Diverticulitis mimicking a tuboovarian abscess. Report of a case in a young woman.

BACKGROUND: Diverticulitis is an uncommon condition in young women. When it occurs, it is often not recognized until complications such as perforation or fistulization occur. There has been no recent discussion in the gynecologic literature of diverticulitis in a young woman presenting as gynecologic disease. CASE: A 31-year-old woman with a long history of "irritable bowel syndrome" developed a 4-5-cm left adnexal mass associated with mild discomfort and dysparunia. Acute worsening of her pain led to abdominal exploration and left salpingo-oophorectomy for an unruptured tuboovarian abscess. She initially improved but then developed a recurrent pelvic abscess. Workup revealed extensive diverticulosis with probable sigmoid diverticulitis. Reexploration, drainage of the abscess and fecal diversion were required. CONCLUSION: Because of the proximity of the left ovary to the sigmoid colon, it is possible for diverticulitis to perforate into the ovary, producing a tuboovarian abscess indistinguishable from that due to other more common causes. A high index of suspicion is required to make the diagnosis, especially in young women. Failure to treat underlying diverticulitis can lead to persistent or recurrent pelvic infection.

Pathophysiologic factors and management of ascites.

Ascites is a manifestation of cirrhosis-induced portal hypertension. Pathogenesis is the result of a complex interaction of mechanical, humoral and neural events. Impaired excretion of sodium by the kidney is a hallmark of ascites, which is addressed by many of the available treatment options. Ascites contributes significantly to the morbidity and mortality rates of cirrhosis by increasing the likelihood of such fatal complications as variceal bleeding, hepatorenal syndrome and spontaneous bacterial peritonitis. Most ascitic patients respond to conservative or medical treatment. Five to 10 percent of the patients are refractory and may be candidates for surgical treatment. Peritoneovenous shunting is effective, and while safety is improved by following certain guidelines, its impact on survival is not clear. Portacaval shunting is also safe and effective. The use is accompanied by a prohibitively high morbidity rate because of encephalopathy, which limits its application despite what seems to be a significant impact on survival.

Negative feedback regulation of the ileal bile acid transport system in rodents.

BACKGROUND: Active transport of conjugated bile acids by ileal enterocytes is a key mechanism for conservation of the bile acid pool. Experiments were performed to determine whether such transport is regulated by substrate load. METHODS: Using anesthetized biliary fistula guinea pigs or rats, the ileum was perfused with ursodeoxycholyltaurine at a concentration causing maximal ileal transport of this bile acid; absorption was assessed by biliary recovery. Before ileal perfusion, animals ingested one of three diets: chow, chow with added conjugated bile acid, or chow with added cholestyramine. RESULTS: In the guinea pig, ingestion of a taurocholate-enriched diet resulted in a 75% decrease in the absorption rate of ursodeoxycholyltaurine. Similar results were obtained with cholylsarcosine (a deconjugation-dehydroxylation resistant analogue) or with chenodeoxycholylglycine, the endogenous bile acid of the guinea pig. In contrast, cholestyramine ingestion caused an increase in ursodeoxycholyltaurine absorption. In the rat, cholyltaurine or cholylsarcosine ingestion also caused decreased ileal transport. In the guinea pig, maximal down-regulation of active ileal bile acid transport occurred after 2-3 days of bile acid feeding; up-regulation required 3-4 days. CONCLUSIONS: Bile acid metabolism is regulated by feedback inhibition of active ileal transport in addition to the well-established feedback inhibition of bile acid biosynthesis in the liver. Together, these two regulatory mechanisms ensure constancy of bile acid secretion.

Effect of replacement therapy with cholylsarcosine on fat malabsorption associated with severe bile acid malabsorption. Studies in dogs with ileal resection.

The efficacy of cholylsarcosine, a synthetic deconjugation-resistant and nonsecretory conjugated bile acid analog for the treatment of fat malabsorption caused by severe bile acid malabsorption, was assessed in an animal model. In two dogs, the ileum and ileocecal valve were resected, causing severe diarrhea, steatorrhea, bile acid malabsorption, and progressive weight loss. Cholylsarcosine was administered as the water-soluble sodium salt by mixing with the dog food. Various doses were explored as well as varying intakes of dog food. Fat absorption was assessed by gravimetric measurement of fecal fat; a nonabsorbable recovery marker (polyethylene glycol mol wt 4000) was used to correct for incomplete fecal collections. Cholylsarcosine caused a 5- to 30-fold increase in fat absorption but had no significant effect on weight loss or fecal weight. Duodenal content was collected during digestion of a meal via a surgically placed Thomas cannula; the aspirates were dilute, acidic, and had a low bile acid concentration. The bile acid concentration increased modestly when cholylsarcosine was administered, but remained below the critical micellization concentration. The results indicate that oral administration of cholylsarcosine improved dietary fat absorption in a canine model of severe bile acid malabsorption with associated steatorrhea and bile acid deficiency in the proximal small intestine. Studies with this compound in patients with nutritional problems because of steatorrhea and severe bile acid malabsorption appear warranted.