61/533. Severe hyperphosphataemia and associated electrolyte and metabolic derangement following the administration of sodium phosphate for bowel preparation. sodium phosphate is widely used as an effective bowel preparation agent. It is used in smaller volumes, leading to improved patient tolerance. Although it is generally safe, cases of severe hyperphosphataemia following sodium phosphate administration have been reported in the literature. The common risk factors identified are advanced age, impaired renal function, impaired colonic motility and multiple doses. However, many doctors remain unaware of the dangers associated with this agent. We report six cases of severe electrolyte and metabolic derangement due to sodium phosphate bowel preparation: two patients had delayed awakening from general anaesthesia, and four patients suffered life-threatening consequences. ( info) |
| In this report, we describe a patient with acute terminal ileitis due to streptococcus pneumoniae, review 3 previously reported cases of isolated enteritis due to S. pneumoniae, and summarize the English-language literature on primary and secondary pneumococcal gastrointestinal diseases. Various theories have been advanced to explain the pathogenesis of this rare and potentially life-threatening form of pneumococcal infection, but the mechanism by which S. pneumoniae causes gastrointestinal disease is still unknown. ( info) |
63/533. Acute disseminated encephalomyelitis in adults: a reappraisal of clinical, CSF, EEG, and MRI findings. OBJECTIVES: To establish an adequate definition of acute disseminated encephalomyelitis (ADEM) in adults, based on our clinical observations of a case-series. methods: Over a period of three years 10 adult patients with a para- or postinfectious disseminated (diffuse or multifocal) syndrome of the CNS fulfilling predefined strict criteria for the diagnosis of ADEM were encountered and systematically followed. RESULTS: The age ranged from 21 to 62 years, two were men. MRI was normal in 5 patients and only mildly abnormal in the remaining patients. CSF was normal in 5 patients and mildly abnormal in the remainder, EEG was abnormal in 7/8 patients. All patients survived and were followed over a period of 30 months (range: 8 to 48 months). Nine patients were left with some residual defects, consisting most often of a mild cognitive impairment. CONCLUSIONS: The EEG as an investigation of brain function can be crucial in establishing the organic nature of disease. MRI is important to exclude other diffuse or multifocal encephalopathies. However, in contrast to previous reports in the literature abnormal MRI should not be considered mandatory in adult ADEM. Difficulties in the diagnosis of ADEM are discussed and the importance of clinical and paraclinical findings for establishing the diagnosis is outlined. ( info) |
64/533. Additive gastrointestinal effects with concomitant use of olestra and orlistat. OBJECTIVE: To report a case of significant additive gastrointestinal effects with concomitant use of orlistat and an olestra-containing snack food. CASE SUMMARY: A 16-year-old African American girl with type 2 diabetes, hypercholesterolemia, and hypertension was participating in a pilot study that tested the safety and efficacy of orlistat. After 2 weeks of orlistat treatment, the patient presented to the clinic with complaints of soft, fatty/oily stools, flatus with discharge, abdominal pain, increased flatus, and fecal incontinence. On further questioning, it was determined that she was also consuming approximately 5 ounces of olestra-containing potato chips on a daily basis. The patient eliminated olestra from her diet and returned to the clinic with substantially diminished gastrointestinal adverse effects, despite continuing to take orlistat. DISCUSSION: This is the first published case describing additive gastrointestinal effects after concurrent use of orlistat and olestra. education about the potential for serious additive gastrointestinal adverse effects is important to prevent premature and unnecessary discontinuation of orlistat therapy. awareness of this potential interaction could be especially important for patients with underlying disease states in which severe gastrointestinal symptoms could result in significant complications. CONCLUSIONS: This case illustrates that significant gastrointestinal distress may result after olestra consumption during orlistat therapy. All patients receiving orlistat for the management of obesity should be properly educated about this potential drug-food interaction. ( info) |
65/533. Diverticular disease of the small bowel: report of 27 cases. Diverticula of the small bowel are usually asymptomatic but occasionally can present with serious complications. Because of the rarity of small bowel diverticulosis and the limited case number in most published reports, we analyzed one of the largest series with symptomatic small bowel diverticular disease. In this retrospective review, we studied 27 symptomatic patients with diverticula of the small bowel that was treated surgically. The study included 13 male and 14 female patients (age range, 30-87 years; mean age, 69.3 years). Fourteen patients underwent an elective operation for chronic refractory symptoms. Thirteen patients underwent emergency surgery because of rupture of the diverticula and associated peritonitis, diverticulitis and small bowel obstruction, or lower gastrointestinal bleeding. Surgical treatment consisted of resection of the intestinal segment containing the diverticula. All patients were symptom-free postoperatively and no "short bowel" problems developed. abdominal pain, gastrointestinal bleeding, and bowel obstruction were the most common clinical symptoms. Small bowel diverticulosis should be treated surgically only when refractory symptoms or severe complications are present. ( info) |
66/533. Pathways of extrapelvic spread of disease: Anatomic-radiologic correlation. Extrapelvic spread of disease, particularly from gastrointestinal tract perforations which may be clinically occult, may first present in the buttock, hip, thigh, and even lower leg, and the extraperitoneal space of the abdomen itself. Clinical manifestations at these remote sites may be very misleading. Anatomic and roentgenologic observations establish the preferential pathways of extrapelvic spread. These are related to the insertions and fascial investments of the iliopsoas, pyriformis, and obturator internus muscles and the ensheathed penetrations of the superior gluteal arteries. Superiorly, extension from the pelvic tissues seeks out the posterior pararenal compartment of the extraperitoneal region of the abdomen. Roentgenologic signs may first identify the presence, extent, and localization of the primary process. ( info) |
67/533. Gastrointestinal manifestations of the muscular dystrophies. Five patients with acute megacolon with varied types of progressive muscular dystrophy are presented. Dysfunction of smooth muscle among patients with muscular dystrophy is reviewed. The extra gastrointestinal roentgen features are summarized. Recognition of the diffuse smooth muscular involvement among patients with muscular dystrophy is stressed for proper diagnosis and patient management. ( info) |
| Autoimmune impairment and destruction of the enteric nervous plexus are thought to play a central role in the pathogenesis of paraneoplastic motility disorders. We present a case of a small-cell lung carcinoma-related paraneoplastic motility disorder associated with abnormal interstitial cells of cajal networks. antibodies against c-Kit and protein gene product 9.5 were used to selectively stain interstitial cells of cajal and the enteric nervous plexus, respectively. A 68-yr-old man presented with anorexia, early satiety, nausea, and weight loss. Investigations revealed gastroparesis, delayed small intestinal transit, and mediastinal lymphadenopathy. The patient was seropositive for type 1 antineuronal nuclear autoantibody and P/Q-type calcium channel antibody. biopsy of mediastinal lymph nodes revealed metastatic small-cell carcinoma cells that were immunoreactive for c-Kit. Immunohistochemical staining of a full-thickness small intestinal biopsy revealed a relatively intact myenteric plexus but a sparse and disorganized interstitial cells of cajal network. The histopathology of this case suggests that interstitial cells of cajal may be a target in the pathogenesis of paraneoplastic motility disorders. ( info) |
69/533. Upper gastrointestinal endoscopic ultrasound and its impact on patient management: 1990-2000. BACKGROUND: Endoscopic ultrasound (EUS) is a relatively new method used in the investigation and staging of upper gastrointestinal tract (UGIT) disease. AIMS: To review practice and outcomes of EUS in an Australian university teaching hospital. methods: The first part of the study was a retrospective review of indications, safety, referral patterns and technical difficulties of all EUS procedures performed at Concord Hospital, new south wales, australia, over a 10-year period from 1990 to 2000. The second part of the study examined the impact of EUS on the management of 225 consecutive cases, as determined by a questionnaire completed by each of the referring doctors. RESULTS: A total of 537 EUS examinations was performed over the 10-year period. Indications for EUS included: (i) assessment of oesophageal lesions (241), (ii) assessment of gastric lesions (184) and (iii) assessment of pancreaticobiliary (112) disease. Cancer staging was performed in 46.7% of oesophageal and 31.4% of gastric cases. Sedation was achieved using intravenous midazolam (5.3 /-1.3 mg; mean /- SD) and 52% of cases required additional intravenous pethidine (48.5 /-10.0 mg; mean /- SD). Technical difficulties were encountered in 11% of cases and these were mainly related to nontraversable luminal stricturing. Of the 537 referrals, 48.2% were from within Central Sydney Area health services, and the remainder were from other Sydney hospitals, new south wales regional centres and interstate. Of 225 questionnaires sent to referring doctors, 146 questionnaires were completed and returned for analysis. EUS aided staging of malignant disease, and confirmed or established a diagnosis in 86% of cases. The diagnostic accuracy of EUS was 76% when confirmed histologically. EUS avoided further diagnostic investigations in the majority of cases and in 25% of cases surgery was avoided. Fine-needle aspiration biopsy (FNAB) during EUS would have been useful in 30% of cases. overall, clinical decision-making and management were changed in one-third of cases. CONCLUSIONS: Endoscopic ultrasound is an accurate, safe and useful imaging method in UGIT disease. The increasing demand for EUS and EUS-guided FNAB suggests an expanding future for EUS in australia. ( info) |
70/533. US and MRI of gastrointestinal graft-versus-host disease. Abdominal problems often complicate the clinical course after bone marrow transplantation. Graft-versus-host disease occurs as a complication of allogenic bone marrow transplantation. In this report, the findings of intestinal involvement are described and correlated with histopathological findings. Increased bowel-wall thickness and increased vascularity were shown by US. MRI demonstrated generalised increased bowel-wall thickness associated with bowel-wall enhancement after administration of i.v. gadolinium. ( info) |