Early abdominal complications following heart and heart-lung transplantation

In the first 11 years of the heart and heart-lung transplantation programme at Papworth Hospital, Cambridge, 356 patients underwent heart transplantation, and 73 patients received both heart and lungs. Out of 429 patients 41 (9.5 per cent) developed abdominal complications within the first 30 days, and 20 of the 41 required surgery. The complications included pancreatitis (10), peptic ulceration (8), and pseudo-obstruction (8), in addition to colonic perforation and small bowel obstruction. When laparotomy was performed it was well tolerated. This paper supports the view that successful management of abdominal complications following transplantation requires prompt diagnosis and treatment. Where doubt exists in the presence of an acute abdomen, laparotomy is the appropriate way to establish a definitive diagnosis.

Use of a somatostatin analogue, octreotide acetate, in the management of acute gastrointestinal graft-versus-host disease

PURPOSE

Because the secretory diarrhea of acute graft-versus-host disease (GvHD) of the gut induces serious metabolic and nutritional disturbances, this study was initiated to assess the use of a somatostatin analogue, octreotide acetate, as adjunctive therapy for severe GvHD of the gut with massive diarrhea.

PATIENTS AND METHODS

In a pilot study, six patients with biopsy-confirmed acute gut GvHD after allogeneic bone marrow transplantation received octreotide 50 to 250 micrograms three times a day subcutaneously.

RESULTS

Three of the six treated patients had a prompt and dramatic reduction in stool volume within 1 to 3 days of initiation of octreotide therapy.

CONCLUSIONS

Somatostatin and its analogues have been used successfully in diarrheal states by antagonism of neuropeptide overproduction, although other potential therapeutic mechanisms include inhibition of fluid secretion, enhanced salt absorption, and inhibition of gut motility. Somatostatin and its analogues may be promising adjunctive agents in the treatment of gastrointestinal GvHD, although assessment in a controlled trial will be required to confirm their therapeutic efficacy.

Kinetics of D-xylose absorption in patients with human immunodeficiency virus enteropathy

D-Xylose absorption was studied in 12 patients with acquired immunodeficiency syndrome (AIDS) or advanced AIDS-related complex who had had diarrhea for more than 8 weeks, averaged an 11% (range, 3% to 21%) body weight loss during the previous 6 months, and had had negative stool examinations for enteric pathogens. Patients were evaluated by duodenal aspiration and biopsy and received both 25 gm oral and 10 gm intravenous doses of D-xylose. Kinetic analysis of D-xylose absorption was characterized by an absorption rate constant (ka) and a rate constant (ko) reflecting nonabsorptive loss. Extent of D-xylose absorption averaged 18.4% +/- 9.3% (+/- SD) in the 12 patients (normal greater than 60%). Percentage of weight loss during the previous 6 months was negatively correlated with ka (r = -0.69; p = 0.018) in the 11 patients in whom this parameter was reduced but was not correlated with either ko or extent of D-xylose absorption. In these patients with human immunodeficiency virus enteropathy, ka was reduced out of proportion to the minor histologic changes present in the duodenal biopsy specimens.

Small bowel obstruction after colon resection for benign and malignant diseases

To determine the etiology and outcome of patients with small bowel obstruction after a colon resection for benign and malignant diseases, the medical records of 118 patients who underwent 120 laparotomies for small bowel obstruction were reviewed. Contrary to previous reports, benign adhesions were responsible for the obstruction in all patients with a history of benign colon disease, 82.6 percent of patients with a history of adenocarcinoma of the colon without known recurrence, and 30.1 percent of patients with known recurrent malignancy. The morbidity and mortality was more related to the etiology of the obstruction rather than the preoperative delay or operative procedure performed. Considering the high likelihood of adhesive obstruction in patients with a history of, or known, metastatic colorectal carcinoma, it is suggested that these not deter surgeons from aggressive early surgical intervention in these patients who develop small bowel obstruction.

PAF-induced bowel necrosis. Effects of vasodilators

Ischemic bowel necrosis in the rat is produced by injecting platelet-activating factor (PAF) intravenously. Since intestinal hypoperfusion is observed after PAF injection, we hypothesize that mesenteric vasoconstriction is the mechanism of bowel injury. We thus studied the effects of vasodilators in this model. We found that: (1) Phenoxybenzamine, prazosin, ICI 198615 (leukotriene antagonist) and PGE1 counteracted the PAF-induced mesenteric flow reduction and ameliorated the bowel injury. However, phenoxybenzamine and prazosin were relatively ineffective in correcting PAF-induced hypotension, showing that bowel injury can be prevented independently of the hypotensive state. (2) Nitroglycerin failed to prevent bowel injury, although it improved the mesenteric blood flow. Thus, in opposition to our initial hypothesis, correction of the mesenteric flow reduction induced by PAF does not always prevent intestineal necrosis. (3) Only phenoxybenzamine, prazosin, ICI 198615, and PGE1 ameliorated PAF-induced hemoconcentration and bowel injury. This suggests a correlation between vascular injury (expressed by "leaky" vessels and the consequent hemoconcentration) and bowel necrosis. (4) Although both nitroglycerin and hydralazine relax smooth muscle, hydralazine seemed to aggravate bowel necrosis. The mechanism remains unclear.

[Gastrointestinal involvement as the first manifestation of Schoenlein-Henoch purpura]

A patient with Schönlein-Henoch purpura presented with gastrointestinal complaints as the first manifestation of the syndrome. The nature of the disease could be diagnosed after the late appearance of haematuria and purpura.

Intestinal pseudoobstruction secondary to amyloidosis responsive to cisapride

A case of chronic intestinal pseudoobstruction secondary to systemic amyloidosis in a patient with multiple myeloma is described. Gastrointestinal symptoms and indices of nutrition improved markedly after commencing treatment with cisapride, which may have been responsible for relatively prolonged survival compared with similar reported cases.

[The effect of menatetrenone on peritoneal adhesion]

The correlation between the dose of menatetrenone and the incidence of post-laparotomy peritoneal adhesion in Ryan's model was investigated with the use of rats. In the menatetrenone treated group, the menatetrenone was intramuscularly given in a dosage of 10 mg immediately after closure of the abdominal wound and every 24 hours for two days. In this group, the incidence of ceco-colonic adhesion was 54% (20/37), whereas the incidence in non-treated group was 26% (10/39) (p less than 0.012). Especially in cases with an air-drying time of 1-2 minutes, the difference between incidences of ceco-colonic adhesion in the menatetrenone and that of the non-treated group was high. The former incidence was 61% (17/28) and that of the latter was 21% (6/29) (p less than 0.01). In addition, the incidence of peritoneal adhesion was proportionally dose-dependent to the menatetrenone. In our clinical retrospective study, the incidence of post-gastrectomy adhesive ileus increased with menatetrenone treatment to a significant degree. It is concluded that prophylactic administration of a large dose of menatetrenone should be avoided, because the incidence of post-laparotomy peritoneal adhesion could be increased.

Chronic diarrhea in essential mixed cryoglobulinemia: a manifestation of visceral vasculitis?

Gastrointestinal involvement occurs frequently in essential mixed cryoglobulinemia, and most often involves the liver and spleen. Intestinal involvement is much less common and is generally felt to be a late and often catastrophic manifestation of the disease due to severe vasculitis. Occasionally, the disorder mimics inflammatory bowel disease, both clinically and radiographically. We recently cared for a patient with essential mixed cryoglobulinemia who developed persistent diarrhea. Endoscopic evaluation revealed scattered petechial lesions in the duodenum and colon as well as prominent lymphoid hyperplasia in the terminal ileum. Mucosal biopsies disclosed the presence of diffuse inflammation. We suggest that this patient's diarrhea was due to intestinal vasculitis and that prominent ileal lymphoid hyperplasia may be a manifestation of essential mixed cryoglobulinemia.

Results of radiotherapy for localised prostatic carcinoma treated at the Prince of Wales Hospital, Sydney

Between 1980 and 1986 a total of 218 patients with localised prostatic carcinoma received radical pelvic radiotherapy at The Prince of Wales Hospital, Sydney. The mean follow-up time was 4.6 years. The five-year actuarial overall survival rate was 63% (death from all causes) and the five-year cancer-specific survival rate was 73% (death from or with prostate cancer). The overall survival was significantly worse with more advanced clinical stage of the disease (P = 0.003) and with poor histological differentiation of the tumour (P = 0.001). The five-year actuarial rate for local control of tumour in the pelvis was 84%. Late treatment-related complications (occurring or persisting beyond six months) were mild or moderate and the majority settled with conservative management. Only five patients experienced severe complications (necessitating surgical treatment). Of 42 patients with normal potency documented before radiotherapy who were not subsequently hormonally manipulated 23 (55%) retained potency at two years. These results for definitive radiotherapy for localised prostatic carcinoma indicate good local control with minimal morbidity and compare favourably with other published results.

Potentially lethal complications of shigellosis

Complications that can lead to death during shigellosis include intestinal as well as systemic manifestations. The former include intestinal perforation, toxic megacolon, and dehydration, and the latter include sepsis, hyponatremia, hypoglycemia, seizures and encephalopathy, hemolyticuremic syndrome, pneumonia, and malnutrition. Data on the frequency of these complications come primarily from hospital-based studies, in which sepsis-either with Shigella or with other Enterobacteriaceae-and hypoglycemia are the most common causes of death. Management of these two complications requires broad-spectrum empiric antibiotic treatment of all severely ill, malnourished patients with shigellosis as well as frequent feedings to prevent hypoglycemia. Unfortunately, in developing countries, access to parenteral broad-spectrum antimicrobial agents is often limited, and frequent feedings are often precluded by the severe anorexia that is characteristic of shigellosis. Realistic approaches to the reduction of mortality from shigellosis must continue to focus on prevention and early antimicrobial therapy rather than on treatment of established complications.

Severe late intestinal complications after abdominal and/or pelvic external irradiation with high energy photon beams

A total of 264 patients were treated between January 1981 and December 1985 for abdominal and/or pelvic tumours with high energy photon beams. Pelvic irradiation encompassed the true pelvis with upper limit located at the L5-S1 junction for 126 patients, at the L4-L5 junction for 107 patients with only 31 patients receiving external irradiation with treatment fields extending up to T12. The dose delivered to the pelvis was in the range 40-50 Gy with 72 (27.27%) patients receiving an extra dose on limited volumes up to 60-65 Gy. Acute intestinal reactions were observed in 38 (14%) patients. Using the Chassagne grading, we observed 14 grade 1,9 grade 2,13 grade 3 and 2 grade 4 late intestinal complications. Incidence of severe late intestinal complications in our series was 5.67% (15/264). Among these 15 patients three died of progression of the disease outside the treated volume, two died because of intestinal complications and/or their treatment and two died of unknown reasons. The remaining eight patients are alive with no evidence of the disease but with marked impairment of their intestinal functions. The analysis of risk factors showed only previous surgery (with laparotomy) to be significant, whereas age, delivered dose and treatment field and marked obesity had no influence on incidence of severe late intestinal complications.

[Intestinal microbial pathology in AIDS. A clinical case series]

Microbial isolates from 60 diarrheic AIDS patients hospitalized to the Infectious Disease Division of Careggi hospital (Florence) are described. Clinical, microbiological and diagnostic features of each case are discussed with emphasis to some rare or underestimated entities in Europe: Campylobacter laridis bacteremia, Whipple-like disease by atypical Mycobacteria, Schistosoma mansoni proctocolitis. Results regarding newly AIDS-related microorganisms are also stressed.

Intestinal ultrasonographic findings in Schönlein-Henoch syndrome

Thirteen children with Schönlein-Henoch syndrome were evaluated for ultrasonographic changes of the gastro-intestinal tract. One patient was examined twice because of a relapse 1 year later. Out of 14 sonographic scans 10 showed abnormal findings, consisting of circumscribed hypo-echoic asymmetrical enlargement of the intestinal wall, the sonographic result of intramural effusions. One patient also had ileocoecal intussusception. Our results suggest that sonography of the intestine is useful to detect changes of the intestinal wall in Schönlein-Henoch syndrome.

[Direct re-instillation through endotracheal intubation tubes during enteral nutrition for short bowel syndrome]

Case report of a 65-year-old man, operated on for small bowel infarction. Only the initial 40 cm of the jejunum, and the last 10 cm of the ileum were vital and could be kept. The ileo-caecal valve and the colon were not resected. Two stomas were carried out: a left-sided jejunostomy, and a right-sided ileostomy. Enteral nutrition was attempted, but jejunal outflow increased. It was therefore decided to attempt re-instillation of jejunal juices directly to the ileum using two 33 CH endotracheal tubes connected with soft chest drain tubing. A bag was placed over the jejunal tube to collect any leakage. Semi-elemental enteral nutrition could then be successfully carried out, and parenteral feeding stopped. With this simple appliance, the patient was able to lead as normal a life as possible. After 42 days of such feeding, the patient had only lost 2 kg in body weight, and intestinal continuity was re-established.