Estrogen-progesterone therapy for recurrent gastrointestinal bleeding secondary to gastrointestinal angiodysplasia.

Recurrent gastrointestinal bleeding ceased after the institution of estrogen-progesterone therapy in a patient with gastrointestinal angiodysplasia without chronic renal failure. The patient did have aortic stenosis and mitral insufficiency murmurs. A therapeutic trial of conjugated estrogen should be considered in patients with recurrent gastrointestinal bleeding secondary to gastrointestinal angiodysplasia after the use of therapeutic endoscopy and/or surgery.

PIP: A case report is presented of a 78-year-old patient with recurrent gastrointestinal bleeding who required frequent hospitalizations and several blood transfusions, both of which ceased after the institution of estrogen-progesterone therapy. The patient was hospitalized in April 1985 with weakness and shortness of breath. Her hemoglobin was 9.8. Indices were suggestive of a microcytic hypochromic anemia. Bone marrow revealed absent iron stores. The patient denied a prior history of melena, hematochezia, or hematemesis. There was no history of peptic ulcer disease. The patient was taking no medications, and she denied alcohol abuse and a family history of bleeding. The physical examination revealed a pale and weak appearing women in no acute distress. An aortic stenosis and mitral insufficiency murmur was her only positive physical finding. Hemoccult positive stool was detected on rectal examination. The patient was transfused with 2 units of packed cells and underwent an evaluation. Subsequently, the patient required 4 more hospitalizations requiring blood transfusions. In October 1985, the patient underwent an exploratory laparotomy and an intraoperative endoscopy of the entire gastrointestinal tract. There was evidence of bleeding in the cecum near the ileocecal valve. The patient underwent an ascending colectomy. The histopathology of the specimen revealed angiodysplasia of the cecum. Postoperatively, during a 5-month period, the patient required 16 units of blood. In March 1985, Enovid E was started, and the patient has not required further hospitalizations or a blood transfusion since. The only side effects of the estrogen-progesterone combination which this patient experienced were vaginal bleeding and mild systolic hypertension. In patients with gastrointestinal angiodysplasia who have cryptogenic gastrointestinal bleeding, despite the use of therapeutic endoscopy and surgery, possibly a trial of estrogen-progesterone therapy should be considered.

The benefits of systematic fiberoptic flexible sigmoidoscopy.

We used the flexible fiberoptic sigmoidoscope (FFS) on 656 subjects who were receiving their yearly physical examinations. Neoplastic disease was disclosed by the FFS in 138 subjects (21%), including 26 adenocarcinomas, 19 of which were out of reach of a rigid sigmoidoscope. Nineteen of the subjects whose adenocarcinomas were found by the FFS had barium enemas, which detected the carcinomas in only 11. Routine FFS in asymptomatic persons is helpful in detecting both premalignant and malignant lesions, it should be seriously considered as a part of regular preventive physical examinations.

Dual system of intestinal thiamine transport in humans.

The transport of thiamine across the intestine has been characterized in rats but has not been adequately studied in humans. To determine the kinetics of thiamine intestinal transport directly in humans, mucosal tissues were obtained during routine endoscopy from normal-appearing sites at the second portion of the duodenum. With 3H-dextran as the marker of adherent volume, the uptake of 14C-thiamine hydrochloride by the excised mucosa was measured in vitro. By this method thiamine uptake was linear with tissue weight and with incubation time up to 5 min. Results showed that at low thiamine concentrations (0.2 to 2.0 microM), uptake was saturable whereas at high concentrations (5 to 50 microM), uptake was linear with thiamine concentrations. Pyrithiamine, anoxia, N-ethylmaleimide, and replacement of sodium chloride by mannitol reduced the uptake of 0.5 microM thiamine by 42%, 37%, 32% and 35%, respectively (p less than 0.05) but had no effect on the uptake of 20 microM thiamine. These data suggest that, as in the rat, the intestinal transport of thiamine in humans proceeds by a coexistent dual system. At physiologic concentrations, thiamine is transported primarily by an energy-requiring, sodium-dependent active process, whereas at higher pharmacologic concentrations thiamine uptake is predominantly a passive process.

Retinopathy following jejunoileal bypass surgery: report of a case.

Vitamin A deficiency associated with retinopathy and night blindness was observed in a patient 4 yr after jejunoileal bypass. Upon further investigation, a multiple vitamin deficiency state was established. Daily supplementation with 30 000 units of vitamin A resulted in normal levels of vitamin A and retinol-binding protein. The patient's night blindness improved, but his retinopathy remained unchanged as demonstrated by fluorescein angiography. We conclude that patients who have undergone jejunoileal bypass should be supplemented with vitamin A since the vitamin A deficiency is preventable and the retinopathy associated with the deficiency may not be totally reversible.

Cimetidine spares the glucuronidation of lorazepam and oxazepam.

Lorazepam (Ativan) disposition and elimination were studied in 8 normal subjects before and after 1 wk of cimetidine therapy, 300 mg taken orally four times a day. In 4 of these 8 normal subjects the disposition and elimination of oxazepam (Serax) were also studied before and after similar treatment with cimetidine. Cimetidine did not alter the elimination of either lorazepam or oxazepam. Since both drugs are eliminated exclusively after conjugation as glucuronide, this study demonstrates a relative sparing of this pathway of biotransformation of drugs in subjects receiving cimetidine.

The role of coronary adrenergic receptors in the response to nitroglycerine and the regulation of large and small vessel resistance.

The role of coronary adrenergic receptors in response to nitroglycerine and in the regulation of large and small coronary vascular resistance was evaluated in two separate studies involving fifteen anesthetized mongrel dog preparations, before and after alpha- and beta-adrenergic blockade, respectively. Coronary blood flow (CBF) was measured through the left anterior descending (LAD) coronary artery by a non-cannulating electromagnetic flow probe. Pressure catheters were inserted into the arch of the aorta and into a distal apical branch of the LAD coronary artery to measure, respectively, aortic pressure (coronary perfusion pressure (PA), peripheral coronary pressure )PC), and coronary artery pressure gradient (PG = PA -PC). End-diastolic resistances to flow were computed as: (a) large coronary end-diastolic resistance (RL = PG/CBF), and (B) small coronary end-diastolic resistance (RS = PC/CBF). Nitroglycerine (NG) alone increased RL to approximately 180--220% of control and reduced RS to about 60% of control, respectively. Following pharmacologic blockade with propranolol (PRO), NG increased RL to about 180% of control and reduced RS to about 60% of control. Following alpha blockade with phenoxybenzamine (PBZ), NG decreased RL to about 78% of control and decreased RS to about 56% of control. It is concluded that while the overall effect of NG on the coronary vascular resistance is one of vasodilation, RL appears to be increased transiently and RS transiently decreased. Alpha adrenergic blockade appears to abolish this response. The increase in RL in response to NG appears to be associated with the systemic hypotensive effect in response to NG. It is proposed that the observed increase in RL is produced by the increase in cardiac sympathetic nerve activity which is initiated by the systemic hypotensive effect of NG.