New salicylate therapies for ulcerative colitis.

Since the development of sulfasalazine about a half century ago, the prognosis for patients with ulcerative colitis has improved significantly. Very recently, the active moiety of oral sulfasalazine, 5-aminosalicylic acid, has been made available as a topical (enema) preparation. In this article, Dr. Bruckstein reviews the advantages of the enemas in the treatment of ulcerative colitis and briefly examines the potential benefits of the new oral salicylate preparations.

Nonsurgical management of cholelithiasis.

Cholecystectomy is accepted and effective therapy for symptomatic cholelithiasis; until recently, it was the only therapeutic option for patients with gallstones. Recently available alternative therapy for cholelithiasis includes oral dissolution therapy with the bile salts ursodeoxycholic acid and chenodeoxycholic acid, extracorporeal shock wave lithotripsy, and instillation of methyl tert-butyl ether directly into the gallbladder. The role of each of these methods in the treatment of patients with gallstones will be reviewed, as well as the epidemiology, pathogenesis, natural history, and roentgenographic characteristics of gallstones, all of which are relevant when choosing appropriate therapy for the individual patient.

Carcinoma of the esophagus. Evaluation and palliation of a deadly disease.

Treatment of squamous cell carcinoma of the esophagus depends on accurate staging of the disease at presentation. Current therapeutic options for patients with localized disease include surgery, radiation therapy, chemotherapy, and endoscopic therapy. Most patients undergo a combination of these therapies. For patients who present with widespread disease, close attention must be paid to palliation of symptoms.

Diagnosis and therapy of acute and chronic diarrhea.

Many patients who present with acute or chronic diarrhea do not have an important organic disease. Most have functional diarrhea. The history, clinical examination, and initial laboratory studies should lead to a provisional diagnosis with respect to organic or functional origin and help define whether the disease affects the small or large intestine. Specific studies are then obtained to define organic causes. The most common causes of acute diarrhea are infections and drugs, while the most common causes of chronic diarrhea are inflammatory bowel disease, malabsorption, parasitic infections, carcinoma of the large bowel, and metabolic diseases. Clinicians should remember that patients with functional diarrhea are as prone to other severe disease as the rest of the population and avoid allowing the functional problem to mask other signs.

Update on colorectal cancer. Risk factors, diagnosis, and treatment.

Colorectal cancer is more common in the Western world than in underdeveloped countries. Diet, longevity, heredity, and presence of other bowel diseases may affect the incidence. Diagnosis is based on results of routine laboratory studies and evaluation of the entire large bowel with air-contrast barium enema and colonoscopy. Surgical resection is the primary therapy for colorectal cancer. Postoperative systemic chemotherapy yields poor results, but hepatic artery infusional chemotherapy offers some benefit to patients who have only hepatic metastases. Follow-up evaluation includes physical examination and laboratory studies every 3 months for the first 2 years and colonoscopy every year.

Chronic hepatitis. The challenge of diagnosis and treatment.

Chronic hepatitis can be caused by a variety of viruses or therapeutic agents, but in about 80% of cases, the cause is unknown. Distinguishing between chronic persistent and chronic active hepatitis is of primary importance in diagnosis and treatment. Percutaneous liver biopsy is necessary to make the distinction. In most cases, chronic persistent hepatitis does not necessitate specific therapy. Chronic active hepatitis responds to a wide range of therapeutic options: corticosteroids, immunosuppressants, antivirals, and immunostimulants. Prognosis depends on the risks and advantages of therapy as well as the severity and cause of the disease.

Dysphagia.

Difficulty in swallowing may result from a motor disorder of the esophagus or an obstructing lesion. Dysphagia for liquids is characteristic of motor disorders, while symptoms on swallowing solid food point to mechanical obstruction. Difficulty initiating a swallow indicates oropharyngeal dysphagia, an abnormality of striated muscle. The major mechanical causes of dysphagia are peptic stricture, esophageal carcinoma and a mucosal ring.

Acute diarrhea.

Acute diarrhea can be life-threatening in the very young, the elderly and the malnourished. Osmotic diarrhea is produced by unabsorbed solutes in the intestinal lumen, while exudative diarrhea is caused by infection and inflammation. Secretory diarrhea results from enterotoxins, oversecretion of gastrointestinal hormones and the action of bile acids. Rapid intestinal transit also may cause diarrhea.

Immunoprophylaxis of viral hepatitis.

Because safe, effective treatment for established viral hepatitis is not available, physicians need to be acquainted with recent advances in prophylaxis. Immune globulin (Gamastan, Gammar) is used for both preexposure and postexposure prophylaxis of hepatitis A, and side effects are rare. Two vaccines (Heptavax-B, Recombivax HB) are licensed for hepatitis B, one is a plasma-derived vaccine, the other a yeast-recombinant vaccine. Indirectly, these also control hepatitis D (delta agent), which needs hepatitis B virus to develop.

Management of the patient with ascites.

Major factors in the development of ascites in the setting of chronic liver disease include portal hypertension and a reduction in plasma oncotic pressure (hypoalbuminemia). Diagnostic paracentesis is indicated on initial presentation of the patient with ascites, when the amount of fluid increases notably, or when the patient's condition suddenly deteriorates. In the management of ascites, attempts should be made to improve the underlying liver disease, and sodium and fluid intake should be restricted. The peritoneovenous shunt is occasionally used to treat intractable ascites.

Managing the percutaneous endoscopic gastrostomy tube.

Percutaneous endoscopic gastrostomy is an effective means of providing alimentation to patients who are unable to swallow. Commercial kits that contain the necessary equipment are now available and are easy to assemble and insert. Because of its safety, efficacy, and cost-effectiveness, this procedure will probably become the preferred technique for inserting the feeding tube. Management of the patient and the tube, as reviewed here, can be learned quickly.

Splenomegaly. When and how to treat.

Splenomegaly results from a variety of illnesses that can interfere with normal splenic function. The great number of potential predisposing factors and clinical settings necessitates a thorough history and careful physical examination that includes well-defined laboratory studies. Appropriate therapy covers a broad range, from doing nothing more than periodic follow-up to laparotomy with splenectomy, depending upon the factors involved in the individual case.

Gaucher's disease associated with Hodgkin's disease.

A patient with chronic adult-onset Gaucher's disease is described. The diagnosis was based on the finding of typical Gaucher cells in the spleen, liver and bone marrow associated with deficiency of glucocerebrosidase. The patient also had Hodgkin's disease, nodular sclerosis type, stage III. The patient is alive and relatively well six years after presentation, having been treated with a combination of chemotherapeutic regimens. Previously reported cases of Gaucher's disease concurrent with Hodgkin's disease are reviewed.