Hepatitis A-induced diabetes mellitus, acute renal failure, and liver failure.

A 38-year-old otherwise healthy man presented with hepatic failure (aspartate aminotransferase of 7212 U/L, alanine aminotransferase of 6629 U/L, total and direct bilirubin of 10.7 mg/dL) and acute renal failure (creatinine of 11.6 mg/dL and blood urea nitrogen of 42 mg/dL), which required hemodialysis when the creatinine increased to 21 mg/dL, with a blood urea nitrogen of 115 mg/dL, and the patient became oliguric. On admission, this patient also had a lipase of 1833 U/L, amylase of 211 U/L, glucose of 210 mg/dL, and reactive IgM antibody for acute hepatitis A. The hepatitis and acute renal failure resolved in 3 months, but this patient continues to have type II diabetes mellitus 7 years after the hepatitis A infection. This case illustrates that hepatitis A infection may be severe with liver failure, acute renal failure, and permanent diabetes mellitus as sequale of this infection.

Steatorrhea and weight loss in a 72-year-old man: primary biliary cirrhosis? Celiac disease? Bacterial overgrowth? What else?

Unintentional weight loss is an ominous sign, particularly when it occurs in the elderly; concern for malignancy is especially worrisome. In this report, we describe a 72-yr-old man who presented with weight loss and was found to have massive steatorrhea. An extensive evaluation revealed evidence of primary biliary cirrhosis (PBC), celiac disease, and small intestinal bacterial overgrowth. No malignancy was identified. The weight loss was attributed to severe steatorrhea due, in part, to intraluminal bile salt deficiency, small bowel mucosal disease, and bacterial overgrowth. Several points are discussed regarding gastrointestinal function in elderly patients with chronic liver disease secondary to PBC. The rare association between PBC and celiac disease in adults is also discussed. Finally, we suggest that bacterial overgrowth plays a significant role in the development of steatorrhea in some persons with PBC and that an assessment for bacterial overgrowth should be performed on persons with steatorrhea and PBC.

Achalasia of the esophagus in association with renal cell carcinoma.

A case of secondary achalasia due to renal cell carcinoma is presented. The patient presented with typical clinical, radiologic, and manometric features of achalasia, and was found to have a renal cell carcinoma with metastases to lymph nodes in the region of the cardioesophageal junction. Direct esophageal involvement could not be demonstrated, however. Complete symptomatic remission was obtained with a single hydrostatic balloon dilatation of the cardioesophageal junction and was maintained until the patient's death 7 months later, perhaps as a result of regression of paraesophageal nodal metastases following radiotherapy, immunotherapy, and chemotherapy.

Diabetic thoracic radiculopathy: electrodiagnostic study.

We investigated the diagnostic value of electromyographic (EMG) examination of the anterior abdominal wall muscles (AWMS) in thoracic radiculopathy and compared it with examination of thoracic paraspinal muscles (TPSM). Technically, examination of AWMS was much easier compared to TPSM. In eight patients with thoracic diabetic radiculopathy at the level of T7-T12, AWMS was abnormal in all and was considered to be diagnostic, whereas AWMS was normal in diabetic lumbar radiculopathy, patients with diabetes mellitus without radiculopathy, patients with unspecified gastrointestinal pain, and patients with musculoskeletal-type back pain. We conclude that EMG evaluation for possible thoracic radiculopathy should include examination of AWMS, and if abnormal, would be of great diagnostic help in patients with unspecified gastrointestinal symptoms.

Clinical application of in vitro studies for barium-enema examination following colorectal biopsy.

A total of 150 colorectal biopsies were performed in 71 patients and correlated with the barium-enema examination (BE). The investigation was divided into two parts. In the first part, involving 19 patients, the depth of each biopsy specimen was determined histologically prior to BE and potential complications related to the biopsy-BE sequence were evaluated. In the second part, involving all 71 patients, the depth of biopsy specimens taken from various colon lesions was determined histologically without regard to the timing of BE. The results confirm previous in vitro findings in pigs and dogs, namely: (a) BE may be performed without delay following a superficial biopsy, but should not be performed until at least 6 days after a deep biopsy; (b) transcolonoscopic biopsies are likely to be superficial, while transproctoscopic biopsies have the potential to be deep; and (c) BE should be delayed at least 6 days following polypectomy or polyp biopsy performed with electrosurgery.