Limitation of amylase creatinine clearance ratio as a diagnostic test for postoperative pancreatitis.

The mean +/- S.E.M. ratio of amylase to creatinine clearance significantly increased at 24 hours after operations on the stomach and gallbladder but not after operations at sites remote from the abdominal cavity. Clinically, the elevated amylase to creatinine clearance ratio was not accompanied by pancreatitis. In dogs, surgical handling of the pancreas alone caused a significant increase in this measurement. The amylase to creatinine clearance ratio is not likely to be helpful in predicting the rare, but serious, postoperative complication of pancreatitis.

Mass in the head of the pancreas in cholestatic jaundice: carcinoma or pancreatitis?

The clinical, biochemical and radiological findings in 16 patients with carcinoma of the head of the pancreas were compared with that of 13 with cholestatic jaundice due to chronic pancreatitis. Patients presenting with malignancy had more severe hyperbilirubinemia (18.5 +/- 2.1 vs 5.6 +/- 1.6 p to ten days of hospital admission was the single most accurate test distinguishing carcinoma from pancreatitis. The mean bilirubin rose in carcinoma but fell in pancreatitis (mean net change 15.1 +/- 2.9 vs 3.9 +/- 0.6, p less than 0.001). Calcification in the pancreatic region was identified on a flat plate of the abdomen in 8/13 with pancreatitis but 0/16 with malignancy. Preoperative percutaneous transhepatic cholangiography was helpful in defining the site of biliary obstruction but the radiologist was unable to clearly predict the definitive diagnosis in five of the 29 patients. A point score based upon the major significant differences noted, predicted the presence or absence of malignancy in all patients (16/16 vs 0/13, p less than 0.01).

Esophagogastrectomy for carcinoma of the middle third of the esophagus.

Elective esophagogastrectomy and reconstruction by esophagogastrostomy were performed on 55 patients with malignant tumors of the midesophagus, despite invasion of contiguous structures in 60% and regional lymph node involvement in 75%. The operations were invariably palliative. Two patients died within thirty days of operation. Dysphagia was relieved and oral alimentation resumed in the other 53. Twenty-nine patients who had experienced painful swallowing and 16 who had vomiting obtained relief. Survival curves show no improvement from previous decades for patients with malignancies of the middle third of the esophagus. The mean survival was 10.4 months. Mean survival of patients with liver metastases was 3.5 months.

Randomized prospective matched pair study comparing peritoneovenous shunt and conventional therapy in massive ascites.

A prospective randomized matched pair study was designed to test the efficacy of the peritoneovenous (LeVeen) shunt as a treatment for massive cirrhotic ascites compared with traditional medical therapy. Patients who failed to lose weight while on a low salt diet and fluids restricted to 1000 ml daily were placed in the study group. Weight loss, decrease in abdominal girth and diuresis were significantly greater (P less than 0.01) for surgical patients than for their medically treated counterparts. The surgical technique is simple, quick and inexpensive. The surgical patients outlived their matched partners in 12 of 14 pairs where a definitive comparison was possible (P less than 0.02). The median stay in hospital after randomization was shortened from 32 days with medical therapy to 15 days for those undergoing the shunt operation. Those treated medically experienced a significant rise in mean blood urea nitrogen and K+ (P less than 0.02). Patients with alcoholic hepatitis, hyperbilirubinaemia (bilirubin greater than 154 mumol/l), peritoneal sepsis, severe coagulopathy and those who had recently bled from oesophageal varices are poor risks for the surgical procedure.

Cutaneous reaction to spironolactone resembling lupus erythematosus.

A cirrhotic male patient was admitted with a skin eruption. He had been taking spironolactone and hydrochlorothiazide for two months prior to admission. The morphology and distribution of skin lesions resembled that of systemic lupus erythematosus (SLE). Histologic changes in the skin biopsy specimen were consistent with SLE. Biopsy specimens of normal and affected skin were reported to show weak focal deposition of IgM and complement at the dermal-epidermal junction. However, there was a striking absence of serologic evidence of SLE. The rash disappeared when all medications were discontinued and reappeared when the patient was given spironolactone. The character and distribution of the rash after spironolactone administration was identical to the previous lesions. It disappeared again when spironolactone was withdrawn. This response to spironolactone is good evidence that it and not chlorothiazide was responsible for the rash. The latter drug has been reported to cause SLE-like skin changes.

Specificity of serum amylase and amylase creatinine clearance ratio in the diagnosis of acute and chronic pancreatitis.

In 31 patients with pancreatitis, the amylase to creatinine clearance ratio (CACR) was significantly greater than for controls (10.7 +/- 1.7 vs. 2.6 +/- 0.3, P less than .001). Sixteen pancreatitis patients with serum amylase (SAm) within the normal range had a mean CACR significantly greater than that of 19 hospital control patients with normal SAm (9.2 +/- 1.5 vs. 3.0 +/- 0.4, P less than .001). For control patients a highly significant inverse correlation between SAm and CACR was observed. No relationship was detected between these parameters for pancreatitis patients. The results suggest that the CACR may be of aid in establishing the diagnosis of pancreatitis even in patients without hyperamylasemia.

Percutaneous transhepatic cholangiography: an experience with the Chiba needle.

Percutaneous transhepatic cholangiography (PTC) with a "skinny" Chiba needle identified the biliary tree in 30 of 31 patients (97%) with extrahepatic obstructive cholestasis (EHC). The method was successful in only eight of 18 patients who had cirrhosis with unexplained jaundice. The biliary tree was visualized after one or two attempts in 23 of 31 patients with EHC (74%). The success rate was significantly greater (p greater than 0.001) in those patients with EHC than in those with EHC, in whom the biliary tree was visualized in 9 of 27 (33%). Difficulties in correctly interpreting the PTC findings in four patients are described.

Ascites: its correction by peritoneovenous shunting.

Patients with refractory ascites and HRS should be considered to present an urgent indication for peritoneovenous shunting. The shunt offers a method of continuous reinfusion of ascitic fluid which corrects avid sodium retention, oliguria and azotemia. Severe encephalopathy, jaundice or peritoneal sepsis--common complications of cirrhosis--contraindicate installation of the shunt before improvement occurs. Associated cardiac disease does not contraindicate the use of the shunt provided that ascitic fluid is removed at the time of operation and large amounts of diuretics are used. This operation has also proved useful in ascites attributed to causes other than cirrhosis. The main complications include disseminated intravascular coagulopathy, hepatic coma and sepsis in a few patients. Results of a randomized prospective study indicate that the shunt should probably be considered in patients with diet-resistant massive ascites even before they prove to be refractory to diuretic therapy.

Reappraisal of esophagogastrectomy for esophageal malignancy.

Esophagogastrectomy performed in eighty-three patients with a thirty day mortality of 7 per cent, a resectability rate of 93 per cent, and no anastomotic leakage, provided dependable relief of malignant obstruction and restored oral alimentation in all surviving patients. Long-term survival was unchanged. The successful resection of all midthird lesions with a 3.9 per cent mortality reflects the capability of current surgery and suggests that surgical palliation of midthird esophageal tumors is preferable to radiotherapy alone.

Regeneration of jejunal mucosa during recovery from malnutrition and pancreatic insufficiency.

A patient with a history of alcohol abuse, who presented with severe malnutrition, was subjected to serial jejunal biopsies during his hospitalization. The improvement in villous size and absorptive cell ultrastructure paralleled his clinical recovery. It is concluded that the caloric and trophic benefits of food, the pancreatic and vitamin replacement therapy and withdrawal of alcohol, all played an integral part in the regeneration of the jujunal mucosa.

A retrospective comparison of functional renal failure in cirrhosis treated by conventional therapy or the peritoneo-venous shunt (LeVeen).

Between 1973 to 1976, 12 ascitic cirrhotic patients with a mean plasma creatinine (pCr) of 4.4 +/- 3.0 mg/dl) were treated conservatively. During the same period 11 cirrhotics with ascites (pCr 4.3 +/- 2.8 mg/dl) were treated with LeVeen peritoneal jugular shunt. In the medically treated group mean survival was 2.4 +/- 2.7 weeks after detection of pCr elevation greater than 2.3 mg/dl. The 11 surgical patients with pCr elevation above 2.3 mg/dl survived a mean of 21.8 +/- 34.5 weeks after surgery. Four patients survived more than six months. The LeVeen shunt also resulted in significant weight loss, reduction in blood urea nitrogen (BUN), elevation of serum sodium, and increase of renal clearance of sodium. In appropriately selected patients it reverses the hepato-renal syndrome.

Alcohol ingestion-induced changes in the human rectal mucosa: light and electron microscopic studies.

Histologic and ultrastructural examination of specimens of rectal mucosa from 11 patients who had recently consumed excessive quantities of alcohol revealed marked pathologic changes. Goblet cells were decreased and a dense mononuclear cell infiltrate was seen on light microscopic study. Electron microscopy revealed swollen, distorted mitochondria and dilated and vesicular endoplasmic reticulum. These abnormalities disappeared after two weeks' abstinence. It is suggested that disordered organelle structure and function might contribute to the diarrhea frequently observed following excessive alcohol intake.

Renal failure in ascites secondary to hepatic, renal, and pancreatic disease. Treatment with a LeVeen peritoneovenous shunt.

Renal failure occurs in ascites of diverse causes. Functional renal failure (the hepatorenal syndrome) in cirrhotic patients is usually progressive and rapidly fatal. Insertion of a LeVeen shunt significantly reduces weight, as well as abdominal girth, and improves preoperative urine flow (488 vs 2,318 ml/24 hr; P less than .001) and natriuresis (12 +/- 15 vs 45 +/- 33 mEq/liter; P less than .003). The shunt should not be inserted in patients with alcoholic hepatitis (bilirubin level greater than 8 mg/100 ml). Ascitic fluid should be discarded at the time of surgery in patients with impaired cardiac function, a bleeding diathesis, and when liver function is more severely deranged.