patients undergoing upper endoscopy were biopsied and tested for H. pylori infection by the Campylobacter-like organism (CLO) test, culture, histology, and PCR. Serum samples were tested by two different serological assays. Patients were considered H. pylori positive if at least two of the four biopsy specimen-based methods yielded positive results. PCR had the highest diagnostic sensitivity (99.4%), followed by histology (92.2%), culture (89.5%), and the CLO test (89.0%). The specificities of all methods were higher than 98%. Of the organisms from the 181 PCR-positive patients, the vacA (s and m regions), cagA, and iceA genotypes were determined by reverse hybridization (line probe assay) or an allele-specific PCR. Organisms that were detected by PCR but that remained undetected by the CLO test were significantly more often vacA s1 (P = 0.006), m1 (P = 0.028), and cagA positive (P = 0.029) than vacA s2, m2, and cagA negative, respectively. Organisms that were detected by PCR but that remained undetected by culture or histology more often contained iceA1 (P = 0. 034 and P = 0.029, respectively) than iceA2. Higher H. pylori density was associated with vacA s2 (P = 0.024), vacA m2 (P = 0.050), and cagA-negative (P = 0.035) genotypes. Also, the diagnostic results of the CLO test (P = 0.001) and culture (P = 0.031) but not those of the PCR (P = 0.130) were significantly associated with the H. pylori density. The rate of detection by the four biopsy specimen-based tests was lower for patients who used proton pump inhibitors, but this was independent of the H. pylori genotypes. These observations may be explained by different bacterial densities, as established by the distinct genotypes of H. pylori, and confirm that the biologies of strains with such genotypes are considerably different.

Assessment of Helicobacter pylori vacA and cagA genotypes and host serological response.

Helicobacter pylori strains can be distinguished by genotyping of virulence-associated genes, such as vacA and cagA. Because serological discrimination between strain types would reduce the need for endoscopy, 61 patients carrying H. pylori were studied by vacA and cagA genotyping of H. pylori in gastric biopsy specimens and by detection of specific serum antibodies. Serological responses to H. pylori were determined by Helicoblot (versions 2.0 and 2.1). Antibodies to CagA also were determined by a rapid anti-CagA assay (Pyloriset screen CagA) as well as by two noncommercially developed enzyme immunoassays, each using a recombinant CagA protein. Assessment of performance of the Helicoblot assays indicated substantial interobserver variation, with kappa values between 0.20 and 0.93. There was no relationship between the serological profiles on the Helicoblot and the genotypes from the same patients, except for strong associations between the presence of anti-CagA and the cagA-positive and vacA s1 H. pylori genotypes. Detection of anti-CagA by the five different assays varied considerably, with kappa values ranging from 0.21 to 0.78. Using the cagA genotype as the "gold standard," the sensitivity and specificity of the anti-CagA assays varied from 71.4 to 85.7% and from 54.2 to 100%, respectively. Thus, serological profiles of antibodies to H. pylori are heterogeneous and, with the exception of anti-CagA antibodies, show no relation to the H. pylori vacA and cagA genotypes. Detection of anti-CagA antibodies is strongly dependent on the test used.

Ursodeoxycholic acid therapy for primary sclerosing cholangitis: results of a 2-year randomized controlled trial to evaluate single versus multiple daily doses.

BACKGROUND/AIMS: Ursodeoxycholic acid has been reported to be of potential benefit for primary sclerosing cholangitis but little is known about the long-term biochemical, histological and radiological efficacy or the optimum frequency of ursodeoxycholic acid administration. METHODS: A 2-year multicentre randomised controlled trial was initiated to assess the effects of ursodeoxycholic acid (10 mg kg(-1).d(-1), given in either single or multiple daily doses, on symptoms, serum liver tests, cholangiographic and histological findings and the occurrence of treatment failure. Liver biopsies were taken and endoscopic retrograde cholangiography was performed at entry and after 2 years; follow-up examinations were at 3-month intervals. Treatment failure was defined as death, liver transplantation, 4-fold increase in serum bilirubin, variceal bleeding, de novo ascites or cholangitis. Actuarial survival was compared with predicted survival using the revised Mayo natural history model for primary sclerosing cholangitis. RESULTS: Forty-eight patients were enrolled. In one case, ursodeoxycholic acid had to be discontinued because of gastro-intestinal complaints. No other side-effects were observed. After 2 years of follow-up, treatment was not associated with a beneficial effect on either symptoms or liver histology. Serum liver tests (alkaline phosphatase, y-glutamyl transferase, aspartate aminotransferase) improved significantly in both groups, while serum bilirubin (which was near normal at entry) and IgG remained stable. No major changes in radiographic bile duct appearance seemed to be present. After 2 years, actuarial survival was 91% (95 CI 83%-99%), which is comparable to the predicted 97% survival rate. Treatment failure occurred in 15% of cases. No significant differences in any of the study endpoints (symptoms, serum liver tests, cholangiographic findings, histology, disease progression) were found between the two groups. CONCLUSIONS: Ursodeoxycholic acid is well tolerated in primary sclerosing cholangitis. Significant effects on biochemical parameters were found and symptoms, bilirubin and histology did not deteriorate. No advantage of a multiple daily dose over a single dose was observed.