Portal hypertensive gastropathy.

Portal hypertensive gastropathy (PHG) is part of a complex syndrome which occurs as a complication of chronic liver disease and portal hypertension (PHTN). At endoscopy, the gastric mucosa shows that mosaic-like pattern and red marks, which are the source of gastric bleeding. Only the severe form of gastropathy is liable to bleed. The pathogenesis of PHG and the hemodynamic changes in PHTN are not completely understood, but chronic increase in portal pressure is a prerequisite for the development of this disorder. It has been suggested that an overproduction of endogenous vasodilators and a reduced vascular sensitivity to endogenous vasoconstrictors contribute to these circulatory disturbances. H2 receptor antagonists and sucralfate are ineffective in the management of bleeding PHG. Two small studies reported that propranolol is effective in arresting mucosal hemorrhage from severe PHG. Other feasible alternatives include transjugular intrahepatic portal-systemic shunt (TIPS) and portal-systemic shunt procedure.

Occult celiac sprue masquerading as severe iron deficiency anemia.

Severe iron deficiency was the presenting manifestation in a patient with occult celiac sprue that went unrecognized for a prolonged time. Endoscopic abnormalities and the absence of typical symptoms may contribute to a delay in diagnosis unless a high index of suspicion is maintained.

Secretin provocation test in the diagnosis of Zollinger-Ellison syndrome.

The secretin stimulation test has become the preferred provocative test in suspected cases of Zollinger-Ellison syndrome. A pure secretin preparation, a gastrin-specific radioimmunoassay, and an appropriate sampling sequence are important for the proper interpretation of this test. Gastric acid analysis is necessary in the assessment of hypergastrinemia to confirm acid hypersecretion and exclude achlorhydria. When properly performed and interpreted, the secretin provocation test offers a safe, expeditious, and reliable means of evaluating patients with hypergastrinemia.

Colon cleansing for diagnostic and surgical procedures: polyethylene glycol-electrolyte lavage solution.

Recent work has shown that polyethylene glycol-electrolyte lavage solutions provide adequate cleansing in preparation for colonoscopy, barium enema, intravenous pyelography, and colon surgery. It is safe and well tolerated by patients, and seems ideal for those with renal or cardiovascular disease who must undergo colon cleansing. We review the development of polyethylene glycol-electrolyte lavage solution and the clinical experience with various colon-cleansing preparations.

Healing of severe perineal and cutaneous Crohn's disease with hyperbaric oxygen.

Recurrent perineal Crohn's disease can be an extremely debilitating complication that may be difficult to treat. We report a patient with progressively worsening perineal and biopsy-proven cutaneous Crohn's disease that had been refractory to surgery and medical treatment (sulfasalazine, steroids, 6-mercaptopurine, metronidazole, antibiotics). As the lesions were reminiscent of problem wounds occurring in other situations, hyperbaric oxygen treatment was instituted while the patient was continued on metronidazole. Response was dramatic with almost immediate relief of symptoms and regression within 2.5 mo of wounds that had previously defied therapy for 8 yr. Clinical remission has not been sustained as four subsequent courses of hyperbaric oxygen have been given over a period of 11 mo. However, the patient has been essentially asymptomatic since her initial course and the extent of her cutaneous disease has been minimal compared with that before hyperbaric oxygen. Hyperbaric oxygen treatment is costly and should not be routinely used in every patient with perineal Crohn's disease. However, this case report may herald an advance in the understanding of the pathogenesis of this complication and ultimately, its therapy.

Alterations in oxygen saturation and ventilation after intravenous sedation for peritoneoscopy.

The effect of intravenous sedation on oxygen saturation and ventilation was studied in 11 patients undergoing peritoneoscopy. Oxygen saturation (mean +/- SD) decreased from baseline (94.7% +/- 1.7%) to nadir (78.6% +/- 10.7%) after sedation. Respiratory depression was evident in these patients by concomitant decreases in minute ventilation and tidal volume. Baseline to nadir arterial blood gas changes in eight patients were consistent with hypoventilation and also suggested a superimposed ventilation perfusion mismatch. Mean respiratory rate did not significantly change during peritoneoscopy. Peritoneal gas insufflation stimulated increased ventilation and oxygen saturation, but no further changes in PCO2 or pH. We conclude that serious arterial oxygen desaturation and possibly some ventilation perfusion mismatch occur after sedation with intravenously administered meperidine-diazepam for peritoneoscopy with resultant hypoxemia, hypercarbia, and acidosis.

Is the gastrin response to secretin provocation a function of antral G-cell mass? Results in the hypergastrinemia of acid hyposecretion.

Some patients with hypergastrinemic achlorhydria may have false-positive secretin provocation as an exaggeration of the normal gastrin response to secretin, presumably related to an increased, or more responsive, antral G-cell mass. To test this hypothesis, we reviewed our experience with secretin provocation in normogastrinemic subjects with presumed normal antral G-cell mass (normal--17, duodenal ulcer--13) and in patients with hypergastrinemia related to changes in antral G-cells (vagotomy--5, hypochlorhydria--7, achlorhydria--10). Basal serum gastrin (mean +/- SEM) was progressively higher for each group; normal (42 +/- 3 pg/ml), duodenal ulcer (53 +/- 4 pg/ml), vagotomy (226 +/- 54 pg/ml), hypochlorhydria (346 +/- 92 pg/ml), achlorhydria (844 +/- 100 pg/ml). On selective analysis of only those with gastrin rises, significant differences (p less than 0.05) in peak gastrin change were found between achlorhydria (93 +/- 21 pg/ml) compared with all other groups and between hypochlorhydria (40 +/- 12 pg/ml) versus normal (6 +/- 1 pg/ml). Linear regression in these responders showed a significant correlation (p less than 0.001) between basal gastrin and peak gastrin change after secretin. There were no false-positive secretin provocation tests, but four achlorhydric patients had gastrin rises greater than 100 pg/ml, whereas no patient in the other categories had rises above 90 pg/ml. Our results support the concept that patients with hypergastrinemic achlorhydria tend to have greater G-cell responsiveness to secretin provocation, which may account for the false-positive results in some such patients.

Biopsy evaluation of chronic active hepatitis. Peritoneoscopy with directed liver biopsy versus blind percutaneous liver biopsy.

In this prospective study of chronic active liver disease, we compared the assessment of hepatic histology in samples obtained by peritoneoscopy with directed liver biopsy and blind percutaneous liver biopsy in 23 cases (22 patients, one patient studied twice). In blinded fashion, a pathologist assessed all specimens for evidence of cirrhosis and degree of necroinflammatory change. Two clinicians independently reviewed clinical and laboratory findings in both sets of biopsies. Each committed in writing recommendations regarding immunosuppressive therapy, follow-up interval, and rebiopsy date. The final diagnosis differed from that made by percutaneous and directed biopsy in 2 of 23 (9%) and 1 of 23 (4%) cases, respectively. Six cases of cirrhosis were correctly diagnosed by both biopsy methods, but only four of the six cirrhotic cases were diagnosed by gross peritoneoscopic findings. In only 2 of 23 (9%) cases was there disagreement in the degree of necroinflammatory change between the blind and directed biopsies that affected treatment recommendations. We conclude that blind percutaneous biopsy adequately diagnoses and monitors activity in viral chronic hepatitis for treatment purposes.