Substances that interfere with guaiac card tests: implications for gastric aspirate testing.

Previous studies have shown that acidic pH and several ingestible substances can cause misleading guaiac tests of gastric aspirates. In this in vitro study, over 100 foods, beverages, and drugs were diluted to concentrations potentially present in the stomachs of outpatients being evaluated for gastrointestinal bleeding. These were mixed with known concentrations of blood and tested with different brands of guaiac cards. Decreased guaiac test sensitivity was associated with activated charcoal, dimethylaminoethanol, red chile, N-acetylcysteine, rifampin, red Jell-O (General Foods Corp, White Plains, NY), orange juice, Pepto-Bismol (Norwich Eaton Pharmaceuticals, Norwich, NY), simethicone, spaghetti sauce, and several red wines. Chlorophyll and methylene blue-containing tablets produced false-positive results, but other blue and blue-green colored tablets did not, except at high concentrations. Previously described false-negative results with vitamin C, bile, and certain antacids were confirmed, as were false-positive results with iodide, bromide, cupric sulfate, iron salts, and hypochlorite. Physicians should exercise caution when interpreting guaiac card tests of gastric aspirates, especially in the outpatient setting.

Large colorectal polyps: colonoscopy, pathology, and management.

Between 1984 and 1987, we reviewed all large (greater than or equal to 3.0 cm) colorectal polyps to determine the efficacy of colonoscopic polypectomy from both an oncologic and technical viewpoint. Forty-eight polyps greater than or equal to 3.0 cm were identified in 46 patients. Twenty polyps were entirely benign, 20 polyps contained noninvasive carcinoma, and invasive carcinoma was present in eight polyps. Four of the invasive cancers were associated with residual adenoma; the remaining four were polypoid carcinomas. Among the eight cases of invasive carcinoma, four had tumors that did not extend through the submucosa. Invasive cancer was more prevalent in left-side sessile lesions but was absent in all 10 right-sided polyps. Thirty-two polyps were removed by colonoscopic polypectomy. Four patients required colectomy after polypectomy for the following reasons: incomplete excision (N = 1), presence of invasive carcinoma at the resection margin (N = 1), and inability to define the level of carcinoma on pathologic examination (N = 2). Two polyps with cancer confined to the submucosa were successfully excised colonoscopically. Complications of polypectomy included three cases of minor hemorrhage. Sixteen polyps (the majority located in the right colon) were removed by primary surgical colectomy. We conclude that colonoscopic polypectomy is oncologically and technically successful for most large colorectal polyps. A minority of large polyps require colectomy because of incomplete removal or the presence of invasive cancer that is not curable with colonoscopic excision.

Familial achalasia in two siblings: significance of possible hereditary role.

Familial achalasia in siblings has been reported previously. We describe the clinical and radiographic findings in two siblings with achalasia. A discussion of the possible hereditary influence in achalasia is presented as well as a pertinent review of the literature.

Intussusception secondary to squamous carcinoma of the lung.

This report describes unusual radiologic and pathologic findings in a patient with multiple small bowel metastases from squamous cell carcinoma of the lung. The diagnostic work-up revealed a large, pleural-based, right lung mass, a large left adrenal mass, two ulcerated small bowel masses, and a unique giant peduncular mass that caused intermittent intussusception. A pertinent review of the literature is presented.

Horse pill ("bute") hemorrhage.

Phenylbutazone (PBZ) is a nonsteroidal antiinflammatory drug (NSAID) that is not commonly prescribed due to the high incidence of serious adverse reactions. However, it is still used extensively in equine medicine, and is readily available to those employed in the care and management of horses. Such persons may take the drug indiscriminately, without medical supervision. We present a 33-year-old male race horse track worker who took phenylbutazone horse pills for a chronic toothache and subsequently suffered a major hemorrhage from a gastric ulcer. Human use of phenylbutazone horse pills should be considered by physicians confronted with patients who have upper gastrointestinal symptoms and gastric injury and who belong to this select group.

Intramural hemorrhage simulating gastric neoplasm.

We report a case of benign gastric ulcer with secondary extensive intramural hemorrhage causing a radiographic appearance consistent with a large ulcerated gastric neoplasm. This is the second such case reported and the first studied with sonography and computed tomographic scan. A brief review of the literature on intramural gastric hematoma is presented.

Acute suppurative obstructive cholangitis due to stones: treatment by urgent endoscopic sphincterotomy.

Endoscopic sphincterotomy is an accepted treatment for retained common bile duct stones, but there is little specific information available regarding its application in acute suppurative obstructive cholangitis with sepsis due to choledocholithiasis. Thirteen patients with this condition were referred to the authors for consideration of urgent endoscopic common bile duct decompression. All had been judged to be poor surgical candidates. Pus was released from the common bile duct by sphincterotomy within 24 hours of admission in all 13. Stones were removed endoscopically in 10 patients (77%) without complications. After endoscopic stone removal, symptoms, signs, and abnormal laboratory values returned to normal rapidly; follow-up endoscopic retrograde cholangiography did not show retained stones. Three patients whose large stones precluded endoscopic removal underwent operative choledocholithotomy. Urgent endoscopic sphincterotomy offers an important alternative in the treatment of acute suppurative obstructive cholangitis secondary to choledocholithiasis.

Processing of aspiration cytology samples. An alternative method.

Cytotechnologists usually assist in smear preparation during radiologic fine needle aspiration (FNA) procedures. An alternative technique is presented that requires neither cytotechnologist participation nor immediate processing. In 111 consecutive patients undergoing FNA procedures, the aspirate was immediately fixed in 50% ethanol. The specimen was refrigerated and later processed in the laboratory as cell block preparations, which often maintained the original histologic architecture, and smears, which demonstrated good nuclear detail without air-drying artifacts. In our patients, this technique was 95% sensitive and 100% specific for the diagnosis of malignancy.

Colonoscopy after Golytely preparation in acute rectal bleeding.

Thirty-five consecutive patients with acute hematochezia, negative gastric aspirates, and negative sigmoidoscopy underwent urgent colonoscopy after Golytely purgation. Mucosal visualization was excellent. Colonic bleeding lesions were identified in 24 of 35 patients, and hemorrhage originating proximal to the ileoceal valve was documented in three of these 35 patients. Therapeutic endoscopic electrocautery, employed in 12 of 35 patients, was effective in 11. The peroral preparation was well tolerated, and there were no complications of the preparation or of colonoscopy. The data suggest that urgent colonoscopy following Golytely purgation is a safe, sensitive, and specific diagnostic procedure that provides an opportunity for early nonoperative treatment of acute colonic hemorrhage.

Endoscopic "salvage" cytology in neoplasms metastatic to the upper gastrointestional tract.

Endoscopic "salvage" cytology was the only successful nonoperative diagnostic method in two patients with malignancy metastatic to the upper gastrointestinal tract. Smears and cell blocks of centrifuged material aspirated from the endoscope channel provided diagnoses of malignancies when other diagnostic techniques had been nonproductive. The results in these cases support the general utility of this technique and indicate its successful application in this specific clinical setting.

Scrotal and abdominal skin necrosis complicating intravenous vasopressin therapy for bleeding esophageal varices.

Two patients with severe liver disease developed scrotal necrosis after intravenous vasopressin infusion for bleeding esophageal varices. One of these patients also developed anterior abdominal wall skin necrosis. Although ischemic complications secondary to vasopressin are probably not totally avoidable, attention to hypovolemia, concomitantly administered pressor drugs, patient position, and points of local pressure may decrease the likelihood of these previously unreported complications.

Gastric secretion and hormonal interactions in multiple endocrine neoplasia type I.

Results of preparathyroidectomy and postparathyroidectomy studies in a patient with multiple endocrine neoplasia type I and gastrinoma suggest that hyperparathyroidism unmasks occult gastrinoma and related secretory abnormalities. Three of four diagnostic findings were later obscured by parathyroidectomy and normalization of serum calcium concentration. Basal acid output, basal acid output/maximal acid output ratio, and serum gastrin concentration were decreased from values consistent with gastrinoma to normal. The secretin stimulation test, though still positive, was attenuated. These observations suggest that in multiple endocrine neoplasia type I, normal values for serum gastrin concentration, gastric secretion, and secretin stimulation may not exclude gastrinoma. The investigations clarify the interpretation of a voluminous but confusing literature on the interrelationship between hyperparathyroidism and altered gastric function in the presence or absence of Zollinger-Ellison syndrome.