Hepatobiliary scintigraphy for cholestasis in congenital hepatic fibrosis. Diagnosis and treatment

A 9-year-old child with congenital hepatic fibrosis had dilated intrahepatic bile ducts and recurrent cholangitis. Choleretic agents were administered to prevent recurrent cholangitis. Response to treatment was monitored with serum bile acid concentrations and computer-assisted technetium Tc 99m iprofenin (Pipida) scintigraphy. Dehydrocholic acid with meals improved hepatobiliary excretion of the radioactive isotope and lowered serum bile acid levels but did not prevent cholangitic attacks when used alone. Sulfamethoxazole and trimethoprim used alone prevented infection, but a steady rise in serum bile acid concentrations suggested increasing cholestasis. During combined drug treatment, the patient remained free of cholangitis for at least two years. Optimal therapy of congenital hepatic fibrosis with cholestasis but without mechanical biliary obstruction may involve the combined use of a choleretic such as dehydrocholic acid plus a suppressive antibiotic.

Six years of experience using patient instructors to teach interviewing skills

In 1974 a competency-based program was developed at the University of Arizona College of Medicine that used patient instructors (PIs) to evaluate interviewing skills objectively. PIs are nonphysicians who are taught to function in the multiple roles of patient, teacher, and evaluator. For each specialty area, objective evaluation instruments have been developed to measure the student's interviewing technique (interview process) and the amount of relevant historical information obtained from the patient (interview content). Data from the six most recent classes of second-year medical students demonstrate that: (a) there is a positive correlation between process and content scores; (b) students learn from their interviews with PIs; and (c) there is a positive relationship between the scores students obtain on their first interview with each of two different PIs in two different specialty areas. It is concluded that the PI program provides an effective way to teach interviewing skills to medical students.

Spur cell anemia associated with extrahepatic biliary tract obstruction

Two patients with extrahepatic biliary obstruction developed spur cell hemolytic anemia. Hemolysis and erythrocyte morphology reverted to normal when the obstruction was relieved. During the hemolytic phase, one patient's plasma converted normal erythrocytes to spur cells and normal plasma converted the patient's spur cells to normal morphology. The spur cells were discovered only when the patients' blood was examined under phase microscopy. We suggest that spur cells may occur in association with biliary obstruction more frequently than previously suspected and that their presence may be uncovered using phase microscopy.

Persistent transaminasemia and fatty liver. Their use in the diagnosis of presymptomatic Wilson's disease

A 41/2-year-old asymptomatic girl with persistent elevated serum transaminase levels for eight months was found to have Wilson's disease. The diagnosis was suspected by the presence of fatty liver and nonspecific chronic hepatitis on liver biopsy and was proved by studies of copper metabolism, including determinations of serum ceruloplasmin and hepatic copper concentrations. Unexplained persistent transaminase elevation in children demand investigation by needle liver biopsy. Th presence of fatty liver and hepatitis should raise the possibility of Wilson's disease, which may then be confirmed by more specific tests. Advantages to early diagnosis include the institution of specific therapy and prevention of progressive liver disease.

Unusual amyloid bodies in human liver

A case of globular amyloid in the liver is reported. The amyloid nature of the unusual deposits was established by special stains and electron microscopy. The significance of globular amyloid in the liver is unknown. Of the three cases reported in the world literature, none was clinically manifest. Two occurred in patients who had diabetes mellitus.

Transient protein-losing enteropathy and enlarged gastric rugae in childhood

Data on two patients with massive but transient protein-losing enteropathy due to gastric disease suggest that antibody-mediated allergic reactions may have been responsible for the clinical picture. The majority of patients described in the literature have had evidence of a preceding or concomitant viral infection, and three of these have had evidence of infection with cytomegalovirus. Recovery occurred relatively rapidly in all patients without sequelae. The syndrome may be a variant of eosinophilic gastroenteritis.

Longitudinal esophageal bands associated with esophageal aperistalsis: speculations on pathogenesis

A 6-year-old girl with ataxia telangiectasia syndrome was found to have multiple bands longitudinally traversing her esophagus, and esophageal aperistalsis. In the past, the patient was also known to have had esophageal candidiasis. The bands may have been congenital or may have been produced when linear ulcers caused by fungal esophagitis undermined mucosal strips and then healed, leaving tissue bands attached only at their extremities to the esophageal wall. The esophageal motor dysfunction may have been attributable to esophageal candidiasis, or may have been a hitherto unrecognized component of the ataxia telangiectasia syndrome.

Ischemic bowel disease attributable to ergot

A 50-year-old woman developed ischemic colitis temporally related to ingestion of a large dose of ergotamine tartrate. The patient did not have cardiovascular, metabolic, or inflammatory conditions predisposing to bowel ischemia. To our knowledge, this is the first patient proved to have developed bowel ischemia secondary to ergot toxicity.

Primary adenocarcinoma of the esophagus arising in a columnar-lined esophagus

A patient presenting with dysphagia and weight loss was found to have a large midesophageal mass. Five biopsies indicated only adenoma but a brush cytology specimen under direct vision was diagnostic of adenocarcinoma. Esophagotomy and resection of tumor, with follow-up radiotherapy were performed; histologic examination confirmed the diagnosis. To date, there has been no recurrence of the tumor. This patient was subsequently found to have a columnar-lined esophagus. Since columnar-lined esophagus may predispose to malignancy, this case illustrates the diagnostic importance of direct-vision cytology in patients with columnar-lined esophagus.