Cholecystogastric fistula presenting with haematemesis: diagnosed by endoscopic retrograde cholangiography.

The case is reported of a 72-year-old woman suffering from morbid obesity, who presented with haematemesis while on anti-coagulant therapy. The source of the bleeding proved to be the gastric exit of a cholecystogastric fistula. Subsequent cholangitis was successfully treated by endoscopic retrograde cholangiography (ERC) and endoscopic sphincterotomy (ES) while simultaneously the extent of the fistula was established. Cholecystectomy and closure of the fistula was contraindicated because of her morbid obesity. She remained well for 6 months but then presented with a gallstone ileus while another stone was found to be escaping from the gastric fistula. Her morbid obesity resulted in surgical procrastination, which eventually proved fatal. This patient experienced both of the most common types of complication in cholecysto-enteral fistulation, cholangitis and gallstone ileus. Although cholecysto-enteral fistulas (CEF) are probably less common than several decades ago, they are now most likely to be diagnosed during ERC. Gastroenterologists therefore need to be aware of their potential to contribute to the diagnosis and treatment of this surgical condition.

Neurologic symptoms due to possible chromium deficiency in long-term parenteral nutrition that closely mimic metronidazole-induced syndromes.

BACKGROUND: We previously described a patient on home parenteral nutrition (HPN) who developed glucose intolerance and neuropathy that only responded to an infusion of chromium. A patient on HPN who had neuropathy and glucose intolerance was studied. He was also on metronidazole, which could have caused the neuropathy, but the symptoms and signs persisted. METHODS: Baseline clinical examination, nerve conduction studies, serum vitamin and trace element levels, and glucose tolerance were measured. Then, 250 micrograms of trivalent chromium as the chloride salt was infused daily for 2 weeks. The above studies were repeated. RESULTS: The patient at baseline had peripheral neuropathy of the axonal type and was glucose intolerant. Serum chromium was raised in this patient above the reference range. Despite raised serum levels, the infusion of chromium resulted in clinical remission that was marked 4 days after starting the infusion. Normalization of nerve conduction also occurred within 3 weeks of the initial study. CONCLUSIONS: Neuropathy and glucose intolerance may occur despite increased serum chromium levels and respond to chromium infusion. The previous use of drugs such as metronidazole should not exclude chromium as a potential treatment for neuropathy in HPN patients.

Harry M. Vars Research Award. Increase in lumbar spine bone mineral content in patients on long-term parenteral nutrition without vitamin D supplementation.

BACKGROUND: We had previously shown that short-term withdrawal of vitamin D in patients with metabolic bone disease complicating home parenteral nutrition (HPN) corrected osteomalacia. We therefore conducted a prospective study of the effect of long term withdrawal of vitamin D in patients on home parenteral nutrition. METHODS: Baseline measurements of bone mineral content, serum levels of calcium, phosphorus, parathormone, 25-OH and 1,25 (OH)2D; urinary calcium; and bone mineral density were measured. Then all parenteral vitamin D was withdrawn and the above parameters were followed for a mean of 4.5 years. RESULTS: Lumbar spine bone mineral content (LSBMC) was 0.79 +/- 0.06 g/cm2 at the start of the study, well below the reference value, 1.16 +/- 0.13 g/cm2. Parathyroid hormone (PTH) (0.48 +/- 0.24 pmol/L) and 1,25-(OH)2D levels (22.8 +/- 7.9 pmol/L) were low and 25-hydroxyvitaniin D levels were normal (33.3 +/- 5.5 nmol/L) before removing vitandn D from the HPN solutions. After withdrawal of vitamin D for 4.5 +/- 0.2 years LSBMC increased from 0.79 +/- 0.06 to 0.93 0.07 g/cm2 (p < 0.005). Calcium phosphorus, magnesium and 25-hydroxyvitamin D did not change significantly, 1,25(OH)2D, and PTH levels became normal after withdrawal of vitamin D. CONCLUSIONS: In selected patients with depressed PTH levels, long-term withdrawal of vitamin D during HPN increases LSBMC and levels of PTH and 1,25(OH)2D. There is no reduction of the mean level of 25-hydroxyvitamin D.

[The treatment of myocardial infarction during the hospital stage and shortly thereafter: now and 10 years ago]. / De behandeling van het myocardinfarct gedurende de ziekenhuisfase en kort daarna: nu en 10 jaar geleden.

OBJECTIVE: Comparison between the early and the late eighties of the application of thrombolysis and revascularisation in the acute phase of a myocardial infarction. LOCATION: University Hospital, Rotterdam. DESIGN: Prospective with historical comparison. METHODS: All patients admitted between May 1987 and May 1990 with a myocardial infarction and aged up to 71 years were included (n = 430). Numbers of procedures and survival during the following year were compared with data of patients admitted from 1981 to the end of 1983 (n = 706). RESULTS: In 1981-1983 thrombolytics were administered to 9% of the patients, in 1987-1990 to 40%. Revascularisation procedures during the next year were performed in 17% and 50% of the patients respectively. Hospital mortality decreased from 14% to 10% (p < 0.05), one-year survival increased from 75% to 83% (p < 0.05). For patients from 1987-1990 one-year survival was higher after thrombolysis treatment: 90% versus 78% without (p < 0.01), and after revascularisation: 94% versus 87% without (p < 0.01). CONCLUSION: Compared with 1981-1983 the treatment is at present more directed towards reperfusion and revascularisation of the ischaemic myocardium, resulting in invasive treatment in 50% of the patients now as opposed to 25% in the early eighties. The survival rate during the first year has improved.