Intestinal metabolism of estrogens.

Estrogen metabolism in the human intestine was studied in two ways. Firstly, by measuring the excretion of 12 estrogens in pooled human late pregnancy feces before and during the administration of ampicillin (2 g/day). Secondly, by administering 5.4 and 20 mg of 16alpha-hydroxyestrone orally to two postmenopausal women and analyzing the estrogens in simultaneously drawn portal and peripheral venous blood samples at time intervals from 0 to 150 min after steroid administration. The majority of the estrogens in normal pregnancy feces were unconjugated. The amounts of estradiol, estreon and 16-epiestriol excreted, relative to the principal estrogen estriol, were greater than in pregnancy bile or urine and 16alpha-hydroxyestrone, an important biliary estrogen, was only present in trace amounts. Considerable quantities of 15alpha-hydroxyestradiol-17beta were also found. Ampicillin administration, which decreases intestinal bacterial steroid metabolism, caused a huge increase in the fecal excretion of conjugated estrogens. In particular it caused very striking increases in the excretion of both unconjugated and conjugated, estriol, 15alpha-hydroxyestrone, 15alpha-hydroxyestradiol and 2-methoxyestrone. These findings emphasize the active role played by the intestinal microflora in estrogen metabolism under normal conditions. Administration of 16alpha-hydroxyestrone resulted in increases in portal venous unconjugated and conjugated 16alpha-hydroxyestrone, 16-oxoestradiol-17beta, 15alpha-hydroxyestrone, 16-epiestriol and conjugated estriol levels. The most significant finding in both subjects was the large increase in portal venous unconjugated 15alpha-hydroxyestrone. This would suggest that the human intestine (or intestinal contents) has the ability to carry out the transformation, 16alpha-hydroxyestrone leads to 15alpha-hydroxyestrone. Increases in the same estrogens were found in peripheral plasma, with the increase in conjugated estriol occurring in peripheral blood before it was seen in portal blood. The largest elevations in peripheral plasma values were seen in unconjugated estriol and conjugated 16alpha-hydroxyestrone in the subject who received the 20 mg dose and in unconjugated 16alpha-hydroxyestrone and 16-oxoestradiol-17beta in the subject who had the 5.4 mg dose. The intestinal and enterohepatic metabolism of estrogens is discussed in relation to these findings.

The Mallory-Weiss syndrome. An analysis of haemostatic function in a bleeding-free period.

The bleeding source in the Mallory-Weiss syndrome is mucosal tears at the gastro-oesophageal junction. It has been suggested that haemostatic defects play an active role in the syndrome's development. This study was made to analyze whether or not such defects are present during a bleeding-free period following the Mallory-Weiss syndrome. Fourteen patients were examined 4 weeks to 5.8 years after the bleeding episode. In most cases the coagulation mechanism was then found to be normal. Mild haemostatic defects were found in four patients, but were not of consistent type.

Atherosclerotic aneurysm of the deep femoral artery. Case report.

Three cases of atherosclerotic aneurysm of the deep femoral artery are described. They demonstrated the differing presentations of atherosclerotic femoral aneurysm, viz. as "asymptomatic" pulsating tumour or with manifestations of distal ischaemia or rapid growth and rupture. A search of the literature revealed 12 cases of atherosclerotic aneurysm in the deep femoral artery, and additionally 11 mentioned in review articles on femoral aneurysm. Notably, five of the 15 (including the 3 here described) cases of deep femoral artery aneurysm presented with rupture, an incidence higher than has been reported for aneurysm of the common or superficial femoral artery. The reason probably is that deep femoral aneurysms are more difficult to diagnose before they have reached a size carrying higher risk of rupture. A more aggressive approach, with operation soon after establishment of the diagnosis, is therefore proposed.

Transmesenteric hernia in the meso-appendix with gangrene of the small bowel.

Reviewing the literature, transmesenteric hernias were found to be rare. A case with herniation in the meso-appendix, intestinal obstruction and gangrene of the small bowel is presented. Surgery was performed and the outcome was uneventful.

Juxtapapillary choledochoduodenal fistula following choledochal exploration and diagnosed by early duodenoscopy.

In 86 patients who had undergone common-duct exploration at surgery for benign biliary disease, duodenoscopy was performed within 4 weeks after the operation. Choledochoduodenal fistula, apparently iatrogenic, was then found in eight patients (9.3%). All eight were among the 35 patients in whom a rigid probe had been passed to the duodenum, giving a fistula incidence of 23% in this group. Four of the eight patients consented to repeat duodenoscopy, which showed healing of fistula within a year in three cases. No patient with choledochoduodenal fistula experienced postoperative biliary symptoms.

Post-operative lesions of the common bile-duct. A cholangiographic investigation.

Cholangiograms were reviewed of 190 patients with gall-bladder disease, who were consecutively operated upon with common bile-duct exploration during a 2.5-year period. Nine patients were excluded for various reasons. In 86 patients endoscopy of the duodenum was also performed after surgery. In 181 patients post-operative cholangiography revealed the following lesions, not found at the pre-explorative examinations: Fistula to the duodenum in 27, ulcers or sinus tracts in 11, ectasia and/or irregularities in another 11. In 17 patients retained calculi were found. The clinical significance of the iatrogenic lesions is probably low, but they must be recognized as such in order not to be radiologically misinterpreted.

Intravenous computed tomographic cholangiography in acute cholecystitis. A comparison with conventional cholangiography.

Forty-nine patients with clinical signs of acute cholecystitis underwent conventional and computed tomographic cholangiography. Among 39 patients with signs of contrast medium in the biliary system at both examinations there was a diagnostic discrepancy in only one patient. Conventional radiography demonstrated cholecystopathy in this patient while contrast medium in the gallbladder and an acute pancreatitis were found at computed tomography. Ten patients with an indeterminate conventional cholangiography had a conclusive computed tomographic examination. Twenty of 30 patients with an abnormal computed tomographic cholangiography underwent cholecystectomy and all had diseased gallbladders. All 17 patients with histopathologically confirmed acute cholecystitis had signs of subserosal edema and/or changes in the omental fatty tissue adjacent to the gallbladder at computed tomography. A layer of tissue of water-density adjacent to the gallbladder and/or changes in omental fatty tissue were also seen in one patient with congestive heart failure and in one with a penetrating duodenal ulcer. None of the 19 patients with a normal computed tomographic cholangiography had a proven acute cholecystitis.