Bowel preparation before colonoscopy. Choosing the best lavage regimen.

A review of the relevant English-language literature on bowel cleansing before colonoscopy yielded results of randomized trials comparing a variety of regimens, including polyethylene glycol (PEG)-electrolyte lavage, 3-day clear liquid diet with laxatives or prokinetics, and oral sodium phosphate, as well as these regimens combined with agents such as metoclopramide, cisapride, and senna. Balancing the importance of such factors as cleansing effectiveness, safety, ease of completion, side effects, patient tolerance, and cost, the authors recommend four methods: (1) PEG-electrolyte solution (eg, CoLyte, GoLYTELY, NuLytely) in combination with senna (eg, X-Prep), (2) PEG-electrolyte solution alone (either single dose or split dose), (3) oral sodium phosphate (Fleets Phosphosoda) given in split dose, and (4) oral magnesium citrate in combination with rectal pulsed irrigation.

Pediatric rectal Dieulafoy's lesion.

Dieulafoy's lesions are an unusual cause of gastrointestinal hemorrhage. The overwhelming majority of lesions are found in the upper gastrointestinal tract, particularly along the lesser curvature of the stomach in the region supplied by the left gastric artery. Rectal Dieulafoy's lesions have never before been reported in the pediatric population, and our case represents only the third reported occurrence of a rectal Dieulafoy's lesion in the English medical literature. Successful treatment was administered, i.e., the combination of sclerotherapy followed by thermocoagulation. We therefore recommend that rectal Dieulafoy's lesion be included in the differential diagnosis of children with severe rectal bleeding and that management follow the same principles used to treat upper gastrointestinal tract Dieulafoy's lesions: injection therapy followed by heater probe coagulation.

Inflammatory diseases of the colon. Narrowing a wide field of symptoms and possible causes.

Symptoms and physical findings may indicate the severity of inflammatory disease of the colon, but detailed history taking is needed to limit the wide spectrum of possible causes. Infectious causes should be ruled out before other disease is assumed to be present. No single test is sufficient to diagnose ulcerative colitis or Crohn's disease. Laboratory testing, histologic assessment, endoscopy, radiology, and bowel studies are often necessary in differential diagnosis. Because of the systemic nature of colitis, manifestations in the musculoskeletal, ocular, dermatologic, hepatobiliary, and other systems may occur and provide clues. Treatment depends on the type and severity of disease. Sulfasalazine (Azulfidine), sulfa-free 5-aminosalicylic acid compounds, and corticosteroids are mainstays of treatment of ulcerative colitis and Crohn's disease. Supportive care and judicious use of antimicrobial therapy are usually effective in colitis due to bacterial, parasitic, and sexually transmitted infections and are useful for symptoms caused by colonic ischemia and vasculitis. Colitis resulting from radiation therapy may present several years after the procedure and can be difficult to diagnose and treat. In many cases of inflammatory colon disease, especially chronic conditions, consultation with a gastroenterologist is highly recommended.

Unusual aspects of acute Q fever-associated hepatitis.

We describe a 37-year-old farmer with a 3-week history of fevers and hepatitis, in whom Q fever was diagnosed. The diagnosis was based on the findings of characteristic "ring" granulomas on a bone marrow biopsy specimen and confirmed by complement-fixation antibody tests to Coxiella burnetii. Unusual aspects of this case included (1) relatively low complement-fixation antibody titers, (2) prolonged prothrombin time, (3) false-positive results of a serologic test for the human immunodeficiency virus (HIV), and (4) ring granulomas that progressed to atypical granulomas in biopsy specimens.

Poison centers in America: how well do they perform.

Marked differences in cell volume, service area, and center resources continue to exist between poison centers certified by the American Association of Poison Control Centers as Regional Poison Centers and those not meeting these criteria. However, the present clinical significance, if any, of these factors remains unproven. The only previous study, conducted in 1980, used only 1 test problem and did not attempt to separately analyze each of the differences between Regional Poison Centers and Non-regional Poison Centers. This study solicited the participation of all 208 US poison centers existing. Fifty-four poison centers (REGIONAL CENTERS 16/34 = 47%, NON-REGIONAL CENTERS 38/173 = 22%) agreed to participate. Three problems were presented to each center by simulated callers. Considerable variation was observed in efficiency and in extent of information provided. Overall, Regional Centers provided complete and correct answers for 83% of the presented cases, while Non-regional Centers did so in 57% of the cases. Although Regional Center status, staff experience, center call volume, medical direction all appear to be important, the most predictive factors were staff and center experience.