Severe abdominal pain in patients with AIDS: frequency, clinical aspects, causes, and outcome

BACKGROUND

The exact prevalence of abdominal pain in AIDS patients, as well as the entire spectrum of causative disorders, has not yet been well defined. In addition, the existing data derive almost exclusively from surgical series describing only those patients who have undergone emergency surgical procedures.

METHODS

We reviewed our experience with patients presenting with severe abdominal pain from a large series of non-selected consecutive AIDS patients seen at our institution over a period of 4 years.

RESULTS

Of 458 patients, 71 (15%) had severe abdominal pain, and its occurrence was associated with a reduced patient survival. Specific diagnoses were made premortem in 42 patients (59%), potential causes of pain were identified at postmortem examination in 23 patients (33%), whereas no specific causes were found in 6 patients (8%). Most of the causative disorders (65%) were AIDS-related, whereas HIV-independent pathologic conditions were found in only 18% of the patients. The predominant site of pain, combined with a few key symptoms, had a high predictive diagnostic value in nearly half of the patients. The indications for emergency laparotomy were limited and substantially similar to those of the non-HIV population.

CONCLUSIONS

Severe abdominal pain frequently complicates the course of AIDS, and its occurrence is associated with reduced survival. In most patients it is due to disorders closely associated with the HIV infection. Specific causes of pain may be identified in most of the cases by an appropriate diagnostic evaluation.

Laparoscopic cholecystectomy using methyl tert-butyl ether: preliminary results

We evaluated the usefulness of methyl tert-butyl ether in gallbladder extraction during laparoscopic cholecystectomy when large stones are present. Five patients with symptomatic gallbladder stones larger than 30 mm underwent laparoscopic cholecystectomy according to the standard procedure. Extraction of the gallbladder without enlarging the 10-mm orifice was not possible because of the large stones. We infused MTBE in the gallbladder through a 9-French polyethylene catheter passed into its neck already pulled out of the umbilical port. The solvent was injected, aspirated after 10 to 15 s, and then immediately reinjected. This procedure continued until the stones softened and it became possible to crush and to remove them easily with a forceps or aspirator. The mean duration of the entire procedure was 7.7 +/- 1.57 min. Methyl tert-butyl ether infusion should be considered during laparoscopic cholecystectomy because it is a cheap and fast method to allow gallbladder extraction when large stones are present.

Percutaneous alcohol sclerotherapy of simple hepatic cysts. Results from a multicentre survey in Italy

The increased use of Ultrasonography (US) has led to increased detection of simple hepatic cysts. For symptomatic cysts treatment is necessary. Until some years ago surgery was the only therapy. We have treated a large number of patients with Percutaneous Alcohol Sclerotherapy (PAS) and evaluated retrospectively the efficacy of this approach. Data on 21 patients with symptomatic simple hepatic cysts were reviewed retrospectively. Cysts had a mean diameter of 9 cm (range: 7-15 cm). PAS was always performed under local anesthesia and US guidance. 25% of the volume was replaced with 95% ethanol and then completely aspirated after 20-30 minutes. No complications or deaths occurred. In all patients symptoms disappeared after treatment. In 15 out of 21 cases there was no evidence of residual cyst on US, computed tomography (CT) or magnetic resonance (MRI). In 6 patients with shorter follow-up, cysts showed a mean reduction in diameter of 50%. The mean follow-up was 18 months (range 6-60 months). We conclude that PAS is easy with low risk for the patients and with good long-term results; it should therefore become the procedure of choice for simple hepatic cysts.

[Resection of the sigmoid via laparoscopy: an experimental study of its feasibility]

The authors describe an experimental laparoscopic sigmoid colon resection performed in the porcine model. The operation begins with the introduction of the laparoscope via an umbilical trocar. Five other trocars are then placed allowing different maneuvers. The sigmoid colon is grasped in order to gain access to its mesenteric vessels which are clipped and divided, carrying out the dissection of the entire sigmoid colon. Two modified Endo-GIA are then fired both cranially and caudally, in order to obtain a closed sigmoid specimen and to maintain patent the lumen of the descending colon and rectum. The sigmoid is removed transanally. A P-CEEA stapler is introduced via the rectum and its detached anvil is put into the lumen of the descending colon. A purse-string is applied and closed around the anvil rod. The P-CEEA is retracted, and the rectal stump closed with another Endo-GIA. After reintroducing the trocar-loaded stapler, the trocar is advanced through the suture line of the rectum and removed via a port. The stapler is then reassembled, fired and extracted through the anus. Taking into account the oncologic criteria, we think that this mini-invasive technique could be applied, after an adequate training period on the animal model, to humans also.

Endometrioma of the liver

Hepatic endometriosis is extremely rare. We describe a patient sent to us with epigastric pain as the only symptom and who was found to have associated endometrioma of the liver and left ovary. We suggest a gynecologic evaluation before surgery for hepatic cyst of unknown cause.

Effects of autonomic nervous system on gastric damage by ethanol in the rat

To study whether or not the autonomic nervous system influences the defense mechanisms of the gastric mucosa, groups of Sprague-Dawley rats were given stimulants and inhibitors of the different components of the vagus and celiac nerves before administration of absolute or 70% w/v ethanol. The effects of vagotomy and sympathectomy on "adaptive cytoprotection" were studied, as were the effects of blocking the muscarinic receptors and stimulation of beta-adrenergic receptors. We found that: (1) cholinomimetic agents and norepinephrine make the damage caused by 70% ethanol worse; (2) atropine is the only agent that fully protects against absolute ethanol; (3) vagotomy and sympathectomy abolish the effects of atropine and adaptive cytoprotection; and (4) beta-adrenergic stimulation replaces conditions that allow adaptive cytoprotection and the protection by anticholinergics. These results suggest that two different reflexes are triggered by ethanol: when low concentrations are given, the beta-adrenergic-mediated effect is prevalent, with protection of the mucosa; when high concentrations are given, the cholinergic-mediated effect is prevalent with damage of the mucosa.

Adaptive cytoprotection: an endoscopic study in man

We studied the protective effect of the mild irritant 20% ethanol against the damage caused by the strong irritant 40% ethanol to the duodenal mucosa of 10 healthy volunteers. At time 0, placebo (1% ethanol) or 20% ethanol (6 ml) was sprayed directly onto the duodenal wall through an endoscope. After 15 min 40% ethanol (50 ml) was given; damage was assessed by endoscopic examination 30 min after ethanol. The damage was scored arbitrarily: score 0, no damage; 1, duodenal hyperemia; 2, one hemorrhagic lesion; 3, two to five hemorrhagic lesions; 4, five hemorrhagic lesions. In separate experiments, the effect of acetylsalicylic acid (20 mg/kg iv) on adaptive cytoprotection was evaluated. It was found that 1) 20% ethanol does not damage the duodenal mucosa, whereas 40% ethanol does; 2) duodenal hyperemia and hemorrhagic lesions caused by 40% ethanol can be prevented by the previous administration of 20% ethanol; and 3) acetylsalicylic acid does not damage the duodenal mucosa but abolishes the protective effect of 20% ethanol. "Adaptive cytoprotection" is a physiological phenomenon in humans too and further supports the probable defensive role of endogenous prostaglandins in the gastrointestinal tract.

Hyperalimentation of jaundiced patients on percutaneous transhepatic biliary drainage

Although percutaneous transhepatic biliary drainage (PTBD) restores hepatic and renal function in patients with obstructive jaundice, it is not certain whether it reduces the rate of complications and death after biliopancreatic surgery. We studied the possibility that the operative risks of jaundiced patients are related to malnutrition and the usefulness of hyperalimentation with PTBD to reduce the incidence of complications. Sixty-four patients with obstructive jaundice and serum bilirubin greater than 200 mumol/l were randomized into two treatment groups (n = 32) with PTBD or PTBD + hyperalimentation. Four patients were withdrawn from the latter group, two for metastatic cancer and two for complications of PTBD. Before starting hyperalimentation, the incidence of malnutrition was assessed by biochemical, immunological and anthropometric tests: malnutrition was found in 70 per cent of the patients. All the patients had good recovery of hepatic function but patients treated with PTBD alone still had high mortality (12.5 per cent) and morbidity (46.8 per cent) after biliopancreatic surgery. When hyperalimentation was provided to patients on PTBD for a period of 20 days before the operation, the incidence of complications fell to 17.8 per cent and mortality to 3.5 per cent. These results suggest that the combined use of PTBD and hyperalimentation, improving both hepatic function tests and the nutritional status of jaundiced patients, can reduce the rate of complications after biliary and pancreatic surgery.

Protection of gastric mucosa in rats. Differences between vagotomy, atropine, and PGE2

We have studied the protective effects of truncal vagotomy, atropine, and PGE2 against gastric mucosal injury produced by necrotizing agents (0.2 N NaOH, 0.6 N HCl, absolute ethanol), acetylsalicylic acid (ASA) and HCl, or serotonin (5HT). Vagotomy, atropine, and PGE2 prevent the effects of different noxious agents. Vagotomy is protective only against 5HT and against ASA + 0.15 N or 0.35 N HCl, whereas atropine and PGE2 are also protective against the necrotizing agents. The effectiveness of vagotomy against ASA + 0.35 N HCl does not depend on the inhibition of acid secretion and supports the hypothesis that removal of the vagal drive counteracts the effect of H+ back-diffusion.

A new technique for preparing continent gastric fistulas in dogs

A new technique is described for making continent gastric fistulas in dogs. It is characterized by an antireflux flap of the gastric wall. It does not require a large laparotomy incision or gastric sutures, is simple, and takes only 30 minutes. Gastric secretion tests have demonstrated that this technique is followed by stable reproducible secretion.

The effects of 9-hydroxy-19,20-bis-norprostanoic acid on mucus, acid and gastrin secretion in duodenal ulcer patients

The effects of 9-hydroxy-19,20-bis norprostanoic acid (rosaprostol, IBI), a new prostaglandin analogue, on gastric secretion and gastrin release were studied in 15 patients with duodenal ulcer. In acute experiments, rosaprostol lowered pentagastrin-stimulated acid secretion by 27-36%, whereas after chronic administration there were no changes in acid secretion or gastrin release (fasting and oxo-stimulated) but N-acetylneuraminic acid (NANA)-glycoproteins increased significantly. Our results indicate that the antisecretory and mucopoietic activities of 9-hydroxy-19,20-bis-norprostanoic acid are the basis of its healing effect in duodenal ulcer patients.

New trends in the diagnosis and therapy of acute cholangitis

For a long time, acute cholangitis has been a difficult therapeutic problem, mostly due to the limited information about the jaundiced patient available from diagnostic investigations. The diagnostic precision of percutaneous transhepatic cholangiography in association with the great therapeutic possibilities of percutaneous transhepatic biliary drainage has solved this problem. The successful results obtained in 37 patients with acute cholangitis prove the value of this approach.

The colonization of Streptococcus faecium in human intestinal tract after oral administration

The colonizing ability of Streptococcus faecium strain SF 68 at different levels of the gastrointestinal tract was assessed in ten patients. They were orally treated with a preparation containing the bacteria in lyophilized form for three days. During an abdominal surgical operation a sample of bacterial content of jejunum, ileum and colon was taken and cultured. The Streptococcus faecium was detected in all treated patients in a quite high concentration compared to the counts of both aerobic and anaerobic germs. These data confirms the rapid growth of SF 68 after oral administration in the gastrointestinal human tract.