Radiation proctitis: a review.

Radiation therapy of cancers in the pelvic region may lead to radiation proctitis. Radiation injury to the rectal wall eventually causes connective tissue fibrosis and obliterative endarteritis with subsequent local tissue ischemia. Patients with radiation proctitis may be minimally ill and heal spontaneously. However, symptoms of proctitis may persist, and the disease progresses to chronic bleeding and/or stricture and fistula formation. Medical therapy is often unsuccessful, and surgery is eventually required. Because of numerous postoperative complications and no guarantee of success, surgery should only be done as a last resort.

Proctalgia fugax: would you recognize it?

Proctalgia fugax is characterized by sudden and sometimes severe rectal pain that occurs by day or night at irregular intervals. The pain results from dysfunction of the internal anal sphincter. Proctalgia fugax has a uniform clinical picture, and it can be easily diagnosed when recognized. The patient can be assured that nothing serious is wrong. Expensive tests, such as computed tomography or magnetic resonance imaging of the pelvis, are not required. Treatment may be difficult, but if the attacks of pain are numerous and severe,, a calcium channel blocker such as nifedipine (Adalat, Procardia) should be tried.

Giardiasis. Taming this pervasive parasitic infection.

Parasitic infection due to Giardia lamblia can produce severe, disabling gastrointestinal symptoms. Outbreaks have been linked to contaminated municipal water supplies and situations involving person-to-person contact. Immunocompromised patients are especially at risk. Because microscopic examination of stool detects the parasite in only about half of infected patients, use of enzyme-linked immunosorbent assay to detect Giardia-specific antigen is becoming increasingly popular. In most patients, therapy with quinacrine (Atabrine) hydrochloride, metronidazole (Flagyl, Protostat), or a combination of the two is effective.

Managing gallbladder disease with prostaglandin inhibitors.

Experimental studies have shown that prostaglandins increase hepatic bile flow and gallbladder mucin production, cause gallbladder dysmotility, and inhibit intraluminal fluid absorption, thus promoting gallstone formation. By virtue of their positive actions on gallbladder fluid secretion, muscle contraction, and inflammatory properties, prostaglandins may also have a role in the pain of acute cholecystitis. Although only a few clinical studies of the role of prostaglandin inhibitors in gallbladder disease have been done, results show that use of drugs such as aspirin or other nonsteroidal anti-inflammatory agents may prevent gallstone formation and promptly relieve acute pain.

Acute acalculous cholecystitis. A review.

Acute acalculous cholecystitis is an uncommon but very serious illness, that, if undiagnosed, may lead to gallbladder perforation and death. The condition has numerous causes that result in bile stasis and ischemia leading to inflammation and infection in the gallbladder wall. The bedside diagnosis may be difficult, especially in critically ill patients. Current imaging techniques including ultrasonography, computer tomography, and radionuclide cholescintigraphy are very helpful. Depending on the clinical situation, the gallbladder should either be drained by a surgical or percutaneous cholecystostomy under local anesthesia or removed.

Gastrointestinal complications of nonsteroidal anti-inflammatory drugs.

Nonsteroidal anti-inflammatory drugs have become increasingly popular, with more than 90 million prescriptions being written annually. These drugs inhibit the intracellular cyclooxygenase enzyme system, thus blocking the production of various prostaglandin compounds. This, in turn, interferes with normal mucosal protective mechanisms, leading to local injury. Gastrointestinal complications of nonsteroidal anti-inflammatory drug use include ulcerations, hemorrhage, perforation, stricture formation, and the exacerbation of inflammatory bowel disease. Treatment involves stopping the drug if at all possible and then instituting more specific therapy depending on the anatomic area that has been injured.

Chronic liver disease. The scope of causes and treatments.

Evaluation of chronic liver disease begins with a carefully taken history, thorough physical examination, and standard laboratory tests. Often, however, other studies are required, such as a viral hepatitis panel, serologic tests for autoimmune markers, tests for antimitochondrial antibodies, measurement of serum iron and ceruloplasmin levels, liver biopsy, and imaging studies of the extra-hepatic bile ducts. Medical treatment of chronic active hepatitis, primary biliary cirrhosis, and primary sclerosing cholangitis remains unsatisfactory. Early treatment of hemochromatosis and Wilson's disease can prevent cirrhosis and liver failure. Liver transplantation is now a viable procedure for patients with end-stage chronic liver disease.

Blastocystis hominis--a potential intestinal pathogen.

The parasite Blastocystis hominis has been found in 10% to 18% of stool specimens submitted to microbiology laboratories. Controversy exists as to whether this organism can cause illness in humans. We have reviewed the records of 65 symptomatic patients with B hominis in their stool. We conclude that B hominis is a potential pathogen that may or may not require drug therapy depending on the overall clinical circumstances, the severity of symptoms, and the presence of other pathogenic organisms.

Needle biopsy of the liver. A critique of four currently available methods.

There are currently four needle biopsy methods for obtaining tissue from patients with possible diffuse liver disease or cancer. These include percutaneous blind needle biopsy, a visually guided needle biopsy at laparoscopy, guided fine-needle biopsies with ultrasonography or computed tomography, and the transvenous liver biopsy. We and others have found the guided fine-needle biopsy technique to be safe, relatively cheap, and highly accurate in the diagnosis of liver cancer. Blind percutaneous biopsy should be reserved for patients with possible diffuse, noncancerous, liver disease. Guided biopsies at laparoscopy can be done if the other two methods fail to give a tissue diagnosis. The transvenous approach is useful in patients with a coagulation disorder.

A primer on gallstones.

Gallstones may now be diagnosed by means of duodenal bile analysis, ultrasonography, oral cholecystography, cholescintigraphy, and cholecystography during endoscopic retrograde cholangiopancreatography. Dissolution or removal of stones can be achieved with oral pharmacotherapy with bile acid derivatives, extracorporeal shock wave lithotripsy, infusion of either methyl tertbutyl ether or monooctanoin (Moctanin), percutaneous transhepatic removal, endoscopic sphincterotomy, or the traditional surgical procedure, cholecystectomy.

The use of metronidazole (Flagyl) in Crohn's disease.

The efficacy of metronidazole in the treatment of Crohn's disease remains unproven. It has not been superior to a placebo in three small studies. Uncontrolled reports suggest it may be of benefit in selected patients who have not responded to previous medical or surgical therapy. Metronidazole therapy can lead to complete healing of perineal fistulas. Persistent concerns over side-effects, carcinogenicity, and bacterial resistance suggest that drug should be prescribed with caution for long-term use.

Corticosteroids in ulcerative colitis: a skeptical view.

Corticosteroids have numerous antiinflammatory actions and have been used in the treatment of ulcerative colitis since 1950. One can expect a remission rate of 60-80% in patients with moderately severe ulcerative colitis and of 40-55% in severe ulcerative colitis. However, this success often is not sustained. There is no universal agreement on the dose, route of administration, or type of corticosteroid used in published treatment regimens. In this editorial, I discuss these matters.

Persistent hemorrhagic gastritis in a patient with portal hypertension and esophagogastric varices: the role of portal decompressive surgery.

Our patient, with cirrhosis, portal hypertension, varices, and chronic gastrointestinal bleeding from hemorrhagic gastritis, illustrates an important therapeutic principle. Since the gastritis is related to vascular changes and congestion of the stomach wall secondary to increased portal pressure, and not inflammation, measures aimed at local healing or surgical removal of the bleeding area fail. One must attempt to lower portal pressure with drugs such as propranolol and/or undertake portal decompressive surgery.