Usefulness of gram staining of blood collected from total parenteral nutrition catheter for rapid diagnosis of catheter-related sepsis

The accuracy of Gram staining of blood drawn from catheters used to administer total parenteral nutrition was compared with paired quantitative blood cultures for the diagnosis of catheter-related sepsis. Gram staining was positive in 11 of 18 episodes of catheter-related sepsis documented by quantitative culture (sensitivity, 61%) but in none of the 5 episodes of fever unrelated to catheter infection. Thus, this procedure enabled the rapid presumptive diagnosis and guidance of antimicrobial therapy for total parenteral nutrition catheter sepsis, with a positive predictive value of 100% and a negative predictive value of 42%.

Benign thoracic schwannoma and postoperative chylothorax: case report and review of the literature

Among all the neurogenic tumours, the benign intrathoracic schwannoma is a rare tumour. Most often it is discovered by accident in the course of a routine X-ray examination of the thorax. Symptoms appear only when size becomes important. The surgical removal of an intrathoracic schwannoma may result in the development of a chylothorax. According to the literature, its treatment remains controversial. The originality of the case we report here is on the one hand the exceptional size of the tumour and the success over the long term of conservative treatment with complete parenteral alimentation, and on the other hand, the inefficacy of the subcutaneous administration of the analogue of somatostatin in reducing a chylothorax with high outflow.

Two cases of water-melon stomach and a review of the literature

We report two cases of "water-melon stomach", which is a peculiar form of gastric antral vascular ectasia, characterized by a specific and striking endoscopic aspect. It is observed in a context of chronic iron deficiency anemia and gastrointestinal blood loss, particularly in elderly female patients. The clinical endoscopic, histologic, pathogenic and therapeutic aspects are described, with review of the literature.

Anorectal stenosis in patients with prolonged use of suppositories containing paracetamol and acetylsalicylic acid

We report five cases in which anorectal stenosis was associated with chronic administration of suppositories containing paracetamol and acetylsalicylic acid. All patients were females taking suppositories for chronic migraine. Patients experienced anal pain, tenesmus, fecal incontinence, and, in two cases, intestinal obstruction. Lesions were characterized by a severe circular narrowing of the distal rectum with superficial ulcerations. Radiographs demonstrated the presence of sinus-tract-like formations in the diseased segment and thickening of the rectal wall. Histologic examination showed signs of chronic inflammation with deep ulcerations associated with obliteration of the lamina propria by a fibromuscular proliferation, as was described in the solitary ulcer syndrome of the rectum. Rectal administration of suppositories was discontinued in all the patients. Two patients were improved by anorectal dilatation, but the remaining three required a left proctocolectomy with subsequent coloanal anastomosis. The use of such suppositories must be restricted.

Endoscopic varix ligation: a promising new technique?

Endoscopic varix ligation is a new promising endoscopic method which compete with endoscopic sclerotherapy both during acute bleeding and the chronic setting where the aim is to obliterate varices as soon as possible with minimal side effects.

Hyperammoniemic coma in a patient with ureterosigmoidostomy and normal liver function

Hyperammoniemic encephalopathy has been reported after ureterosigmoidostomy. Its development is related to a problem of bacterial overgrowth and, most often, is favored by the presence of an underlying liver dysfunction. We report the case of a 43-year-old woman with a ureterosigmoidostomy done 28 years earlier who developed hyperammoniemic coma induced by an acute rectocolitis and in the absence of any detectable liver dysfunction. Neither administration of Lactilol and neomycin nor rectal tube drainage were effective; systemic antimicrobial therapy effective against the urease-producing gram-negative bacilli was required and led to a decrease in serum ammonia levels and a dramatic clinical improvement.

Factors related to early mortality in cirrhotic patients bleeding from varices and treated by urgent sclerotherapy

Variceal haemorrhage in cirrhotic patients carries a high early mortality even when balloon tamponade or emergency sclerotherapy are applied. The aim of this study to identify patients dying within six weeks of their first variceal haemorrhage. One hundred and twenty one patients with parenchymal cirrhosis presenting with the first variceal bleeding episode between June 1983 and December 1988 were studied. Nineteen patients were excluded for various reasons. Emergency sclerotherapy was carried out in cases of active bleeding or where there were endoscopic signs of recent bleeding, and then regularly repeated afterwards. Of the 24 variables studied and included in a multivariate analysis using a logistic regression model, three had an independent prognostic value: encephalopathy, prothrombin time, and the number of blood units transfused within the 72 hours of time zero. The subsequent regression equation was able to predict 89% of the patients who will die and 97% of the patients who will still be alive six weeks after their first variceal haemorrhage treated by sclerotherapy. Pugh score was less discriminatory than these last three variables in terms of accuracy of adjustment, goodness of fit to the model, receiver operating characteristic curves, and percentage correct prediction. To measure the accuracy of the prediction rule, our model was applied to another series of 28 cirrhotic patients admitted with their first variceal bleeding during the next period (January 1989 to May 1990). Death and survival were correctly predicted in respectively 82% and 94% of the cases. The use of this score is recommended for the selection of patients with high early mortality after variceal bleeding despite sclerotherapy, and for the design of new therapeutic trials.

[Therapeutic efficacy of 5-ASA molecules in idiopathic intestinal inflammatory diseases: critical review]

Sulfasalazine has been the most widely prescribed drug for patients with inflammatory bowel disease. Clinical trials have established its usefulness in treating patients with active ulcerative colitis and Crohn colitis and its important role in maintaining remissions in patients with ulcerative colitis. Despite its widespread acceptance, the usefulness of sulfasalazine has been limited by the occurrence of adverse reactions in about 10 to 20% of the patients. Now the aminosalicylates are emerging as a treatment for both ulcerative colitis and Crohn disease. We have critically reviewed the clinical trials assessing the efficacy of 5-ASA molecules. Therapeutic efficacy of 5-ASA appears to be as good as sulfasalazine but causing less adverse effects. In mild to moderate ulcerative colitis relapse, 2g 5-ASA is active while 1 g 5-ASA seems equivalent to 2g sulfasalazine for maintaining remission. 5-ASA enema in the treatment of distal ulcerative colitis is helpful and can replace topical cortisone administration. Administration of 1g 5-ASA enema a day seems to be the best regimen. In case of Crohn's disease, preliminary studies are encouraging but more date are required to define the indications as well as the regimen.

Colonoscopic snare polypectomy: analysis of 1485 resections comparing two types of current

The complications related to 1485 colonic snare polypectomies were analyzed according to the type of current which was used for resection. From January 1982 to August 1986 (period 1), blended current was used in 758 snare polypectomies, while continuous coagulation current was applied in 727 polypectomies from September 1986 to October 1989 (period 2). The incidence of complications observed in the entire series was low, consisting of 0.26% perforations and 0.9% major hemorrhages. There were no deaths in this series. Twelve of 14 hemorrhages occurred after resection of polyps larger than 1 cm. Although the incidence of complications was not statistically different in the two groups, there was a significant difference in the timing of hemorrhages. All of the major hemorrhages were immediate (eight) when the blended current was used, but delayed (six; from 2 to 8 days after polyp resection), when pure coagulation current was applied.

Venous thromboangiitis associated with regional enteritis

Thromboembolic complications occurring in patients with Crohn's disease are increasingly reported and are associated with a high mortality. The mechanism by which the thrombogenic process occurs is unclear. As recent findings suggest that Crohn's disease is a chronic vasculitis with multifocal gastrointestinal infarctions secondary to an imbalance of the cellular hemostatic pathway, extradigestive thrombotic complications might be mediated by the same vascular immune reaction. We report an unusual case of recurrent venous thrombosis associated with regional enteritis, the main point of interest being two-fold: first, this case provides a morphological evidence for an angiitic process as the cause of extradigestive thrombosis; second, the gastrointestinal disease remained subclinical for more than four years although the patient developed major venous thrombotic complications.

Percutaneous endoscopic gastrostomy

From March 87 to March 92, fifty eight patients were referred to our department for percutaneous endoscopic gastrostomy (PEG). The modality of the feeding tube insertion is described. The most common indications for placement were neurologic disorders in 62% of the cases (n = 36) and malignant diseases in 32% (n = 19). The success rate of the technique was 98.3% (n = 57). No procedure-related mortality was observed. A low rate of major complication (1.7%) and minor complication (10.5%) was noted. Feeding tubes were removed in 21% of patients (n = 12); none of them with malignant disease. Survival curve analysis demonstrated that 50% of patients died within 3 months of PEG placement. Such results raise questions about the selection of patients undergoing PEG. Our experience of patients undergoing PEG. Our experience suggests that PEG is easy and safe, even in debilitated patients, having an acceptable life expectancy.

Operative colonoscopic endoscopy

There are several conditions where operative colonoscopy is useful. Acute colonic pseudo-obstruction or Ogilvie's syndrome is characterized by a acute distension of the colon. Although medical management may be sufficient in many cases, endoscopic decompression must be performed when colonic distension is greater than 12 cm. Insertion of decompression tube to avoid rapid recurrence seems to be adequate. In case of massive lower intestinal hemorrhage, colonoscopy seems to be more accurate than mesenteric angiography. Such endoscopic examination requires an experienced endoscopist. Colonoscopic polypectomy has become the standard method for removal of colonic polyps. Factors influencing the rate of complications have been studied. While the number of complications was very low, we have observed that all the major hemorrhages were immediate when the blended current was used, but delayed when the pure coagulation current was applied. Endoscopic laser photocavitation is a valuable palliative method treating rectal adenocarcinoma in well selected patients. Indeed, if the patients survive sufficiently long after initial therapy, it becomes increasingly difficult to achieve persistent palliation with laser therapy.

Treatment of peptic ulcer severe bleeding

The success of a defined management policy op peptic ulcer haemorrhage which incorporates endoscopic therapeutic intervention depends on the early identification of a high risk group of patients and a high risk group of ulcers. The high risk group of patients consists of those likely to experience further bleeding on the basis of clinical prognostic indicators: shock and severe anaemia on admission and the pattern of bleeding; or tolerate rebleeding and emergency surgery poorly: patients over 60 years and those with associated disease. UGI endoscopy should be performed early (within 6-12 hours) in this group in order to identify the bleeding point and provide prognostic information regarding the risk of further haemorrhage. Peptic ulcers with major stigmata of recent bleeding (spurting or non-bleeding visible vessel) have high risk of rebleeding, the risk is even greater when major stigmata of recent haemorrhage (SRH) are associated with shock on admission. Patients with such ulcers should be monitored intensively and receive endoscopic haemostatic treatment in order to terminate active haemorrhage or prevent rebleeding thereby avoiding the need for emergency surgery with its attendant morbidity and mortality. Patients with ulcers with minor or no SRH have a very low risk of rebleeding and don't require intensive monitoring or endoscopic treatment and can be discharged from hospital early. Ulcers which cannot be completely characterized have an intermediate risk of rebleeding and should be managed as high risk lesions. Secondary to the anatomy of the visible vessel any haemostatic endoscopic treatment should be applied around, but avoiding, the sentinel clot. Well-designed randomized controlled trials of endoscopic haemostatic treatment of peptic ulcer haemorrhage in which stratification of risk was based on the SRH, have demonstrated for non-bleeding vessel a significant reduction in rebleeding and in emergency surgery, for spurting bleeding benefit was found only for the rebleeding risk. No advantage was demonstrated in each group of patients in term of mortality. Such studies also demonstrate the superiority of the Nd:YAG laser over the Argon laser. Perforation is a rare complication of Nd:YAG laser photocoagulation (less than 1%). Precipitation or aggravation of arterial haemorrhage during treatment of a visible vessel, as a result of a direct hit, is a more frequent complication (0-29%). Further laser treatment is successful in terminating 75% of these induced bleeds, the remainder requiring surgery. Preinjection of the ulcer with adrenaline does not appear to prevent this complication.(ABSTRACT TRUNCATED AT 400 WORDS)

Endoscopic treatment of esophagogastric varices

We report our current management of variceal bleeding with endoscopic sclerotherapy. We emphasize the importance of resuscitation and of recording at time zero and within the first 72 hours clinical and laboratory indicators, as these influence the management of these patients. Primary sclerotherapy using Histoacryl for active bleeding and Ethoxysclerol for recent bleeding should be performed as soon as the patient is stable hemodynamically. As we have identified factors related to the severity of hemorrhage and of liver failure degree which can predict early failure of sclerotherapy, patients presenting with these findings should be, in the future, referred quickly toward alternative therapies among which non-surgical intrahepatic shunt appears a promising modality.

[Enteroscopy: methods and results]

Recent advances in the instrumentation and techniques of enteroscopy now permit examination of the small bowel. This report is on the use of a prototypic small bowel enteroscopy to investigate patients with gastrointestinal bleeding of obscure origin. We used the sonde-type enteroscope (Olympus Corp.) that migrates distally responding to peristaltic activity. This instrument has neither tip deflection controls nor interventional capability. Small bowel enteroscopy was performed in 17 patients. Arteriovenous malformations were visualized in 5 patients but three of them suffered from Rendu-Osler disease. Small bowel enteroscopy can be useful in the evaluation of patients with gastrointestinal bleeding of obscure origin. However, patients must be well selected on basis of negative routine examinations because this method is time-consuming.

[Acute dilatation of the colon]

Dilated colon is provoked by obstructing lesions, toxic megacolon or colonic pseudoobstruction. The obstructing lesions of the colon are colonic volvulus, inflammatory bowel disease with stenosis or colonic cancer. Toxic megacolon is more often caused by I.B.D. and rarely by infectious diseases. Etiological diagnosis is possible after clinical and radiological evaluation. Colonoscopy is always indicated, except in toxic megacolon. Balloon dilatation of strictures, palliative treatment of colonic carcinoma by Laser procedures, reduction of colonic volvulus and aspiration of colonic pseudoobstruction are the principal indications of therapeutic colonoscopy in the non surgical treatment of dilated colon.

Macroscopic and microscopic gut lesions in seronegative spondyloarthropathies

A retrospective study by ileocolonoscopy and multiple biopsies was performed on 96 patients with seronegative spondylarthropathy, 17 patients with osteoarthritis (OA) and 19 patients with chronic abdominal discomfort. Under these conditions, inflammatory gut lesions were detected in 66.7% of the patients with spondyloarthropathy, 12.5% with OA and 15.8% with chronic abdominal discomfort. In 10 patients treated by sulfasalazine (Salazopyrine), pathologic lesions disappeared simultaneously with an improvement of the rheumatic conditions. comparison between patients treated and untreated with nonsteroidal inflammatory drugs (NSAID) demonstrated that NSAID did not enter into the etiopathology of the intestinal lesions. Our study therefore confirms the high incidence of inflammatory gut lesions among patients with spondylarthropathy which seems not to be related to NSAID therapy.