α-Methyldopa-induced hepatitis during the postpartum period.

A 34-year-old woman, with a history of pre-eclampsia, was diagnosed with α-methyldopa-induced hepatotoxicity, after she presented with severe jaundice and hepatitis 8 weeks following delivery. Laboratory investigations and liver biopsy ruled out other causes of hepatitis. She continued to improve clinically after cessation of α-methyldopa, and was discharged 10 days after admission. This case report emphasises that it may not be possible to predict which patients may develop α-methyldopa-induced hepatitis, hence regular monitoring of liver function tests during treatment should be implemented.

Duodenal eosinophilia and early satiety in functional dyspepsia: confirmation of a positive association in an Australian cohort.

BACKGROUND AND AIM: Functional dyspepsia (FD), defined by unexplained pain or discomfort centered in the upper abdomen, is common. Diagnosis and treatment of FD based on the symptom-based Rome criteria remains challenging. Recently, eosinophilia in the duodenum has been implicated in the pathophysiology of FD in adults, specifically increased eosinophils in early satiety and postprandial distress, but the association remains controversial. The aim of this study was to characterize upper gastrointestinal (GI) tract pathology, specifically duodenal eosinophilia, in an Australian cohort of patients with FD. METHODS: Patients prospectively referred for an upper GI endoscopy (n = 55; mean age, 49.6 years; 61.8% female) were stratified to FD cases (n = 33) and controls (n = 22) using Rome II criteria. All subjects completed a validated bowel symptom questionnaire. The eosinophil count per square millimeter in the duodenal bulb (D1) and second part (D2) was assessed and Helicobacter pylori status determined by gastric histology. Associations with clinical symptoms were assessed. RESULTS: Cases and controls were demographically similar. Duodenal eosinophilia was significantly increased in subjects experiencing early satiety (P = 0.01) and postprandial fullness (P = 0.001). This association was seen in D2 but not D1. Abdominal pain was associated with eosinophilia in both D1 (P = 0.02) and D2 (P = 0.005). Smoking was also associated with higher eosinophil counts in D2 (P = 0.007) and symptoms of early satiety (P = 0.02). CONCLUSIONS: Duodenal eosinophilia occurs in a subset of FD. The potential role of duodenal eosinophils in FD has implications for diagnosis and therapeutic trials.

Gastrointestinal Mantle Cell Lymphoma-A Tale of Two Endoscopies.

INTRODUCTION: A 52-year-old male with a 2-year history of typical gastroesophageal reflux symptoms and concomitant weight loss despite good appetite is presented in this paper. Endoscopy showed hypertrophic gastric folds and multiple antral ulcers which were considered benign both histologically and macroscopically. The diagnosis at the time of presentation was moderate chronic gastritis. Eighteen months later, the patient presents with overt adenopathy in all peripheral lymph nodes and was subsequently diagnosed with mantle cell lymphoma (MCL). DISCUSSION: On second presentation, the patient underwent a repeat endoscopy with biopsy and immunohistochemical (IHC) testing of gastrointestinal and lymph node tissue. The gastrointestinal endoscopy showed multiple polypoid nodules in the first and second parts of the duodenum and multiple sessile polypoid masses carpeting the colon. Gastric and lymph node biopsies were consistent with a diagnosis of MCL and MLP showing immunoperoxidase staining positive for cyclin D1, CD20 and bcl-2. A repeat IHC testing of the gastrointestinal tissue collected on initial endoscopy also showed a positive expression of the IHC markers consistent with MCL. In retrospect, an earlier detection of MCL was possible when the patient had first presented.

The impact of laxative use upon symptoms in patients with proven slow transit constipation.

BACKGROUND: Constipation severity is often defined by symptoms including feelings of complete evacuation, straining, stool frequency and consistency. These descriptors are mostly obtained in the absence of laxative use. For many constipated patients laxative usage is ubiquitous and long standing. Our aim was to determine the impact of laxative use upon the stereotypic constipation descriptors. METHODS: Patients with confirmed slow transit constipation completed 3-week stool diaries, detailing stool frequency and form, straining, laxative use and pain and bloating scores. Each diary day was classified as being under laxative affect (laxative affected days) or not (laxative unaffected days). Unconditional logistic regression was used to assess the affects of laxatives on constipation symptoms. RESULTS: Ninety four patients with scintigraphically confirmed slow transit constipation were enrolled in the study. These patients reported a stool frequency of 5.6 ± 4.3 bowel motions/week, only 21 patients reported <3 bowel motions/week. Similarly, 21 patients reported a predominant hard stool at defecation. The majority (90%) of patients reported regular straining. A regular feeling of complete evacuation was reported in just 7 patients. Daily pain and/or bloating were reported by 92% of patients. When compared with laxative unaffected days, on the laxative affected days patients had a higher stool frequency (OR 2.23; P <0.001) and were more likely to report loose stools (OR 1.64; P <0.009). Laxatives did not increase the number of bowel actions associated with a feeling of complete evacuation. Laxative use had no affect upon straining, pain or bloating scores CONCLUSIONS: The reporting of frequent and loose stools with abdominal pain and/or bloating is common in patients with slow transit constipation. While laxative use is a significant contributor to altering stool frequency and form, laxatives have no apparent affect on pain or bloating or upon a patients feeling of complete evacuation. These factors need to be taken into account when using constipation symptoms to define this population.

Working overseas, weakness, anaemia, and nematodes.

We report the case of a 51-year-old female who went overseas for six-months to teach English and upon her return to Australia developed severe anaemia and weakness. She was admitted to hospital, and had subsequent blood transfusions and a colonoscopy which revealed nematodes. She was treated and made a full recovery.

Gastric metastasis in renal cell carcinoma: a case report and systematic review.

BACKGROUND: Published report of cases of gastric metastases arising from renal cell carcinoma is a rare event and treatment of such patients can be difficult. Gastrectomy may be a surgical alternative; however, the prognosis for the majority of patients is very poor. METHODS: We report a rare case of a patient with a metastatic renal cell carcinoma that metastasized to the stomach. In addition, we conducted a systematic review of the literature to assess the prevalence of reports and to gain a greater understanding of this particular metastatic cancer spread from the kidney to the stomach. RESULTS: Published reports of metastases from the kidney to the stomach are not as rare as previously thought with three times of the number of reports found to what most authors thought actually existed. The majority of reports occurred among males (77%). The mean age of presentation was 65 years for males and 68 years for females (range, 40-84 years). Average time from nephrectomy to presentation of gastric metastases was 7 years for both males and females (range, 0-24 years). CONCLUSION: Females with gastric metastases from the kidney are slightly older than males, and no difference exists between males and females in terms of the time interval between nephrectomy and subsequent metastasis or select patients treatment options.

A case of chronic intestinal pseudo-obstruction secondary to primary visceral myopathy.

BACKGROUND: A 13-year-old girl presented to the emergency room at her local hospital with an acute onset of vomiting, severe abdominal pain and distension. There was evidence of small-bowel obstruction on plain abdominal x-ray. Throughout the girl's adolescent years she was admitted to hospital numerous times for recurrent abdominal symptoms and underwent multiple sequential laparotomies. She had marked weight loss and a poor quality of life. The patient's symptoms were initially managed with intravenous fluids, bowel rest, and nasogastric decompression of the upper gut. INVESTIGATIONS: Peripheral blood tests with biochemistry and measurement of serum folate, vitamin B(12), albumin, 25-hydroxyvitamin D, inflammatory markers, autoantibodies and thyroid function; gastrointestinal imaging (plain abdominal x-ray, small-bowel series, colonic transit study, and abdominal CT with oral contrast); MRI of the brain and lumbar puncture; upper endoscopy; and laparotomy with sero-muscular biopsy of the small bowel. DIAGNOSIS: Chronic intestinal pseudo-obstruction secondary to primary visceral myopathy. MANAGEMENT: Prokinetic agents including oral cisapride and tegaserod, a venting gastrostomy, and total parenteral feeding.

Granulation and fibrotic esophagus.

There is very little information in the medical literature on fibrotic esophageal lesions. These lesions do not appear to be malignant, but are recalcitrant to different treatments including removal, and the use of esophageal stents does not discourage the lesion from continuing to grow. The cause of these lesions remains unknown and the reasons for overgrowth in stents are poorly understood. We report on a patient who presented with dysphagia and a recalcitrant fibrotic esophageal lesion.

Prevalence of faecal incontinence and associated risk factors; an underdiagnosed problem in the Australian community?

OBJECTIVE: To determine the prevalence of faecal incontinence in the community and evaluate identifiable risk factors. DESIGN AND SETTING: Cross-sectional survey using a validated questionnaire. A short version of the questionnaire was sent to 220 subjects and a long version to 770 subjects, randomly selected from western Sydney, Australia. MAIN OUTCOME MEASURES: Self-reported faecal incontinence, defined as involuntary loss of anal sphincteric control leading to unwanted release of liquid or solid faeces (not flatus) at an inappropriate time or in an inappropriate place, within the past 12 months. The long questionnaire also sought information on bowel habit and potential risk factors for faecal incontinence. RESULTS: The response rate was 66%. The prevalence of solid or liquid faecal incontinence was 2% and 9%, respectively. The mean age of subjects with faecal incontinence was 53 years; 55% were women. After adjusting for age and sex, there was a significant association between faecal incontinence and perianal injury (P = 0.03), perianal surgery (P < 0.001), feelings of incomplete defecation (P < 0.0001), loose or watery motions (P < 0.0001) and urgency (P < 0.0001). Seven of 48 subjects with faecal incontinence reported being asked by their physician about faecal incontinence and nine of 33 reported seeking medical advice for their incontinence. Subjects with faecal incontinence perceived their health to be significantly poorer than did other subjects (P = 0.02). CONCLUSION: There is a high burden of faecal incontinence in the community, and the prevalence in men may be greater than is usually appreciated. Despite significant associated morbidity, most cases of faecal incontinence were unrecognised by doctors.