Clinical value of serum lactate measurement in diagnosing acute mesenteric ischaemia.

Acute mesenteric ischaemia (AMI) is a life-threatening disease with a mortality rate around 60%. This high mortality rate is largely caused by diagnostic delay, which means there is a pressing need for a reliable biomarker. In clinical practice, serum lactate measurement is often used for the diagnosis of AMI. To assess the diagnostic value of serum lactate, we performed a literature search. Lactate has two different isomers. The well-known L-lactate, produced by anaerobic glycolysis, and the more unknown D-lactate which is only produced by intestinal bacteria. In this review, we present and evaluate the current literature on the diagnostic value of the measurement of both lactate isomers. Furthermore, we suggest another biomarker which might have the potential to serve as a useful diagnostic test in the future.

Survival after resection of a primary malignant melanoma of the small intestine in a young patient: report of a case.

The occurrence of primary melanoma of the small intestine is rare. We describe the case of a 25-year-old man found to have a primary melanoma of the ileum. The patient presented with gradual onset of abdominal pain, fever, diarrhea, weight loss and fatigue. A preoperative diagnosis of a small intestinal tumor was based on the findings of computed tomography scanning. This diagnosis was confirmed at laparoto-my and a partial small bowel resection was performed. Histopathological examination of the resected specimen clarified the exact nature of the lesion, confirming the diagnosis of melanoma. Thorough postoperative investigation did not reveal a primary lesion in the skin, gastrointestinal tract, oculus or brain. Thus, we diagnosed this tumor as a primary lesion. One year after his operation, the patient remains well without any evidence of recurrence. Thus, we diagnosed this small bowel tumor as a primary melanoma of the small intestine.

Endoclips for fixation of nasoenteral feeding tubes: a review.

BACKGROUND: Maintaining the position of an endoscopically placed nasoenteral feeding tube beyond the pylorus is often problematic because of retrograde migration. Fixation of a feeding tube to the small intestinal wall with an endoclip may prevent this. This article reviews available literature on the feasibility, efficacy and safety of endoclips for fixation of nasoenteral feeding tubes. METHODS: A systematic search of the English literature was performed using MEDLINE, EMBASE and Cochrane databases to identify articles assessing the use of endoclips for fixation of feeding tubes, as well as articles assessing duration of attachment of endoclips. RESULTS: Five cohort series were identified that evaluated the applicability of endoclips for fixation of feeding tubes to the small intestinal wall. In all patients, except one, a nasoenteral feeding tube could be successfully fixated to the small intestinal wall. During follow-up, no spontaneous migrations of feeding tubes were observed. No complications related to placement or removal of endoclips were observed. Three comparative studies evaluated duration of attachment of different types of endoclips to the gastrointestinal wall. Duration of attachment ranged from less than 1 week to more than 18 weeks, depending on the type of endoclip. CONCLUSIONS: Based on available literature the use of endoclips for fixation of nasoenteral feeding tubes is feasible, effective and safe. Data from randomized controlled trials are needed.

Phaeochromocytoma in various disguises.

Patients with phaeochromocytoma may present a broad spectrum of clinical manifestations as presented here in 5 case reports. Pathophysiology, clinical management, pharmacotherapy and associated diseases are discussed. Although catecholamine measurements in both urine and blood as well as modern localisation techniques are valuable adjuncts to establishing the diagnosis, a high index of suspicion remains the key to this diagnosis.

Antibiotic policies in Dutch hospitals for the treatment of patients with serious infection.

In order to assess the guidelines available in Dutch hospitals for the treatment of patients with serious infection of unknown aetiology, 39 antibiotic formularies used in 88 hospitals were analyzed. The recommendations considered were those for the treatment of sepsis for which the source was not apparent or which originated in the urinary tract, respiratory tract or abdomen. beta-Lactam antibiotics (most commonly amoxycillin and cefuroxime) were the preferred agents for empirical therapy of infections of all types; an aminoglycoside was also included in the majority of regimens, irrespective of the clinical presentation. However, there were wide variations in the choice and dosages of the drugs administered. Because of the absence of local data for the susceptibilities of blood culture isolates, the appropriateness of the recommendations could not be properly evaluated.

Effects of supplemental dietary calcium on quantitative and qualitative fecal fat excretion in man.

Oral calcium supplementation is thought to be a useful interventional agent to decrease colon cancer risk. This is supposedly due, at least in part, to the binding of bile acids and fatty acids by calcium in the colon, thus prohibiting the damaging effects of these substances to the epithelium. To determine the effects of calcium supplementation on fecal fat excretion, 24 subjects kept a fat and calcium constant diet for one week and were supplemented with either 0, 2 or 4 g elemental calcium as calcium carbonate in a double-blind fashion. At the end of the week 72-hour feces was collected, and total fat, neutral fat, fatty acids and the ratio of polyunsaturated and saturated fatty acids (P/S ratio) were measured. Calcium dose-dependently increased the percentual excretion of total fat as related to fat intake: 6.8 +/- 0.9% during 0 g, 7.4 +/- 1.0% during 2 g and 10.2 +/- 1.4% during 4 g, r = 0.44, p = 0.03. This was due to increased fatty acid excretion, excretion of neutral fat was not affected, nor was the P/S ratio. It is concluded that calcium supplementation modestly increases fecal fatty acid excretion. No adverse metabolic effects are to be expected from this in case of long-term calcium supplementation in subjects at increased risk for colon cancer.

Growth hormone-, alpha-subunit and thyrotrophin-cosecreting pituitary adenoma in familial setting of pituitary tumour.

A patient with acromegaly and hyperthyroidism due to a growth hormone-, thyrotrophin- and alpha-subunit-secreting pituitary adenoma is described. His decreased father had suffered from a pituitary tumour, and was likely to have had acromegaly as well. Plasma growth hormone and insulin-like growth factor I concentrations were elevated, with levels between 10 and 20 micrograms/l and 4.4 and 7.3 kU/l, respectively. In spite of hyperthyroidism (free thyroxine, 45 pmol/l; free triiodothyronine, 24 pmol/l), plasma thyrotrophin remained at 2.8 mU/l without any response to thyrotrophin-releasing hormone and could not be suppressed with exogenous administration of triiodothyronine. Plasma alpha-subunits were raised to 3.3-3.7 U/l (normal 0.4-1.1 U/l). Pathological examination of the surgically removed tumour showed a pituitary adenoma with the immunohistochemical presence of growth hormone, thyrotrophin, prolactin and alpha-subunit. This is the first report of a growth hormone-, thyrotrophin- and alpha-subunit-producing pituitary adenoma, which occurred in a familial setting.