The diagnosis of intra-abdominal abscesses in patients with severe Crohn's disease

A series of 24 patients with severe relapses of Crohn's disease responding poorly to conventional treatment with corticosteroids was studied to determine the incidence of intra-abdominal abscesses and the best means to detect them. Ultrasound scans proved to be difficult to interpret and unreliable. Computed tomography demonstrated abnormal bowel thickening in most cases, and showed seven of the eight intraabdominal abscesses. 111In leucocyte scintigraphy always demonstrated inflamed areas of bowel, but underestimated the extent of disease in three patients and overestimated it in five. All eight abdominal abscesses were detected, and there were no false-positive results. It was always possible to distinguish the abscess from inflamed bowel wall. Intra-abdominal abscess is not uncommon in patients with severe relapses of Crohn's disease which are not responsive to corticosteroid therapy, being present in about one-third of patients. 111In leucocyte scintigraphy is a simple and helpful test for differentiating between active inflammatory bowel disease and complicating abscesses, contributing significantly to the management of patients with severe Crohn's disease.

Systemic elastolytic granulomatosis with cutaneous, ocular, lymph nodal, and intestinal involvement. Spectrum of annular elastolytic giant cell granuloma and sarcoidosis

A 15-year-old Japanese girl had widespread annular serpiginous erythematous plaques, bilateral granulomatous uveitis, bloody diarrhea, and seronegative arthralgia. She also had anemia and leukopenia. The histopathologic findings were compatible with those of annular elastolytic giant cell granuloma. Elastolytic granulomas were also found in the cervical lymph nodes, terminal ileum, parietal peritoneum, and mesentery. Bilateral hilar lymphadenopathy, hypercalcemia, and an increased level of angiotensin converting enzyme were not observed throughout the clinical course. To the best of our knowledge, systemic elastolytic granulomatosis has not been previously described in annular elastolytic giant cell granuloma or sarcoidosis. This case may represent a type of granulomatosis in the broad spectrum of annular elastolytic giant cell granuloma and sarcoidosis.

[Intestinal osteopathy following partial gastric resection]

26 years after a partial gastric resection (Billroth II) for recurrent gastric ulcer a 62-year-old man developed severe intestinal osteopathy. For three years he had increasing pain in the lower back and hip with a noticeable waddling gait. Serum concentration of calcium (2.0 mmol/l) and 25-hydroxy-vitamin D3 (38 mmol/l) were reduced, those of alkaline phosphatase (572 U/l) and parathormone (532 pg/ml) increased. Radiology demonstrated Looser's zones in the ribs and iliac crest. Osteodensitometry showed obviously diminished bone density. Iliac crest biopsy revealed signs of osteomalacia and secondary hyperparathyroidism. Within three months of starting oral vitamin D3 and calcium the symptoms had definitely receded and serum concentrations of calcium and alkaline phosphatase had become normal (2.4 mmol/l and 156 U/l, respectively). Osteopathic symptoms are often the expression of an abnormal calcium/phosphate metabolism. The cause often lies in the gastrointestinal tract; not rarely it is a late complication of a gastrojejunostomy.

[The syndromal approach to the diagnosis of toxic food poisonings]

The authors criticize the nosological principle of the diagnosis of toxic infections and believe that in a vast majority of cases such diagnosis must be based on syndromes. The only exceptions are cases of mass outbreaks and hospital infections. The definition of alimentary toxic infection is given, the difficulties of their clinical diagnosis and the ways to overcome these difficulties are indicated.

The prenatal diagnosis of imperforate anus with rectourinary fistula: dilated fetal colon with enterolithiasis

The finding of extraluminal calcifications is commonly reported and usually indicates intrauterine intestinal perforation with intraperitoneal extravasation of meconium, most often associated with intestinal obstruction and/or atresias. Intraluminal calcification of meconium is more rare and appears to result from the mixing of stagnant urine and meconium in utero. The presence of the intraluminal calcifications in a dilated loop of intestine, particularly with an associated urinary tract abnormality, should suggest a rectourinary fistula. Two cases of prenatally diagnosed imperforate anus with rectourinary fistulae are reported.

Intestinal failure--the clinical problem

Intestinal failure can be the end result of a wide variety of disease processes that impair the ability of the gut to adequately digest and absorb food. Patients with established intestinal failure may require parenteral nutrition support and/or abdominal surgery to reverse the disease process involved. Selected patients with irreversible intestinal failure can be managed in experienced units by home parenteral nutrition.

Prevention and therapy of radiation-induced bowel discomfort

In a double-blind randomized placebo-controlled study, including 70 patients treated with radiotherapy of localized malignancies in the pelvis, the effects of prophylactic sucralfate in preventing bowel discomfort were evaluated. Radiotherapy was delivered in a conventional manner with high-energy photons in a total dose of 62-66 Gy (target dose, 1.8-2.2 Gy) during 6.5 weeks. Dose granules of sucralfate or placebo were given 2 weeks after irradiation started and continued for 6 weeks. All analyses were performed blindly. The patients in the sucralfate group had significantly less problems with acute (5 weeks) and chronic (66 weeks) bowel discomfort. The consumption of loperamide was also reduced in the sucralfate group, and the weight decrease was less pronounced. No adverse effects were seen. Thus, sucralfate seems to be beneficial in minimizing the problems of bowel discomfort during and after irradiation of malignancies in the pelvis. These results are discussed in relation to other related observations.

[A prospective study of chronic radiation lesions of the small intestine after radiotherapy of gynecologic cancer]

A prospective study was made of 80 patients with a history of gynecological malignancy, and who had received radiotherapy 2 to 5 years previously in the same centre, with the aim of determining the incidence of lesions of the small intestine after pelvic radiotherapy. Various moderate gastrointestinal symptoms were seen in 33 patients and incapacitating diarrhea in 2. Thirty-seven patients underwent gastrointestinal investigations. The great majority had a good nutritional status and normal laboratory results. Fecal losses on a normal oral diet and alpha-1-antitrypsin clearance were most often normal (3 cases of steatorrhea, 8 of creatorrhea). Small bowel barium studies revealed minor abnormalities of folds in 5 cases. There was no correlation between clinical symptomatology and the existence of laboratory and radiological abnormalities. This study shows the usual good tolerance of pelvic radiotherapy by the small intestine, at least in the mid-term. Routine investigations seeking sub-clinical intestinal lesions do not appear to be justified in patients who have undergone pelvic radiotherapy.

The role of strictureplasty in Crohn's disease

Crohn's disease is a panintestinal disease of unknown aetiology and a tendency to recrudescence throughout the patient's life. It is therefore impossible to cure Crohn's disease by medical therapy or surgical excision. In spite of this, the majority of patients can be managed through their disease and maintained in a good state of health by a combination of medical and surgical treatment. Early attempts at surgical management of Crohn's disease in the 1930's and 1940's involved bypass procedures which were marred with serious complications of sepsis, development of cancer and increased rate of recurrence. By the 1950's resection became the preferred operation but there soon arose a controversy about the amount of bowel that should be removed. There were some who advocated radical excision; removing all diseased bowel with a large margin of apparently normal tissue on each side of the resection. Others found less radical resection safer as it preserved gut and also had no apparent effect on the rate of recurrence of the disease. Although this argument continued, the balance gradually shifted towards less radical surgery. Furthermore, the wave of conservatism led to the evolution of the concept of minimal surgery.

[Atraumatic Clostridium septicum infection in granulocytopenia]

A fatal Clostridium septicum infection occurred in three patients. Case 1. A 55-year-old man died of septicaemia resulting from granulocytopenia of uncertain aetiology; it was associated with perforation of ileal mucosal ulcers. Autopsy revealed neutropenic enterocolitis and diffuse gas formation, especially in the brain, caused by Clostridium septicum. Case 2. A 18-year-old boy developed a caecal invagination during imipenem-induced granulocytopenia. A fulminant postoperative Clostridium septicum infection ended fatally. At autopsy many ulcers were found at the site of invagination with gas formation involving all organs. Case 3. Myonecrosis of the left arm, caused by Clostridium septicum, developed without external cause in a 12-year-old girl with congenital neutropenia. Despite aggressive surgical intervention she died of toxic shock. Autopsy revealed caecal mucosal ulcers as the portal of entry of Clostridium septicum.

[The cause of the activation of an epidemic process of intestinal infections in the 70s]

In the seventies a considerable rise in dysentery morbidity was observed in all republics of the USSR, in the whole of the USSR, in Bulgaria and in the German Democratic Republic. An increase in cholera morbidity in the world, as well as in the number of countries affected by this infection, was registered. A tendency towards a rise in virus hepatitis incidence was observed in the USSR. The dynamic study of the ozone content in the stratosphere, solar activity, disturbances in the magnetic field of the Earth, air temperature for the period of 1967-1980 was carried out. Strong and moderate correlation between dysentery and air temperature in summer was established. The maximum morbidity level in the USSR in 1972 was probably the consequence of unusually high air temperature in summer.

Oesophageal and severe gut involvement in the haemolytic uraemic syndrome

Between 1982 and 1989, 78 children with diarrhoea-associated haemolytic uraemic syndrome (HUS) were referred to this hospital. Most presented with abdominal pain, bloody diarrhoea and vomiting. Seven had severe gastrointestinal involvement, four of whom required resection for bowel perforation or necrosis. One also developed an oesophageal stricture, a previously unreported complication of HUS. These seven children had a high incidence of other complications including hypertension, and cerebral and pancreatic involvement. One died from severe cerebral involvement, one has a residual neurological deficit and one has residual renal impairment. Severe gastrointestinal involvement did not significantly affect the long-term outcome. Simple haematological indices helped predict severe gut involvement. Four of the 78 children had undergone appendicectomy before the diagnosis of HUS was made. The operative findings were in no case typical of primary acute appendicitis, although histological examination did confirm inflammation of the appendix in two patients. Diagnosis is difficult in early disease, but increased awareness may help prevent unnecessary appendicectomy.

The effects of Escherichia coli and its endotoxin on amyloidogenesis in ducks

To compare the effects of two inocula on the induction of amyloidosis in normal and thymectomized ducks, 180 normal and 50 thymectomized ducks were injected intravenously weekly for up to 16 weeks with either crude endotoxin or crude whole cell extract of a virulent strain of Escherichia coli (O78), and another 60 ducks were injected with normal saline as study control. During the first 5 weekly injections, the initial doses of inducing agents were the smallest and then adjusted upward to the maximum study doses (1 or 2 mg/bird of crude endotoxin and 15-18 x 10(8) bacteria/bird of crude whole cell extract), which were then maintained over the course of the study. The incidence of amyloid deposition were: 50.00% (25/50) for thymectomized ducks that received 1 mg/bird/week of crude endotoxin, 61.67% (37/60) for intact ducks that received 15 x 10(8)-18 x 10(8) bacteria (crude whole cell extract)/bird/week, 53.33% (32/60) for intact ducks received 2 mg/bird/week of crude endotoxin, and 63.33% (38/60) for intact ducks received 1 mg/bird/week of crude endotoxin. The results suggest that crude whole cell extract and crude endotoxin induced amyloidosis in ducks at similar rates and that, in ducks, thymectomy has no appreciable effect on the occurrence of amyloidosis.

Bladder carcinoma--a 20-year review of radical irradiation therapy

Between 1967 and 1986, 319 patients, judged unsuitable for cystectomy, were scheduled to receive curative radiation treatment for transitional cell cancer of the urinary bladder. Crude and corrected 5-year survival for all stages were 18% and 28%, respectively. Corrected 5-year survival by stage was: T1-57%, T2-31%, T3-16% and T4-6%. Fifty-seven patients (18%) never completed the scheduled treatment and all but two of them died in a short time from tumour progression. Local response could be evaluated in 179 of the 262 patients, who completed the radiation treatment. In 130 patients (73%) complete local response was observed and 49 patients (27%) had persistent tumour. Corrected 5-year survival in the responder group was 53% compared to 8% in the non-responder group. Intestinal complications occurred in 51 patients, of whom 24 were operated upon and another four died before operation from radiation-induced intestinal complications. More than 80% of all intestinal and/or urinary tract complications were observed within 3 years after irradiation. During this period, special attention should be paid to detect and treat radiation complications to prevent fistula formation or perforation, with poor prognosis. The dose per radiation fraction and the radiation technique appeared to be the most important factors for the development of intestinal complications.

Malakoplakia of the small intestine as a cause of enterocutaneous fistula

A case of malakoplakia of the small intestine presenting as an abscess of the anterior abdominal wall is described in a 28-year-old black Zimbabwean man. The patient developed an enterocutaneous fistula after incision and drainage of the abscess. Light and electronic microscopy revealed Michaelis-Gutmann bodies in some von Hansemann cells. He did well for eight months following laparotomy and resection of the fistula, but later died of a severe chest infection and septicaemia. It is suggested that malakoplakia in this case behaved like a locally aggressive lesion. Von Hansemann's histiocytes were sighted in the subcapsular sinus and germinal centres of nearby lymph nodes.

[The development of intestinal dysbacteriosis in sexually mature rats after thymectomy]

Thymectomy in puberal rats resulted in the development of pronounced enteric dysbacteriosis, correlating with the degree of T- and B-lymphocyte deficiency in the lymphoid organs and the blood stream during the first 2 months. Microbiocenosis restores probably due to more intensive functioning of alternative regulating mechanisms. A simple and informative characteristic indicating the degree of dysbacteriosis developing in the intestine is proposed: the index of dysbacteriosis.

Postcolectomy syndromes

Resection of the colon and rectum may produce both transient and permanent alterations in colonic function. Furthermore, the nature of some operative techniques may result in autonomic denervation of the rectum and associated pelvic viscera. An understanding of the mechanism of injury and the subsequent functional abnormalities is necessary to provide adequate therapy.

Massive evisceration: a complication following sacrospinous vaginal vault fixation

This report describes a spontaneous vaginal vault prolapse in association with massive evisceration following sacrospinous vaginal vault fixation. Careful attention to surgical technique is critical to the success of the operation. In particular, good apposition of the vaginal vault to the sacrospinous ligament and adequate repair of an enterocele should avoid this complication.

Long-term treatment sequelae following external beam irradiation for adenocarcinoma of the prostate: analysis of RTOG studies 7506 and 7706

Significant late intestinal and urinary morbidity from external beam irradiation for adenocarcinoma of the prostate has been a constant concern of both the urologist and the radiation oncologist. We analyzed two large Radiation Therapy Oncology Group trials (7506 and 7706) using primary irradiation in the treatment of local or locoregional adenocarcinoma of the prostate to assess morbidity via the Radiation Therapy Oncology Group scoring scheme (grade 1-5). One thousand twenty patients were treated in total with a minimum follow-up of 7 years in the surviving patients. There was a 3.3% incidence of intestinal complications defined as grade 3 toxicity or more with .6% of patients experiencing bowel obstruction or perforation. Urinary complications defined as grade 3 toxicity or more were found in 7.7% of patients with only 0.5% experiencing morbidity that would require a major surgical intervention such as laparotomy, cystectomy, or prolonged hospitalization. Intestinal and urinary complications were evaluated in reference to several parameters that might have an impact on their incidence (i.e., previous laparotomy, stage of disease, hypertension, positive lymph nodes, previous transurethral resection, total dose, and energy of accelerator used). Only total dose (greater than 70 Gray) was found to have a significant impact on the incidence of the urinary complications. None of these factors had a significant impact on the incidence of intestinal complications. These data from two large multi-institutional trials represent a fair estimate of the actual incidence of major intestinal and urinary complications from external beam irradiation in the management of local and locoregional adenocarcinoma of the prostate. Since the incidence of these major complications remains very low, we believe that external beam irradiation remains an excellent alternative to radical prostatectomy in the management of these patients.

[The dynamics of the formation of an infection focus in the intestines]

The problem of the stability of the development of Shigella population in the intestine, depending on the dose of the infective agent, is analyzed. The agent is reproduced in the intestinal mucosa in short cycles, starting with adhesion and followed by penetration, intracellular multiplication and, finally, emission of free bacteria and hulled tops of villi with Shigella intracellular microcolonies. This form of emission maintains high concentration of bacteria and ensures, in case of the adhesion of hulled material, high local concentration provoking the repetition of the cycle. Depending on the dose, chains of cycles either progressively develop or maintain a constant level, or become extinct. Stable development of the chains of infectious cycles forms a focus of infection in the body (in the intestine). The growth of the populations of infective agents in live tissues, following the chain of cycles, produces a new type of microbial culture, differing from the types obtained by batch and flow cultivation. The aggregation and accumulation of infective agents in the hulled material is the particular case of the formation of infections, highly active particles and accumulations of infective agents, ensuring the development of infection with a relatively small number of organisms.

[Meteorism]

Gastrointestinal bloating is a common complaint met within the general practitioner's office. The most important cause of this symptom is an increase in the volume of gas in the gastrointestinal tract. Differential diagnoses include aerophagia, ingestion of gas-producing foods, gastric hypersecretion, bacterial overgrowth in the small intestine, disordered gastrointestinal transit, malabsorption or maldigestion of carbohydrates. In addition, nonulcer dyspepsia and the irritable bowel syndrome must be excluded. The diagnosis is based on a history of eructation, heart burn, flatulence and diarrhea, dietary habits, physical examination, laboratory analysis and apparative diagnostic measures. Therapy depends on the underlying cause of the disease.

Evisceration and other complications of abdominal drains

Drainage following major abdominal surgery remains controversial. A case of small bowel evisceration through a Wallis drain site after an abdomino-perineal excision of rectum is reported as a complication of abdominal drainage.

Diverticulum of a Meckel's diverticulum containing a stone

An 18 year old girl presented with acute abdominal pain and a calcified opacity in the pelvis. She proved to have a Meckel's diverticulum which had a secondary diverticulum at its apex, containing a stone. Meckel's stones are uncommon and diverticula of a Meckel's diverticulum exceedingly rare. This is only the second recorded case of such a diverticulum containing a stone, and the first to describe a calcified stone in this location.