Transient pseudo-hypoaldosteronism following resection of the ileum: normal level of lymphocytic aldosterone receptors outside the acute phase.

Pseudo-hypoaldosteronism (PHA) is due to mineralocorticoid resistance and manifests as hyponatremia and hyperkalemia with increased plasma aldosterone levels. It may be familial or secondary to abnormal renal sodium handling. We report the case of a 54-year-old woman with multifocal cancer of the colon, who developed PHA after subtotal colectomy, ileal resection and jejunostomy. She was treated with 6 g of salt daily to prevent dehydration, which she stopped herself because of reduced fecal losses. One month later she was admitted with signs of acute adrenal failure, i.e. fatigue, severe nausea, blood pressure of 80/60 mmHg, extracellular dehydration, hyponatremia (118 mmol/l); hyperkalemia (7.6 mmol/l), increased blood urea nitrogen (BUN) (200 mg/dl) and creatininemia (2.5 mg/dl), and decreased plasma bicarbonates level (HCO3-: 16 mmol/l; N: 27-30). However, the plasma cortisol was high (66 microg/100 ml at 10:00 h; N: 8-15) and the ACTH was normal (13 pg/ml, N: 10-60); there was a marked increase in plasma renin activity (>37 ng/ml/h; N supine <3), active renin (869 pg/ml; N supine: 1.120), aldosterone (>2000 pg/ml; N supine <150) and plasma AVP (20 pmol/l; N: 0.5-2.5). The plasma ANH level was 38 pmol/l (N supine: 5-25). A urinary steroidogram resulted in highly elevated tetrahydrocortisol (THF: 13.3 mg/24h; N: 1.4+/-0.8) with no increase in tetrahydrocortisone (THE: 3.16 mg/24h; N: 2.7+/-2.0) excretion, and with low THE/THF (0.24; N: 1.87+/-0.36) and alpha THF/THF (0.35; N: 0.92+/-0.42) ratios. The number of mineralocorticoid receptors in mononuclear leukocytes was in the lower normal range for age, while the number of glucocorticoid receptors was reduced. Small-bowel resection in ileostomized patients causes excessive fecal sodium losses and results in chronic sodium depletion with contraction of the plasma volume and severe secondary hyperaldosteronism. Nevertheless, this hyperaldosteronism may be associated with hyponatremia and hyperkalemia suggesting PHA related to the major importance of the colon for the absorption of sodium. In conclusion, this case report emphasizes 1) the possibility of a syndrome of acquired PHA with severe hyperkalemia after resection of the ileum and colon responding to oral salt supplementation; 2) the major increase in AVP and the small increase in ANH; 3) the strong increase in urinary THF with low THE/THF and alpha THF/THF ratios; 4) the normal number of lymphocytic mineralocorticoid receptors outside the acute episode.

[A 1993-1995 epidemiological survey of home parenteral nutrition in approved centers for adults in France]. / Données épidémiologiques 1993-1995 de la nutrition parentérale à domicile en centres agréés chez l'adulte en France.

OBJECTIVES: A 1993-1995 three year epidemiological survey of home parenteral nutrition was performed through in France in approved centers for adults. METHODS: Data were retrospectively collected each year on a standardized questionnaire focussing on indications and short term outcome. RESULTS: All centers (n = 14) participated in the study and 524 new adult patients were recruited. The overall incidence was unchanged at 3.75 patients/10(6) adults. Indications for AIDS rose (8 to 18%) whereas other indications were stable. Prevalence increased by 19%: 4.40 adults/10(6) patients at 01.01.1996. At six months, the probability to stay on treatment was 19.5% for AIDS and cancer indications but 52% for others, whereas death rates were 59% and 9% respectively. CONCLUSIONS: For both cancer and AIDS indications, short-term treatment was due to a poor prognosis. For other diagnosis, complicated with a short bowel in 51% of cases, prognosis was excellent but associated with treatment dependency. The latter point focuses on the need for additional treatments in irreversible intestinal failure.

[Percutaneous drainage of a presacral and spinal extra-dural abscess complicating Crohn's disease]. / Drainage percutané d'un abcès présacré et rachidien extra-dural compliquant une maladie de Crohn.

A 43-year-old man with Crohn's disease was hospitalized because of bilateral radicular pain secondary to a presacral abscess penetrating into the extra-dural space from L5 to S3. Conservative treatment using computed tomography guided percutaneous drainage of the abscess and parenteral antibiotherapy allowed complete recovery.

Remaining small bowel endoscopic lesions at surgery have no influence on early anastomotic recurrences in Crohn's disease.

OBJECTIVES: We recently demonstrated that 65% of patients operated on for Crohn's disease (CD) had lesions of the small bowel at perioperative endoscopy (POE). These lesions were unrecognized before surgery in more than half of the patients. The aim of this study was to assess the prognostic value of endoscopic small bowel lesions let in place at time of surgery on further anastomotic endoscopic relapse. METHODS: Twenty one patients (10 women, 11 men, mean age 34 yr) had an enteroscopy from the terminal ileum to the ligament of Treitz during an ileocolectomy performed for CD. All patients were subsequently enrolled in a placebo-controlled trial of mesalazine for the prevention of early endoscopic relapse; 10 patients received placebo, and 11 received mesalazine (1.5 g/day) for 12 wk after surgery. At the end of this trial, they all had a colonoscopy with inspection of the anastomosis and the neoterminal ileum. RESULTS: POE was completed up to the angle of Treitz in all 21 patients. In 10/21 cases (47%), mild lesions were found distributed at random along the small intestine 30 cm beyond the resection margin. At colonoscopy performed 12 wk later, lesions were found in 11/21 cases (52%) between section margin and were estimated to be 25 cm over the anastomosis. Endoscopic recurrence occurred in 5/10 patients who received placebo and 6/11 patients who received mesalazine. Endoscopic recurrence occurred in 5/10 patients having lesions at POE and in 6/11 patients who had no lesions. There was no relationship between endoscopic recurrence at 12 wk and presence of lesions at initial POE, whatever the postoperative treatment. CONCLUSION: Endoscopic lesions let in place after "curative" surgery have no influence on early endoscopic anastomotic recurrences in CD.

Perioperative endoscopy of the whole small bowel in Crohn's disease.

The aim of this study was to search for small bowel lesions by means of a perioperative endoscopy in 20 patients operated on for Crohn's disease. Seven women and 13 men (mean age 29 years) had a total retrograde exploration to the angle of Treitz during an ileocolectomy (16 of 20 patients) or a colonic or ileal resection (four of 20 patients). Endoscopic exploration was completed, through an enterotomy, from the surgical area to the angle of Treitz. Periendoscopic biopsy samples were taken on macroscopic lesions and every 20 cm systematically. In 13 of 20 cases, various lesions scattered over the whole small intestine were found. These were aphthoid ulcerations (10 patients), superficial ulcerations (seven patients), mucosal oedema (three patients), non-ulcerative stenosis (three patients), erythema (two patients), pseudopolyps (two patients), deep ulcerations (two patients), and ulcerative stenosis (one patient). In seven patients none of the lesions detected at perioperative endoscopy had been recognised by preoperative evaluation or surgical inspection of the serosal surface. A typical granuloma was found at biopsy of lesions identified by endoscopy in three cases and at biopsy of an apparently healthy area in one case. Thus 65% of patients operated on for Crohn's disease had lesions of the small intestine detected by endoscopy, which were unrecognised before surgery in more than half of the cases.

[Bacterial translocation in Crohn disease]. / Translocation bactérienne dans la maladie de Crohn.

Bacterial translocation is the passage of viable endogenous bacteria from the gastrointestinal tract to mesenteric lymph nodes and other internal organs. The aim of this work was to study bacterial translocation in patients operated on for Crohn's disease. Twenty-eight patients, mean age 29 years, not having received any antibiotics since at least 8 days, presenting with ileal (n = 12), ileo-colonic (n = 14) or colonic (n = 2) Crohn's disease were studied. In 25 out of 28 cases (89%) indication for surgery was strictures inducing an upper small bowel distension in 9 out of 25 patients. Mesenteric lymph nodes and liver biopsies, portal blood samples and peritoneum swabs were harvested after laparotomy and before gut opening. Bacterial translocation, defined as the presence of intestinal bacteria in at least one of the specimens, was present in 8 out of 28 patients. This was found in lymph nodes draining surgical territories in 7 out of 8 cases. Bacterial strains involved in translocation included E. coli (n = 5), Enterococcus (n = 3), Clostridium perfringens (n = 2), Proteus (n = 2), and Bacteroides fragilis (n = 1). The rate of translocation differed neither according to Crohn's disease site nor with perforating or non perforating type of the disease. Five out of 9 patients operated on for strictures with proximal distension had a translocation. In conclusion, bacterial translocation was identified in 29% of patients operated on for Crohn's disease in this series. Distension of the intestine proximal to a digestive stricture could favor the occurrence of bacterial translocation in Crohn's disease.

Liver glutathione and cytochrome P450 activity in experimental infection: study of the relative effects of infectious stress and malnutrition.

OBJECTIVE: To study the effects of infection and malnutrition on liver glutathione and cytochrome P450 (P450) in rats. DESIGN: Controlled experimental groups (12 groups). ANIMALS: Adult male Sprague-Dawley rats. INTERVENTIONS: Experimental endocarditis, pyelonephritis, or peritonitis were caused. Controls included free-fed rats and sham-operated rats, pair-fed to infected animals. Infection was verified by tissue culture. Rats were killed 3 days (acute infection) or 10 days (chronic infection, except endocarditis) after the induction of infection. RESULTS: Sham rats had lower liver weights, liver/body weight, and liver glutathione values than controls. Infected rats had larger liver weights and liver/body weight ratios and liver glutathione content than shams, and larger liver/body weight ratios than controls (acute infection). Infected rats had lower P450 values than both shams and controls. CONCLUSION: The malnutrition associated with infection caused decreased liver weight and glutathione content. Infection increased the liver weight, and liver glutathione content, but caused severe reduction in liver P450. If the same finding is true in infected patients, it could have consequences for the management of such patients.

Bacterial translocation in colorectal cancers.

Bacterial translocation, the passage of viable indigenous bacteria from the gastrointestinal tract to the mesenteric lymph nodes and other internal organs, has been poorly studied in man to date. Pericolonic lymph nodes, liver, portal blood, and peritoneum specimens were harvested before antibiotics were administered during 20 operations for colorectal cancer and compared with those obtained in 20 operations for non colorectal conditions. Bacterial translocation, defined as the presence of intestinal bacteria in at least one of the specimens, was found in 13 patients (65 percent) in the colorectal cancer group as compared to 6 (30 percent) in the control group (p less than 0.05). The increased incidence of bacterial translocation in colorectal cancers was mainly due to the presence of bacteria in the pericolonic lymph nodes adjacent to the cancer. These findings suggest that intestinal bacteria translocate from the bowel lumen in a high proportion of patients with colorectal cancer and further stress the need for prophylactic antibiotics in colorectal cancer surgery.

Paraneoplastic intestinal pseudo-obstruction as the presenting feature of small-cell lung cancer.

A previously healthy 50-year old man presented with acute small bowel obstruction. No etiology was found at laparotomy. Postoperatively, the patient remained symptomatic with nausea, vomiting and severe constipation. Gastroscopy revealed retained food in the stomach. Gastric emptying of solids and liquids was dramatically decreased at scintigraphy. The colon was dilated on X-ray study. Chest X-ray revealed a pneumopathy and a small-cell lung cancer was discovered at bronchoscopy. The patient died 5 months after onset. Histologic study of the gut showed widespread degeneration of the myenteric plexus with plasma cell infiltration, Schwann cell proliferation and a reduced number of neurons of which many were abnormal. Intestinal pseudo-obstruction can reveal a small-cell lung cancer; the mechanism of neuronal impairment leading to pseudo-obstruction remains unknown, but could be related to the pathophysiology of paraneoplastic syndromes.