Massive hepatic hemorrhage associated with cardiopulmonary resuscitation.

We treated two patients with laceration of the liver that was precipitated by cardiopulmonary resuscitation (CPR) and recognized antemortem. Both patients had myocardial infarctions and had received heparin sodium therapy. They had excruciating abdominal pain and bled massively, resulting in hypovolemic shock. When severe abdominal pain associated with hypovolemic shock occurs in a patient who has received CPR, hepatic laceration, hematoma, or both should be considered. This is even more imperative to recognize in the patient who has received anticoagulation therapy.

Food iron and lead absorption in humans.

Food iron and lead absorption were measured simultaneously in 28 subjects by extrinsically labeling three consecutive meals with the radioactive tracers, iron 59-sulfate and lead 203-chloride. Absorption was measured directly in all subjects by whole-body counting and indirectly in 15 subjects by assessing subsequent levels of tracer in blood. Iron status of the subjects ranged from iron deficient to replete, thus providing a wide range of iron absorption. Statistically significant positive correlations were obtained between food-iron and lead absorption measured by whole-body counting and also between the tracer levels of iron and lead in the blood. However, the correlation between the absorption of the two elements was not strong, as evidenced by the fact that only 50% of the subjects who hyperabsorbed iron also hyperabsorbed lead.

Efficacy and safety of famotidine in the management of benign gastric ulcers.

The worldwide experience with famotidine in the management of benign gastric ulcers is reviewed. Analysis of data from 15 countries has shown that famotidine is more effective than placebo in treating gastric ulcers. Relief of pain is achieved earlier in famotidine-treated patients. Complete endoscopic healing may be expected in 64 to 80 percent of patients within eight weeks following the initiation of therapy. Response to famotidine does not appear to be affected by age, sex, smoking, regular alcohol consumption, or duration of disease. Short-term oral famotidine, at a dose of 40 mg daily, is well tolerated, and there have been no serious adverse experiences attributed to its administration. The efficacy of famotidine is comparable to that of other histamine (H2)-receptor antagonists.

Endometriosis. An important condition in clinical gastroenterology.

Endometriosis, a condition defined by the presence of ectopic endometrium, is a disorder of increasing incidence and a significant cause of gastroenterologic distress in young women. Although clinical manifestations vary considerably depending upon the anatomic extent of disease, characteristic abdominal complaints and typical physical findings continue to be associated with misdiagnosis and delayed recognition of gastrointestinal involvement. The authors of this paper review the medical literature concerning endometriosis of the digestive tract--emphasizing modes of presentation, risk factors, diagnostic testing, complications, and therapy. Greater familiarity with the disease and heightened awareness of its sequellae are needed and prerequisite to improved medical management.

Occult GI bleeding in the alcoholic.

Consecutive admissions (1020) for alcohol detoxification were evaluated. Twenty-two (2.2%) of the 990 patients without overt bleeding tested positive for the presence of fecal occult blood. Subsequent endoscopic evaluation of this population revealed a substantial prevalence of peptic ulcer disease (23.8%) and premalignant colonic neoplasia (31.6%). Upper GI mucosal inflammation was present in all patients. As in the general population, occult blood loss in the stool of alcoholics appears to be an important marker for colorectal neoplasia and to be of clinical significance in the prevention and early detection of colon cancer. Fecal occult blood should not be attributed to alcohol ingestion without the exclusion of coexistent pathology.

Large-bowel hemangiomas.

A case of large-bowel hemangioma is presented, and radiologic and histologic abnormalities are illustrated. Ultrasonographic features, not previously described, are reported. The literature is reviewed and the frequency of misdiagnosis is emphasized. Pathologic classification, epidemiologic factors, and etiology are considered. Clinical manifestations and current approaches to recognition and management are summarized. Vascular tumors are serious, albeit uncommon, intestinal lesions. Greater awareness of the condition and earlier consideration of the diagnosis are prerequisites to lessened morbidity and improved survival.

Tracheoesophageal fistula complicating herpes esophagitis in AIDS.

Immunocompromised individuals are susceptible to a variety of esophageal infections. Organisms responsible for esophagitis in patients with the acquired immunodeficiency syndrome (AIDS) are briefly reviewed. Usually confined to the esophageal mucosa, pathogens known to have the potential for transmural invasion are identified. The first report of tracheoesophageal fistulization in an AIDS patient with herpes esophagitis is presented.

Hemoperitoneum from a ruptured varix in cirrhosis. Case report and literature review.

A cirrhotic patient with hemoperitoneum is presented. The diagnosis of ruptured retroperitoneal varices was made at laparotomy and the patient becomes the second reported case to survive hospitalization for bleeding intra-abdominal varices. The formation of varices as a consequence of portal hypertension is discussed; the differential diagnosis and evaluation of hemoperitoneum is considered and the seven previously reported cases of intra-abdominal variceal hemorrhage are reviewed.

Adenocarcinoma of the small bowel. Clinical features, similarity to regional enteritis, and analysis of 338 documented cases.

A case of ileal adenocarcinoma is presented and the clinical features of adenocarcinoma of the small bowel are discussed. Special attention is paid to the differentiation of this tumor from Crohn's disease. Analysis of Connecticut Tumor Registry data on 338 cases of small intestinal adenocarcinoma occurring between 1935 and 1978 reveals a predilection for the elderly but no sex predominance (male/female = 0.965). Two hundred fifty-four patients were followed for at least 5 yr, and the overall (1935-1978) 5-yr survival rate was 17.3%. No improvement in survival has taken place in Connecticut over the past 40 yr.

Bleeding after liver biopsy in a patient with systemic mastocytosis and malabsorption.

Systemic mastocytosis, with its diffuse infiltration of mast cells into various organs, has resulted in intestinal malabsorption and bleeding diatheses. The pathophysiology underlying these phenomena is unclear, but may be related to the release of histamine and heparin containing mast cell granules. A patient with systemic mastocytosis had malabsorption and developed massive bleeding after percutaneous liver biopsy. Histologic involvement of skin, duodenum, rectum, liver, and bone marrow was documented. Mastocytosis should be considered in the differential diagnosis of malabsorption.

Phycomycosis of the gastrointestinal tract.

A case of gastrointestinal phycomycosis, a highly lethal fungal infection, is presented. Radiographic, operative and histopathologic features are discussed. Pathogenesis of the disease and the importance of underlying illness, malnutrition, immunosuppression and antibiotic therapy are considered. The literature is reviewed and current approaches to diagnosis and management are summarized. Greater awareness of the clinical setting in which gastrointestinal phycomycosis may develop and earlier consideration of the diagnosis are prerequisite to improved survival.

Factors affecting delivery of bile to the duodenum in man.

Studies utilizing balloon-occludable T or duodenal tubes in subjects with and without gallbladders were undertaken to identify the contribution of the gallbladder, the sphincter of Oddi, and bile salts to the delivery of bile to the duodenum. Patients with and without a functional sphincter of Oddi and with and without a gallbladder were compared. The presence of a functional sphincter of Oddi in duodenal tube patients reduced bile salt output by more than 67% from that observed in T-tube patients. When cholecystectomized and normal patients were compared using the duodenal tube, peak bile salt output was significantly increased in normal subjects, reflecting gallbladder contraction, but total bile salt output was not significantly increased suggesting that the gallbladder has a minor role in bile delivery. Exogenous infusion of cholecystokinin produced much more stable bile secretion than did endogenous release of cholecystokinin by intraduodenal infusion of essential amino acids. This rhythmic release of bile after endogenous cholecystokinin release was related to the concentration of bile salts in the intestinal lumen. Thus, delivery of bile to the duodenum is wave-like and is predominantly controlled by the sphincter of Oddi.

Suppression of nocturnal acid secretion with famotidine accelerates gastric ulcer healing.

Although nocturnal acid secretion has been emphasized in the pathophysiology and treatment of duodenal ulcer, its importance in gastric ulcer disease has been questioned. To explore this area, this multicenter U.S. trial compared the effect of a once-daily nighttime dose of H2-receptor antagonist with placebo on the healing of gastric ulcer and relief of associated symptoms. One hundred fifty-seven patients with endoscopically verified benign gastric ulcers were randomized in a double-blind fashion to either famotidine (40 mg at bedtime) or placebo. Antacid tablets were allowed as needed. The healing rates for famotidine were 45%, 66%, and 78% at weeks 4, 6, and 8, respectively. In comparison, placebo healing rates were 39%, 44%, and 64%. These differences were statistically significant in favor of famotidine at weeks 6 (p less than or equal to 0.01) and 8 (p less than or equal to 0.05), as well as in a life-table analysis (p less than or equal to 0.05). Nocturnal famotidine was also significantly better than placebo with respect to time to complete relief of pain and to the percentage of patients with complete relief of pain. No concomitant factor (including ulcer size, ulcer location, smoking history, or regular alcohol use) affected healing rates in this study. Famotidine was well-tolerated and no serious clinical or laboratory adverse effects were judged to be related to this dosing regimen of famotidine. In conclusion, suppression of nocturnal acid secretion with famotidine (40 mg at bedtime) was more effective than placebo in promoting the healing of acute benign gastric ulcer and its associated symptoms. The results of this study suggest that suppression of nocturnal acid secretion alone is as effective as "around the clock" acid suppression in the healing of benign gastric ulcer.