Cholecystocolic fistula: an unusual presentation and diagnosis by endoscopic retrograde cholangiopancreatography.

This report describes a patient with a cholecystocolic fistula whose presentation was unusual because it lacked the signs and symptoms that suggest biliary disease (abdominal pain, food intolerance, and belching) and because the fistula was not visualized on barium enema but was apparent on endoscopic retrograde cholangiopancreatography after incidental pneumobilia discovered on ultrasound directed our attention to the biliary tree. A previous Billroth II with vagotomy may have predisposed to the development of the fistula.

Sulfasalazine-induced abnormal sperm penetration assay reversed on changing to 5-aminosalicylic acid enemas.

Sulfasalazine, a drug used in the treatment of inflammatory bowel disease, has been associated with male infertility, an effect attributed to sulfapyridine rather than to 5-aminosalicylic acid (5-ASA), the presumed therapeutically active component of sulfasalazine. Recently, the sperm penetration assay (SPA) has been found to be an accurate method of quantitating male fertilization potential. We report the case of a man with ulcerative colitis in whom infertility and a markedly abnormal SPA were demonstrated while he was taking sulfasalazine. Shortly after discontinuing sulfasalazine and initiating treatment with 5-ASA enemas, his SPA became normal and his wife became pregnant. The SPA is a useful screening test for sulfasalazine-induced male infertility. On the other hand, 5-ASA enemas do not appear to be associated with an abnormal SPA.

Delta agent hepatitis.

Since its chance discovery a mere decade ago, the delta agent has been characterized as a novel pathogen that poses the risk of developing into a scourge of modern times. With its unique single-stranded circular RNA, exclusive dependence on HBV for its replication, and characteristic ability to suppress hepatitis B synthesis, the delta agent has emerged as an important global cause of fulminant hepatitis and progressive liver disease. Persons at greatest risk of delta infection are those living in endemic areas and HBsAg-carrier parenteral drug abusers, hemophiliacs, hemodialysis patients, and homosexual men in nonendemic areas. Widespread dissemination appears possible. There is as yet no known effective treatment for established delta infection, and, for the present, clinicians must concentrate on preventing HDV infection by incorporating vigorous use of the hepatitis B vaccine into strategies for preventing HBV infection.

5-Aminosalicylic acid enemas in refractory distal ulcerative colitis: long-term results.

In this trial, we examined the role of 4-g 5-aminosalicylic acid (5-ASA) enema in the long-term management of patients with previously refractory distal ulcerative colitis. Of 20 such patients treated with nightly 5-ASA enemas, 16 improved symptomatically, with 15 achieving clinical remission and 14 achieving sigmoidoscopic remission within 3 to 5 wk. An attempt was made to maintain clinical remission with 5-ASA enemas in these 16 by successively decreasing the frequency of administration to every other night and then every third night, as long as remission was maintained. Relapses were treated by reinstituting nightly 5-ASA enema administration followed by another attempt at tapering the frequency of administration. Follow-up has ranged from 5 to 16 months. Nine patients were rapidly tapered to every third night administration, but six relapsed. Of these six, four were brought into remission with reinitiation of nightly enemas and tapered to every three nights, whereas one ultimately required enemas every two nights for control and one required enemas nightly (with mild symptoms). Six other patients relapsed when the enemas were tapered to every two nights, and after retreatment on a nightly regimen, four could be maintained on an every third night regimen while two have required every second night administration. One patient has required nightly administration from the outset. Currently, one patient is off all medication, while eight are on an every third night, three are on an every second night, and three are on a nightly schedule. We conclude that in patients with distal ulcerative colitis refractory to conventional therapy but responsive to 5-ASA enemas, relapse is common as the frequency of 5-ASA enema administration is decreased, although some patients may be maintained on a less than nightly schedule. The optimal maintenance regimen remains to be determined.

Medical care of the surgical patient with gastrointestinal disease.

Common perioperative gastrointestinal disorders of surgical patients are presented. Recommendations for appropriate medical evaluation and management are described.

Embryopathic effects of cyclophosphamide.

Cyclosphosphamide, dissolved in saline, was injected into the air sac of white Leghorn chick eggs in dose levels of 0.005, 0.007, 0.010, 0.012, 0.015, and 0.017 mg per egg. Eggs received a single injection of cyclophosphamide on Days 0, 1, 2, or 3 of incubation. Control eggs were injected with an equivalent volume of saline (0.1 ml per egg). In all 904 chicken eggs were used for this study. Surviving embryos were sacrificed when they reached 11 days of incubation. The LD50 values for Days 1, 2, and 3 were 0.017, 0.007, and 0.012 mg per egg, respectively. The overall incidence of abnormal embryos for Days 0, 1, 2, and 3 were 7, 6.3, 12, and 22%, respectively. Abnormalities such as reduced body size, everted viscera, short and twisted limbs, eye defects, abnormal beak, and short and twisted neck were commonly seen in survivors no matter when exposed to cyclophosphamide. The teratogenicity of cyclophosphamide was noted to be the highest in the embryos treated on Day 3. The present study has demonstrated that cyclophosphamide is toxic and teratogenic during the period of early organogenesis in the chick embryos.