[When should patients with bleeding peptic ulcer resume oral intake? A randomized controlled study]. / Quand faut-il reprendre l'alimentation orale après hémorragie ulcéreuse gastro-duodénale? Etude contrôlée randomisée.

OBJECTIVES: Patients presenting with bleeding peptic ulcers are often kept fasted. The contribution of feeding in bleeding recurrence rate is unknown. The aim of this prospective controlled study was to evaluate the effect of early feeding in (a) the bleeding peptic ulcer recurrence rate and (b) the outcome of patients with severe bleeding peptic ulcer. PATIENTS-METHODS: From January through December 1995, all consecutive patients admitted for active bleeding from peptic ulcer were included. All patients underwent emergency endoscopic injection with adrenaline around and into the base of the ulcer and were randomized in two groups. Group A patients (n = 12) received milk on day 1, mixed warm feeding on day 2 and normal diet from day 3, Group B patients (n = 14) were nil by mouth until day 3, then received milk on day 4, mixed warm feeding on day 5, and normal diet from day 6. Twenty-six patients (17 men, 9 women, mean age 71 years) were included. RESULTS: On day 0, both groups (group A vs group B) were comparable (mean +/- SD): hemoglobin (8.8 +/- 2.7 vs 8.1 +/- 2.0 g/dL), transfusion requirements in the first 24 h after admission (2.2 +/- 2.0 vs 2.1 +/- 1.4 units), localization of ulcers (duodenal ulcer: 8 vs 9, gastric ulcer : 4 vs 5). There were no significant differences in group A and group B for bleeding ulcer recurrence rate (0 vs 1 patient) and transfusion requirements (2.6 +/- 2.1 vs 3.3 +/- 2.1 units). Hospital stay was significantly shorter in group A (6.8 +/- 2.1 days) than in group B (9.9 +/- 3.7 days), P = 0.01. CONCLUSION: These results did not provide any evidence of advantages of fasting in patients with active bleeding peptic ulcer treated by endoscopic sclerotherapy. Early feeding did not worsen outcome in patients with active bleeding peptic ulcer and reduced hospital stay.

[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.

Anomalous pancreatico-biliary ductal union with cystic dilatation of the bile duct.

We report, in an adult, an asymptomatic association between cystic dilation of the bile duct (type IV A in Todani's classification) and anomalous pancreatico-biliary ductal union (APBD) with stones in a long common channel. In APBD, the connection between the common bile duct and the main pancreatic duct is located outside the duodenal wall andis therefore not under the influence of the sphincter of Boyden. An abnormally long common channel is in excess of 15 mm. Two types of convergence anomalies are defined according to whether the bile duct opens into the main pancreatic duct (BP) or the main pancreatic duct into the bile duct (PB). In APBD, there is probably a reverse pressure gradient between the bile and pancreatic ducts, with regurgitation of pancreatic juice into the bile duct, repeated attacks of cholangitis, stenosis and cystic dilatation. A long common channel is associated with a higher incidence of carcinoma of the gall bladder of the bile duct.

Long-term outcome of severe radiation enteritis treated by total parenteral nutrition.

The outcome of 31 patients with severe radiation enteritis treated by total parenteral nutrition (TPN) was analyzed. Before initiation of parenteral nutrition, 18 of the patients had not had abdominal surgery, while 13 had either a resection or an intestinal bypass for radiation enteritis. Median follow-up was 2 1/2 years (range: 1 month to 12 years) from the time of initiation of parenteral nutrition. Surgery was required in 15 cases because parenteral alimentation could not be continued. Only eight of these 15 were able to resume a normal oral intake. Total parenteral nutrition allowed oral feeding to be resumed in 11 (36%) after a median follow-up of 40 months (range: 6-142 months). In general, total parenteral nutrition was well tolerated and was associated with low morbidity. Eighteen patients died, 13 of complications due to radiation therapy, four of cancer recurrence, and one of an unrelated cause. Survival probability was 58% at one year and 36% at five years. When possible, prognostic factors present either before or at initiation of total parenteral nutrition were analyzed. Age, predisposing vascular factors (hypertension, diabetes mellitus, or vascular disease), and enteric fistula and/or perforation were found to have prognostic value. The probability of clinical radiation enteritis recurrence was 34% at one year and 47% at two years. A clinical recurrence of symptoms was more frequent but not significantly so after parenteral nutrition as compared to surgical therapy of radiation enteritis. Although TPN corrected denutrition and allowed deferred surgery in some patients, severe radiation enteritis remains a poorly predictable progressive disease with numerous relapses.

Hepatitis associated with amoxycillin-clavulanic acid combination report of 15 cases.

Fifteen cases of hepatitis related to a combination of amoxycillin and clavulanic acid are reported. Most patients were aged 60 years or more and there were more men than women (sex ratio 4:1). The amoxycillin-clavulanic acid had been given at doses ranging from 0.5 to 6 g/day (mean 2 g/day) for seven to 60 days (mean 18 days). In 11 cases, the first symptoms appeared one to four weeks after stopping treatment. Jaundice was observed in all patients and was frequently associated with pruritus. Serum aminotransferase activities were increased in all patients and were generally two to 10 times the upper limit of normal. Serum alkaline phosphatase activity was considerably increased, from two to seven times the upper limit of normal. Histological examination of the liver, performed in seven patients, showed centri- or panlobular cholestasis in all cases, associated with granulomatous hepatitis in one. The prognosis of amoxycillin-clavulanic acid induced hepatitis seemed to be good. None of the patients exhibited biological or clinical features of hepatic failure and the course of the disease was characterised by the resolution of jaundice within one to eight weeks and a complete recovery within four to 16 weeks. Taking into account the number of treated subjects and reported cases, we estimated the risk of developing hepatitis with this drug combination to be very low, probably below 1/100,000. Our data suggest that the risk of hepatotoxicity may be increased in elderly men given lengthy treatment. The association of hepatitis and signs of hypersensitivity may suggest an immunoallergic mechanism of hepatotoxicity in some patients.

Lipomatous hypertrophy of the cardiac interatrial septum: an unusual complication in long-term home parenteral nutrition in adult patients.

The aim of this study was to report unusual echocardiographic findings in patients on long-term home parenteral nutrition suggesting lipomatous hypertrophy of the cardiac interatrial septum. Seven patients (two women and five men, mean age 58 years) were prospectively evaluated by two-dimensional echocardiography before and during home parenteral nutrition for severe short-bowel syndrome. Parenteral caloric intake was 33 +/- 4 kcal/kg per day (mean +/- SD), with a mean supply of lipid emulsion of 1 g/kg per day. The first echocardiography, performed before initiation of home parenteral nutrition, was normal in the seven patients. The second echocardiography, performed 5 to 43 months (mean 20 months) later, revealed a significant increase of the thickness of the atrial septum in all patients (+8.3 +/- 3.6 mm; p less than 0.01), consistent with the diagnosis of lipomatous hypertrophy in four patients, and moderate fat accumulation in two others. The septum thickness measured after the nutritional support period was significantly correlated (p less than 0.05) with the total amount of nutrient and lipid infused. Cardiac nuclear magnetic resonance imaging was performed in two patients; it suggested the adipose nature of interatrial septum deposit. None of the patients developed clinical or electrocardiographic symptoms during the period of nutrition. We suggest that patients undergoing long-term home parenteral nutrition be screened for this new and unusual cardiac abnormality. Whether the latter might have clinical consequences in these patients remains to be determined.

Pharmacokinetics and bioavailability of ranitidine in normal subjects and cirrhotic patients.

Pharmacokinetic parameters of ranitidine were determined comparatively in nine cirrhotic patients and eight healthy volunteers after administration of a single oral (150 mg) or intravenous dose (50 mg). Bioavailability was virtually the same in patients and in normal subjects, and there was no significant difference between the two groups for total plasma clearance, intravenous elimination half-life, or volume of distribution. The mean maximum plasma concentration was 43% higher in patients than in volunteers, but the difference was not significant. The values for the kinetic parameters did not significantly differ between patients with and without ascites or with and without hepatocellular insufficiency. These results indicate that ranitidine kinetics are not appreciably altered in cirrhotic patients and that reduction of dosage is not required in such patients unless their renal function is impaired.

[Relations between physical exertion and protein-energy metabolism. Application to nutritional support of hospitalized patients]. / Relations entre activité physique et métabolisme protéino-énergétique. Application á l'assistance nutritive du malade hospitalisé.

The relationship between physical activity, nutritional requirements and protein-energy metabolism is well-established. However, and contrary to bedside practice at home, non-ambulatory techniques of enteral or parenteral nutrition are often used in hospitalized patients, even those who are able to move about. The purpose of the present study is: (a) to review the relationship, as we know it at present, between physical activity and protein metabolism in both normal subjects and patients with denutrition, and (b) to demonstrate that using from the start, or as early as possible, ambulatory techniques of enteral or parenteral nutrition does represent, both physiologically and psychologically, a decisive step forward in the care of hospital patients.

Effects of cyclic (nocturnal) total parenteral nutrition and continuous enteral nutrition on circadian rhythms of blood lipids, lipoproteins and apolipoproteins in humans.

The aim of the present study was to investigate the occurrence and characteristics (acrophase, amplitude) of circadian rhythms of serum total cholesterol, free-fatty acids (FFA), triglycerides, lipoproteins (HDL-, LDL-, and VLDL-cholesterol), apolipoproteins A and B, glucose and total proteins in hospitalized patients fed with 12 h nocturnal total parenteral nutrition (TPN) (from 8 PM to 8 AM) including lipids, patients fed with continuous enteral nutrition over 24 h daily spans, and patients eating 3 meals a day serving as controls. All the subjects were synchronized with diurnal activity and nocturnal rest in the hospital routine. The results showed the following: 1) circadian rhythms of total cholesterol, triglycerides, FFA, HDL-, LDL-cholesterol, apolipoprotein A and total proteins were detected in both TPN patients and controls, rhythms of apolipoprotein B and glucose in TPN patients only; in enteral nutrition patients, rhythms were detected for total proteins, glucose and triglycerides only; 2) a significant shift in triglyceride and FFA acrophases was observed in TPN patients, as compared with controls; 3) 24 h mean of both triglyceride and cholesterol concentrations remained unchanged after one month, in both TPN and enteral nutrition patients. The present approach, by extending results of previous investigations, leads one to conclude that, on both a metabolic and a chronobiological basis, cyclic nocturnal TPN is well-tolerated.

[Familial occurrence of cancer of the colon and the rectum: results of a 3-year case-control survey]. / Prévalence familiale du cancer du côlon et du rectum: résultats d'une enquête "cas-témoins" de 3 ans.

A case-control study of the familial prevalence (first-degree relatives) of colorectal carcinoma (CRC) was performed from October 1979 through March 1983 in: (a) 170 consecutive patients with histologically proved rectal (n = 64) or colonic (n = 106) adenocarcinoma; cases of familial polyposis coli and cancer family syndrome were systematically excluded from the study; (b) 170 control subjects, who were free of CRC or colorectal adenoma(s) and matched to patients according to sex and age; (c) 170 consecutive patients with common rectal or colonic adenoma(s), and no evidence of polyposis coli; (d) 100 patients with cancer of various organs, excluding CRC and primary tumours known to be epidemiologically related to CRC. Results of family studies were expressed as "proved" (when the pathological report was received) or "probable" CRC. Eighteen (10.6 p. 100) of the 170 patients with CRC had at least one first-degree relative with past or present proved CRC, and 14 (8.2 p. 100) with probable CRC; the corresponding figures were 3 (1.7 p. 100) proved and 3 (1.7 p. 100) probable CRC in the control group, 14 (8.2 p. 100) proved and 11 (6.5 p. 100) probable CRC in the "adenoma" group and 1 (1 p. 100) and 3 (3 p. 100) in the non-colonic carcinoma group. The relative risk of CRC in close relatives was 6.3 and 4.7 in the CRC and adenoma groups respectively. For the variables studied no significant differences were found between males and females.(ABSTRACT TRUNCATED AT 250 WORDS)

[Massive sarcomatous infiltration of the liver disclosed by jaundice and hepatocellular failure in Waldenström's disease]. / Infiltration sarcomateuse massive du foie révélée par un ictère et une insuffisance hépatocellulaire au cours d'une maladie de Waldenström.

We report herein the case of a patient with Waldenström macroglobulinemia in whom an immunoblastic sarcoma produced acute jaundice and hepatic failure. Transvenous liver biopsy, performed because of coagulation deficiencies, revealed massive infiltration of the liver by the sarcoma. Immunofluorescence study showed numerous portal and sinusoidal cells stained exclusively by anti-micron anti-kappa antisera. As shown by others in the literature, this study supports evidence for the same clonal origin of the two proliferations. Chromosomal abnormalities were found in marrow and blood cells (trisomy 5 and 20, 6 q-, 7 q+, and 8 p-); their role in emergence of sarcoma is discussed. This case shows that immunoblastic sarcoma emerging during the course of Waldenström macroglobulinemia may be revealed by severe hepatic manifestations.

[Chronic radiation-induced esophagitis after treatment of oropharyngolaryngeal cancer: a little-known anatomo-clinical entity]. / Cesophagites radiques chroniques, après traitement de cancers oro-pharyngo-laryngés: une entité anatomo-clinique méconnue.

Chronic esophagitis induced by radiation therapy (CRE) for carcinoma of the oropharynx and larynx, and involving an initially normal esophagus, is poorly known, and often confused with a locally recurrent malignancy. By reporting 8 consecutive cases, the aim of this study is to contribute to proving that cervical CRE does indeed exist. Eight men, aged 58 to 76 years, developed complete aphagia (7 cases) or severe dysphagia (1 case), 2 to 56 months (median 8.5 months) after radiation therapy for carcinoma of the laryngopharyngeal area. In 5 patients, the primary tumour and/or chains of cervical lymph nodes were removed before radiation therapy; in the 8 patients, the esophagus was endoscopically free of disease. The total dose of radiation exceeded 60 grays in 6 patients. Although they were initially considered as suffering from a locally recurrent malignancy on a clinical basis, none of the 8 patients had patent signs (either endoscopic or histologic) of recurrence. In each case a severe lesion of the cervical esophagus was documented (stenosis 7 cases, giant ulceration 1 case): the diagnosis of CRE was based on endoscopic, histological, and evolutive criteria. Six patients were treated by prolonged nutritional support (via enteral route, 5 cases; parenteral route, 1 case); endoscopic dilatations were used as a single treatment or in association with nutritional support in 4 cases. Three patients died of CRE-induced regional complications; post mortem examination, performed in 2 cases, confirmed CRE without evidence of locally recurrent malignancy.(ABSTRACT TRUNCATED AT 250 WORDS)

Jejunal IgA and C3 deposition in adult Henoch-Schönlein purpura with severe intestinal manifestations.

An adult male patient with Henoch-Schônlein purpura and severe intestinal involvement is reported. Henoch-Schönlein purpura was documented by microscopic and immunofluorescent studies of the skin and kidney. At duodenojejunoscopy there were multiple ulcerations and thickening of mucosal folds. Microscopic and immunofluorescent studies of duodenum and proximal jejunum showed submucosal vasculitis and granular deposits of immunoglobulin A and complement components (C3) in the vessel walls, similar to those observed in the skin and kidney. This patient exhibited severe and prolonged intestinal lesions of Henoch-Schölein purpura, and was resistant to a 10-day course of total parenteral nutrition. However a dramatic clinical response was observed within 24 h after the initiation of plasma exchange therapy; steroids were not used. Intestinal involvement in anaphylactoid purpura may be associated with local immunologic abnormalities similar to those observed in cutaneous vessels and glomerular mesangium.

Effects of prolonged, purine-free total parenteral and enteral nutrition on urate homeostasis in man.

The influence on human urate homeostasis of prolonged, totally purine-free nutritional support, using total parenteral (TPN) or elemental enteral (EN) nutrition, is not well known. In a prospective study, we measured weekly serum uric acid, renal urate excretion and clearance, together with parameters of hydration, in 58 normally hydrated patients receiving prolonged (15 to 170 days) purine-free TPN (30 patients) or EN (28 patients) for various gastrointestinal disorders. A marked, early and sustained decrease (p less than 0.001) in serum uric acid was observed in TPN (155 +/- 9 mumol/l at day 7 versus 318 +/- 13 mumol/l before nutrition, mean +/- SEM) as well as in EN patients (192 +/- 11 mumol/l at day 7 versus 320 +/- 16 mumol/l before nutrition), together with a significant (p less than 0.01) rise in renal urate clearance. The urate clearance/glomerular filtration rate ratio increased significantly, while there was no significant change in natremia or plasma osmolarity. Serum urate and urate clearance returned to normal within 8 days of refeeding with a normally purine-containing diet. Replacement of TPN by EN or vice versa, or substitution of glucose by fructose resulted in no change in hypouricemia. A 4-day oral supply of purines (125 mg/day) in EN patients was associated with a 53% rise (p less than 0.01) in serum urate. We conclude that prolonged, purine-free TPN and elemental EN are a new cause of marked hypouricemia which is mainly due to increased urate clearance, the mechanism of the latter is still poorly known, but is not related to extracellular volume expansion.