Stercoraceous and spontaneous perforations of the colon

The natural histories of stercoraceous and spontaneous perforations of the colon have many similarities which justify their being considered in the same treatise. Both entities are infrequently diagnosed preoperatively, and both entities are associated with a high mortality. Although the incidence of stercoraceous and spontaneous perforations of the colon is difficult to determine, their occurrence demands a high index of suspicion for early diagnosis and treatment. A critical review of available cases emphasizes the importance of a better understanding of the natural history of both entities, for it is only in this way that the high mortality associated with both can be improved upon. At least stercoraceous perforations of the colon appear to be preventable, and consideration is given to this aspect.

Possible deleterious hemodynamic effect of nifedipine on portal hypertension in patients with cirrhosis

The acute effects of nifedipine, 10 mg administered sublingually, were studied in 10 patients with alcoholic cirrhosis. Nifedipine significantly increased cardiac output and reduced systemic vascular resistance. Nifedipine also increased the hepatic venous pressure gradient by 15% (P less than 0.01). Hepatic blood flow and azygos blood flow did not change significantly. It is suggested that nifedipine increases portal pressure and thus may be deleterious to patients with portal hypertension.

Oxygen and bile acid content in the azygos blood. Clues to the azygos derivation in patients with portal hypertension

In patients with cirrhosis, elevation of azygos blood flow has been attributed on indirect grounds to cephalad portosystemic collaterals. To gather more information on the origin of the azygos blood, we studied the oxygen and bile acid content of the azygos and mixed venous blood in patients with portal hypertension. Azygos oxygen saturation was 59.6 +/- 6.0% in 8 controls, and significantly higher in 35 patients with cirrhosis (76.7 +/- 7.6%; P less than 0.01) as well as in 6 patients with noncirrhotic portal hypertension (84.0 +/- 8.2%; P less than 0.01). High oxygen saturation, however, was not correlated to azygos blood flow in patients with cirrhosis. In cirrhotic patients, total bile acid concentrations were 28.1 +/- 20.4 mumol/l in the pulmonary artery and 25.9 +/- 17.6 mumol/l in the azygos vein, giving an azygos to mixed venous ratio of 0.95 +/- 0.18. These results provide new evidence that elevated azygos blood flow in patients with portal hypertension is derived from the portal system, and perhaps predominantly from the splenic territory.

Pump-intensity-dependent frequency shift in Stokes and anti-Stokes spectra generated by stimulated four-photon mixing in birefringent fiber

The output spectra of the Stokes and anti-Stokes fields generated by stimulated four-photon mixing in birefringent fiber are investigated both experimentally and theoretically and are found to be dependent on the pump intensity. The pump-intensity-dependent changes in their frequency shifts are measured in 15-m long birefringent fiber by time-resolved spectroscopy using a 500-H(z)Q-switched Nd:YAG laser (lambda = 1.0642microm) as the pump source. Also, the Stokes gain coefficient is calculated as a function of the frequency shift and the pump power for the present phase-matching process where the mutually perpendicular polarization components are involved. The theoretical results agree well with the experimental data obtained.

Clonidine induced variations of plasma norepinephrine and blood pressure in essential hypertension

To assess the contribution of sympathetic outflow to blood pressure in patients with essential hypertension, clonidine induced variations of plasma norepinephrine, mean arterial pressure and the pulse rate three hours after a 300 μg dose of oral clonidine, an antihypertensive agent that decreases central sympathetic outflow, were studied.

Baseline and clonidine suppressed plasma norepinephrine levels were not significantly different between the normal controls and patients with essential hypertension. The average plasma norepinephrine level, mean arterial pressure and pulse rate were significantly decreased from the baseline value in both normal control and essential hypertension (p<.005). The depressor response to sympathetic inhibition after clonidine were exaggerated in significant proportion in patients with essential hypertension compared to normal control group.

Our study suggests that the pressor sensitivity to norepinephrine plays more important role than sympathetic overactivity in some patients with essential hypertension.

Beneficial hemodynamic effects of ketanserin in patients with cirrhosis: possible role of serotonergic mechanisms in portal hypertension

We studied the acute effects of ketanserin, a serotonin S2 antagonist, on systemic and splanchnic hemodynamics in 11 patients with cirrhosis. Mean arterial pressure decreased moderately but significantly after ketanserin. This effect was maximal at 5 min and correlated to the severity of cirrhosis. Cardiac index and systemic vascular resistance were not significantly changed. The hepatic venous pressure gradient, used as an index of portal pressure, significantly decreased after ketanserin (-23%). Azygos blood flow, a reflection of superior portosystemic collateral blood flow, also significantly decreased (-26%), but this effect was delayed, progressive and not correlated to the arterial pressure decrease. Hepatic blood flow was unchanged. These findings suggest that the systemic and splanchnic circulations may be hypersensitive to ketanserin in cirrhotic patients, and that serotonergic mechanisms may contribute to maintain portal hypertension. New specific antiserotonergic drugs deserve further evaluation for potential therapeutic implications in portal hypertension.

Reduction of intrahepatic vascular space in the pathogenesis of portal hypertension. In vitro and in vivo studies in the rat

To elucidate a possible role for reduction of intrahepatic vascular space in the pathogenesis of portal hypertension, we studied a partially hepatectomized rat model in vitro and in vivo. The in vitro study used livers from normal, 1/3-hepatectomized, and 2/3-hepatectomized rats, and rats with cirrhosis caused by chronic bile duct ligation, for isolated, perfused flow-pressure plotting. Resistance to perfusion increased such that significant differences were found between all groups except the last two, which showed similar resistances. The in vivo study measured splanchnic blood flow by radioactive microspheres and portal pressure in anesthetized sham-operated and 1/3- and 2/3-hepatectomized rats. Although absolute portal tributary blood flows did not change, portal flow per gram of remnant liver showed significant increases: 1.57 +/- 0.32 ml/min X g liver, 2.52 +/- 0.60 ml/min X g liver, p less than 0.01; 3.48 +/- 1.04 ml/min X g liver, p less than 0.01, respectively. Although intrahepatic resistance increased significantly only in the 2/3-hepatectomized group, portal pressures increased significantly in both groups of hepatectomized rats: normal, 7.5 +/- 1.1 mmHg; 1/3-hepatectomized, 9.4 +/- 1.1 mmHg; and 2/3-hepatectomized, 11.1 +/- 1.2 mmHg. Thus, decreased intrahepatic vascular space caused by resection and hepatocellular hypertrophy leads to portal hypertension, thereby suggesting that this reduction in space may be the pathogenic factor common to a number of different theories of portal hypertension.

Structural and metabolic correlates of cell injury in the hypertrophied myocardium during valve replacement

To characterize the ultrastructural and metabolic changes occurring in the hypertrophied ventricle during cardiac operations in man, we studied 36 patients with valvular heart disease undergoing valve replacement, during which multiple doses of cold potassium cardioplegic solution were administered (Group I). Each patient had substantial ventricular hypertrophy according to measurements made of left ventricular mass, with a mean of 232.1 +/- 19.8 gm/m2 (normal: 92 +/- 16 gm/m2). Serial biopsy specimens were obtained from the left ventricular apex at the initiation of bypass, during the cross-clamp interval, and during reperfusion. Each specimen was scored from 0 to 4 according to ischemic changes in nuclear chromatin, mitochondrial swelling, myofibrillar edema, glycogen depletion, and overall cell morphology. Myocardial pH and temperature were measured continuously in the left ventricular free wall. During the cross-clamp period, ischemic injury was evidenced by changes in nuclear chromatin (0.38 +/- 0.10 to 1.25 +/- 0.21, p less than 0.0001), intracellular edema (0.43 +/- 0.06 to 0.97 +/- 0.14, p less than 0.002), overall cell morphology (0.37 +/- 0.06 to 0.97 +/- 0.14, p less than 0.001), and mitochondria (0.10 +/- 0.05 to 0.19 +/- 0.07, p less than 0.0001). During reperfusion, mitochondrial swelling increased further (0.19 +/- 0.07 to 0.35 +/- 0.08, p less than 0.0001) and glycogen stores were depleted (0.63 +/- 0.13 to 0.96 +/- 0.17, p less than 0.02), while the other structures remained unchanged. Myocardial pH declined during ischemic arrest from 6.89 +/- 0.04 to 6.40 +/- 0.04 (p less than 0.001). The changes in myocardial pH in Group I were compared to changes in myocardial pH in 10 patients (Group II) with no left ventricular hypertrophy undergoing isolated coronary bypass graft operations with the same protective techniques. In contrast to Group I, myocardial pH did not fall in Group II during ischemic arrest (6.98 +/- 0.06 to 6.94 +/- 0.05, p = not significant). Thus, with the use of current myocardial protective techniques, ultrastructural and metabolic changes indicative of ischemia are produced in the hypertrophied myocardium. The structural alterations consist of changes in nuclear chromatin and intracellular edema during the ischemic phase and by mitochondrial swelling during reperfusion.

Squamous cell carcinoma of the larynx in young adults

Clinical and pathologic features of squamous cell carcinoma in 33 young adults (19 to 34 years) are presented. The most important difference between these patients and older subjects with squamous cell carcinoma of the larynx is the female preponderance in the young. Sixty percent were smokers but no other predisposing factors were uncovered. Histologic grade of malignancy had no impact on prognosis but, as it is with any head and neck site, the most important prognostic predictor is clinical stage.

Reversal of adrenaline-induced increase in azygos blood flow in patients with cirrhosis receiving propranolol

In patients with cirrhosis, endogenous catecholamines may influence the circulatory effects of propranolol. We intended to evaluate the interaction of adrenaline and propranolol on azygos blood flow, an estimate of blood flow in the superior portosystemic collateral circulation. We investigated 6 patients with cirrhosis, 5 with good liver function, receiving an intravenous infusion of adrenaline (50 ng/kg/min) before and after administration of propranolol. The median value for baseline azygos blood flow was increased from 700 ml/min (range 340-1 470 ml/min) to 1 050 (range 570-1 840 ml/min) with adrenaline alone (P less than 0.05), and decreased to 610 ml/min (range 260-1 190 ml/min) with propranolol alone (P less than 0.05). The infusion of adrenaline given after propranolol further reduced azygos blood flow to a median value of 530 ml/min (range 200-730 ml/min) (P less than 0.05). Thus, following beta-adrenergic blockade, there is a reversal of the effects of adrenaline on azygos blood flow, which corresponds to a potentiation of the effects of propranolol. Similar endogenous adrenaline-propranolol interactions may play a role in preventing recurrent variceal bleeding in cirrhotic patients.

Gallstones in women younger than thirty

In contrast to the usual 2:1 female:male ratio for the presence of gallstones, we found that the 12 patients with symptomatic gallstones under age 30 in this study were all female. This prompted a retrospective study of clinicopathologic findings in these 12 women with gallstones. Chemical analyses of the gallstones confirmed that all were cholesterol stones. Obesity and pregnancy proved to be the outstanding risk factors. The mechanism of obesity and pregnancy as lithogenic factors are reviewed and discussed.

Diverticular disease of the colon in Korea

This study is designed to determine the relative prevalence and characteristics of diverticular disease of the colon in Korea. We did a retrospective evaluation of 16,964 consecutive barium enemas performed at Koryo General Hospital between January 1971 and October 1986, and found 100 patients with diverticular disease of the colon. The results are as follows: 1) Colonic diverticula were found in 100 patients, and incidence of 0.59% in 16,964 consecutive barium enemas. The male to female ratio was 2.1:1. 2) Incidence rose with advancing age from 0.45% in the second decade to 2.5% in the seventh decade. 3) Patient age ranged from 19 to 77 years with more than 70% of the patients in the 5th, 6th and 7th decades. 4) The greater majority (81%) of the diverticular disease the right colon. 5) Fifty percent of the cases were classified as multiple diverticula. 6) The mean age of patients with right sided diverticula was 47.5 years and that of patients with left sided diverticula was 57.7 years. The mean age of single diverticular patients was 50.4 years and that of multiple diverticular patients was 48.4 year. 7) Associated diseases were hemorrhoids (18%), gall stones (12%) and previous appendectomy (11%). Among the 29 patients who had hemorrhoids and or a previous appendectomy, 28 of those had right sided diverticula.

Effects of Sophora flavescens Ait. on haemodynamics and ventricular fibrillation threshold in anaesthetized dogs

The effects of an ethanol extract of the plant Sophora flavescens Ait. on haemodynamics and ventricular fibrillation threshold were studied in pentobarbitone-anaesthetized dogs. It was found that intravenous injection of the extract, 120 mg/kg, caused transient but significant depression in systolic and diastolic blood pressure, heart rate, left ventricular pressure and dLVP/dtmax, as well as elevation of ventricular fibrillation threshold. These preliminary findings suggest that the ethanol extract of Sophora flavescens Ait. possesses pharmacological activities resembling those of antiarrhythmic agents, but the mechanisms of action are unclear.

Hemodynamic effects of a clonidine-induced decrease in sympathetic tone in patients with cirrhosis

A decrease in plasma noradrenaline--a reflection of sympathetic nervous system activity--by clonidine, a centrally acting alpha 2-agonist, could reduce the hyperdynamic circulation observed in cirrhosis and may thereby decrease portal hypertension. Plasma noradrenaline concentration and plasma renin activity as well as systemic and splanchnic hemodynamics were measured in 12 patients with cirrhosis and ascites before and after administration of either 150 micrograms of clonidine or placebo. Plasma noradrenaline concentration significantly decreased in all patients after clonidine administration, whereas plasma renin activity did not change significantly. There were statistically significant reductions of cardiac output (-17.4%), mean arterial pressure (-12.2%), hepatic venous pressure gradient (-19.7%) and azygos blood flow (-26.6%) after administration of clonidine. No significant correlation was found between the reduction of plasma noradrenaline concentration and changes in systemic or splanchnic hemodynamics. Hepatic blood flow was not changed by clonidine. Placebo administration had no effect on any laboratory or hemodynamic measurement. We conclude that the reduction in sympathetic nervous system activity by clonidine and the subsequent decrease in the hyperdynamic circulation suggests that sympathetic overactivity contributes to the circulatory derangements in patients with cirrhosis.

Advantage of Fontana-Masson stain in capsule-deficient cryptococcal infection

We describe light and electron microscopic findings in three cases of pulmonary infection caused by capsule-deficient Cryptococcus neoformans (CDCN) and emphasize the value of the Fontana-Masson silver (FMS) stain in diagnosing cryptococcosis. Capsule-deficient C neoformans infections, including coccidioidomycosis, histoplasmosis, typical cryptococcosis, blastomycosis, candidiasis, and pneumocystosis were used as controls. Several stains including mucicarmine, alcian blue, and FMS were done on tissue sections from all of the above mentioned infections. It was found that while the FMS stain was positive only in the organisms of CDCN and typical C neoformans, the mucicarmine was positive only in typical C neoformans. The negativity of the mucicarmine in the organisms of CDCN reflected the absence of capsular material as demonstrated by ultrastructural study. Therefore, when fungal cultures are not available or are negative, and tissue mucicarmine is negative, the FMS stain is a valuable alternative for use on tissue sections. It may be used, along with routine fungal stains, when a yeast-forming fungal infection is suspected.

Role of portasystemic shunts in the hyperkinetic circulation of the portal hypertensive rat

We evaluated the role of portasystemic shunts in the hyperkinetic circulatory state in rats with portal hypertension. Cardiac output and regional blood flow were measured by the radioactive microsphere technique in rats with portal hypertension caused by portal vein stenosis, in rats with end-to-side portacaval shunts, and in sham-operated rats. Cardiac output was significantly higher in rats with surgical shunts than in those of the two other groups and was significantly lower in sham-operated rats compared with portal hypertensive rats. Portal tributary blood flow and hepatic arterial blood flow expressed in absolute flow as well as in percentage of cardiac output were significantly increased in rats with surgical shunts compared with other groups. These blood flows were also significantly higher in portal hypertensive rats than in sham-operated animals. A significant correlation was found between cardiac output and portal tributary blood flow in rats with portal vein stenosis and in rats with surgical shunts; this correlation was absent in sham-operated rats. This study shows that the hyperkinetic circulatory state in rats with portal hypertension and a normal liver is related to the presence of portasystemic shunts but not to portal hypertension per se.

Domperidone-induced increase in lower oesophageal sphincter pressure does not affect azygos blood flow in patients with cirrhosis

An increase in lower oesophageal sphincter pressure induced by domperidone has previously been reported to decrease superior portosystemic collateral flow in patients with portal hypertension owing to cirrhosis. Although a 10-mg intravenous dose of domperidone was effective in increasing lower oesophageal sphincter tone in a group of six patients with cirrhosis, the same dose failed to affect azygos blood flow in a matched group of six patients. The results do not support the hypothesis that an increase in lower oesophageal sphincter tone can decrease flow through oesophageal varices in patients with cirrhosis.

Squamous cell carcinoma of the colon and rectum

Squamous cell carcinoma of the colon and rectum is a relatively rare entity. Although much of this disease entity remains enigmatic, treatment tenets are the same as those accepted for adenocarcinoma of the colon and rectum. Although prognosis of squamous cell carcinoma of the colon and rectum appears to be worse than that of adenocarcinoma, an aggressive approach to this neoplasm is indicated in order to improve survival rates.

Hemodynamic characterization of chronic bile duct-ligated rats: effect of pentobarbital sodium

Systemic and splanchnic hemodynamics of the chronic bile duct-ligated rat were characterized by radioactive microspheres. Conscious and pentobarbital sodium-anesthetized, bile duct-ligated and sham-operated rats had cardiac output and regional organ blood flows determined. The conscious bile duct-ligated rat compared with the sham-operated showed a hyperdynamic circulation with an increased cardiac output (153.3 +/- 9.8 vs. 112.6 +/- 6.0 ml/min, P less than 0.005) and portal tributary blood flow (21.32 +/- 1.43 vs. 12.79 +/- 1.47 ml/min, P less than 0.005). Pentobarbital sodium anesthesia induced marked hemodynamic changes in both sham-operated and bile duct-ligated rats. The latter group was especially sensitive to its effects; thus, comparison of cardiac output and portal tributary blood flow between anesthetized bile duct-ligated and sham-operated rats showed no significant differences. We conclude that the rat with cirrhosis due to chronic bile duct ligation is an excellent model for hemodynamic investigations but should be studied in the conscious state, since pentobarbital sodium anesthesia eliminates the hyperdynamic circulation.

Plasma apolipoproteins and lipids in normal persons and patients with hypertension

We measured apolipoprotein A (ApoA), apolipoprotein B (ApoB), and lipid levels in 115 hypertensive patients and 100 normal subjects in order to evaluate the risk of atherosclerotic heart disease in hypertensive patients. The hypertensive patients were divided into the following subgroups: blood pressure controlled (A) and uncontrolled hypertensive subgroup (B), and without complication (C) and with complication (D).

In the hypertensive group, the mean plasma ApoA, ApoB, total cholesterol, triglyceride and beta-lipoprotein (LpB) levels were significantly higher than in the normal control group. The plasma high density lipoprotein cholesterol (HDL-cholesterol) level was not significantly different between the hypertensive group and the normal control group. ApoB/A ratio in the hypertensive group was higher than in the normal control group, but the difference was not significant statistically.

In the hypertensive subgroups, plasma Apo A was higher in all the hypertensive subgroups compared to normal control group, but these differences were not statistically significant. In subgroup B, C and D, the plasma ApoB level increased significantly as compared to the normal control group, but not so in the subgroup A. All of the subgroups had significantly higher levels of triglyceride and LpB level than the normal control group. HLD cholesteol level of all of the subgroups did not show any significant difference as compared to the normal control group. In subgroup B, C and D, the ApoB/A ratio was not significantly different from the normal control group. In the subgroup A, ApoB/A ratio was lower than in the normal control group, this was not significant statistically. Between subgroup A and B, and subgroup C and D, all of the plasma lipids and apolipoproteins did not show significant differences.

Thus our results showed that ApoB, LpB and triglyceride, which are closely related to atherosclerotic heart disease, were significantly increased in any of hypertensive subgroups compared to the normal control group.

Expression of the NKTa clonotype in a series of human natural killer clones with identical cytotoxic specificity

Over a period of 3 yr, a series of ten NK clones that express a unique clonotypic T cell receptor-like structure, termed NKTa, has been generated from a single individual. These clones were derived from either peripheral blood nonadherent cell fractions (JT9, JT10, JT11), NKH2-purified cells (CNK8, CNK9), or NKTa-purified cells (CNK11, CNK12, CNK13, CNK14, CNK15). Flow cytometric analysis of peripheral blood mononuclear cells from this individual showed that NKTa+ cells occur with a frequency of approximately 0.15%. The existence of NKTa+ cells in peripheral blood was confirmed by use of immunorosette enrichment techniques, flow cytometric purification, and subsequent clonal expansion of NKTa+ cells. Phenotypic analysis of NKTa+ clones showed that all expressed NKH1 as well as T3, T8, T11, T12, and Mo1 antigens. Only five of ten clones expressed NKH2 antigen. All NKTa+ clones had broad cytolytic activity against a series of seven different target cells that was similar to that of other NK clones. In addition, cytotoxicity of each clone could be inhibited by preincubation of effector cells with monoclonal anti-NKTa or by preincubation of target cells with monoclonal anti-TNKTAR. Although half of the NKTa+ clones appeared phenotypically different from the other half with regard to the expression of NKH2 antigen, analysis of T cell receptor gene rearrangements indicated that all NKTa+ clones contained identical gene rearrangements of C beta 2.

Haemodynamic rebound phenomena after abrupt cessation of propranolol therapy in portal hypertensive rats

The haemodynamic effect of sudden termination of propranolol therapy was studied in sham-operated and portal hypertensive rats. All animals were injected with propranolol (20 mg/kg/day) or saline i.p. for 10 days, then had an isoproterenol infusion test performed 48 h or 72 h after cessation of injections. The dose of isoproterenol required to increase the heart rate by 50 beats/min (CD50), was significantly lower in both sham-operated and portal hypertensive rats at 48 h after propranolol withdrawal. Maximum chronotropic response (Rmax), was significantly higher only in portal hypertensive rats at 48 h after propranolol withdrawal. These results show the existence of a transient beta-adrenergic hypersensitivity state following propranolol withdrawal in normal and portal hypertensive rats.