Duodenal erosion with bleeding from a non-functioning islet cell tumour. A case report.

A patient with a clinically non-functioning pancreatic islet cell tumour in the medial wall of the duodenum with erosion of the overlying mucosa presented with gastro-intestinal bleeding. At gastroduodenoscopy, the tumour with its apical ulcer was thought to be a leiomyoma. The lesion was excised locally and two other non-functioning APUDomas were shelled out of the body and tail of the pancreas.

Subclavian vein stenosis and axillary vein 'effort thrombosis'. Age and the first rib bypass collateral, thrombolytic therapy and first rib resection.

Three patients presented with axillary vein 'effort thrombosis'. Intravenous streptokinase for 3 days followed by heparin for 10 days restored patency and relieved symptoms. Pretreatment diagnosis and the effect of streptokinase were confirmed venographically and an abnormality in the subclavian vein just medial to the first rib was demonstrated. This stenosis was most severe and had a prominent bypass collateral in the oldest patient. It is proposed that, in the absence of superimposed thrombosis, the damage to the vein in predisposed patients is progressive with age, with establishment of permanent collaterals. Transaxillary first rib resection is advised to prevent compression of the veins in the thoracic outlet.

Importance of hypovolaemic shock and endoscopic signs in predicting recurrent haemorrhage from peptic ulceration: a prospective evaluation.

The incidence of rebleeding was studied prospectively in 177 patients with acute gastrointestinal haemorrhage from peptic ulceration with reference to the degree of haemodynamic insult on admission and the presence of endoscopic signs of recent haemorrhage on initial endoscopy. Rebleeding occurred in two (2%) of 114 patients without shock, in seven (18%) of 38 with tachycardia (pulse rate greater than 100 beats/min, systolic blood pressure greater than 100 mm Hg), and in 12 (48%) of 25 with shock (systolic blood pressure less than 100 mm Hg). A similar gradient was noted with the presence of endoscopic signs alone. Rebleeding occurred in four (5%) of 79 patients with no endoscopic signs, in none of 40 with black spot only, in 11 (23%) of 48 with a clot, and in five (50%) of 10 with a visible vessel on endoscopy. When the incidence of rebleeding was assessed in shocked patients, however, it was significantly higher in those with important signs (clot or visible vessel), in 11 (79%) out of 14 patients, than in those with no signs, in one (9%) out of 11 (p less than 0.001). These data suggest that the association of shock with important endoscopic signs is a stronger predictor of rebleeding than either shock or important signs alone. More aggressive treatment may be warranted in this small group of patients.

The bleeding gastric ulcer--will it bleed again, and if so, why? A case for repeat endoscopy in evaluating stigmata.

Nine patients qualified for surgery for a bleeding gastric ulcer--all had a 'visible vessel'. Three of these vessels were thrombosed including 2 in patients who had been in shock. The smallest patent vessel was 0,35 mm in diameter, and 6 of the bleeding vessels were subserosal. The features thought to predispose to further bleeding were vessel size, a lateral hole in the main trunk of the vessel and, possibly, previous recanalization or ingestion of a drug which affected haemostasis. Five of 6 patent arteries had a cap of thrombus over the breach forming a false aneurysm. It is suggested that clinically these should pulsate, enlarge, leak--with persistent fresh thrombus in the ulcer crater on repeat endoscopy--and finally rupture. Where the underlying vessel is thrombosed the stigmata of a non-pulsatile 'visible vessel' or thrombus in the ulcer should disappear on repeat endoscopy. The sizes of the arteries in the normal antrum are tabulated.

Platelet and other tests followed sequentially for 14 days after operation.

Nineteen patients were studied twice before and sequentially from 1 h to 14 days after operations lasting about 1 h. Eighteen tests were carried out, ideally on all the nine occasions blood collections were planned. Only significant changes are summarized. Immediately after the operation the plasma PF4 and beta TG were raised in parallel suggesting some platelet 'release' had occurred. At this time platelet aggregation to ADP and collagen had decreased by 57% to 64% and the plasma cyclic AMP had doubled. Next day these abnormalities had returned towards normal. By day 2 the fibrinogen and the heparin neutralizing activity were maximal; they returned towards normal by day 14. On day 14, when presumably all platelets present at operation had been removed the new platelets were 53% more numerous and 9.5% smaller; they contained 23% less PF4 and 42% less serotonin and 5-HT uptake was decreased, but the total amount of 5-HT and PF4 in the circulation probably remained constant. In summary these operations transitorily upset platelet function for a few hours and the platelets formed postoperatively were abnormal.

Amputation of gangrenous toes--effect of sepsis, blood supply and debridement on healing rates.

While 32% of the patients in this series who required amputation in the lower limb presented with infected or gangrenous toes, only 9% had pedal pulses. In a prospective study of 26 phalangectomies and 9 ray or transmetatarsal amputations, the definition of a successful procedure was taken as a healed, painless wound at 1 month. By 1 month, 6 wounds were healed, 5 pain-free and granulating and 8 septic or painful; 16 patients had had further surgery. In the end 14 of 35 feet were salvaged, with 2 patients lost to follow-up and 4 with painful or septic feet. The 15 patients who later required below-knee or above-knee amputations were pain-free, but 7 could not be rehabilitated on prostheses. Blood supply and sepsis affected the healing rate, whereas diabetes was unimportant. The final salvage rate was apparent within 1 month of the initial surgery. In the absence of a pedal pulse, the use of clinical judgement for the selection of patients with dry gangrene gave a 50% salvage rate, but only 8 patients were selected for local surgery out of the total of 24 in this category. Sixteen amputations were performed for sepsis in the absence of a pedal pulse; no wound healed and only 2 patients had a clean, pain-free, granulating wound at the end of the 1-month period. Direct arterial surgery played an important role in restoring the pulse prior to amputation.

A pilot study of the effect of Gemfibrozil on some haematological parameters.

In a double-blind 13 week study the effects of Gemfibrozil were compared with placebo. Gemfibrozil was given to 10 patients with evidence of severe atherosclerosis; four similar patients acted as controls. As expected, in the treated group, total cholesterol and triglycerides decreased significantly and HDL cholesterol increased. The Fibrinogen did not change although the ESR increased markedly and the heparin neutralizing activity (HNA) of the plasma decreased (p = 0.01). The antithrombic activity increased. The change in the HNA correlated weakly to the total cholesterol both before and during treatment. These findings show that some of the effects of Gemfibrozil on atherosclerotic humans are similar to those of Clofibrate but others are different.

Vascular hamartomas of the gastrointestinal tract. Case reports.

Three patients with vascular hamartomas of the gastro-intestinal tract are described. These congenital lesions are distinct from hereditary telangiectasia and acquired lesions including vascular ectasia (angiodysplasia). The classification of these hamartomas is based on the capillary and reticular phases of development of the vascular tree, and the reticular forms are further subdivided into venous, arterial or arteriovenous fistulas, and haemolymphatic hamartomas. The typical features diagnosis and management are discussed.

Intraplatelet serotonin and plasma 5-hydroxyindoles in health and disease.

Using a fluorometric test sensitive to serotonin (5-HT) and to other 5-hydroxyindoles (5-HIs) it was shown that platelets take up 5-HT and that the added 5-HT and the inherent test-positive material in platelet lysate can be directly measured. However, platelets do not take up 5-hydroxyindole acetic acid or the 5-HIs from the plasma. Thus, 5-HT and the other 5-HIs can be distinguished. Various methods of liberating intraplatelets 5-HT were investigated. Several anticoagulants, temperatures, and speeds of centrifugation were employed, with no effect on the results. It was found that in healthy donors, with increasing age, there was a decrease in intraplatelet 5-HT and an increase in plasma 5-HIs. The quantities of these substances were inversely related. In acute myocardial infarction, the 5-HT was normal taking age into account, but the plasma 5-HIs were increased. In postoperative patients, the platelet 5-HT was low and the plasma 5-HIs were normal. In patients with chest pain but no myocardial infarction, both platelet 5-HT and plasma 5-HIs were normal. The relevance of these findings to 5-HT metabolism and the evidence for in vivo activation of platelets is discussed.

Platelet function in acute myocardial infarction patients compared with controls.

A considerable number of tests were carried out comparing 33 patients with acute myocardial infarction (MI), 13 patients with chest pain (CP) and 47 controls. There was some evidence that the plasma platelet factor 4 (PF4) was different in the three groups. The heparin neutralizing activity (HNA) of platelet poor plasma was increased in the MI patients relative to the controls and the intra-platelet HNA was decreased. Malondialdehyde (MDA) formation by platelets maximally stimulated by thrombin was decreased in MI whilst the plasma 5-hydroxyindoles (5HIs) in MI was greatly increased. The acute phase proteins alpha 1 acid glycoprotein and fibrinogen were significantly raised in MI. The results in the CP group were intermediate between the MI and the controls. These findings define more precisely the changes in acute MI and are relevant to the concept of exhausted platelets.

The effect of ICI 55,897 and clofibrate on platelet function and other tests abnormal in atherosclerosis.

There is considerable evidence that the quantity or quality of plasma lipids influences platelet function tests, and clofibrate reduces high plasma lipids and alters some platelet tests. Clofibrate was accordingly given to patients with vascular disease who were at risk of thrombosis. The heparin thrombin clotting time (HTCT), initially short and thus possibly reflecting increased activation, was regularly returned to normal after about a month's delay. The fibrinogen was also normalized but the initially abnormal anti-thrombic activity became more abnormal. ICI 55,897, an analogue of clofibrate, also normalized the HTCT and the fibrinogen and had no adverse effect on the anti-thrombin levels. This compound has no effect on plasma lipids. If it can be shown that the correction of abnormal tests conveys clinical benefit these findings suggest that ICI 55,897 might clinically be more beneficial than clofibrate. However, direct comparison of clofibrate and ICI 55,897 suggests that clofibrate is more effective in normalizing the HTCT. The mechanism underlying these drug-induced changes are unknown but they cannot be directly related to lipid changes.