Intestinal vascular malformations.

Eleven patients with intestinal vascular malformations (VMs), all diagnosed by angiography, are presented. Two of the VMs were incidental findings in patients treated for other problems; the other nine patients all presented with gastrointestinal hemorrhage, and all had resection of the portion of intestine containing the VM. None has rebled. The specimens from these nine patients revealed a variety of histological findings. One VM was the vasculature of small bowel leiomyoma. Three other specimens contained obvious VMs without associated findings, and one specimen contained no identifiable pathology. In the remaining four specimens, a variety of inflammatory conditions were found on histological study, including one case of Crohn's disease and another of ischemic colitis. In only one of these specimens did we identify the VM. None of these last four cases conforms to the degenerative lesions described by Boley and his colleagues. Therefore, we propose a fourth type of VM that is associated with or perhaps secondary to another disease of the intestine. We precisely localized one VM in the duodenum during operation with the Doppler ultrasonic flow detector, thus enabling us to limit the extent of the resection. We also propose the use of this technique for pinpointing the area where sections should be made for histological study.

Endogenous hyperinsulinism.

Endogenous insulin excess as a cause of hypoglycemia was described soon after the epic discovery of insulin in 1921. Rosco Graham removed an insulinoma and cured a patient's hypoglycemia in 1929. Adenomatosis of the islet cells as a cause of hypoglycemia was described in 1944 by Frantz, who advocated subtotal pancreatectomy for this disorder. Whipple's triad of 1. symptoms precipitated by fasting with 2. associated blood sugars of 50 mg.% or less and 3. relief of symptoms by glucose administration, is the classic description of the symptom complex of hyperinsulinism. Currently the opportunity for accurate diagnosis of hyperinsulinism has been enhanced by the availability of serum insulin radioimmunoassay (IRI). Nonetheless, delay in diagnosis with potentially tragic consequences is still common and this prompted a review of the clinical material at St. Luke's Hospital. Nine cases of organic hyperinsulinism were diagnosed between 1965 abd 1979 and form the basis of this report.

Colonoscopic removal of a gallstone obstructing the sigmoid colon.

For the patient with a single gallstone obstructing the colon, this technique offers nonoperative relief of the obstruction, allowing definitive operative therapy to be accomplished at a later time on a more elective basis. The patient should be carefully observed during the interval for intervening recurrent gallstone ileus.