Chronic intestinal pseudo-obstruction: diagnosis and treatment.

Chronic intestinal pseudo-obstruction is a rare syndrome characterized by recurrent episodes of small bowel obstruction without evidence of a structural obstructing lesion. The two pathophysiologic types of this motility disorder are myopathic and neuropathic. The latter may affect extrinsic or intrinsic neural control of gut motility. Diagnosis is based on (1) recognition of the clinical syndrome and exclusion of mechanical obstruction by endoscopy, radiologic studies, or laparotomy and (2) manometric studies of the stomach and small bowel. Full-thickness biopsy specimens for histologic analysis may not be essential for the diagnosis in the future. The goals of treatment are the restoration of normal gut peristalsis and the correction of nutritional deficiencies. Prokinetic medications, surgical excision in cases of localized disease, and parenteral nutrition are frequently necessary. Management is difficult because of the lack of efficacious medications, extension of the disease to other regions, and complications of central parenteral nutrition. Prokinetic agents, venting enterostomies for relief of symptoms, and enteral supplementation are being evaluated in this intractable and serious condition.

Venopulmonary fistula: a rare complication of central venous catheterization.

Venopulmonary fistula occurred in a 13-year-old girl, 2 weeks after insertion of a silicone parenteral nutrition catheter. "TPN pneumonia" evolved to life-threatening respiratory failure. Complete resolution of the respiratory insufficiency followed removal of the catheter.

[Colitis cystica profunda]. / Colitis cystica profunda.

In two patients, women of 65 and 76 years old, colitis cystica profunda was diagnosed, a rare, benign disease of colon and rectum. In the first patient, radio-enteritis, in the second patient mucinous adenocarcinoma was diagnosed as well.

Vasopressin-related bullous disease of the legs.

We report a 33-year-old man who developed cutaneous necrosis of the lower extremities with extensive bulla formation after i.v. administration of vasopressin for the treatment of bleeding esophageal varices. Due to its potent nonselective vasoconstrictive action, vasopressin not only may induce cardiac and gastrointestinal ischemia, but cutaneous ischemia as well. As in our patient, this may lead to extensive necrotic skin lesions at sites distant from the infusion.

L-tryptophan-induced eosinophilia-myalgia syndrome.

This report describes three Belgian cases of the eosinophilia-myalgia syndrome associated with the use of L-tryptophan-containing products. Three women, aged 51, 53 and 73 years, were taking L-tryptophan for 2 months to 2 years, at 500, 1500, and 2250 mg d-1, respectively. All developed disabling myalgias, fatigue, and a variable skin rash, in association with marked eosinophilia. In one patient, symptoms and eosinophilia reappeared after rechallenge with L-tryptophan. Discontinuation of the drug resulted in gradual disappearance of the symptoms, signs and laboratory abnormalities in two patients. One patient was treated with corticosteroids because of persisting myalgias. Because of the non-specific clinical manifestations, clinicians from all subspecialties of internal medicine might be confronted with such patients and should be aware of this new entity.

Ileocolonic transfer of solid chyme in small intestinal neuropathies and myopathies.

The aims of this study were to assess gastric emptying, small bowel transit and colonic filling in patients with motility disorders, with particular attention to the patterns of colonic filling. Gastrointestinal transit was assessed using a previously validated radiolabeled mixed meal. Fourteen patients with clinical and manometric features of chronic intestinal pseudoobstruction & classified as intestinal neuropathy and 6 as intestinal myopathy, were studied. The results were compared with those from 10 healthy controls studied similarly. Gastric emptying and small bowel transit of solids were significantly slower in both groups of patients than in healthy controls (P less than 0.05). In health, the ileocolonic transit of solid chyme was characterized by intermittent bolus transfers. The mean size of boluses transferred to the colon (expressed as a percentage of ingested radiolabel) was significantly less (P less than 0.05) in patients with intestinal myopathy (10% +/- 4% (SEM)] than in healthy controls (25% +/- 4%) or in patients with intestinal neuropathy (25% +/- 4%). The intervals between bolus transfer of solids (plateaus in the colonic filling curve) were longer (P less than 0.05) in myopathies (212 +/- 89 minutes) than in health (45 +/- 7 minutes) or neuropathies (53 +/- 11 minutes). Thus, gastric emptying and small bowel transit were delayed in small bowel neuropathies and myopathies. Bolus filling of the colon was less frequent and less effective in patients with myopathic intestinal pseudoobstruction, whereas bolus transfer was preserved in patients with neuropathic intestinal pseudoobstruction.

Prehospital thrombolytic treatment of acute myocardial infarction with anisoylated plasminogen streptokinase activator complex.

In cooperation with a group of general practitioners (GP), we investigated the possible risk and benefit of prehospital initiation of thrombolytic therapy in acute myocardial infarction (AMI) with anisoylated plasminogen streptokinase activator complex (APSAC) at the patient's home. During a 14-month period, 58 patients with suspected AMI were evaluated by their GP using a protocol with strict inclusion and exclusion criteria. The GP alerted a special mobile intervention team which administered APSAC at home in 13 of the 19 patients. Coronary reperfusion was achieved in ten of these 13 patients. Apart from short and easily treated episodes of bradycardia and/or hypotension after the injection of the thrombolytic drug in four of 13 patients, no major adverse events were noted in the early treatment period. The estimated time gain by treating the patient at home instead of starting the treatment in the coronary care unit was 46 +/- 14 min. Therefore, at-home initiation of thrombolytic treatment seems feasible, fast, and safe.

Human gastric emptying and colonic filling of solids characterized by a new method.

Our first aim was to compare 111In-labeled Amberlite IR-12OP resin pellets and 131I-labeled fiber in the assessment of gastric and small bowel transit and colonic filling in healthy humans. Both radiolabels were highly stable for 3 h in an in vitro stomach model and remained predominantly bound to solid phase of stools collected over 5 days [90.5 +/- 2.1 (SE)% for 131I and 87.4 +/- 1.4% for 111In). The lag phase of gastric emptying was shorter for 111In-pellets (30 +/- 11 min compared with 58 +/- 12 min for 131I-fiber, P less than 0.05). However, the slope of the postlag phase of gastric emptying and the half time of small bowel transit were not significantly different for 111In-pellets and 131I-fiber. Filling of the colon was characterized by bolus movements of the radiolabel (10-80% range, 26% mean) followed by plateaus (periods of no movement of isotope into colon lasting 15-120 min, range; 51 min, mean). Half of the bolus movements occurred within 1 h of the intake of a second meal. Thus 111In-labeled Amberlite pellets provide an excellent marker for the study of gastric and small bowel transit and colonic filling in humans. The ileum acts as a reservoir and transfers boluses of variable sizes into the colon, often soon after the intake of a subsequent meal.

Hepatic hydrothorax: report of two cases.

This paper describes two patients with liver cirrhosis presenting with right sided hydrothorax. The diagnosis of hepatic hydrothorax was confirmed by a radionuclide study using an intraperitoneal injection of radioactive 99mTc-tin-colloid, demonstrating the one-way transdiaphragmatic flow of fluid from the peritoneal to pleural cavities. Pleural taps, salt restriction and diuretics resulted in volume depletion and impaired renal function in the first patient. Medical therapy and a single thoracocentesis were successful in the other patient.

Herpes simplex virus type 1 colitis: an unusual cause of diarrhea.

Herpetic infections of the gastrointestinal tract are a well-recognized entity. Involvement of the colon seems to be very rare. A 78-yr-old woman developed bloody diarrhea and abdominal discomfort 2 months after surgical treatment for adenocarcinoma of the transverse colon. Colonoscopy revealed diffuse hemorrhagic, erosive, aphtoid, and ulcerative lesions. Histology showed nonspecific inflammatory changes. Herpes simplex virus type 1 (HSV-1) was isolated from endoscopic biopsy and stool specimens. The patient responded rapidly to symptomatic treatment with loperamide. This case demonstrates the potential for HSV-1 to induce infectious colitis; failure to obtain microbiologic evaluations and the rapid response to empiric, symptomatic treatment may be responsible for the rarity of diagnosis of this infection. The implications of this diagnosis are probably more relevant in immunosuppressed individuals, and may be important in the elderly population.