Intestinal Perforation in ACTH-Dependent Cushing's Syndrome.

Previous studies have linked systemic glucocorticoid use with intestinal perforation. However, the association between intestinal perforation and endogenous hypercortisolism has not been well described, with only 14 previously published case reports. In this study, we investigated if intestinal perforation occurred more frequently in patients with ectopic ACTH syndrome and in those with a greater than 10-fold elevation of 24-hour urinary free cortisol level. Of 110 patients with ACTH-dependent Cushing's syndrome followed in two clinics in Canada, six cases with intestinal perforation were identified over 15 years. Age of patients ranged from 52 to 72, five females and one male, four with Cushing's disease and two with ectopic ACTH production, one from a pancreatic neuroendocrine tumor and one from medullary carcinoma of the thyroid. Five had diverticular perforation and one had intestinal perforation from a stercoral ulcer. All cases had their lower intestinal perforation when the cortisol production was high, and one patient had diverticular perforation 15 months prior to the diagnosis of Cushing's disease. As in previously reported cases, most had hypokalemia and abdominal pain with minimal or no peritoneal symptoms and this occurred during the active phase of Cushing's syndrome. Whereas all previously reported cases occurred in patients with 24-hour urinary free cortisol levels greater than 10-fold the upper limit of normal when measured and 11 of 14 patients had ectopic ACTH production, only one of our patients had this degree of hypercortisolism and four of our six patients had Cushing's disease. Similar to exogenous steroid use, patients with endogenous hypercortisolism also have a higher risk of intestinal, in particular diverticular, perforation and should be monitored closely for its occurrence with a low threshold for investigation and surgical intervention. Elective colonoscopy probably should be deferred until Cushing's syndrome is under control.

Evaluation of sodium deficit in infants undergoing intestinal surgery.

BACKGROUND: Sodium is a critical growth factor for children. Severe deficits cause growth impairment and cognitive dysfunction. Both the diagnosis and risk of sodium depletion in children undergoing intestinal surgery are poorly understood. METHODS: With IRB approval, children undergoing intestinal surgery (2009-2012) who had a urine sodium measurement were retrospectively reviewed. Sodium deficits were defined: urine sodium <30 mmol/L and <10 mmol/L were deficient and severely deficient, respectively. Demographics, weight changes, and intake (sodium, fluid, and nutritional) were tabulated. Data were analyzed using regression analysis and Mann Whitney U tests. RESULTS: Thirty-nine patients, 51.3% female, with a gestational age of 32.2 weeks and weight of 1.43 kg were identified. The most common diagnoses were NEC (38.5%), intestinal atresia (20.5%), and isolated perforation (10.3%). Sodium deficiency was documented in 36/39 (92%) and 92.9% for those in continuity. Severe deficiency occurred in 64%. Urine sodium was significantly correlated with weight gain (p=0.002). Weight gain in patients with urine sodium <30 mmol/L was significantly decreased vs. those ≥30 mmol/L (+0.58 g/d vs. +21.6 g/d, p=0.016). CONCLUSION: In this population, sodium depletion is common in children undergoing intestinal surgery, even when the colon is in continuity. Correction of the sodium deficit to achieve urine sodium >30 mmol/L is associated with improved weight gain.

Effect of parenteral nutrition on muscle amino acid output and 3-methylhistidine excretion in septic patients.

The effects of adequate total parenteral nutrition (TPN) on nitrogen excretion, urea N percentage, 3-methylhistidine excretion, and leg amino acid output, were studied during the ten-day period following abdominal surgery for generalized peritonitis in nine patients. The first two postoperative days were without nutritional intake, TPN was started on the third postoperative day (57 cal/KgBW--40% as Intralipid--0.30 g of N/KgBW). Leg amino acid outputs were done before TPN (DO), then two days (D2) and eight days (D8) after TPN. Total nitrogen and urea N percentage did not significantly differ before and after TPN. Between DO and D2 there was a significant reduction of urinary 3-methylhistidine (467 +/- 37 to 280 +/- 29 mumol/24 h-P less than 0.001) and leg amino acid release (604 +/- 103 to 254 +/- 87 nmol/mn/100 g of calf muscle--P less than 0.01) reflecting reduction in muscle hypercatabolism despite the persistence of the septic state. Between D2 and D8, 3-methylhistidine remained stable while leg amino acid release continued to decrease (254 +/- 87 to 68 +/- 40 nmol/mn/100 g--P less than 0.05). This association suggests an increased muscle protein synthesis. A closer examination of the clinical evolution of these patients, especially concerning their septic evolution, shows that only improved patients with recovery from sepsis increased their muscle protein synthesis. Thus, in septic hypercatabolic patients TPN seems to be able to reduce muscle catabolism while the increase in protein synthesis is mainly the consequence of recovery from the septic state. In such patients TPN should be used as a preventive therapeutic measure.

[A clinical-radiological investigation concerning the accuracy of diatrizoate (Gastrografin) in the demonstration of anastomosis dehiscence and perforation of the gastro-intestinal tract (author's transl)]. / Klinisch-radiologische Untersuchung über die Treffsicherheit des Diatrizoat-(Gastrografin-) Testes zum Nachweis von Anastomosendehiszenzen und Perforationen des Gastrointestinaltraktes

A Gastrografin test is described for diagnosing perforations and dehiscence of anastomoses in the gastro-intestinal tract by carrying out a simple urine analysis. False positive and false negative results can be avoided by obtaining radiographs of urine samples under standard conditions. The accuracy of the method was checked in 97 patients by comparing the results of the urine analysis with radiographic examinations and with the clinical course. From this, it appears that the test is reliable, simple and capable of being used anywhere. The test is therefore recommended a) where there is a lack of radiographic facilities, b) for immobile patients, c) where there is clinical suspicion of a perforation or dehiscence of an anastomosis in the absence of radiographic findings and d) in individual cases where the radiographic changes are positive.