Venous complications of sclerotherapy for esophageal varices.

Although endoscopic sclerotherapy is effective in controlling bleeding from esophageal varices, the effects of sclerosing agents on the extrahepatic portal and splenic veins have not previously been investigated. This study of 21 men with portal hypertension and variceal bleeding compares the morphology of the portal and splenic veins in 11 who had received endoscopic sclerotherapy versus 10 patients who did not. The mean number of injections per patient was 11 +/- 5, the mean volume of 1.5 percent sodium tetradecyl injected was 23 +/- 15 ml, and the interval between the last injection and surgery was 15 +/- 6.5 days. Among the 11 patients who had endoscopic sclerotherapy, portal vein thrombosis occurred in 4 (36 percent). Two of these patients died from acute liver failure; the other two had shunt procedures. Histologic changes included intimal thickening and medial fibrosis in seven patients, thrombus in four patients, and destruction of the venous architecture in two patients. Of the 10 patients with portal hypertension who did not have endoscopic sclerotherapy, all had medial fibrosis of the portal vein, with thrombus and intimal thickening present in only 1. These findings suggest that endoscopic sclerotherapy for esophageal varices should be used cautiously in patients who may later require a shunt. Moreover, further studies are necessary to evaluate the long-term effects of injecting sclerosing agents into the portal circulation before widespread use of prophylactic sclerotherapy can be recommended.

Secretagogue-induced enzyme release from the exocrine pancreas of rats following adaptation to a high protein diet.

The mechanisms of pancreatic adaptation to dietary changes and whether these changes are reflected in the serum are not fully understood. The present study investigates secretagogue-induced release of digestive enzymes from dispersed pancreatic acini as well as the concentrations of these enzymes in serum and pancreas after adaptation to a high protein diet. Adult rats were fed an 8.5% casein diet ad libitum. After 14 d the rats were divided into three groups and fed isoenergetic diets constituting 8.5, 24 or 40% protein for an additional 6 d. No significant differences in final body weight or pancreatic weight were observed among the groups of rats. Rats adapted to the 40% protein diet showed significantly higher trypsin and chymotrypsin activity in pancreatic homogenates than rats fed the 8.5% protein diet. These changes in pancreatic enzyme content were not reflected in serum. Pancreatic acini isolated from the 8.5% protein group showed a markedly reduced responsiveness to cholecystokinin (CCK-8), secretin- and carbachol-induced enzyme release in comparison to the other two dietary groups, although basal enzyme release was the same in all groups. These results indicate that the secretion of pancreatic enzymes following a physiological stimulus is affected by a low protein, high carbohydrate diet.

Alcohol and the gastrointestinal tract.

The effects of acute and chronic ethanol ingestion on esophageal motility and the potential complications of these alterations are reviewed. Injury to the gastric mucosa and the small intestine and alterations in intestinal absorption can also result from alcohol abuse.

The role of the Ito cell in perivenular and intralobular fibrosis in alcoholic hepatitis.

The role of the Ito cells in perivenular and intralobular scarring in alcoholic liver disease was examined morphologically. There was a substantial decrease in the number of Ito cells in the midzone of the hepatic lobule in both fatty liver and alcoholic hepatitis as judged by light microscopy. By electron microscopy, however, an increase in "activated" Ito cells or a few fibroblasts were found in small foci of fibrosis in association with inflammation and hepatocellular degenerative changes in most cases of alcoholic hepatitis. Cytoplasmic protrusions of activated Ito cells extended to the hepatocytes undergoing degenerative changes including Mallory body formation. There was an apparent transition from Ito cells to activated Ito cells and to fibroblasts. It is suggested that Ito cells may play a role in perivenular and intralobular fibrosis in alcoholic hepatitis.

Influence of age on the clinical presentation of acute biliary tract disease.

The influence of age on the presenting manifestation of acute biliary tract disease was evaluated by retrospective review of all cases in which this diagnosis was confirmed at operation over a 30-month period. Results indicated that acute biliary tract diseases in elderly patients presents in a manner not statistically significantly different from younger patients (p greater than 0.05 for all parameters studied). Although such disorders in the elderly occasionally present in an unusual fashion, the majority of older patients present with abnormalities such as pain, jaundice, fever, and leukocytosis as commonly or even more frequently than younger patients.

Endoscopic retrograde cholangiopancreatography.

The ERCP report in the patient's chart was compared with findings on common duct exploration or cystic duct cholangiography in 72 patients and found to have a sensitivity of 90.4 percent, a specificity of 98 percent, and an accuracy of 95.8 percent. Factors having the potential to influence the accuracy of ERCP were errors in interpretation by the surgeon and the radiologist and the operative technique of cholecystectomy. Also, the interval between the performance of the procedure and operation was particularly important in the patient with multiple small gallstones or small common duct stones. Small gallstones may spontaneously pass from the gallbladder to the common duct, or small common duct stones may spontaneously pass into the duodenum; therefore, the longer the interval between ERCP and operation, the greater the likelihood of a discrepancy. At operation, gallstones may be squeezed into the common duct during manipulation of the gallbladder unless the cystic duct is obstructed before manipulation of the gallbladder. We found ERCP sufficiently accurate to make cystic duct cholangiography unnecessary in most patients with cholelithiasis having a preoperative ERCP examination.

Antibiotic-associated colitis with normal-appearing rectum.

A patient was recently seen with pseudomembranous colitis. He had severe disease of the proximal colon, with normal-appearing rectum and distal sigmoid, three weeks after administration of prophylactic antibiotics for surgery. The patient improved after discontinuing the antibiotics. Fiberoptic colonoscopy should be performed in patients suspected of having pseudomembranous colitis, even when sigmoidoscopy results are normal.

Metastatic lung carcinoma involving the gastrointestinal tract.

A review of 147 autopsies performed over a 4.5-year period on patients with a diagnosis of primary carcinoma of the lung revealed that 18 (12%) had metastatic lesions in the gastrointestinal tract. Fourteen had a single focus of gastrointestinal involvement, while four had multiple lesions in the gastrointestinal tract. Large cell carcinoma accounted for a large percentage (33%), out of proportion to the general occurrence of this cell type (12%). Twelve of the 18 patients had signs or symptoms suggesting gastrointestinal involvement but only four were diagnosed premortem. Gastrointestinal involvement in metastatic carcinoma of the lung occurs more frequently than realized and is often overlooked.

Duodenal villous adenoma.

Villous adenomas of the upper gastrointestinal tract, although rare, are difficult to diagnose and treat because of their location, invasiveness, and association with adenocarcinoma. Two patients with duodenal villous adenoma and upper abdominal pain as the presenting symptoms are described. Endoscopy is important for early diagnosis. The recommended treatment is simple excision with biopsy, or pancreaticoduodenectomy if adenocarcinoma is present.

Lymphocyte sequestration by the liver in alcoholic hepatitis.

The possibility that lymphocytes are sequestered by the liver in patients with alcoholic hepatitis was investigated. Sixteen patients who had liver biopsy specimens taken were studied as follows: The T- and B-lymphocyte populations of the peripheral blood and liver biopsy digest were quantitated. The liver biopsy specimens were studied by light and electron microscopy for lymphocyte-hepatocyte interaction. The data were analyzed by comparing the results of patients with and without the presence of Mallory bodies (MBs) in the liver. When MBs were present, the percentage of T cells was significantly increased in the liver compared with peripheral blood. By electron microscopy, two livers with MBs showed lymphocyte-hepatocyte interaction. The results support the concept that lymphocytes participate in a cell-mediated immune process when MBs are present in the liver.

Colonic varices. A complication of pancreatitis with splenic vein thrombosis.

A patient with recurrent gastrointestinal bleeding was found to have varices at the splenic flexure at colonoscopy. Angiography revealed complete occlusion of the splenic vein. Although the patient did not have cirrhosis, he did have a history of pancreatitis which presumably was responsible for the splenic vein thrombosis. This case represents a compartmentalized form of portal hypertension which requires careful endoscopic and radiographic studies for proper evaluation. Successful treatment was accomplished by splenectomy.