Laparoscopic treatment of acute mesenteric torsion.

Acute torsion of the small bowel mesentery is a diagnostically challenging cause of acute abdominal pain, which most commonly afflicts pediatric patients with midgut malrotation. We describe a case of mesenteric torsion in an adult patient that had manifested as acute abdominal pain. The patient had a remote history of prior abdominal surgery, presenting on multiple occasions with undiagnosed acute intermittent abdominal pain. Diagnosis of mesenteric torsion was made by contrast enhanced CT and the ailment was successfully treated with laparoscopic surgery without recurrence.

Radiofrequency energy delivery to the gastroesophageal junction for the treatment of GERD.

BACKGROUND: In this multi-center study, the feasibility, safety, and efficacy of radiofrequency (RF) energy delivery to the gastroesophageal junction (GEJ) for the treatment of gastroesophageal reflux disease (GERD) were investigated. METHODS: Forty-seven patients with classic symptoms of GERD (heartburn and/or regurgitation), a daily anti-secretory medication requirement, and at least partial symptom response to drugs were enrolled. All patients had pathologic esophageal acid exposure by 24-hour pH study, a 2 cm or smaller hiatal hernia, grade 2 or less esophagitis, and no significant dysmotility or dysphagia. RF energy was delivered with a catheter and thermocouple-controlled generator to create submucosal thermal lesions in the muscle of the GEJ. GERD symptoms and quality of life were assessed at 0, 1, 4, and 6 months with the short-form health survey (SF-36). Anti-secretory medications were withdrawn 7 days before each assessment of symptoms and pH/motility study. Medication use, endoscopic findings, esophageal acid exposure, and motility were assessed at 0 and 6 months. RESULTS: Thirty-two men and 15 women underwent treatment. At 6 months there were improvements in the median heartburn score (4 to 1, p < or = 0.0001), GERD score (26 to 7, p < or = 0.0001), satisfaction (1 to 4, p < or = 0.0001), mental SF-36 (46.2 to 55.5, p = 0.01), physical SF-36 (41.1 to 51.9, p < or = 0.0001), and esophageal acid exposure (11.7% to 4.8%, p < or = 0.0001). Esophagitis was present in 25 patients before treatment (15 grade 1 and 10 grade 2) and 8 had esophagitis at 6 months (4 grade 1 and 4 grade 2, p = 0.005). At 6 months, 87% no longer required proton pump inhibitor medication. There was no significant change in median lower esophageal sphincter pressure (14.0 to 12.0 mm Hg, p = 0.19), peristaltic amplitude (64 to 66 mm Hg, p = 0.71), or lower esophageal sphincter length (3.0 to 3.0, p = 0.28). There were 3 self-limited complications (fever for 24 hours, odynophagia lasting for 5 days, and a linear mucosal injury that was healed after 3 weeks). CONCLUSION: RF energy delivery significantly improved GERD symptoms, quality of life, and esophageal acid exposure while eliminating the need for anti-secretory medication in the majority of patients with a heterogeneous spectrum of clinical disease severity but with minimal active esophagitis or hiatal hernia.

Lupus abdominal crisis owing to rupture of an ileocolic aneurysm with successful angiographic treatment.

There are many causes of acute abdominal pain, or abdominal "crises," in patients with systemic lupus erythematosus (SLE), most frequently the causes are serositis or vasculitis. Vasculitis generally causes small vessel abnormalities and may present with symptoms owing to mucosal damage, such as pain, diarrhea, or bleeding. We present a patient with SLE who had the acute onset of severe abdominal pain while hospitalized for a lupus flare and who was found to have a ruptured ileocolic aneurysm with intraperitoneal bleeding. She was successfully managed with angiographic embolization, without further complications. Although angiography is well established as a therapeutic intervention for mesenteric aneurysms of various etiologies, this is the first case of an SLE-related ileocolic aneurysm so managed. This entity should be considered in the differential diagnosis of abdominal pain in patients with lupus, and angiographic embolization should be considered in its management.

The columnar-lined (Barrett's) esophagus. Can progression to cancer be prevented?

The risk of adenocarcinoma in patients with columnar-lined, or Barrett's, esophagus has risen dramatically in recent decades. In this article, Dr Stollman explains the difficulties in defining the condition and examines current strategies in prevention and management.

Acute small bowel pseudo-obstruction due to AL amyloidosis: a case report and literature review.

Amyloidosis may uncommonly present with intestinal pseudo-obstruction. Previous reports have described an acute presentation with AA amyloid and a more chronic syndrome with AL amyloid. We report the case of a 78-yr-old man who presented with clinical and radiographic features of an acute small bowel obstruction and who, at laparotomy, was found to have intestinal pseudo-obstruction due to AL amyloidosis. We believe this case represents the first report of acute pseudo-obstruction from AL amyloidosis; awareness of this presentation may facilitate earlier diagnosis.

The efficacy of proton-pump inhibitors in acute ulcer bleeding: a qualitative review.

Despite remarkable progress in the treatment of chronic peptic ulcer disease, acute gastroduodenal ulcer hemorrhage remains a therapeutic challenge. Numerous trials of H-2 receptor antagonists have not consistently shown a significant benefit in such patients. Proton-pump inhibitors, which more profoundly suppress gastric acid, are being increasingly evaluated. We have performed a qualitative systematic review to analyze the results of these trials to determine if a reasonable consensus can be reached. We searched for all published, randomized, controlled studies that evaluated proton-pump inhibitors in patients with acute peptic ulcer hemorrhage. The primary outcomes evaluated were: (A) persistent or recurrent bleeding; (B) need for surgery; and (C) mortality. Sixteen trials were evaluated, enrolling 3154 patients. Four of the sixteen studies showed a statistically significant decrease in overall rebleeding rate, and two described specific benefit in patients with Type IIa and IIb endoscopic stigmata. Four studies also showed a significantly decreased surgery rate, but none demonstrated a significant mortality reduction. Proton-pump inhibitors may improve outcome in acute peptic ulcer bleeding, but the available clinical data remain inconsistent. Further study is necessary to define the optimal dosage, route of administration, duration of therapy, and subsets of patients most likely to benefit.

University of Miami Division of Clinical Pharmacology therapeutic rounds: irritable bowel syndrome-pathophysiology, diagnosis, and treatment.

Irritable bowel syndrome, or IBS, is a common disorder of the bowels that causes significant patient morbidity, work-absenteeism, physician visits, and, frequently, extensive evaluations. The syndrome has been classified as a functional disorder because of the lack of clearly elucidated pathophysiology, although altered visceral sensitivity, intestinal motility, and psychosocial factors all likely play a role. Treatment includes fostering a strong, trusting relationship with the patient, with pharmacotherapy directed at the predominant symptoms. The authors review the pathophysiology, diagnosis, and treatment of this difficult disorder.

Diverticular disease of the colon.

Diverticular disease of the colon is quite common in developed countries, and its prevalence increases with age. Although present in perhaps two thirds of the elderly population, the large majority of patients will remain entirely asymptomatic. Nonetheless, an estimated 20% of those affected may manifest clinical illness, mainly diverticulitis, with its potential complications of abscesses, fistulas, and obstruction, as well as lower intestinal hemorrhage. The purpose of this report is to review our understanding of the epidemiology, pathophysiology, clinical presentation, and treatment options for this disorder.

University of Miami Division of Clinical Pharmacology therapeutic rounds: update on diagnosis and treatment of gastroparesis.

Gastroparesis, defined as delayed gastric emptying because of abnormal gastric motility in the absence of mechanical outlet obstruction, is a common problem causing significant morbidity. Although many cases are caused by diabetes, more than 90 different conditions are known to interfere with normal gastric motor function (Scand J Gastroenterol 1995;30[suppl]:7-16). Patients may present with nausea, vomiting, heartburn, early satiety, or postprandial pain. The current gold standard for quantifying gastric emptying is nuclear scintigraphy. The main goal of treatment is to improve patient comfort by accelerating the rate of gastric emptying, which may be achieved through dietary changes and the use of prokinetic agents. In rare instances, relief can only be obtained with surgical intervention. This report reviews the pathophysiology, clinical presentation, evaluation, and treatment of patients with gastroparesis, an understanding of which will lead to more effective patient care.

The uncleared fundal pool in acute upper gastrointestinal bleeding: implications and outcomes.

BACKGROUND: The implications and outcomes of patients with an uncleared fundal pool of blood found at emergent upper endoscopy are not well described. METHODS: We reviewed the records of 484 consecutive patients who presented over a 12-month period to our medical center with acute upper gastrointestinal hemorrhage. All patients underwent upper endoscopy within 24 hours of their initial presentation. Patients with an uncleared fundal pool of blood at initial endoscopy were included in this study, and their findings and outcomes were compared with a randomly selected subgroup of these same patients who did not have residual gastric blood. RESULTS: Sixty-one patients (13%) had uncleared fundal pools despite gastric lavage and patient positioning. Findings on initial endoscopy included esophageal varices in 29 (47%), gastric ulcer in 12 (20%), portal hypertensive gastropathy in 5 (8%), Mallory-Weiss tear in 5 (8%), duodenal ulcer in 5 (8%), gastric varices in 4 (7%), Dieulafoy's lesion in 2 (3%), and other in 7 (11%). Twelve of these 61 patients had multiple findings and 4 (7%) had no lesion identified. Thirty-two of the 61 patients (52%) had at least one follow-up endoscopy, with new fundal lesions identified in 13 (41%): portal hypertensive gastropathy in 8, gastric ulcer in 2, gastric varices in 2, and leiomyoma in 1. Of these 13 new findings, 5 (38%) were judged significant either by the presence of active bleeding or stigmata of recent hemorrhage. Of the 4 patients with no identifiable lesion on initial endoscopy, 3 had a follow-up endoscopy and 2 were found to have a significant new finding in the fundus. The control group had a statistically significant lower percentage of endoscopic findings related to portal hypertension. Recurrent bleeding during the index hospitalization occurred in 54% of the patients with uncleared fundal pools versus 11% of the control group (0 < 0.01). Length of stay, number of units of blood transfused, need for emergent surgery for bleeding, as well as overall and bleeding-related mortality were all significantly greater in the patients with the uncleared fundal pool than in the control patients. CONCLUSIONS: The inability to clear a fundal pool of blood at emergent upper endoscopy is associated with significant morbidity and mortality. Further, new fundal lesions can be identified in 41% of patients on follow-up examination, with many being clinically significant. These data support the importance of clearing a fundal pool in patients undergoing endoscopy for upper gastrointestinal bleeding.

CO2 provocation of panic: symptomatic and manometric evaluation in patients with noncardiac chest pain.

OBJECTIVES: Occult panic disorder (PD) may underlie 10-43% of chest pain syndromes in patients with normal coronary arteries. A variety of agents, such as intravenous lactate, oral caffeine, and inhaled CO2, has been identified that may provoke panic attacks in susceptible patients. The aims of this study were (1) to better define the relationship between noncardiac chest pain syndromes and panic disorder; and (2) to assess the diagnostic utility of PD provocative testing with inhaled CO2 in eliciting chest pain and/or esophageal manometric disturbances. METHODS: Fourteen patients with chest pain syndromes and negative coronary angiograms or stress thallium tests were evaluated for PD and underwent (1) standard esophageal manometry followed by continuous manometric recording; (2) inhalation by face mask of room air or 35% CO2, single blinded, in random order; (3) a previously validated Acute Panic Inventory questionnaire administered before and immediately after each inhalation; and (4) Tensilon 10 mg i.v. administration. RESULTS: Of 14 patients, 8 met DSM-IIIR criteria for panic disorder. Mean Acute Panic Inventory scores (reflecting panic symptoms) increased significantly after CO2 inhalation relative to room air in all patients. Of 14 patients, 8 (4 PD, 4 non-PD) experienced chest pain after CO2 inhalation, whereas no patient had chest pain after room air inhalation. Of 14 patients, 5 had pain with Tensilon (4 of 5 whom responded to CO2). No specific manometric abnormalities occurred during any chest pain episode. CONCLUSION: CO2 inhalation is as effective as Tensilon in provoking chest pain in patients with noncardiac chest pain. The high prevalence of PD in such patients suggests that CO2 inhalation, a known panicogen, may be useful in evaluating such patients. The mechanism of CO2 induced chest pain remains unknown, but does not appear to be attributable to demonstrable esophageal motility abnormalities.

Sting of the puss caterpillar: an unusual cause of acute abdominal pain.

We report the case of a 41-year-old man with abdominal pain after envenomization by a puss caterpillar. The patient's medical history and physical examination revealed classic symptoms, leading to the correct diagnosis and appropriate therapy with intravenous calcium gluconate. Although severe, local reactions to puss caterpillar envenomization have been previously described, to our knowledge this is the first report of a patient with severe, acute abdominal pain caused by a puss caterpillar's sting.