Intramural Esophageal Hematoma Secondary to Food Ingestion.

Intramural esophageal hematoma (IEH) is a rare cause of submucosal esophageal bleeding and it is on the spectrum of esophageal wall injury along with mucosal tears (Mallory-Weiss syndrome) and full thickness perforation (Boerhaave's syndrome). Its risk factors include coagulopathy, trauma (foreign body ingestion or esophageal instrumentation) or it can happen spontaneously. It presents with a triad of chest pain, dysphagia, and hematemesis; however, the triad is only present in 35% of patients. We are presenting a case of IEH secondary to food ingestion that was managed successfully by conservative measures.

Rapid diagnosis of infected ascitic fluid using leukocyte esterase dipstick testing.

OBJECTIVES: Ascitic fluid infection is presumptively diagnosed when the fluid polymorphonuclear leukocyte (PMN) concentration equals or exceeds 250 cells/microl. The leukocyte esterase (LE) test has been shown to be a good predictor of the presence of PMNs and bacteria in urine and other body fluids. This study examines the value of the Multistix 10 SG LE Dipstick test for the rapid diagnosis of infected ascitic fluid. METHODS: One hundred thirty-six ascitic fluid samples were evaluated by PMN count, culture, and LE Dipstick testing. LE dipstick values of "small" or greater were considered positive. For each sample, the LE test result was compared to the corresponding PMN count and culture result. RESULTS: Ten of the 11 LE-positive samples had PMN >/=250 cells/microl, while 10 of 12 samples with PMN >/=250 cells/microl were also LE-positive. Of the 125 LE-negative samples, 123 were also negative by PMN count. One hundred twenty-three of the 124 samples with PMN <250 cells/microl had negative LE tests. There was a less concordant relationship between the LE test and culture results. The sensitivity and specificity of the LE test for detecting ascitic fluid PMN >/=250 cells/microl were 83% and 99%, respectively, with a positive predictive value of 91% and a negative predictive value of 98%. CONCLUSIONS: The Multistix leukocyte esterase test is useful for the prompt detection of an elevated ascitic fluid PMN count, and represents a convenient new method for the rapid diagnosis of infected ascitic fluid.

Progressive cholestatic liver disease associated with clarithromycin treatment.

The authors report a case of an acute toxic cholestatic reaction to clarithromycin, proven by liver biopsy, in a patient with comorbid diseases, prior exposure to erythromycin and ultimate death. No autopsy was performed. A 59-year-old woman with diabetes mellitus and chronic renal insufficiency received clarithromycin 500 mg twice daily for 3 days for acute maxillary sinusitis and then developed a rash and jaundice. She was hospitalized 11 days after stopping clarithromycin. Progressive cholestatic jaundice accompanied by oligo-anuric renal failure requiring hemodialysis ensued. Liver biopsy showed pure bilirubinostasis without parenchymal inflammation. On the 22nd hospital day, after clinical deterioration, she died from an apparent cardiopulmonary death. This is the first report in the literature of a fatality associated with a short-term, low (1 g) daily dose of drug-induced pure cholestasis, an entity not previously identified with severe drug-induced hepatotoxicity.