Black esophagus: a case series and literature review of acute esophageal necrosis.

Black esophagus or acute esophageal necrosis (AEN) is a rare medical disorder which is characterized by a diffuse circumferential black esophageal mucosa. The majority of patients present with signs of upper gastrointestinal bleeding. Diagnosis is made based on esophagogastroduodenoscopy. Treatment consists of intravenous fluids, proton pomp inhibitors and additional therapies to treat the underlying illness. In this article we present five cases of patients with AEN and briefly review the literature of AEN.

Small bowel carcinoma mimicking a relapse of Crohn's disease: a case series.

We describe three patients diagnosed and treated for presumed (relapsing) Crohn's disease, but who were subsequently diagnosed with a small bowel carcinoma. This case series underlines the necessity of performing a full work up in the diagnosis of CD and to consider small bowel carcinoma in patients with small bowel CD failing medical therapy.

Herpes simplex virus oesophagitis in a pregnant woman.

Herpes simplex virus (HSV) oesophagitis is well described in immunocompromised patients. In immunocompetent individuals HSV oesophagitis is rare. We present a case of HSV oesophagitis in a pregnant woman. A possible explanation for HSV oesophagitis during pregnancy is the decreased cellular immunity, leading to an increased frequency and severity of viral infections. Antiviral therapy is advocated in pregnancy.

Proton pump inhibitor therapy in gastro-oesophageal reflux disease decreases the oesophageal immune response but does not reduce the formation of DNA adducts.

BACKGROUND: Chronic oesophageal inflammation and related oxidative stress are important in the pathogenesis of erosive oesophagitis (EO) and its malignant progression. AIM: To study the effect of proton pump inhibitors (PPIs) on oesophageal cellular immune response and oxidative damage in EO patients. METHODS: Forty gastro-oesophageal reflux disease (GERD) patients [non-erosive reflux disease (NERD): 15, EO: 25] were included, after 7 days off antisuppressive drugs. EO patients were randomized to 20-mg rabeprazole once daily for either 4 or 8 weeks with baseline and follow-up endoscopy with distal oesophageal biopsies. T lymphocytes, macrophages and mast cells were quantified by immunohistochemistry. DNA adducts were measured by analysis of 8-oxo-deoxyguanosine levels. RESULTS: Erosive oesophagitis patients had more T lymphocytes and CD8(+) T lymphocytes in squamous epithelium than NERD patients (P = 0.001, P = 0.002, respectively). Levels of DNA adducts between both groups were, however, not different (P = 0.99). Four- and eight-week rabeprazole treatment in EO patients resulted in a significant decrease in number of T lymphocytes and CD8(+) T lymphocytes (all P < 0.05). PPIs did not, however, affect levels of DNA adducts. CONCLUSIONS: Short-term PPI therapy in EO patients reduces the oesophageal cellular immune response, but does not change oxidative damage. PPI therapy may therefore not be effective in reducing the risk of oesophageal cancer in GERD patients.

Maintenance treatment with budesonide 6 mg versus 9 mg once daily in patients with Crohn's disease in remission.

BACKGROUND: In previous trials, budesonide 6 mg/day was able to prolong the time to relapse in patients with quiescent Crohn's disease and budesonide 9 mg/day was effective in active disease with limited side effects. The aim of this study was to compare the effectiveness of budesonide 9 mg vs 6 mg once daily on the maintenance of remission and occurrence of adverse events. METHODS: Double-blind, randomised trial in patients with Crohn's disease in remission. Patients were randomised to receive 6 mg/day or 9 mg/day of budesonide (Budenofalk) without concomitant treatment for Crohn's disease. Endpoints were the time to relapse and relapse rates after one year. RESULTS: Seventy-six patients were randomised to 6 mg/day and 81 patients to 9 mg/day. Survival analysis showed no differences in the time to relapse. One-year relapse rates were not significantly different (6 mg group 24%; 9 mg group 19%). Any adverse event was reported in 61 and 68% of patients in the 6 mg and 9 mg groups, respectively; none of the 12 serious adverse events were drug related. CONCLUSION: The one-year relapse rates were low and not significantly different between the group of patients treated with budesonide 6 mg vs 9 mg/day. Also, time to relapse and the number of adverse events were similar in both treatment groups.

[Relapsing infections with Clostridium difficile]. / Recidiverende infecties met Clostridium dificile.

Two women, aged 78 and 85 years, presented with watery diarrhoea and fever after a course of antibiotic therapy. Pseudo-membranous colitis was diagnosed, which was adequately treated. In both patients the C. difficile colitis relapsed, which was successfully treated with a pulse and tapering scheme of vancomycin. C. difficile infection is a frequent cause of antibiotic-associated diarrhoea. Clinical presentation can vary in severity. Cytotoxin testing, immunoassay and endoscopy are important tools in diagnosing C. difficile colitis. Like the first infection, the first relapse must be treated with metronidazole or vancomycin. To treat a second relapse, a pulse and tapering dose of vancomycin has been recommended. Nevertheless, multiple recurrences may occur, which are difficult to treat.

[Collagenous colitis: macroscopically invisible, but with various treatment options]. / Collagene colitis: macroscopisch onzichtbaar, maar niet onbehandelbaar.

Two female patients, aged 54 and 67 years, respectively, had suffered from watery diarrhoea for several weeks or months without cramps or blood in the stools. The findings upon physical examination, blood and faecal examination and endoscopy were normal, and subsequent histological examination of intestinal biopsies revealed collagenous colitis. After treatment with a high-fibre diet, sulphasalazine and either prednisone or budesonide, the symptoms subsided. Collagenous colitis is a chronic watery diarrhoea disorder with unknown aetiology and pathogenesis. It is characterised by macroscopically normal mucosa, while histopathologically an abnormal thickening of the subepithelial collagenous layer and an increase in the number of intra-epithelial lymphocytes is found. There are various treatment options such as dietary fibre, mesalazine or bismuthsubsalicylate. Recently budesonide has been found to have a favourable effect both clinically and histologically. Complications of the disease are rare.

Life-threatening hypokalaemia and quadriparesis in a patient with ureterosigmoidostomy.

We report quadriparesis as a result of severe hypokalaemia and acidosis in a 50-year-old man who had undergone ureterosigmoidostomy for bladder extrophy 48 years earlier. Aggressive suppletion with intravenous potassium and bicarbonate combined with potassium-sparing diuretics and ACE inhibitors resulted in complete restoration of the serum potassium and resolution of the neurological symptoms. The underlying mechanism as well as the treatment of hypokalaemia and hyperchloraemic metabolic acidosis after ureterosigmoidostomy are briefly discussed.

Circadian rhythm of rectal motor complexes.

PURPOSE: Prolonged rectal pressure recordings have revealed that the rectum exhibits typical bursts of regular pressure waves, also called rectal motor complexes. Although there is consensus regarding the characteristics of rectal motor complexes, their function is poorly understood. Furthermore, data regarding the circadian rhythm of these complexes are either lacking or conflicting. Therefore, we conducted a study to investigate the circadian rhythm of rectal motor complexes in fully ambulant subjects. Because a meal is a powerful and physiologic stimulus to elicit colonic pressure activity, we also studied the effect of a meal on these rectal motor complexes. METHODS: Prolonged ambulant anorectal pressure recordings were performed in 12 healthy volunteers (male:female ratio, 6:6; median age, 27 (range, 22-53) years). A total of 139 rectal motor complexes were observed in >300 hours of recording. RESULTS: All subjects exhibited rectal motor complexes during the daytime, whereas in five subjects, no rectal motor complexes were observed during sleep. The number of rectal motor complexes was significantly lower during sleep (diurnal vs. nocturnal, 8 vs. 1 per subject, P < 0.0001). Furthermore, the duration and peak amplitude of these nocturnal rectal motor complexes were significantly reduced. On the ambulant recordings, the subjects marked a total of 20 meals. During the first 2 hours after these meals, rectal motor complexes were noted in 65 percent of the cases. The postprandial frequency of rectal motor complexes was significantly higher than the overall frequency (2/hour vs. 0.4/hour, P = 0.004). CONCLUSIONS: These findings suggest that sleep results in a reduction of rectal motor activity, whereas a meal provides a stimulus for increased rectal motor activity in fully ambulant subjects.

A comparison of 3 types of covered metal stents for the palliation of patients with dysphagia caused by esophagogastric carcinoma: a prospective, randomized study.

BACKGROUND: There are currently 3 types of covered metal stents available in Europe for palliation of patients with malignant dysphagia. Their relative merits have not been compared in a prospective, randomized study. METHODS: One hundred consecutive patients with esophagogastric carcinoma were randomized to placement of an Ultraflex stent, a Flamingo Wallstent, or a Gianturco-Z stent. Malignant strictures of the esophagus were treated by insertion of a small-diameter stent (n = 71), whereas those involving the gastric cardia were treated with a large-diameter stent (n = 29). RESULTS: At 4 weeks, dysphagia had improved in all patient groups (p < 0.001), but the degree of improvement did not differ among the 3 groups (p = 0.14). There were differences among the 3 stent types with respect to major complications (Ultraflex stent: 8/34 [24%], Flamingo Wallstent: 6/33 [18%], and Gianturco-Z stent: 12/33 [36%]), but these were not statistically significant (p = 0.23). Nine patients (26%) with an Ultraflex stent, 11 (33%) with a Flamingo Wallstent, and 8 (24%) with a Gianturco-Z stent had recurrent dysphagia (p = 0.73), mainly because of tumor overgrowth or stent migration; 12 of 13 episodes of migration involved small-diameter stents in the esophagus. CONCLUSIONS: All 3 covered metal stents evaluated offer the same degree of palliation of patients with malignant dysphagia. Placement of Gianturco-Z stents was associated with more complications as compared with Ultraflex stents and Flamingo Wallstents. Although stent migration is reduced by increasing stent diameter, tumor overgrowth remains an intractable problem that requires a new approach.

[Tubercular granulomas of the liver in a Somalian patient notwithstanding a chronic hepatitis C]. / Granulomen in de lever bij een Somalische patiënt met chronische hepatitis C toch veroorzaakt door tuberculose.

A 44-year-old male Somalian immigrant was admitted to hospital for evaluation of upper abdominal pain and painful joints (neck and shoulders). Chronic active hepatitis caused by hepatitis C virus was diagnosed. Further examination was instituted because of the simultaneous finding of granulomas in a liver biopsy. In hepatitis C liver granulomas may be found. Infection by Mycobacterium tuberculosis was established, however, after extensive investigation. Treatment was started with tuberculostatic drugs, after which the complaints of the patient disappeared, liver enzyme levels decreased and granulomas in the liver disappeared. No side effects of the tuberculostatic treatment were seen on the course of the hepatitis C.

Malignancy in Peutz-Jeghers syndrome? The pitfall of pseudo-invasion.

Peutz-Jeghers syndrome is a malignancy-associated polyposis syndrome. We describe a histopathologic phenomenon easily encountered when examining the nature of Peutz-Jeghers polyps but that is underreported in the literature. This phenomenon of "pseudo-invasion" may mimic invasive carcinoma due to epithelial displacement and erroneously give the impression, both macroscopically and microscopically, that a malignancy is involved. This potential pitfall is illustrated by the case of a patient with Peutz-Jeghers syndrome who was thought to harbor a metastasizing adenocarcinoma in his small bowel with peritoneal metastasis as a perioperative finding. Histologic examination, however, revealed pseudo-invasion.

Recent developments in screening, diagnosis and surgical treatment of hepatocellular carcinoma.

A relationship between the pathogenesis of hepatocellular carcinoma (HCC) and various types of underlying liver disease has been clearly demonstrated. Presently, this knowledge has not led to efficacious screening programmes for identifying patients with curable primary liver cancer at an early stage. Screening strategies should be improved in order to realize optimal management of patients with HCC. Detection and staging of primary liver cancer is hampered by the quality of imaging techniques and treatment is restricted by access to modalities such as liver transplantation. In this review recent developments in the management of hepatocellular carcinoma are discussed and an algorithm is proposed to define the most optimal approach for screening, diagnosis and surgical treatment.

Successful management of hemolysis in ABO-nonidentical orthotopic liver transplantation by steroid therapy: a case report.

Hemolysis due to donor-derived B lymphocytes has been reported in patients who have undergone ABO-nonidentical orthotopic liver transplantation (OLT). Yet, until now, little was known about the management of this transplantation-induced hemolysis. In this report we describe our experience with hemolysis in a patient after OLT. In addition, based on theoretical assumption, we hypothesize that corticosteroids can be helpful in the management of ABO-nonidentical OLT-induced hemolysis.

Spontaneous bacterial peritonitis: an indication for liver transplantation?

BACKGROUND: Spontaneous bacterial peritonitis (SBP) is a serious complication in patients with cirrhosis and ascites with a poor prognosis. The survival pattern and the reasons for not performing a liver transplantation after an episode of SBP were analysed. METHODS: A retrospective analysis during the period 1987-1992 in a tertiary referral and liver transplantation centre. RESULTS: Sixty episodes of SBP were diagnosed in 52 patients with ascites. Thirty-two percent of the patients died within 30 days and 78% within 1 year. Forty patients who survived less than 1 year did not receive a liver transplantation for the following reasons: death within 30 days (n = 12), age above 65 years (n = 10), medical contraindications (n = 6), active alcohol abuse (n = 6), refusal of transplantation (n = 2), death while being analysed for, or awaiting transplantation (n = 4). Two patients had an auxiliary liver transplantation but died postoperatively. CONCLUSION: SBP is a serious complication in patients with cirrhosis and ascites, with a high first-year mortality and a high recurrence rate. Although long-term survival after an episode of SBP is possible, liver transplantation should be considered for the patients with a progressive liver disease after a first episode of SBP.

High interleukin-6 production within the peritoneal cavity in decompensated cirrhosis and malignancy-related ascites.

To assess the diagnostic and prognostic value of interleukin-6, interleukin 1 beta, and tumor necrosis factor-alpha assays in plasma and ascites, we measured these cytokines in eight patients with malignancy-related ascites and 32 patients with decompensated cirrhosis. Five patients had an episode of bacterial peritonitis, during which one or more ascitic fluid samples were analyzed. Interleukin-6 and tumor necrosis factor-alpha were not significantly different between the cirrhotic and the malignant groups: ascitic interleukin-6 13,816 +/- 15,314 vs 28,138 +/- 23,403 pg/ml, plasma interleukin-6 542 +/- 719 vs 559 +/- 604 pg/ml; ascitic tumor necrosis factor-alpha 19 +/- 50 vs 12 +/- 31 pg/ml, plasma tumor necrosis factor-alpha 3.4 +/- 8.2 vs 6.1 +/- 13.8 pg/ml. During an episode of bacterial peritonitis there was a significant increase only in ascitic interleukin-6 (133,268 +/- 99,743 pg/ml), which declined after antibiotic treatment. None of the parameters was associated with 6-month survival (11 of the 40 patients died within 6 months). There was a correlation (r = 0.675; p = 0.002) between plasma interleukin-6 levels and the Child-Pugh score in patients with cirrhosis, but not with the etiology of the liver disorder. Plasma interleukin-6 levels correlated with IgA levels (r = 0.649; p = 0.004) but not with C reactive protein, sedimentation rate, fibrinogen, IgM or IgG. These results do suggest that interleukin-6 is produced within the peritoneal cavity in hepatic and malignant ascites. There is a sharp increase in the local production of interleukin-6 during an episode of bacterial peritonitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Levels of soluble intercellular adhesion molecule 1, eicosanoids and cytokines in ascites of patients with liver cirrhosis, peritoneal cancer and spontaneous bacterial peritonitis.

The levels of the eicosanoids leukotriene B4, prostaglandin E2, prostacycline and thromboxane B2, the cytokines interleukin-1 beta, interleukin-6 and tumour necrosis factor-alpha and soluble intercellular adhesion molecule 1 were measured in ascites and plasma samples of patients with liver cirrhosis (53), peritoneal cancer (26) and spontaneous bacterial peritonitis (10) to assess their value as a possible diagnostic and prognostic parameter in the course of the disease. Soluble intercellular adhesion molecule 1, of the eicosanoids prostaglandin E2 and leukotriene B4, and the protein concentration in ascites were all significantly elevated in ascites of patients with peritoneal cancer in comparison to ascites of patients with liver cirrhosis. In ascites of patients with spontaneous bacterial infection interleukin-6 concentration was significantly elevated and the protein concentration was significantly lower in comparison to the other two groups. None of these parameters, however, seems to be of practical use as a diagnostic parameter, as there is an overlap between all the levels of these mediators in ascites of liver cirrhosis, peritoneal cancer and spontaneous bacterial peritonitis group. Soluble intercellular adhesion molecule 1 levels were much higher in plasma than in ascites, in contrast to interleukin-6 levels which were much higher in ascites than in plasma. Soluble intercellular adhesion molecule 1 in ascites correlated with soluble intercellular adhesion molecule 1 in plasma (r = 0.6926, P = 0.0001). Soluble intercellular adhesion molecule 1, interleukin-6 and the number of polymorphonuclear cells in peritoneal fluid correlated during episodes of infection in patients with a peritonitis. For this reason soluble intercellular adhesion molecule 1 and interleukin-6 could be of prognostic value for patients with peritonitis.

Diagnostic analysis of total protein, albumin, white cell count and differential in ascitic fluid.

Accurate and precise procedures are described for the measurement of total protein, albumin, white cell count and differential in ascitic fluid. The total protein method (biuret) on the serum chemistry analyser, Bayer-Technicon Chem-1, was calibrated against the biuret reference method in the measuring range from 1-100 g/l, covering serum as well as ascitic fluid values. The albumin method (bromcresol green) on the Chem-1 was calibrated for the measurement range from 1-50 g/l against the new human plasma protein international reference preparations and compared to the nephelometric method on the Beckman Array, which was also calibrated against these reference preparations. A good correlation was obtained for total protein between the Chem-1 (y) and the biuret reference method (x) in 58 ascitic fluids (y = 1.02x -0.3; r = 1.00). A good correlation between the Chem-1 (y) and the Array (x) was also obtained for albumin (r = 0.99). The bromcresol green method, however, which is not fully specific, resulted in significantly higher results (y = 1.32x - 1.3). The immunochemical procedure is considered the more accurate and therefore the bromcresol green method is not suitable for the determination of albumin in ascitic fluids. The white cell count in ascitic fluid can be measured reliably by most haematology analysers if the sample is fresh and homogeneous, but the differential is flagged as a result of differing morphology. Handmade smears from ascitic fluid, however, show uneven distribution of cells and disturbed morphology.(ABSTRACT TRUNCATED AT 250 WORDS)