Laparoscopic diagnosis of peritoneal mesothelioma. Report of a case and review of the diagnostic approach

This is the second report of a malignant peritoneal mesothelioma diagnosed by laparoscopy and guided needle biopsy and the first with photographic documentation of the lesion. The case illustrates the following points: (1) diagnosis of peritoneal mesothelioma should be considered in the evaluation of exudative ascites; (2) the only definitive diagnostic procedure is to obtain tissue for histology; and (3) laparoscopy with biopsies under direct vision is an accurate and safe technique which is underutilized and should be considered as the diagnostic procedure of choice when peritoneal disease is suspected.

Esophageal achalasia secondary to gastric carcinoma. Report of a case and a review of the literature

A case of invasive gastric carcinoma mimicking idiopathic achalasia radiologically, endoscopically and manometrically is described. This is only the second case of tumor-associated achalasia with a positive mecholyl test where there was no demonstrable histological tumor involvement of the myenteric plexus in the body of the esophagus. The interpretation of the manometric findings including the positive mecholyl test are discussed in the light of these histological findings. The short duration of symptoms, the presence of anemia and guaiac positive stools, along with subtle radiologic abnormalities of the gastric fundus were aspects of this case which should increase the index of suspicion and lead to the correct diagnosis. In the evaluation of patients with the achalasic syndrome, a tumor-associated functional and organic disorder mimicking idiopathic achalasia in all respects has to be considered.

Injury to the male posterior urethra in fractured pelvis: a new classification

The present criteria to diagnose a ruptured posterior urethra in cases of a fractured pelvis do not provide accurate information on the degree and site of the urethral injury. A method of retrograde urethrography in such patients is described and the results obtained in 15 cases are reported. On the basis of these results a new classification of membranous urethral rupture in cases of fractured pelvis is proposed: type 1--the prostate or urogenital diaphragm is dislocated but the membranous urethra is merely stretched and not severed, type 2--the membranous urethra is ruptured above the urogenital diaphragm at the apex of the prostate and type 3--the membranous urethra is ruptured above and below the urogenital diaphragm. The clinical significance of these lesions is discussed and a plea is made for the more widespread use of retrograde urethrography in patients with a suspected posterior urethral rupture.

The effect of stressful diagnostic studies and surgery on anterior pituitary hormone release in man

The hormonal response of the anterior pituitary was studied in 10 normal males undergoing treadmill exercise testing, in 5 male patients undergoing diagnostic gastroscopy, and in 8 male patients undergoing elective surgery under general anaesthesia. Serum TSH was depressed below the baseline value at 2 and 3 h post-treadmill exercise, at 1, 2 and 3 h post-gastroscopy and from 10 min through 2 h post-surgery. Serum triiodothyronine was depressed below the baseline value at 10 min through 2 h post-surgery. Serum prolactin, growth hormone and cortisol were elevated by all three stressful procedures. Both gastroscopy and surgery resulted in an elevation of serum luteinizing hormone levels. There was no significant change in serum FSH levels in any of the three procedures. The post-stress depression in TSH levels could result from the suppressive effect at the hypothalamic-pituitary level of high serum levels of cortisol generated by the stress of the procedures.

Healing of duodenal ulcer with an antacid regimen

To determine whether a large-dose antacid regimen is effective in promoting healing of duodenal ulcer, 74 patients with endoscopically proved duodenal ulcer completed a 28-day double-blind clinical trial comparing such a regimen with an inert placebo. The ulcer healed completely in 28 of the 36 antacid-treated as compared to 17 of the 38 placebo-treated patients (P less than 0.005). The antacid regimen was not more effective than placebo in relieving ulcer symptoms. Presence or absence of symptoms during the fourth treatment week was a poor predictor of presence or absence of an ulcer crater. Ulcers of placebo-treated patients who smoked cigarettes were less likely to heal than those of nonsmokers (P = 0.03). Except for mild diarrhea, no side effects of the antacid regimen were observed. We conclude that a large-dose antacid regimen hastens the healing of duodenal ulcer.

A controlled trial of metoclopramide in symptomatic gastroesophageal reflux

Since metoclopramide increases lower-esophageal-sphincter pressure in patients with gastroesophageal reflux, we compared the effects of metoclopramide, 10 mg four times daily, with those of placebo on symptoms in 31 patients with chronic heartburn. Eighteen patients completed a random-order, double-blind crossover study of two consecutive eight-week periods. The final 13 patients crossed over only if their symptoms were not substantially improved after the first eight weeks. Response of low-esophageal-sphincter pressure to metoclopramide did not correlate significantly with symptomatic improvement. After the metoclopramide treatment period, mean basal pressure was unchanged from values before study. In both treatment periods, metoclopramide-treated patients had significantly more symptomatic improvement than the control group (P less than 0.05).

Comparison of metoclopramide with other dynamic tests of prolactin secretion

Metoclopramide, a derivative of procainamide, was compared with thyrotropin releasing hormone (TRH), N3im-methyl-TRH and chlorpromazine as a prolactin (PRL) releaser in 11 euthyroid males. The peak response of serum PRL and the maximum increment of serum PRL (max deltaPRL) were greater (P less than 0.0005) after the administration of metoclopramide (deltaPRL 24.1 +/- 1.5 (SE) ng/ml) than after either TRH (14.9 +/- 1.5 ng/ml) or chlorpromazine (7.0 +/- 2.1 ng/ml). There were no significant differences between the peak and max deltaPRL responses to metoclopramide or N3im-methyl-TRH. Metoclopramide produced a small increase in serum thyrotropin and small reductions of serum growth hormone, luteinizing hormone and follicle-stimulating hormone. Metoclopramide may be useful for dynamic testing of PRL release. It offers the advantage of oral administration; a 10 mg dose produces a larger, more sustained increment in serum PRL than other agents used to evaluate prolactin reserve.

Metoclopramide stimulates prolactin secretion in man

Serum prolactin concentrations increased approximately 6-fold after oral or intravenous administration of 10 mg of metoclopramide to adult men. Prolactin remained significantly elevated up to 9 h after oral metoclopramide and for at least 2 h after iv metoclopramide. Bethanechol did not increase serum prolactin, and atropine did not inhibit metoclopramide-induced prolactin elevation, suggesting that the cholinergic-like properties of metoclopramide were not responsible for the observed prolactin responses. Pre-treatment with 500 mg L-dopa inhibited the early metoclopramide-induced prolactin increase, which is consistent with the possibility that metoclopramide acts by inhibiting dopamine-mediated hypothalamic secretion of prolactin inhibitory factor. As a potent stimulus of prolactin release, metoclopramide may be useful in clinical investigation of hypothalamic-pituitary function.

Perirenal lymphocyst formation in renal transplant recipients: diagnosis and pathogenesis

Perirenal lymphocyst formation occurred in 7 of 46 consecutive renal allografts which had survived at least one month. This complication developed from one to four and one-half months post-transplantation, resulted in a specific spectrum of clinical signs and symptoms, and was best diagnosed by a combination of intravenous pyelography and ultrasonic examination of the transplanted kidney. The lymph fluid is of recipient origin and its collection appears to be related to use of a high-dose immunosuppressive regimen and to a conscious decision to avoid the use of postoperative surgical drains. Surgical intraperitoneal marsupialization of the lymphocyst emerges as the clear treatment of choice for peritransplant lymphocyst formation.

Urinary continence after repair of membranous urethral stricture in prostatectomized patients

Prostatectomy by open or transurethral techniques usually destroys the function of the internal sphincter (bladder neck), which is the first line of defense against incontinence. Urinary continence then depends upon the intrinsic smooth muscle sphincter of the membranous urethra and the striated external sphincter. Unfortunately, a significant incidence of membranous urethral stricture occurs after a prostatic operation. Most such strictures can be managed with periodic dilatation but some are difficult and dangerous to dilate. Complications such as recurrent acute retention, bacteremia, false passages, stone formation, fistulas and so forth are indications for surgical cure of the stricture. However, can urethroplasty of the membranous urethra be carried out in these patients without inevitable incontinence? At our center 33 prostatectomized patients have had a 2-stage urethroplasty for refractory membranous urethral strictures. Nine patients had troublesome stress incontinence after the first-stage operation but only 4 of these had continuing incontinence after the second-stage operation. These patients had been noted to have transient postoperative stress incontinence after the prostatectomy. Although there is a risk of incontinence after urethroplasty of the membranous urethra in prostatectomized patients, the risk is sufficiently low that the operation should not be denied patients with refractory strictures in whom the only alternative eventually will be some form of urinary diversion.

The clinical value of ascitic fluid culture and leukocyte count studies in alcoholic cirrhosis

Because of the paucity of studies establishing the accepted leukocyte count is sterile ascites, less than 300 WBC per mm3 with 25% polymorphonuclear (PMN) leukocytes, peritoneal fluid WBC counts and bacterial cultures were studied in 63 consecutive hospitalized patients with alcoholic cirrhosis and ascities. In 58 culture-negative patients the ascitic fluid WBC count range was 28 to 1800 and 50% of counts were greater than 300 WBC per mm3. The percentage of PMN leukocytes ranged from 2 to 98%. Five patients with spontaneous bacterial peritonitis (SBP), proven by positive cultures, had an ascitic WBC count range of 300 to 6320 WBC per mm3 and a PMN leukocyte range of 20 to 76%. Physical findings did not allow clear separation of the two groups. Anaerobic organisms were not found. It is concluded: (1) differentiation of SBP from sterile ascities relies on prompt ascitic fluid bacteriology; (2) the improved survival of 40% of SBP patients in this study may be related to an increased awareness of the entity and early treatment.

Effect to gastric alkalinization on lower esophageal sphincter pressure and serum gastrin

The purpose of this study was to measure the effect of alkaline intragastric pH on lower esophageal sphincter pressure (LESP) and on serum gastrin concentration in man. One hundred ten milliliters each of 0.1 N NaHCO3 and control solution were instilled into the stomach for 30 min in random order. Neither LESP nor serum gastrin were higher during the alkali instillation than during the control instillation. Individual subject's peak gastrin and peak LESP during the alkali period were not significantly higher than the corresponding basal values. We conclude that intragastric alkalinization did not increase total radioimmunoassayable serum gastrin concentration or LESP.

Comparative effects of metoclopramide and bethanechol on lower esophageal sphincter pressure in reflux patients

The effects of oral metoclopramide, 10 and 20 mg, bethanechol, 25 mg, and placebo on lower esophageal sphincter pressure (LESP) were studied in 15 men with symptoms of gastroesophageal reflux and basal LESP less than 11 mm Hg. Each drug produced a significant increase in LESP when compared to placebo. Metoclopramide, 20 mg, produced a greater increase than either metoclopramide, 10 mg, or bethanechol, 25 mg. Serum gastrin concentrations were not altered by any of the drugs. Side effects were unremarkable. The LESP increasing effect of metoclopramide might be useful in treatment of gastro-esophageal reflux.

The pre-operative diagnosis of renal hamartoma

The characteristic angiographic findings in renal hamartoma consist of: a large dilated feeding vessel passing through the mass, multiple multisacculated aneurvsmal dilatations (bunch of grapes), a delicate discrete discrete neovascularity without A-V shunting, and 'onion peeling' on the venous phase. In addition radiolucent areas within the renal mass indicate a high fat content. When these findings are present renal hamartoma can be diagnosed confidently. Racial nephrectomy and needless sacrifice of a whole kidney for a benign lesion can be avoided. Heminephrectomy may be sufficient, thus saving the patient valuable renal tissue. Four cases of renal hamartoma are presented. Plain film and angiographic studies are shown. All four showed the characteristic angiographic findings of renal hamartoma and were diagnosed pre-operatively.