Haemoperitoneum secondary to intrahepatic gallbladder perforation.

A 70-year-old man presented to the accident and emergency department with a 1-day history of right upper quadrant pain and nausea. Examination revealed mild tenderness in the right upper quadrant but no evidence of peritonism or haemodynamic instability. The patient was admitted to the general surgical ward with a diagnosis of cholecystitis and remained stable overnight. In the morning, he developed acute severe pain in the upper abdomen. Examination found him to be tachycardic, tachypnoeic and to have peritonism in the upper abdomen. An urgent CT scan demonstrated cholecystitis but also a small amount of fluid in the pelvis, with Hounsfield units suggestive of blood. The patient proceeded to laparotomy and was found to have massive haemoperitoneum secondary to intrahepatic gallbladder perforation causing liver capsule tear. Cholecystectomy was performed and the liver packed until haemostasis was achieved. The patient made an uneventful recovery.

Enhancement of gastric emptying of solids by erythromycin in patients with Roux-en-Y gastrojejunostomy.

BACKGROUND: Roux-en-Y reconstruction is sometimes associated with symptoms that suggest food stasis, as a result of dysmotility of either the gastric remnant and/or the efferent jejunal limb. OBJECTIVE: To study the possible effect of intravenous erythromycin lactobionate on gastric emptying of solids in patients who have undergone a Roux-en-Y procedure. PATIENTS: Twenty-four patients with a Roux-en-Y procedure participated in the study. Ten of them had undergone truncal vagotomy with pyloroplasty; the remaining 14 had undergone a Billroth II subtotal gastrectomy as the initial antiulcer procedure. Sixteen healthy subjects served as controls. METHODS: All healthy subjects and patients underwent assessment of gastric emptying of a standard radiolabeled solid meal after administration of placebo or 200 mg of erythromycin lactobionate intravenously. Scanning was done with a gamma camera, and emptying curves were constructed. From these curves the half-time of gastric emptying was calculated. RESULTS: Patients with severe symptoms of gastric stasis had a significantly longer half-time than did patients with mild or no symptoms (P=.002). Patients with a Billroth II subtotal gastrectomy as the initial antiulcer procedure had a significantly worse grade of symptoms (P=.01) and a significantly prolonged half-time (P=.02) compared with patients with a truncal vagotomy with pyloroplasty as the initial antiulcer procedure. Erythromycin significantly reduced the half-time in the controls (P<.001) and all patients after Roux-en-Y procedure (P<.001). CONCLUSION: Erythromycin could be a useful prokinetic drug in patients with Roux stasis syndrome.

Effect of oral cisapride on gallbladder emptying during fasting and postprandial states.

RATIONALE AND OBJECTIVES: The purpose of the study was to determine the effect of orally administered cisapride on gallbladder emptying in healthy subjects during fasting and postprandial states. MATERIALS AND METHODS: Gallbladder emptying was assessed by means of ultrasonography in 10 healthy male subjects (age range, 25-33 years; mean age, 28.6 years +/- 3.2 [standard deviation]) under four randomly applied conditions: (a) after oral intake of a placebo tablet, (b) after oral intake of 10 mg of cisapride during fasting, (c) after oral intake of a placebo tablet followed 30 minutes later by ingestion of 300 mL of fresh whole milk (postprandial emptying), and (d) after oral intake of 10 mg of cisapride followed 30 minutes later by ingestion of 300 mL of milk. RESULTS: Cisapride given during the fasting state induced gallbladder contraction by 44.1% +/- 12.6 (standard deviation) of its initial volume. Gallbladder emptying started after 19.4 minutes +/- 12.6 and reached its peak 51 minutes +/- 5.7 later. The ejection fraction after administration of only cisapride was significantly less than that after placebo and milk ingestion (44.1% +/- 12.6 vs 60.6% +/- 8.5, P < .0002). Oral administration of cisapride 30 minutes before milk consumption induced gallbladder emptying, which started approximately 10 minutes before milk ingestion. The ejection fraction after administration of cisapride with milk was significantly greater than that after consumption of placebo and milk (67.1% +/- 8.8 vs 60.6% +/- 8.5, P < .02). CONCLUSION: Oral cisapride induces contraction of the gallbladder during the fasting state and enhances postprandial gallbladder emptying.

Erythromycin enhances oesophageal motility in patients with gastro-oesophageal reflux.

BACKGROUND: Intravenous (i.v.) erythromycin enhances gastric emptying and oesophageal motility in both healthy and disease situations, acting either as a motilin or acetylcholine agonist. The purpose of the present paper was to investigate any possible effect of i.v. erythromycin on oesophageal motility in patients with gastro-oesophageal reflux (GOR). METHODS: In 15 patients with GOR (proven on 24-h ambulatory oesophageal pH measurement), standard oesophageal manometry was performed after i.v. injection of placebo and 200 mg erythromycin, in a random blind fashion. RESULTS: Erythromycin significantly increased lower oesophageal sphincter (LOS) pressure from 17 +/- 5 to 41 +/- 10 mmHg (P < 0.001), without affecting the postdeglutition relaxation of LOS. Erythromycin also increased the amplitude (from 79 +/- 34 to 97 +/- 40 mmHg; P < 0.001), duration (from 3.4 +/- 0.6 to 3.8 +/- 0.6 s; P = 0.005), velocity (from 3.1 +/- 0.8 to 3.5 +/- 1.15 cm/s; P = 0.0047) and strength (from 149 +/- 84 to 201 +/- 103 mmHg.s; P < 0.001) of peristalsis at 5 cm proximal to the LOS. Similarly, the drug increased the amplitude of peristalsis at 10 and 15 cm proximal to the LOS (from 70 +/- 39 to 77.4 +/- 37 mmHg; P = 0.049 and from 36 +/- 20 to 49 +/- 36 mmHg; P = 0.004, respectively) and the duration of peristalsis at the same levels (from 3.1 +/- 0.6 to 3.3 +/- 0.5 s; P = 0.011, and from 2.7 +/- 0.6 to 3 +/- 0.5 s; P = 0.003, respectively). CONCLUSION: Intravenously administered erythromycin improves impaired oesophageal motility in patients with GOR. This observation might be of clinical use.

Common bile duct stones: an unusual case of diarrhoea through a mucous fistula.

We present a very unusual case of diarrhoea in a 77-year-old man. He had a previously complicated surgical history, with a loop ileostomy and a colonic mucous fistula. He developed a sudden onset of diarrhoea from his mucous fistula. A contrast enema suggested a cholecystocolonic fistula and subsequent computed tomography demonstrated a common bile duct stone caused a degree of obstruction. The patient was treated successfully by endoscopic retrograde cholangiopancreatography and stone extraction. This case demonstrated the role that contrast enema may still play in unusual cases of diarrhoea.

Bleeding gastric varices--a rare complication of ovarian cancer.

Splenic venous hypertension (or 'left-sided portal hypertension') is a rare underlying cause of gastro-oesophageal varices. Ovarian carcinoma recurring beyond 10 years, following primary treatment with no interval disease, is also a rare occurrence. We report an unusual case of bleeding gastric varices secondary to splenic venous obstruction as a result of metastatic ovarian carcinoma. This occurred 21 years following surgery and adjuvant chemotherapy for primary ovarian carcinoma. To our knowledge, until now, there have been no reported cases of splenic venous hypertension due to ovarian carcinoma. This case report illustrates the successful emergency management of this condition by splenectomy, with complete resolution of varices confirmed endoscopically at 6 weeks. It is followed by a brief discussion regarding varices due to splenic venous hypertension.

Cutaneous electrogastrography for the assessment of gastric myoelectrical activity in type I diabetes mellitus.

OBJECTIVE: Gastric dysrhythmias have been noted in diabetic patients with upper GI symptoms attributed to delayed gastric emptying. The aim of this study was to assess gastric myoelectrical activity in patients with asymptomatic insulin-dependent diabetes mellitus. METHODS: Nine healthy subjects (five men, four women) and ten patients with insulin-dependent diabetes (six men, four women) participated in the study. Percutaneous electrogastrography was applied with a portable device on all subjects for 2 h before, during, and 2 h after the ingestion of a standard meal. Spectral analysis of the traces was performed on a personal computer using devoted software. The parameters assessed were 1) the percentile distribution of the three spectra of gastric slow-wave frequency, defined as follows: bradygastria for 0-2.4 cycles/min, normogastria for 2.5-3.6 cycles/min, and tachygastria for 3.7-9 cycles/min; and 2) the fed/fasting ratio of slow-wave power at all three spectra of frequencies. RESULTS: Bradygastria was significantly more common during the entire period of recording (p = 0.024), and in particular during the fasting state (p = 0.0008) and the period of meal consumption (p = 0.0001) in diabetic patients than in controls. In addition, the presence of normogastria did not increase significantly after the meal in diabetic patients as it did in controls. In diabetic patients, the slow-wave power decreased postprandially at the spectra of bradygastria and normogastria, unlike the controls, who exhibited a respective postprandial increase (fed/fasting power, controls vs patients:p = 0.0006 for bradygastria, p < 0.0001 for normogastria). CONCLUSIONS: Gastric dysrhythmias are present even in diabetic patients without upper GI symptoms attributed to gastric stasis. Increased presence of bradygastria and failure to increase the slow-wave amplitude postprandially are the predominant forms of abnormal myoelectrical activity in these cases.

Resection rectopexy for rectal prolapse. The laparoscopic approach.

BACKGROUND: Resection rectopexy through open laparotomy is an established procedure for the treatment of rectal prolapse. METHODS: Resection rectopexy was successfully performed in 10 multiparous women by the laparoscopic approach (LAP), and the results were compared to those of eight women with laparotomy resection rectopexy (OPEN). Preoperative and postoperative assessment included anorectal manometry, defecography, and measurement of large-bowel transit. RESULTS: The duration of the operation was longer in the LAP than in the OPEN group (p < 0.01). Morbidity was lower (p < 0.01) and hospital stay was shorter (p < 0.001) after the LAP than in the OPEN group. Prolapse was cured in all cases. Postoperatively, anal resting and squeeze pressures and rectal compliance increased significantly in both groups of patients (p = 0.007, p = 0.003, and p < 0.001, respectively). In all patients, the operation resulted in acceleration of large-bowel transit (p < 0.001) and in more obtuse anorectal angles at rest (p = 0.007). In addition, sampling events were observed more commonly (p = 0.008) postoperatively. Preoperatively, incontinence was present in 13 patients (seven LAP and six OPEN) and persisted in four of them after rectopexy (two LAP and two OPEN). CONCLUSIONS: Resection rectopexy for rectal prolapse can be performed safely via the laparoscopic route. Recovery is uneventful and of shorter duration after the laparoscopic than after the open approach. Similarly satisfactory functional results are obtained with both procedures.

Impairment of anorectal function in diabetes mellitus parallels duration of disease.

PURPOSE: The aim of this study was to investigate any possible relation between the severity of anorectal dysfunction in diabetes mellitus and duration of disease and presence of microangiopathy or neuropathy or both. METHODS: Standard multiport anorectal manometry was performed in 25 healthy control subjects (10 males; age (mean +/- 1 standard deviation), 62 +/- 14 years) and 38 patients with diabetes mellitus. Patients were divided into two groups according to the duration of the disease: Group A (19 patients) with a duration less than 10 years (7.2 +/- 2.5; 8 males; age, 57 +/- 18) and Group B (19 patients) with a duration longer than 10 years (19.8 +/- 5.6; 6 males; age, 62 +/- 15). RESULTS: Results are reported as mean +/- one standard deviation. Patients showed lower resting and squeeze anal pressures (P < 0.01), impaired rectoanal inhibitory and anocutaneous reflexes, and reduced sensitivity in rectal distention (P = 0.004) as compared with controls. In addition, Group B showed a significantly increased incidence of microangiopathy (P = 0.04) and autonomic and peripheral neuropathy (P = 0.002), significantly reduced basal and squeeze anal pressures (52 +/- 16 vs. 64 +/- 24 mmHg; P = 0.03 and 98 +/- 39 vs. 124 +/- 54 mmHg; P = 0.04, respectively), reduced amplitude of slow waves (7.3 +/- 3 ts. 9.5 +/- 3.7 mmHg; P = 0.03), anal leak in smaller rectal volumes (P = 0.003), and reduced response of the anal sphincter at the anocutaneous reflexes (29 +/- 14 vs. 39 +/- 14 mmHg; P = 0.05) compared with Group A. The former group of patients exhibited a significantly higher incidence of fecal incontinence (P = 0.008). CONCLUSION: Patients with long-standing diabetes mellitus have increased incidence of fecal incontinence and severely impaired function of both the anal sphincters and the rectum. These findings could be attributed to the increased incidence of microangiopathy and autonomic and peripheral neuropathy observed in this subset of diabetic patients.

The effect of erythromycin on human esophageal motility is mediated by serotonin receptors.

OBJECTIVE: Erythromycin exhibits prokinetic properties. The drug enhances esophageal and gastric motility by acting as a motilin agonist and promoting acetylocholine release. 5-HT3 receptors are involved in the spontaneously occurring migrating motor complex and the effect of erythromycin on antral motility in dogs. The aim of the study was to investigate the hypothesis that 5-HT3 receptors are also involved in the action of erythromycin on the human esophagus. METHODS: A total of 18 healthy volunteers underwent standard esophageal manometry on three different occasions in a double-blind, placebo-controlled, randomized manner, as follows: 1) after placebo, 2) after 200 mg of erythromycin i.v., and 3) after 200 mg of i.v. erythromycin subsequent to pretreatment with either 4 mg of i. v. ondansetron (serotonin receptor antagonist) (10 subjects) or 12 microg/kg of i.v. atropine (8 subjects). RESULTS: Erythromycin significantly increased a) the amplitude of peristalsis at 5 cm (from 87 +/- 19 mm Hg to 108 +/- 26 mm Hg; p = 0.0007), 10 cm (from 72 +/- 24 mm Hg to 81 +/- 26 mm Hg; p = 0.016), and 15 cm (from 47 +/- 15 mm Hg to 55 +/- 17 mm Hg; p = 0.014) proximal to LES, b) the duration of peristalsis at 5 cm (from 4.5 +/- 0.9 s to 5.7 +/- 1.2 s; p < 0.0001) and 10 cm (from 4.1 +/- 1 s to 4.9 +/- 1 s; p < 0.0001) proximal to the LES and c) the strength of peristalsis at 5 cm proximal to the LES (from 180 +/- 49 mm Hg x s to 276 +/- 100 mm Hg x s; p < 0.0001), and decreased the velocity of peristalsis at distal esophagus (from 4.1 +/- 1 cm/s to 3.8 +/- 0.9 cm/s; p = 0.03). In addition, erythromycin significantly increased the resting pressure of the LES (from 36 +/- 10 mm Hg to 44 +/- 12 mm Hg; p = 0.002). Pretreatment with ondansetron totally reversed all of the effects of erythromycin to the placebo state. Pretreatment with atropine not only prevented the effects of erythromycin, but it reduced the amplitude and strength of peristalsis at the distal esophagus at significantly lower levels than after placebo. CONCLUSIONS: Erythromycin exerts its prokinetic action on the lower esophagus by stimulating cholinergic pathways. This action includes not only an increase in LES pressure, but significant increases in the amplitude and duration of esophageal peristalsis, as well. 5-HT3 receptors are also involved in this process.