Benign ulcer in a hiatus hernia complicated with a pericardial fistula.

Penetration of the pericardium by upper gastrointestinal lesions is uncommon. It usually results from trauma, perforation of foreign objects, perforation from gastric or thoracic neoplasm or spontaneous perforation. Unfrequently it is a complication of a benign peptic ulcer of the esophagus or the stomach. Survival from peptic ulcers penetrating to the heart is very rare. From a review of the English literature only 11 survivors have been described. We report the successful outcome of a 76 year old lady with a benign ulcus in a hiatus hernia perforating into the pericardium. Diagnosis of the fistula was established after methylene blue swallow. Treatment consisted of early pericardiotomy and drainage followed by surgical correction of the ulcer and fundoplication of the hiatus hernia.

Escherichia coli endocarditis of a native mitral valve with paravalvular pseudoaneurysm formation and fatal hemopericardium.

Until recently only few cases have been described of acute infective endocarditis with E. Coli limited to a normal native mitral valve. Furthermore, mechanisms of so called abcess formation and rupture are still uncompletely understood. We report the case of an E. Coli endocarditis developing a rapidly progressive pseudoaneurysm of the mitral annulus. At necropsy diffuse infectious tissue weakening with pseudoaneurysm formation of the mitral ring and dissection into an hemorraghic pericard were seen. The authors further discuss the changing pattern of infectious agents causing acute infective endocarditis of the native mitral valve, transesophageal echocardiographic characteristics of paravalvular cavities and insights in mechanisms of pseudoaneurysm formation and dissection from clinicopathological findings.

Chylothorax and chylous ascites due to malignant lymphoma.

Chyle is a fluid rich in triglycerides and is characterized by the presence of chylomicrons. Chylous effusions are unusual complications of malignant neoplasms, usually lymphomas. The combination of chyloperitoneum and chylothorax is very rare. When abdominal lymphatics are obstructed, chylous ascites results and eventually leads to a chylothorax. We present the case of a 68-year-old woman with a chyloperitoneum and a right-sided chylothorax due to an underlying malignant B-cell lymphoma. After thoracocentesis and replacement therapy with medium chain triglycerides, she was treated with a combination of cyclophosphamide, vincristine and prednisone. This has resulted in a regression of the chylous effusions. A short review of the literature describes causes, diagnosis and therapy of chylous effusions.

Infectious gastroenteritis: are they all the same?

Campylobacter jejuni and Salmonella spp are the most frequently cultured micro-organisms in infectious gastroenteritis among patients hospitalized at the departments of gastroenterology and geriatrics. As a whole, the hospitalized patient population with Campylobacter gastroenteritis is a younger one, compared to the Salmonella-infected group. Both pathogens can be associated with a biochemical pancreatitis, which is usually without clinical importance. However, serious complications can occur, with a predominance of visceritis for C. jejuni, and renal function impairment for Salmonella spp. Finally, an asymptomatic carrier state is well known in the Salmonella infection spectrum, whereas C. jejuni might cause a recurrent disease in some patients.

Effects of serotonin on rat ileocolonic transit and fluid transfer in vivo: possible mechanisms of action.

The aim was to investigate the action of serotonin (5HT) on function of the ileocolonic junction (ICJ) in vivo. In anaesthetised rats, models were developed to study the effects of intra-aortic (ia) serotonin on ileocolonic and colonic transit, and the effects on transit of a number of 5HT receptor antagonists. In the first series of experiments, a bolus of saline labelled with 99mTc DTPA was instilled 20 cm proximal to the ICJ and transit was assessed three hours later by the geometric centre of the spread of isotope. In the second series, similar techniques were used on the postcaecal colon and transit assessed two hours later. In the third series of experiments, the effects of ia 5HT on ileal net fluid flux was evaluated by standard perfusion experiments with 14C polyethylene glycol (PEG) 4000 as a non-absorbable marker in rat plasma-like electrolyte solution. Compared with ia saline, 5HT accelerated ICJ transit significantly (p < 0.05). This acceleration was comparable with the effect of ia bethanechol. The effects of 5HT on ICJ transit were inhibited by the intraperitoneal (ip) infusion of atropine, the 5HT receptor antagonists, methysergide, ketanserin, zacopride, and the 5HT4 agonist, SC53116. Methysergide, zacopride, and SC53116 given with ia 5HT slowed ICJ transit to rates below those of ia saline alone. When these same agents were given together with ia saline, the ICJ transit was not significantly altered. Serotonin, at the dose that accelerated ICJ transit, did not significantly alter colonic transit or ileal fluid transport. In conclusion, 5HT is a potent pharmacological stimulant of transit across the rat ICJ in vivo; the action of 5HT is mediated partly through muscarinic neurones and several 5HT receptor subtypes.

The role of nitric oxide in inhibitory non-adrenergic non-cholinergic neurotransmission in the canine lower oesophageal sphincter.

1. The role of nitric oxide (NO) in non-adrenergic non-cholinergic (NANC) neurotransmission was studied on circular muscle strips of the canine lower oesophageal sphincter (LOS). Electrical field stimulation evoked frequency-dependent relaxations, which were resistant to adrenergic and cholinergic blockade and abolished by tetrodotoxin. 2. Exogenous administration of NO induced concentration-dependent and tetrodotoxin-resistant relaxations which mimicked those in response to electrical stimulation. 3. NG-nitro-L-arginine (L-NNA), a stereospecific inhibitor of NO-biosynthesis, inhibited the relaxations induced by electrical stimulation but not those by exogenous NO or vasoactive intestinal polypeptide (VIP). 4. The effect of L-NNA was prevented by L-arginine, the precursor of the NO biosynthesis but not by its enantiomer D-arginine. 5. Haemoglobin abolished the NO-induced responses and reduced those evoked by electrical stimulation. 6. Cumulative administration of VIP induced concentration-dependent relaxations, which were slow in onset and sustained. A complete relaxation to VIP was not achieved and the relaxations were not affected by L-NNA. 7. In conclusion, our results provide evidence that NANC relaxations are mediated by NO, suggesting NO or a NO releasing substance as the final inhibitory NANC neurotransmitter in the canine LOS.

Release of nitric oxide upon stimulation of nonadrenergic noncholinergic nerves in the rat gastric fundus.

The possible role of nitric oxide (NO) as inhibitory nonadrenergic noncholinergic (NANC) neurotransmitter was studied in the rat gastric fundus. NO induced tetrodotoxin-resistant NANC relaxations in longitudinal muscle strips similar to those induced by electrical stimulation. Incubation with the stereospecific inhibitors of the NO biosynthesis NG-monomethyl-L-arginine (L-NMMA) and NG-nitro-L-arginine (L-NNA) resulted in an increase of the basal tension which was reversed partly by L-arginine, but not by D-arginine. L-NMMA and L-NNA inhibited the relaxations to electrical stimulation, but not those induced by ATP, vasoactive intestinal polypeptide (VIP), norepinephrine or NO. This inhibitory effect was prevented by L-arginine, but not by D-arginine. In a second series of experiments, the gastric fundus served as donor tissue in a superfusion bioassay with de-endothelialized rings of rabbit aorta as detector tissue. The fundus released a labile factor with vasodilator activity upon electrical stimulation. This release was inhibited by tetrodotoxin and L-NNA, whereas it was increased by L-arginine. The biological activity was enhanced by superoxide dismutase and eliminated by hemoglobin. Our results indicate that NO is formed and released upon brief stimulation of the NANC nerves in the rat gastric fundus which is essential for the transient relaxations in this preparation. Therefore, we suggest NO or a NO releasing substance as inhibitory NANC transmitter in the rat gastric fundus.