Oesophageal tuberculosis: a review of eleven cases.

Tuberculous infection of the oesophagus is rare. This is confirmed by our present review of cases managed in our teaching hospitals over a period of 18 years which uncovered only 11 patients. The main presentation is that of dysphagia whose algorithm of investigation should seek to differentiate tuberculosis from carcinoma, the more common cause of this symptom. Of the 11 patients, 9 presented with dysphagia while 2 had haemorrhage; 7 had an abnormal plain chest radiograph, of whom 4 had a mediastinal mass lesion (3 were lymphadenopathy and one an abscess). All but one had an abnormal radio-contrast oesophagogram, including a mediastinal sinus in two and a traction diverticulum in another two. The mainstay of investigation was oesophagoscopy through which diagnostic biopsy material was obtained in half of the patients. In the other half diagnosis was by either biopsy of associated mediastinal (3) or cervical (1) lymph node masses or by acid fast bacilli positive sputum (1). The diagnosis was established post-mortem in one patient. Treatment was primarily non-operative with standard anti-tuberculosis drug therapy. Two patients underwent a diagnostic thoracotomy and one a drainage of mediastinal abscess together with resection and repair of oesophago-mediastinal sinus during the early part of the series. Outcome of management was very rewarding in 9 patients and death occurred in 2 patients, one of whom had his anti-tuberculosis drug therapy interrupted by severe hepatitis B virus infection. The other death occurred in a patient whose haemorrhage from an aorta-oesophageal fistula was not established ante-mortem. It is recommended that when biopsy material of the oesophagus is unobtainable or non-diagnostic in patients with dysphagia, especially with an abnormal chest radiograph or human immunodeficiency virus infection, effort should be made to obtain biopsy material from associated lymph nodes, even by thoracotomy if necessary, or culture of biopsy from the radiologically abnormal part oesophagus and sputum for mycobacteria, in order to establish the diagnosis of this rare but eminently treatable cause of dysphagia. Clinicians should be aware of tuberculosis of the oesophagus as a possible cause of haematemesis in patients with otherwise unexplained upper gastrointestinal haemorrhage.

Assessing operability in squamous carcinoma of the oesophagus. Are pre-operative investigations unreliable?

Pre-operative investigations, although providing useful information, were unreliable in predicting resectability in patients with malignant oesophageal lesions. Chest radiographs excluded metastasis and active tuberculosis. The barium swallow examination determined the length of the lesion and displayed various displacements, none of which excluded resectability. Tumour infiltration of the airways was the only change visible at bronchoscopy that contraindicated resection. Computed axial tomography was unreliable in excluding extra-oesophageal tumour extension and operability. As all these pre-operative investigations have their limitations in assessing operability, exploration of the lesion is essential to determine resectability for squamous carcinoma of the oesophagus, provided there is prior histological confirmation of a malignant oesophageal lesion.

Clinical patterns of presentation of breast cancer in women of different racial groups in South Africa.

The ages at presentation of white patients with breast cancer were found to be significantly higher than those of blacks, Indians and coloureds; 73% of white women fell into the postmenopausal group, in marked contrast to only 35% of Indians, while blacks and coloureds had similar proportions of pre- and post-menopausal patients. A significantly higher incidence of poorly differentiated tumours was seen in Indian and black patients. Blacks showed a significant tendency to present with more advanced disease, while whites were generally diagnosed at a much earlier stage.

Control of major haemorrhage associated with pancreatic pseudocysts by transcatheter arterial embolization.

Massive haemorrhage from a pancreatic pseudocyst is an uncommon cause of upper gastrointestinal bleeding. The condition carries a high mortality and presents a major clinical problem both in terms of timely diagnosis and appropriate surgical therapy. Four patients are presented with pseudocyst-related bleeding arising from the gastroduodenal artery. In all instances the bleeding was successfully controlled by transcatheter embolization with gelfoam. No untoward sequelae were noted and the occlusion remained effective as shown by follow-up angiography 2 months later. The importance of early diagnostic angiography is stressed and it is concluded that interventional angiography may obviate the need for high risk emergency surgery.

Nuclear and cytoplasmic oestrogen receptors in human mammary carcinoma.

Methods for the measurement of cytoplasmic and nuclear oestrogen receptors (CER and NER) are described. CERs and NERs were found to be labile at ambient temperatures; the receptors are stable for up to 1 year when stored in liquid nitrogen. Over a period of 5 years, 51% of the breast adenocarcinomas examined in women proved to be positive for CER; four adenocarcinomas of the breast obtained from men were all positive for CER; in those tumours examined for both CER and NER, 46% proved positive for CER and 30% positive for NER; no tumour was found to be positive for NER and negative for CER. In older female patients, the percentage of patients positive for oestrogen receptors increased and they were present in higher concentrations; in younger Indian women the same tendency was observed. The percentages of receptor-positive tumours in Indians, Blacks and Whites are similar. Neither the stage of the tumour nor the presence of nodal metastases influenced receptor positivity; there was no significant difference in the time to recurrence between receptor-positive and receptor-negative patients in the small number with reliable follow-up data.

Delayed presentation of traumatic diaphragmatic hernia.

Twenty-five patients with traumatic diaphragmatic hernia discovered at least five months after injury are described, of whom 18 were male and seven female. All but one hernia occurred on the left side. Stab wounds were the etiological factor in 22 patients and blunt trauma in three. The diagnosis was most often made by a chest or abdominal radiograph, but barium ingestion confirmed the diagnosis in ten patients. Intercostal drainage of gastric contents provided the diagnosis in two patients. In all nine patients initially approached by a thoracotomy or a thoracoabdominal incision, the hernia was easily reduced and the defect repaired. Although reduction and repair were easily accomplished by the abdominal route in seven patients, this approach was unsatisfactory or inadequate in six others. The colon and stomach were usually in the chest, and strangulation occurred in five patients. The mortality was 20% but rose to 80% when gangrene was present.

Traumatic diaphragmatic hernia.

A series of 58 cases of traumatic diaphragmatic hernia following blunt and penetrating injury is reviewed. The problems of radiodiagnosis are outlined and the need for barium contrast studies of the entire gastrointestinal tract to ensure recognition of isolated small bowel herniation is emphasized. Surgical access via laparotomy is recommended in the immediate post-traumatic presentation, whereas thoracotomy is preferable in cases diagnosed after a latent interval. Penetrating injury resulted in smaller diaphragmatic defects, greater morbidity and higher mortality due mainly to infective complications.

Ultrastructure of duodenal epithelial cells in patients with active duodenal ulcers and after treatment with cimetidine.

Comparative ultrastructural studies were conducted on biopsy specimens taken under direct vision by endoscopy from the normal duodenum, from the edge of deep and flat duodenal ulcers, and from areas 1 cm away from such ulcers. In addition, the ultrastructure of biopsy tissue from the scar of ulcers which healed after 6 weeks' therapy with the histaminastructural studies of tissue form the edge of both flat and deep duodenal ulcers showed gross pathological changes, particularly with regard to microvilli. Cells from the edge of deep ulcers showed increased secretory activity. Epithelial tissue 1 cm from flat duodenal ulcers exhibited ultrastructural changes far more severe than cells 1 cm from deep duodenal ulcers. The epithelial tissue from the scar area after 6 weeks' treatment appeared capable of regaining a fully functional role, although it was not normal in all specimens.

The use of neurolept analgesia for gastro-intestinal endoscopy.

A prospective double-blind study of the effects of sedation in 142 patients undergoing gastro-intestinal endoscopy was performed. Four regimens were studied (neurolept analgesia with and without topical anaesthesia, and anticholinergic and topical anaesthesia, with and without diazepam). Droperidol and fentanyl without topical anaesthesia yielded the best results as far as tolerance and side-effects were concerned. It is suggested that this form of neurolept analgesia be used for gastro-intestinal endoscopy.

Premedication with flunitrazepam in gastro-intestinal endoscopy.

Administration of 2 mg flunitrazepam (Rohypnol; Roche) to patients before gastro-intestinal endoscopy caused significantly less anxiety and achieved significantly greater sedation than diazepam (Vallium; Roche). No differences were found between any of the trial groups with respect to ease of intubation, tolerance of the procedure, gastric peristalsis, and the state of the pylorus. Memory of the procedure was significantly less vivid in the groups who received 2 mg flunitrazepam, than in the other groups. The patients who received 2 mg flunitrazepam showed a significantly greater willingness to undergo a repeat procedure, both when asked immediately after the procedure, and when asked on the next visit. Pulse rate increased in all groups during the procedure. No change in respiratory rate or in systolic and diastolic blood pressure occurred in any group.

Traumatic haemobilia: case reports.

Injury to the liver may result in traumatic haemobilia. Three cases are reported, with differing clinical presentation resulting from different forms of injury. Haemobilia may present difficulties in diagnosis, particularly if there has been a long delay between injury and presentation. The use of selective hepatic arteriography as a diagnostic aid and treatment by hepatic artery ligation are outlined.

The effect of acid-stimulating and inhibiting drugs on the ultrastructure of gastric parietal cells in man.

The ultrastructure of the human parietal cell at rest, after stimulation of gastric acid secretion by pentagastrin and after inhibition with propantheline or cimetidine, an H2-receptor antagonist, was studied. On stimulation there was an increase in the total secretory surface area of the gastric gland and canaliculus, with a concomitant decrease in the tubulovesicular system. On inhibition there was a decrease in the secretory surface area and a corresponding increase in the tubulovesicular system. These results are in agreement with other reports and support the hypothesis that during secretion of acid the tubulovesicular system increases the secretory surface by eversion or fusion of the vesicles and tubules with the plasmalemma. On inhibition there is thought to be reformation of the tubulovesicular system by pinocytosis. There is also ultrastructural evidence for the theory of membrane flow between the tubulovesicular system and the microvilli of the canaliculus and gastric lumen. Furthermore, there was an increase in lysosomal activity after the administration of the inhibiting drugs. It is suggested that the increased lysosomal activity could be involved in reducing the quantity of membrane after the membrane flow which occurs on gastric acid inhibition.

Pulsion intubation for palliation of carcinoma of the oesophagus.

One hundred and eighty-one patients with carcinoma of the upper thoracic oesophagus were intubated perorally using a Procter-Livingstone tube. The mortality was 16-6 per cent but, in the patients who survived, the palliation achieved, as judged by improved swallowing, was considered satisfactory. Factors influencing the success of intubation are also considered.

Palliation of malignant esophago-respiratory fistulae by permanent indwelling prosthetic tube.

Malignant esophago-respiratory fistula is an incurable condition calsing severe distress to those patients suffering from it. Sixty two successive patients with esophago-respiratory fistulae, secondary to squamous cell carcinomas of the esophagus, were intubated for palliation. The first 14 were intubated by a traction technique using the Celestin tube, and the remaining 48 were intubated by the Procter-Livingstone tube inserted by a pulsion method. Celestin intubation had a mortality of 64.3% but 75% of those intubated by the Procter-Livingstone tube were discharged from hospital, swallowing satisfactorily and relieved of their respiratory distress. In our experience the insertion of the Proctor-Livingstone tube by a pulsion technique, can be performed in a few minutes, with little morbidity and allows the patient to be discharged from hospital within 3-4 days of the procedure. It is a successful and acceptable method of treating malignant esophago-respiratory fistulae.

Klippel-Trenaunay syndrome. A case report and review of the literature.

Clinical and radiological assessment of a female patient suffering from varicose veins revealed many of the features first described by Klippel and Trenaunay. The findings are presented in detail and the lymphographic features are illustrated. The previous literature is briefly reviewed.