[Anaplastic astrocytomas of the medulla oblongata. A rare differential diagnosis in orthostatic hypotension]. / Anaplastisches Astrozytom der Medulla oblongata. Eine seltene Differentialdiagnose bei orthostatisch bedingter Hypotonie.

HISTORY AND PHYSICAL EXAMINATION: A 39-year-old women was admitted for evaluation of dizziness and hypotension. During standing the blood pressure dropped from 130/80 to 80/40 mmHg. Ten weeks before admission she had recurrent cerebral convulsions. Neurological evaluation showed a slight left hemiparesis. Computed tomography of the brain revealed a 1.5 +/- 1 cm cyst in the left tempral region. It was thought that the cause of the recurrent convulsions was alcohol abuse. During the next few weeks orthostatic hypotension increased and she was not able to work. INVESTIGATIONS: At admission abnormal findings included hypotension, horizontal nystagmus, and deviation of the soft palate to the right. After the patient was brought to an upright position during standardized passive tilt testing she showed a defect in the sympathetic limb of the baroreceptor reflex arc. Head magnetic resonance tomography showed a signal-enhancing tumour in the cervicomedullary region. TREATMENT AND CLINICAL COURSE: Before a planned biopsy could be performed the patient died of respiratory arrest. Postmortem examination revealed an anaplastic grade III astrocytoma extending form the pons to the medulla oblongata. CONCLUSION: Upright tilting leads to pooling of blood in the legs. One of the normal compensatory responses is a reflex tachycardia which our patient did not show as a sign of an afferent defect. Patients with orthostatic hypotension as a prominent symptom should be investigated with a standardized tilt test. In special patients, additional neurological investigations are necessary.

[Postvagotomy complications: stomach bezoars - case report and review of the literature]. / Postvagotomiekomplikation: Magenbezoare - Fallbericht und Literaturübersicht.

A 59 year old female with multiple gastric surgical procedures (Billroth I and Billroth II) for recurring ulcer disease developed a gastric phytobezoar following an additional truncular vagotomy within 2 months. Already 1 month after complete endoscopic removal the phytobezoar recurred in spite of dietary restrictions. The phytobezoar was successfully dissolved by oral Cellulase-therapy. The truncular vagotomy and its influence on gastric motility has to be considered as the cause of the repeated bezoar formation.

[Stress ulcerations: pathogenesis and prevention]. / Stressulcerationen: Pathogenese und Prophylaxe.

Clinically inapparent gastric stress ulcerations are a frequent complication of extensive trauma, intracranial diseases, burns, sepsis, respiratory insufficiency etc. With improvement of the underlying disease the acute erosions will disappear, however, approximately 20% of the patients will develop major gastro-intestinal bleedings. Besides the known and above mentioned risk factors gastric acid must be present for acute stress lesions to develop. Therefore, attempts at prophylaxis against stress erosions have focused on a decrease of intragastric hydrogen ion concentration. In a number of clinical trials during recent years it was documented that neutralization of gastric content (elevation of intragastric pH to 3.5 or higher) will prevent stress ulcers and their life threatening complication: exsanguinating hemorrhage. Therefore critically ill patients should receive high doses of antacids or cimetidine in combination with antacids to prevent acute stress ulcerations.