St. Anthony's fire (ergotamine induced leg ischemia)--a case report and review of the literature.

Ergotism, once an epidemic disease, is now a rare disorder. The most common manifestation is acute peripheral ischemia due to vasospasm, with an incidence of 0.001%. We report a case of a middle-age woman who presented with ergotamine-induced leg ischemia, due to chronic use of ergotamine-containing medications for migraine headaches. The diagnosis was confirmed with arteriography results, and she responded well to vasodilator therapy. The pharmacology, clinical presentation, diagnostic approach, and therapy of ergotism are reviewed.

Relief of sleep apnea after intravascular stenting for superior vena cava syndrome.

A rarely reported association of sleep apnea and superior vena cava stenosis from mediastinal fibrosis is described. A case is presented where substantial improvement in the sleep parameters and the symptoms of sleep apnea occurred subsequent to superior vena cava thrombolysis and stent angioplasty.

[The effect of coffee and tea upon lower esophageal sphincteric function.].

The effects of coffee and tea upon lower esophageal sphincteric (LES) function were examined in a blinded crossover study of 12 healthy subjects. Lower esophageal sphincter pressure (LESP) and lower esophageal (LE) pH were measured simultaneously by a sleeve sensor and a pH probe for 20 minutes before and 90 minutes after intragastric instillation of four test solutions, which contained either regular coffee (C), decaffeinated coffee (D), tea (T) or water (W). C and T solutions had the same caffeine content, 160 mg. As compared with control (W), LESP was significantly lower after C and T, but not after D. The data for LE pH paralleled those for LESP. Thus, the greatest number of reflux episodes occurred after T and C. Difference from control (W) was statistically significant for T but not for C. We conclude that both regular coffee and tea have adverse effects upon LES function, whereas decaffeinated coffee does not. This study provides a rational basis for limiting intake of both caffeinated coffee and tea in patients with clinically important gastroesophageal reflux.

Mammographic findings after stereotaxic biopsy of the breast performed with large-core needles.

PURPOSE: To evaluate changes seen on mammograms obtained after large-core stereotaxic biopsy of the breast. MATERIALS AND METHODS: Twenty-seven patients underwent stereotaxic breast biopsy performed with large-core, 14-gauge needles. At least five core samples were obtained from each lesion. The mammograms obtained before biopsy were compared with those obtained 6 months later in the 24 patients in whom follow-up was performed. RESULTS: The only changes seen on the postbiopsy mammograms were due to tissue sampling (ie, fewer microcalcifications or defects were seen in areas of lesions from which tissue had been extracted). CONCLUSION: Large-core needle biopsy of the breast does not produce change or deformity that can be recognized on mammograms. Parenchymal scarring, architectural distortion, fat necrosis, or other identifiable changes seen after surgical biopsy of the breast are not seen after large-core, stereotaxic breast biopsy.

Symptomatic biliary obstruction associated with juxtapapillary duodenal diverticulum.

We describe a 56-year-old woman with symptomatic biliary obstruction associated with a duodenal diverticulum. Cholangiography revealed a dilated common bile duct with prominent distal obstruction of unusual configuration. Liver function tests were normal. Pain has not recurred since choledochojejunostomy.

Immunological aspects of gastritis and pernicious anaemia.

Pernicious anaemia (PA) and chronic atrophic gastritis (CAG) aggregate in families, occur more often in women, and are associated with various heritable traits such as fair skin and blue eyes. They are linked to certain HLA types. Linkages are relatively weak for A and B antigens, but somewhat stronger in the case of DR antigens. There are strong associations between PA and other organ-specific autoimmune diseases, particularly those affecting the thyroid. Discordance for PA in monozygotic twins has been reported, and it may well be that expression of the disease requires, in a genetically susceptible individual, initial injury to the gastric mucosa by some environmental agent such as a virus or some physical irritant, with perpetuation of injury then depending upon autoimmune mechanisms. Numbers of T cells are substantially increased in the gastric mucosa of patients with PA, but the ratio of T suppressor to T helper cells is normal. There is a relatively greater increase in numbers of cells not of T lineage, presumably B-cells. Gastric autoantibodies, both to different components of the parietal cell and to two sites on the IF molecule, are present in a majority of patients with PA. There is evidence that these autoantibodies, especially PCA, may be cytotoxic to parietal cells, and may also inhibit their maturation and proliferation. Antibodies to chief cells have not been described, and the parallel disappearance of these cells in atrophic gastritis is unexplained. The peripheral blood lymphocytes of some patients with autoimmune gastritis transform, or produce lymphokines, when exposed to gastric antigens, and patients with PA have been shown to have delayed type cutaneous hypersensitivity to gastric antigens. The relevance of these observations to the pathogenesis of their gastric mucosal lesion is unclear. There is a growing body of evidence to support the operation of humoral immune mechanisms in autoimmune gastritis, but this clearly does not preclude the coexistent involvement of cellular mechanisms. For example, impaired suppressor T cell function has been strongly implicated in certain other autoimmune disorders, but has received scant attention in PA. By generally accepted criteria, PA is an excellent example of an organ-specific autoimmune disease. As yet, there is no acceptable single unifying hypothesis which will account for all of the phenomena which have been described in the disease.(ABSTRACT TRUNCATED AT 400 WORDS)

Antireflux treatment for asthma. Improvement in patients with associated gastroesophageal reflux.

Fifteen patients with both nonallergic asthma and symptomatic gastroesophageal reflux were studied before and after an eight-week period of vigorous antireflux therapy, which included ranitidine hydrochloride, 150 mg twice a day. Pulmonary and esophageal symptoms were recorded on daily diary cards. Therapy was associated with prompt amelioration of reflux symptoms and with a less dramatic and more delayed improvement in pulmonary symptoms. Objectively, esophageal erosions healed completely in eight of the ten patients who had them at the beginning of the trial, and pulmonary function measurements improved significantly. Intraesophageal infusions of physiologic saline and 0.1N hydrochloric acid in patients and healthy controls did not significantly alter pulmonary function, as measured by standard spirometry. There is a subset of patients in whom bronchoconstriction is triggered by gastroesophageal reflux. Treatment of reflux in such patients may improve their asthma.

Changes in distal esophageal function in response to cooling.

The effects upon esophageal motility of water at room temperature and 0 degrees C, taken as repeated small boluses and as 200-ml volumes swallowed as rapidly as possible, were compared before and after pretreatment with isosorbide denitrate 5 mg sublingually, in nine young healthy subjects and two patients with esophageal spasm. Iced water caused reduced strength, increased duration, and reduced velocity of distal esophageal contractions. It also reduced the force of lower esophageal sphincteric contraction, an effect that was more transient than that seen in the esophageal body, but it did not alter the magnitude of sphincteric relaxation. Esophageal responses in normal subjects with water at the two temperatures were not affected by isosorbide denitrate. The responses to iced water in the two patients with esophageal spasm were qualitatively similar to those in normal subjects. These findings indicate that cooling brings about a transient state of relative paralysis in the distal esophagus and lower esophageal sphincter. Taken in conjunction with other observations, they are consistent with the notion that cold-induced chest pain, whether in normal subjects or in patients with esophageal motor disorders, is related to esophageal distension.

Colonic varices. Report of an unusual case diagnosed by radionuclide scanning, with review of the literature.

We report a patient who developed recurrent massive lower gastrointestinal bleeding after successful obliteration of esophageal varices by sclerotherapy. A radionuclide study was very helpful in establishing diagnosis of the lesion responsible, a varix in the cecal area. Bleeding subsided after creation of a portacaval anastomosis. The literature pertaining to colonic varices is reviewed.

The prognosis of gastric outlet obstruction.

A retrospective study was undertaken to examine the prognosis of gastric outlet obstruction with specific reference to patients with obstruction due to peptic ulcer. During the 10-year period 1970-1979, 68 patients with gastric outlet obstruction were admitted to our hospital. Obstruction was caused by peptic ulceration in 55 of these patients, all of whom initially were managed conservatively. Thirty-four, however, required surgical decompression during their first admission for obstruction, and 11 needed surgery for a subsequent episode of obstruction. Of the ten patients who have not undergone surgery, six died within 3 years of their first episode of obstruction and three of the four survivors continue to have recurrent obstructive symptoms. Overall, 92% (45/49) of patients who have lived for more than 3 years after their presentation with gastric outlet obstruction due to peptic ulcer have required surgery for relief of obstruction.

Splenic torsion. An unusual cause of splenomegaly.

A 28-year-old woman who presented with acute abdominal pain and splenomegaly was found to have little functioning splenic tissue on liver-spleen scan but a large homogeneous spleen by computerized axial tomography. Laparotomy revealed torsion of the splenic pedicle and extensive splenic infarction. The presentation, pathophysiology, and diagnostic difficulties of this case are discussed. Splenic torsion should be considered in the differential diagnosis of painful splenomegaly.

Recurrent hemorrhage into the pancreatic duct from a splenic artery aneurysm.

We describe a case of upper gastrointestinal hemorrhage secondary to splenic artery aneurysm-pancreatic duct fistula, with associated partial common bile duct obstruction and pancreatitis. The literature is reviewed briefly in order to stress distinctive clinical features and caveats in diagnosis. Angiography is the most definitive diagnostic study; surgical resection is curative.

Toxic megacolon associated with methotrexate therapy.

We describe the case of a patient with psoriasis who developed severe colitis, with toxic megacolon, after a course of treatment with methotrexate. The duration of her colitis, which was eventually resolved by using conservative measures, was far greater than that of other drug-related complications, which included bone marrow depression, jaundice, and renal failure. The literature pertaining to this rare manifestation of methotrexate toxicity is reviewed. A prolonged illness and relative sparing of the distal colon appear to be characteristic of this form of colitis.

Gastric mucosal lymphocyte subpopulations in pernicious anemia and in normal stomach.

Gastric mucosal lymphocyte subpopulations were determined by an indirect immunoperoxidase method applied to cryostat sections of gastric biopsies obtained from 12 patients with pernicious anemia (PA group) and from 12 patients whose stomachs were endoscopically and histologically normal (comparison group). T-Cell populations were identified by means of monoclonal antibodies directed against all T cells (UCHT1), T suppressor cells (anti-Leu-2a), and T helper cells (anti-Leu-3a). Non-T cell numbers were estimated indirectly. Concentrations of all T cells, T suppressor cells, T helper cells, and non-T cells were all significantly greater in the PA than in the comparison group. The most striking difference was in non-T cell numbers, which showed an approximately sixfold increase in the PA group. Mean T/non-T cell ratios in PA and comparison groups were significantly different (0.49 and 1.50, respectively). T suppressor/T helper cell ratios were similar in the two groups. There were highly significant positive correlations between numbers of non-T and T helper cells, and non-T and T suppressor cells in PA, but not in comparison groups. If, as seems likely, the majority of non-T cells in these gastritic stomachs were in fact cells of B lineage, these results would be consistent with the hypothesis that gastric mucosal damage in pernicious anemia is mediated primarily by a humoral mechanism, which may involve cytotoxic autoantibodies.

Symptoms of irritable bowel syndrome in ulcerative colitis in remission.

The prevalence of symptoms suggestive of a motility disturbance similar to the irritable bowel syndrome was investigated in 98 patients with ulcerative colitis in remission, and a similar number of age- and sex-matched healthy controls. Thirty-three per cent of patients compared with 7% of controls fulfilled the criteria for such a syndrome (p<0.01). Contrary to expectations these symptoms were not confined to patients with distal disease. Other symptoms such as constipation were also very common in the colitic group (31%).

Diagnosis of oesophageal spasm by ergometrine provocation.

Oesophageal spasm may mimic the pain of myocardial ischaemia. Forty-two patients who were thought to have angina until investigations failed to show any cardiovascular abnormality, were examined for oesophageal disease. Ergometrine provocation during oesophageal manometry caused significant deterioration in oesophageal motility, associated with familiar pain, in 24 patients. Ten age-matched controls were examined in a similar way and ergometrine produced motility changes in four and pain in two. Six volunteers with coronary artery stenosis and exercise-induced angina did not develop oesophageal motility changes during the pain. Ergometrine provocation is useful in establishing the diagnosis of oesophageal spasm in patients with recurrent angina-like pain but no cardiac abnormality.

Alteration of esophageal peristalsis by body position.

In order to determine the effect of body position on esophageal peristalsis, normal subjects were studied by manometry in upright and supine positions. In each position, responses to a standard sequence of "dry" and "wet" swallows were recorded. Amplitudes, durations, and propagation times of esophageal contractions were uniformly greater with wet than with dry swallows. Peristaltic amplitudes were greater throughout the length of the esophagus in the supine than in the upright position. Peristaltic wave durations were relatively little influenced by body position, while propagation times were shorter in the upper esophagus but longer in the proximal half of the lower esophagus in the upright than in the supine position. All differences were more marked with wet than with dry swallows. Thus, esophageal peristalsis is significantly altered by body position, and the effect of the latter is bolus-dependent.