Prolonged intrahepatic cholestasis secondary to acute hepatitis A

Viral hepatitis characterized by prolonged cholestasis has not been associated with a specific serologic marker. We report the cases of six patients presenting with a clinical syndrome typical of cholestatic hepatitis who were subsequently found to have acute hepatitis A. Usual features include pruritus, fever, diarrhea, and weight loss with serum bilirubin levels greater than 10 mg/dL, and a clinical course lasting at least 12 weeks. All patients recovered completely without sequelae. Knowledge of this unusual manifestation of hepatitis A may help avoid potentially invasive procedures involved in the evaluation of suspected obstructive jaundice and facilitate appropriate immunoprophylactic measures.

Cimetidine usage for unlabeled conditions in an ambulatory care service

With the intent of cost containment, we conducted a survey of cimetidine usage in the Ambulatory Care Service of our Veterans Administration Medical Center. During a period of six months, this drug was prescribed for 132 patients. Only about 20% received cimetidine for FDA approved conditions. Treated conditions not approved by the FDA (unlabeled) included undiagnosed abdominal pain, past peptic ulcer disease, reflux esophagitis, and a variety of other conditions. Fourteen percent of the patients had demanded the drug. Irrespective of whether a confirmed diagnosis was present or not, most patients taking cimetidine had symptomatic relief. It is unclear whether more regulations or improved physician education would be the better method to control improper and unnecessary use of a drug that is generally safe but has potentially serious side effects.

Electron microscopic evidence of non-A, non-B hepatitis markers and virus-like particles in immunocompromised humans

Characteristic pathological alterations of the liver in chimpanzees inoculated with non-A, non-B hepatitis sera have been described, but no corresponding findings have been reported in humans. Electron microscopic studies of the liver biopsy specimens of two homosexual patients with acquired immune deficiency syndrome, one without hepatitis (Patient 1) and one with chronic active hepatitis in remission (Patient 2), revealed the cytoplasmic tubular structures which are characteristic of chimpanzee non-A, non-B hepatitis. A cluster of 23 nm double-shelled particles was also seen in the cytoplasm of a hepatocyte in patient 1 who had received a blood transfusion 8 days before the biopsy. These particles were smaller than the Dane particles, Epstein-Barr virus, cytomegalovirus or herpes simplex virus, and different from hepatitis A virus particles; the antibodies to all of which are found in high concentration in acquired immune deficiency syndrome patients. These observations may reflect the morphologic findings for non-A, non-B hepatitis infection in humans.

Pyogenic liver abscess complicating common bile duct stenosis secondary to chronic calcific pancreatitis. A rare presentation

Pyogenic liver abscess is a rare presentation of common bile duct stenosis secondary to chronic calcific pancreatitis. Two cases are described in this report; in both cases, biliary obstruction was present in the absence of jaundice. Successful therapy of the abscesses was accomplished with antibiotics alone and without continuous percutaneous drainage or surgical intervention. Definitive therapy should include eventual surgical correction of the biliary obstruction.

Bilateral nipple necrosis after intravenous vasopressin therapy

Bilateral nipple necrosis developed in two patients after intravenous vasopressin therapy for bleeding esophageal varices. When vasopressin therapy was promptly tapered and discontinued, recovery of skin changes occurred gradually. The role and some of the reported complications of vasopressin therapy in bleeding esophageal varices are discussed herein.

Gossypin-induced analgesia in mice

A flavonoid, gossypin, was evaluated for its analgesic action by using acetic acid-induced writhing in mice and was compared with morphine. Gossypin inhibited writhing in a dose-dependent manner. This action was antagonised by naloxone. The pA2 values for morphine-naloxone and gossypin-naloxone were almost identical suggesting a definite involvement of opiate receptors in the analgesic action of gossypin.

Hemosuccus pancreaticus: a cause for obscure gastrointestinal bleeding--diagnosis by endoscopy and successful management by total parenteral nutrition

Hemorrhage through the pancreatic duct (hemosuccus pancreaticus) is discussed in a patient with alcoholic chronic pancreatitis and anemia. The pancreatic duct as the source of bleeding was determined by use of duodenoscopy; abdominal arteriograms were normal. It is postulated that the patient's bleed was intermittent and of venous origin, probably associated with pancreatic pseudocyst formation. Total parenteral nutrition could be considered in treatment of the condition if bleeding is not life threatening.

Strongyloidiasis. When to suspect the wily nematode

Strongyloidiasis is a tenacious soil-transmitted nematode infestation endemic in the south-eastern United States. Thirty-three cases were diagnosed in a series of 1,290 stool examinations in 971 patients at Veterans Administration Medical Center, Mountain Home, Tennessee. Most patients had a concurrent major illness, such as chronic lung disease, serious bacterial infection, or cancer. A minority presented with gastrointestinal symptoms alone. Skin rash was uncommon. Eosinophilia, IgE elevation, and skin anergy were common. Atypical presentations included severe proctitis, colitis, and exacerbation of inflammatory bowel disease. In a patient with the hyperinfection syndrome, the diagnosis was made only at autopsy. Since strongyloidiasis seems to present like an opportunistic illness, all physicians, not just those in endemic areas, should consider its presence in the appropriate setting.

Ibuprofen protects platelet cyclooxygenase from irreversible inhibition by aspirin

Previous investigations have shown that ibuprofen inhibits the second wave of platelet aggregation and blocks the conversion of 14C-arachidonic acid to thromboxane. However, the influence of the drug on platelet function and cyclooxygenase is transitory, lasting only 24 hours. The present study has taken advantage of the short-lived influence of ibuprofen to study its interaction with the long-term effects of aspirin. As expected, both aspirin and ibuprofen suppressed platelet cyclooxygenase activity and function, but addition of aspirin to ibuprofen-treated platelets did not increase the degree of inhibition in vitro. Platelet function and prostaglandin synthesis recovered completely 26 hours following ingestion of ibuprofen, but remained compromised 26 hours after taking aspirin. When 650 mg of aspirin was administered after ibuprofen, platelet function and cyclooxygenase activity recovered as completely at 26 hours as did platelets which had been exposed to ibuprofen alone. Thus, prior exposure to ibuprofen in vivo completely protected cyclooxygenase from the irreversible effects of aspirin. Our findings indicate that ibuprofen-like indomethacin and other nonsteroidal antiinflammatory drugs react with the heme group of cyclooxygenase to prevent arachidonic acid conversion. Since ibuprofen completely blocks the effects of aspirin in platelets in vitro and in vivo, aspirin's primary influence on inhibition of cyclooxygenase must also be through action on the heme portion of the enzyme, rather than acetylation of the protein.

Acute hepatitis associated with campylobacter colitis

A patient with proven campylobacter fetus ss. jejuni acute colitis developed hepatocellular dysfunction, which paralleled the course of the colitis. Liver biopsy showed nonspecific reactive hepatitis. Other causes of acute hepatocellular damage were excluded. The patient made a complete recovery.

Penicillin induced human platelet dysfunction and its reversal by epinephrine

Antibiotics administered orally can impair platelet function and cause a bleeding diathesis. Platelet function impairment induced by antibiotics such as penicillin, carbenicillin and tetracycline could be corrected by exposing the refractory platelets to epinephrine first and then challenging with other agonists. Penicillin used in this study inhibited the platelet aggregation response and release reaction without blocking the ability of these platelets to convert arachidonic acid to thromboxane. The thromboxane generated in the presence of penicillin could not activate the platelets when threshold concentrations of arachidonate was used as stimulus. Epinephrine stimulation restored the platelet membrane sensitivity and normalized the platelet response to the action of agonists. These studies demonstrate that both by in vitro as well as in vivo routes penicillin induced temporary impairment of platelet function. The refractoriness was not due to the interference of membrane receptors for various agonists or due to the depletion of serotonin, adenine nucleotides or inhibition of cyclooxygenase activity. Penicillin inhibits some essential mechanism involved in platelet activation by agonists and this process may be calcium dependent. Epinephrine through alpha adrenergic stimulation restores the mechanism by which agonists initiate platelet activation.

Nonhealing duodenal ulceration due to candida

An important role for candida in gastric and duodenal ulcer disease is being increasingly recognized. Causative factors implicated include the frequent use of cimetidine, and immunosuppressive or antibiotic therapy. Concerning cimetidine, there is no clear-cut evidence that the drug depresses cell mediated immunity; on the contrary, there is evidence that delayed hypersensitivity is enhanced. Acid reduction is the alternate and more likely explanation for any role of cimetidine in gastric and duodenal candidiasis. We report a patient with a duodenal ulcer, which repeatedly bled and failed to heal in hospital on standard antacid and cimetidine therapy. Candida was identified in the ulcer and treated, using mycostatin suspension, resulting in complete healing. We feel that candida involvement of duodenal ulcers may be more common than is generally recognized, and may be the cause for nonhealing in certain patients already on optimum therapy.

Failure of the aortic valve to open during inspiration in cardiac tamponade

A new echocardiographic sign, failure of the aortic valve to open during inspiration, is described in a 35-year-old man with cardiac tamponade. There was disappearance of the radial pulse and blood pressure during inspiration and the usual clinical and echocardiographic signs.

Effect of acetaminophen and salicylate on aspirin-induced inhibition of human platelet cyclo-oxygenase

Recent studies have shown that salicylic acid, a metabolite of aspirin, effectively competes for the same site on the platelet cyclo-oxygenase enzyme. In the present investigation we have evaluated the effect of salicylate and acetaminophen on aspirin induced inhibition of cyclo-oxygenase and platelet function. Results of our studies show that both drugs at equimolar concentrations had no inhibitory effect on aspirin induced blockage of cyclo-oxygenase or platelet function. Even at higher concentrations acetaminophen failed to protect cyclo-oxygenase or prevent inhibition of platelet function by aspirin. Salicylate at concentrations above 5 mM effectively blocked the inhibition of cyclo-oxygenase activity and platelet aggregation in response to arachidonate.

Systemic vasopressin therapy for Mallory-Weiss bleeding

Over a period of one year, five of 101 patients admitted to our center because of upper gastrointestinal bleeding were found to have a Mallory-Weiss tear. This condition usually responds to conservative management. Torrential bleeding necessitating surgery is uncommon. Three of the patients, reported here, bled torrentially and were considered surgical candidates. Two received systemic vasopressin while being prepared for operation, with rapid, dramatic cessation of bleeding. Although this is a limited experience, we are impressed enough to believe that intravenous vasopressin should be given a trial in all hospitalized patients who continue to bleed from a tear in the region of the esophagogastric junction.

A clinical experience with the NCGT graft

A comparison of 130 grafts done in 101 patients included 47 veins, 25 Johnson & Johnson dialdehyde-starch-tanned collagen prostheses, and 58 NCGT grafts that had been followed for a 40-month period. This study had documented the fact that in spite of frequent poor runoff, a useful result is provided by the NCGT graft apparently due in part to its built-in nonthrombogenic structure providing a cumulative patency of 73%. The patency rate was even superior with venous bypasses. Therefore, we still feel that the autogenous vein provides the most useful bypass conduit available in vascular reconstruction. In situations where a vein could not be used or was not available the NCGT graft offers an equally useful nonthrombogenic surface to maintain prolonged patency. Thus, collagen appropriately modified can provide a useful prosthesis in vascular reconstruction.