Amoxicillin/clavulanate-associated hepatic failure with progression to Stevens-Johnson syndrome.

OBJECTIVE: To describe a patient who developed hepatic failure, Stevens-Johnson syndrome (SJS), and died after receiving amoxicillin/clavulanate therapy. CASE SUMMARY: A 37-year-old white man without significant past medical history received a 10-day course of amoxicillin/clavulanate for treatment of pneumonia. Thirty-two days after starting amoxicillin/clavulanate, he developed jaundice, rash, pruritus, and increasing fatigue. On further evaluation, with the exclusion of toxicity from other drugs or diseases, the time course to development of cholestatic jaundice correlated with the use of amoxicillin/clavulanate. The patient consequently died with progressive hepatic failure, renal failure, and SJS. DISCUSSION: Hepatic injury has been reported with amoxicillin/clavulanate. Signs and symptoms of jaundice and pruritus may appear up to to six weeks after stopping therapy. Most cases of liver injury have been benign and reversible on discontinuation of the amoxicillin/clavulanate. Reported hepatic reactions have been mainly cholestatic, with some mixed cholestatic/hepatocellular liver function test abnormalities. CONCLUSIONS: Clinicians should be aware of amoxicillin/clavulanate as a drug capable of causing hepatitis with eventual systemic dysfunction. While recovery is usually complete following withdrawal of the drug, in patients with rash associated with hepatic dysfunction, renal insufficiency, or other unusual symptoms, earlier consideration of initiating systemic steroids or liver transplantation referral, in hopes of avoiding progressive systemic response, might be worthwhile.

Bleeding from polypoid colonic arteriovenous malformations.

The endoscopic appearance of vascular ectasias has been well characterized. We present two cases of bleeding polypoid colonic arteriovenous malformations.

Nonsteroidal anti-inflammatory drugs: gastroduodenal injury and beyond.

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) is extensive, and the upper gastrointestinal (GI) side effects of these drugs have been well recognized. Although much attention has been focused on gastroduodenal ulceration and attendant complications, it is becoming more apparent that NSAIDs exert potentially important effects on the small bowel and colon. The widespread effects of NSAIDs on the GI system, including theories of pathogenesis, will be presented here.

Cecal volvulus: decompression and detorsion with a colonoscopically placed drainage tube.

Cecal volvulus is an uncommon cause of intestinal obstruction. Operative management is the accepted form of treatment. We report a patient with cecal volvulus who was a poor surgical risk and was successfully treated by decompression and detorsion with the use of a decompression tube inserted through the colonoscope.

Endoscopic retrograde cholangiopancreatography in the diagnosis and management of postcholecystectomy cystic duct leaks.

Two patients with postcholecystectomy cystic duct leaks are presented. Both patients were symptomatic and septic in the postoperative period. After endoscopic biliary decompression, the biliocutaneous fistulae closed rapidly, and rapid resolution of symptoms was achieved.

Effect of narcotic premedication on scintigraphic evaluation of gallbladder perforation.

A case of gallbladder perforation is presented in which a small bile leak was demonstrated by cholescintigraphy while the patient was receiving meperidine, but not after meperidine was discontinued. The scintigrams obtained during meperidine therapy also showed a pattern of bile-duct obstruction. It is suggested that increased biliary pressure secondary to meperidine administration permitted visualization of the leak. Use of narcotic drugs may be a useful pharmacologic intervention in cases of peritonitis due to small or obscure bile leaks.

Clinical significance of the preoperative plasma carcinoembryonic antigen (CEA) level in patients with carcinoma of the large bowel.

Preoperative levels of perchloric acid extractable plasma CEA were measured in 911 patients with complaints of the digestive system. A final diagnosis of benign disease was made for 579 patients; 332 patients were found to have cancer. Data for the preoperative CEA values were examined for clinical significance as an aide to diagnosis, preoperative disease staging, and prognosis. The results of our analysis support the conclusions of many investigators that the CEA assay is not a clinically useful diagnostic test, but it shows limited value in preoperative staging and a somewhat stronger correlation with prognosis.

Clinical evaluation of the Makari Intradermal Test in patients with cancer of the colon and rectum.

A clinical study to evaluate the Makari Intradermal Test (MIT) involved 180 patients seen with symptoms suggestive of malignant disease, 85 of whom were subsequently shown to have carcinoma of the large bowel, and 66 asymptomatic volunteers. The prognostic value of initial and serial studies relative to patient-survival rate and the efficacy of serial studies in detecting disease in long-term follow-up of patients with resected malignant lesions were evaluated. On the basis of this study, the MIT appears to merit further investigation, not as a definitive diagnostic procedure, but as a survey for identifying patients with early malignancy or individuals at high risk to malignant epigenesis.

Ultrasonography of pancreatic lithiasis.

The ultrasonograms of 13 patients with pancreatic lithiasis associated with chronic alcoholic pancreatitis were reviewed and compared with the abdominal radiographs. Although plain radiographs were sufficient to establish the presence of pancreatic calcifications, in many cases ultrasound provided the additional information concerning duct dilatation and lithiasis in the main duct. The progressive formation of stones with extrusion into the duct of Wirsung was observed in one case. Ultrasound enabled assessment of pancreatic size and detection of focal enlargement or associated carcinoma. Ultrasound serves as a useful guide to appropriate clinical management in patients with this disease.

The diagnosis of post-cholecystectomy cystic duct fistula utilizing endoscopic retrograde cholangiopancreatography.

A patient developed persistent right upper quadrant pain and tenderness following cholecystectomy. An endoscopic retrograde cholangiopancreatogram showed leakage of bile through the cystic duct remnant into the subhepatic space. The endoscopic retrograde cholangiopancreatographic findings (ERCP) are described.

Ultrasonography of biliary tract dilatation without jaundice.

The significance of intrahepatic biliary distension in the nonjaundiced patient was studied. Biochemical profiles and endoscopic and surgical findings were evaluated. Biliary tract disease was proven in 11 of 12 patients, with nine of the 11 having concurrent pancreatic disease. Ultrasound proved a more sensitive indicator of partial biliary obstruction than the serum bilirubin levels. The biliary tract of nonjaundiced patients with ultrasonographic evidence of biliary distension should be evaluated by additional studies regardless of the biochemical profile.