Cytotoxic T-lymphocyte-associated antigen 4 antibody-induced colitis and its management with infliximab.

Anti-CTLA-4 antibodies are human monoclonal antibodies previously studied in the treatment of metastatic melanoma (MM). CTLA-4 is an inhibitory receptor on cytotoxic T cells, blockade of which will activate T cells allowing them to attack malignant cells. Normal host cells may also be affected, and immune-mediated enterocolitis can occur. This is a prospective observational study on the use of corticosteroids and infliximab in the treatment of patients with immune-mediated colitis secondary to anti-CTLA-4 antibody treatment of MM. Five patients presented with colitis after medication administration. Patients were treated with high-dose corticosteroids for 1 week, but diarrhea did not completely abate in any of them. They were then treated successfully with infliximab. One patient had recurrence of symptoms and responded to repeat treatment with infliximab. Patients who develop immune-mediated colitis after administration of anti-CTLA-4 antibodies have previously been reported to respond to corticosteroids, but in our study, all required treatment with infliximab.

Gastrointestinal manifestations of diabetes mellitus.

This review briefly outlines the gastrointestinal manifestations of diabetes mellitus. Usually, gastrointestinal abnormalities are asymptomatic. Severe gastrointestinal dysfunction may be quite debilitating, however. Gastrointestinal symptoms that are a consequence of diabetes may be confused with other primary gastrointestinal disorders. We attempt to provide a clinical approach to differentiating the basis of symptoms and outline the therapeutic plan that we generally employ. Much additional research is necessary to clarify our understanding of the pathophysiology of the gastrointestinal complications of diabetes and to develop improved therapeutic strategies.

Effects of SMS 201-995, a somatostatin analogue, on the exocrine pancreatic secretion and gut hormone release in dogs.

The effect of SMS 201-995, an analogue of somatostatin, on pancreatic exocrine secretion was investigated in both interdigestive and digestive states in dogs. In four dogs with gastric and Thomas duodenal cannulas, the pancreatic juice was collected by direct cannulation of the main pancreatic duct. SMS 201-995 was infused intravenously at doses of 0, 15, 30, 60, and 120 ng/kg/hr for 2 to 3 hours in the following experimental conditions: (1) interdigestive pancreatic secretion, (2) pancreatic secretion stimulated by the intravenous infusion of both secretin, 0.06 CU/kg/hr, and cholecystokinin octapeptide (CCK8), 0.03 microgram/kg/hr, and (3) pancreatic secretion after ingestion of a test meal. Pancreatic juice was analyzed for volume and outputs of bicarbonate and protein. Plasma levels of motilin, pancreatic polypeptide (PP), CCK, and secretin were determined by radioimmunoassay. SMS 201-995 inhibited significantly the pancreatic secretion and release of hormones, including secretin, CCK, PP, and motilin, in all three experimental conditions. The inhibitory action of SMS 201-995 on pancreatic secretion and hormone releases was dose dependent.

Neodymium-YAG laser. A new palliative tool in the treatment of colorectal cancer.

Twenty-four patients with colorectal carcinoma and one patient with a recurrent, transitional-cell, vesical tumor invading the rectum but not amenable to surgical resection underwent neodymium-YAG laser therapy. There were 16 men and nine women with an average age of 75.6 years (range, 35 to 93 years). There were 14, 6, 1, 1, and 3 tumors found in the rectum, rectosigmoid colon, transverse colon, descending colon, and ascending colon, respectively. Symptoms consisted of bleeding or partial obstruction. Twelve patients were high-risk surgical candidates, 11 patients had widespread disease, and two patients had another primary tumor not controlled by a previous surgical procedure. The tumor was eradicated in two patients. There were two complications, namely, a perforation and a rectovaginal fistula. Thirteen patients died from their disease. The remaining patients have been kept free from obstruction and bleeding.

Enteric coccidiosis among patients with the acquired immunodeficiency syndrome.

Ten patients were identified at Jackson Memorial hospital/University of Miami Hospitals and Clinics with enteric coccidial infection due to Cryptosporidium spp. or Isospora belli. All had the acquired immunodeficiency syndrome as manifested by Kaposi's sarcoma or multiple opportunistic infections, or both. They presented with profuse diarrhea associated with weakness, anorexia, and weight loss. Routine examinations of stools for eggs and parasites as performed by the hospital laboratory were negative in all patients. Sugar flotation and modified acid fast techniques were used in the Tropical Disease Laboratory to identify oocysts of Cryptosporidium spp. in stools of seven patients. Malabsorption, characterized by a low 5-hour D-xylose and positive fecal fat, was observed in 6/6 of these patients. In three other patients Isospora belli oocysts were identified in stool specimens or via a duodenal string test. Spiramycin was the only drug found to be effective in treating patients with cryptosporidiosis. Patients with Isospora belli responded to a prolonged course of trimethoprim-sulfamethoxazole.

Sandostatin for control of catheter drainage of pancreatic pseudocyst.

Primary treatment for pancreatic pseudocyst is evolving from surgical intervention to needle aspiration with catheter drainage. The latter treatment results in a similar rate of resolution but has less patient morbidity. This study evaluated the adjuvant role of Sandostatin, which inhibits basal and stimulated pancreatic secretion, in the management of three patients with pancreatic pseudocysts who had prolonged catheter drainage subsequent to percutaneous drainage. Inhibition of secretion occurred in all three patients, as evidenced by decrease in catheter output, which allowed the catheter to be removed. All three patients have remained asymptomatic for 9, 10, and 15 months, respectively. In summary, Sandostatin decreased persistent catheter drainage from chronic pancreatic pseudocysts.

Pancreatitis caused by measles, mumps, and rubella vaccine.

Acute pancreatitis may result from viral infections, including mumps, coxsackie B, Epstein-Barr, and varicella. However, viral pancreatitis has not been reported after immunization with viral vaccines. We report the occurrence of acute pancreatitis in an adult who had received measles, mumps, and rubella II vaccine (MMR II).

Acute pancreatitis secondary to pancreatic carcinoma. Study Group Participants.

Acute pancreatitis (AP) has been recognized as a presentation of patients with pancreatic carcinoma (PC). However, the natural history of patients with PC who present with AP as the first manifestation is largely unknown. The aim of this study was to determine the time between the presentation of AP and diagnosis of PC and what factors should alert the clinician to suspect underlying PC in patients with AP. Nineteen physicians completed the survey forms that encompassed 45 patients with a diagnosis of AP preceding a diagnosis of PC. Information included the patient's age, gender, race, conditions that could account for the AP, criteria for diagnosis of AP, severity of AP, criteria for diagnosis of PC, time between the diagnosis of AP and PC, pathology of the carcinoma, extension of the disease, treatment of PC, and survival after the diagnosis of PC. The study population consisted of 45 patients, 27 (60%) men and 18 (40%) women whose average age was 58 years (range, 32-89). Thirty-eight patients were Caucasian, five were black, one was Japanese, and one Arabian. The number of AP episodes before PC diagnosis ranged between one and 15 (mean + 2 SD). AP was mild in 40 (89%) and severe in five (11%). The time between the onset of AP and the diagnosis of PC averaged 34 weeks (range, 1-52). Symptoms on presentation of AP included abdominal pain 45 (100%), weight loss 15 (33%), and jaundice 3 (7%). CA 19-9 was available in 13 patients, eight of whom had levels >100 at the time AP was diagnosed. Abnormal imaging suggestive of PC was detected by ultrasonography in 17 patients, by computed tomography in 30, endoscopic retrograde cholangiopancreatography in 20, and endoscopic ultrasonography in three. Tissue diagnosis was obtained in 43 of 45 (96%) patients; by surgery in 25 patients, needle aspiration in 14, laparoscopy in one, autopsy in two, and lymph node in one. Pathology revealed adenocarcinoma in 37 patients, squamous cell carcinoma in two, undifferentiated carcinoma in two, islet cell in one, and cystadenocarcinoma in one. Surgical findings in 26 patients included 19 with a nonresectable lesion or metastasis and seven patients with resectable lesion for cure. Thirteen patients (28%) were alive 1 year after the diagnosis of PC. The patients had a mean of two (range, one to 15) episodes of AP before the diagnosis of PC, and this was associated with a delay of 34 weeks from AP to diagnosis of PC. Patients with PC who presented with AP were generally older than 50 years of age and the severity of the pancreatitis was mild. The survival rate of patients with PC who presented initially with AP was >25% at 1 year compared with 20% 1 year overall survival of patients with PC. AP seems to be an early presentation of PC and should be sought in patients with idiopathic pancreatitis.

Pancreatic fungal infections: a case report and review of the literature.

Pancreatic necrosis as a consequence of acute pancreatitis usually implies a poor prognosis. Infection is the most common complication affecting mortality and appears to be increasing. While bacterial infections, particularly with coliforms, account for the majority of cases of infected necrosis, fungal infections are being more frequently documented. This may be due to increased recognition through improved laboratory techniques, more aggressive diagnosis by percutaneous aspiration, or the more widespread use of broad-spectrum antibiotics or parenteral nutrition. While the majority of documented fungal pancreatic infections have been with Candida species, recent reports have highlighted the importance of Torulopsis glabrata. This haploid yeast of the family Cryptococcaceae is a fungal commensal organism accounting for 16% of all human yeast isolates. Here we report the first case of T. glabrata infection complicating pancreatic necrosis and review the current knowledge of pancreatic fungal infections complicating acute pancreatitis. Superimposed infection, either bacterial or fungal, needs to be diligently sought in patients with pancreatic necrosis who fail to improve or deteriorate despite supportive care.

Acute pancreatitis.

Acute pancreatitis is an inflammatory disease of variable clinical severity. The pathologic conditions that correlate with clinical severity and with local systemic complications range from mild edema to pancreatic an peripancreatic necrosis. This article discusses diagnosis, etiology, laboratory evaluation, and imaging studies with respect to acute pancreatitis. Assessing the prognosis, detecting complications, and therapy are discussed also.

Occult gastrointestinal bleeding. General overview and approach.

Occult gastrointestinal bleeding is most commonly defined as an acute or chronic loss of blood, the source of which has not been identified after gastroscopy, colonoscopy, and upper gastrointestinal series have been performed. As the title suggests, this article provides a general overview of this disorder. Specific topics discussed include etiology, diagnostic procedures, laboratory studies, radiologic procedures, radionuclide studies, angiography, and endoscopy.

Diagnostic and therapeutic approach to pancreatic cancer.

Adenocarcinoma of the pancreas ranks fourth as a cause of cancer death in adults in the United States and is the second most common cause of cancer deaths of all GI-related carcinomas. It usually presents late in its course. The clinical features are discussed, with emphasis on those that allow early detection of the disease, as well as a review of diagnostic methods and pre- and perioperative staging, which will allow the appropriate application of surgical and palliative therapeutic modalities. Despite the significant progress that has been made, further research studies are needed to advance our therapeutic approach to this aggressive cancer.

Nd-YAG laser applications in surgical endoscopy: a single center comprehensive experience.

A retrospective review of endoscopic procedures using the Nd-YAG laser was carried out for patients treated between September 1984 and November 1986. Two hundred twenty two procedures were performed on 104 patients (58M:46W) during this 26 month period. The study encompasses a unique period of time in this center, as it includes the initial use of the endoscopic laser technique, the learning curves associated with its application, and finally, the time when its use became routine. Treatment of tumors was the indication in 47 per cent of the cases. Gastrointestinal bleeding of benign cause was the indication in nearly half of the patients; arteriovenous malformations were the most common causes of bleeding. Laser photocoagulation of hemorrhoids was performed in 11 cases. Upper endoscopy was the route in 33 per cent of procedures. Anoscopy, flexible sigmoidoscopy, and colonoscopy were the routes in the remainder. The time spent on the procedure and the energy delivered were found to be variables of the type of lesion and the endoscopic route. Nd-YAG laser endoscopy can be used safely and effectively for a variety of bleeding and obstructive gastrointestinal conditions. Appropriate certification for granting of privileges to laser endoscopists is of utmost importance.

Parasitic causes of pancreatic and biliary tract disease: a growing concern in a highly mobile population.

A leading cause of biliary tract disease and pancreatitis worldwide is parasitic disease. In the United States, increased global travel and the AIDS epidemic has led to a rise in the frequency of parasitic disease. Biliary disease and pancreatic disease secondary to parasitic infestation is relatively new in this country, with the first case being described in 1977. These diseases are no longer the exclusive realm of infectious disease specialists and require general practitioners and gastroenterologists to be well versed in the spectrum of parasitic pancreatic and biliary disease.

Evaluation of Army field sanitation during Blazing Trails '87.

US medical personnel serving in Ecuador analyzed how the field sanitation procedures of troops employed in Blazing Trails '87 had impact on living conditions and overall health of the troops. Such a situation allowed evaluation of USAR troop training and preparedness in field sanitation. Results indicate that field sanitation training needs to be improved at the unit level.

Acute pancreatitis and its complications. Diagnostic and therapeutic strategies.

The most common causes of acute pancreatitis are biliary tract disease and alcoholism, but other causes account for about 10% of cases. Acute pancreatitis can be divided clinically into mild and severe (necrotic) disease. Risk of complications and death varies with the etiology, severity, and number of episodes and is highest in severe cases and biliary tract-related disease. Amylase determination is the best diagnostic serum screening test. Ultrasonography, computed tomography, and endoscopic retrograde pancreatography are also extremely useful in diagnosis. Treatment of acute pancreatitis usually consists of supportive measures; the roles of peritoneal lavage and surgery remain controversial. Pseudocysts occur in about 25% of patients but can be treated successfully with appropriate therapy.

A hypothetical case of gastrointestinal bleeding: incorporating a management self-test.

In this case study of upper gastrointestinal bleeding, a problem-solving question-and-answer format is used and is accompained by referenced discussion. The clinical area covered is one in which endoscopic and angiographic tools are available for diagnosis and tamponading devices and angiographic perfusion techniques exist for mangement. Of course, many varibles affect diagnostic and therapeutic decisions, but logic often dictates directions in management. The availability of skilled endoscopists and angiographers is an important factor in the optimal management of the patient with upper gastrointestinal bleeding in whom the source of bleeding is unknown.

Intractable peptic ulcer disease.

The intractable ulcer is usually complicated because of posterior penetration, obstruction, or postbulbar or channel location; or it is an atypical ulcer such as those occurring with the ZE syndrome, hyperparathyroidism, and the milk-alkali syndrome. The management of intractability depends upon finding the cause and initiating the appropriate therapy. Many abdominal diseases may masquerade as intractable ulcers, so every patient must be evaluated thoroughly to prove that his ulcer is indeed intracetable.