An unusual case of biventricular cardiac failure.

We present a patient with acute retrosternal pain and dyspnoea. Clinical examination revealed a woman in shock with a loud holosystolic murmur and congested jugular veins. Echocardiography showed severe mitral insufficiency. At transoesophageal echocardiography a large mass was seen in the right atrium. The differential diagnosis was a thrombus or an intracardiac tumour. Subsequent histology revealed a non-Hodgkin lymphoma in the right atrium, the wall of the left atrium extending to the mitral valve and further location in the pelvis and duodenum. The discussion incorporates a brief overview of the literature.

The 1998 national Belgian consensus meeting on HP-related diseases: an extensive summary. The HP Belgian contact group organized in CHU Brugmann, Brussels.

"HP testing must be regarded as ONE of the important elements of the proper diagnostic work-up of a DISEASE, managed in close cooperation between GP's and specialists": that's the key message of the national consensus meeting held in CHU Brugmann on February 6th and 7th 1998. HP testing (usually by 2 direct methods: RUT-histology) and eradication treatment (ER), in infected patients, are strongly recommended in: 1. Past or current GDU (absolute indication), regardless of activity, complication(s), NSAID intake; 2. Low-grade MALT Lymphomas (Stage IE1) unequivocally diagnosed, managed and followed-up in specialised centers; 3. Post endoscopic resection of EGC. ER is advisable in HP carriers with a family history of gastric cancer. Chronic atrophic-, lymphocytic-, giant folds gastritis and hyperplastic polyps are acceptable indications for ER as well as scheduled long-term NSAID treatment in individuals with known HP status. Systematic ER in HP+ patients with fully investigated NUD is not indicated but could be considered in individual patients. Extra alimentary disorders and auto immune gastritis are no indication and there was no consensus for a "test and treat" policy in patients under 45 yrs old without alarm symptoms. Systematic screening of asymptomatic individuals is not recommended. A correct monitoring of eradication after treatment is recommended, mainly by UBT. In severe or refractory PUD, symptom recurrence and follow-up of EGC and Maltomas, endoscopic follow-up with HP testing is mandatory. The recommended first line treatment course (except known allergy or intolerance) is PPI full dose bid, Clarithromycin 500 mg bid Amoxycillin 1000 mg bid (7 days minimal 10 days maximal). RBC-based schemes must be locally validated and quadruple therapy is proposed when retreatment is needed. Culture, optional after the first treatment failure, is strongly recommended after a second failure. Overall, ER therapies are safe and neither the decreased efficacy of acid-lowering drugs, nor the possible increased risk of peptic oesophagitis are considered as contra-indications to eradicate. ER is cost-effective and cost-beneficial in PUD and adjusted number of pills delivered would cut costs. No clear economic data are currently available for a potential benefit of ER in GC prevention or NUD management. A national monitoring of HP resistance (Macrolides and Imidazoles) must be organized by specialised centers.

Rectourethral fistula due to Crohn's disease.

Fistulas between the large bowel and the prostatic urethra, due to Crohn's disease, are very uncommon. Pneumaturia and an abnormal urethral discharge are the most common symptoms. Diagnosis is made by a voiding cystourethrogram or a retrograde urethrography. Treatment is usually difficult with a high percentage of recurrence. A well documented case is presented.

[Colitis cystica profunda]. / Colitis cystica profunda.

In two patients, women of 65 and 76 years old, colitis cystica profunda was diagnosed, a rare, benign disease of colon and rectum. In the first patient, radio-enteritis, in the second patient mucinous adenocarcinoma was diagnosed as well.

Giant ovarian cyst.

Case report of a patient with a giant ovarian cyst. On the basis of literature data, surgery and histology problems, as well as oncological therapy are discussed.

[Small intestinal ulceration and stenosis induced by non-steroidal anti-inflammatory agents]. / Dundarmulceratie en -stenose geïnduceerd door niet-steroïdale anti-inflammatoire farmaca.

UNLABELLED: We report a case who developed a small bowel ulceration in a long segment of distal duodenum and proximal jejunum, a few days after he had taken high doses of diclofenac. After a month, it was complicated by a stenosis of the same segment. Nonsteroidal antiinflammatory drugs have recently been recognised as a possible etiologic factor of small bowel ulcerations. Clinical findings are aspecific. Complications of small bowel ulcerations are: obstruction, perforation or bleeding. Those have to be treated by surgery. We proposed a physiopathologic model and correlated it with histological findings. CONCLUSION: careful prescription of those drugs has to be pursued and one should think about a small bowel ulceration in a patient with an abdominal syndrome, who takes non-steroidal antiinflammatory drugs.

Nephrogenic diabetes insipidus. An unusual presentation of recurrent rectal cancer.

The occurrence of diabetes insipidus (DI) in patients with systemic cancer is caused usually by tumor metastasis to the hypothalamus or posterior pituitary. A 43-year-old man with DI 8 months after radical surgery for a poorly differentiated adenocarcinoma of the distal rectum is reported. A therapeutic trial of intranasal desmopressin acetate did not correct the hyposthenuria, thus localizing the defect to the kidneys. A large tumor recurrence in the pelvis caused bilateral hydroureteronephrosis, resulting in nephrogenic DI. This report shows that not all cases of DI in cancer patients are of central origin.

L-tryptophan-induced eosinophilia-myalgia syndrome.

This report describes three Belgian cases of the eosinophilia-myalgia syndrome associated with the use of L-tryptophan-containing products. Three women, aged 51, 53 and 73 years, were taking L-tryptophan for 2 months to 2 years, at 500, 1500, and 2250 mg d-1, respectively. All developed disabling myalgias, fatigue, and a variable skin rash, in association with marked eosinophilia. In one patient, symptoms and eosinophilia reappeared after rechallenge with L-tryptophan. Discontinuation of the drug resulted in gradual disappearance of the symptoms, signs and laboratory abnormalities in two patients. One patient was treated with corticosteroids because of persisting myalgias. Because of the non-specific clinical manifestations, clinicians from all subspecialties of internal medicine might be confronted with such patients and should be aware of this new entity.

Vasopressin-related bullous disease of the legs.

We report a 33-year-old man who developed cutaneous necrosis of the lower extremities with extensive bulla formation after i.v. administration of vasopressin for the treatment of bleeding esophageal varices. Due to its potent nonselective vasoconstrictive action, vasopressin not only may induce cardiac and gastrointestinal ischemia, but cutaneous ischemia as well. As in our patient, this may lead to extensive necrotic skin lesions at sites distant from the infusion.

Herpes simplex virus type 1 colitis: an unusual cause of diarrhea.

Herpetic infections of the gastrointestinal tract are a well-recognized entity. Involvement of the colon seems to be very rare. A 78-yr-old woman developed bloody diarrhea and abdominal discomfort 2 months after surgical treatment for adenocarcinoma of the transverse colon. Colonoscopy revealed diffuse hemorrhagic, erosive, aphtoid, and ulcerative lesions. Histology showed nonspecific inflammatory changes. Herpes simplex virus type 1 (HSV-1) was isolated from endoscopic biopsy and stool specimens. The patient responded rapidly to symptomatic treatment with loperamide. This case demonstrates the potential for HSV-1 to induce infectious colitis; failure to obtain microbiologic evaluations and the rapid response to empiric, symptomatic treatment may be responsible for the rarity of diagnosis of this infection. The implications of this diagnosis are probably more relevant in immunosuppressed individuals, and may be important in the elderly population.

Ileocolonic transfer of solid chyme in small intestinal neuropathies and myopathies.

The aims of this study were to assess gastric emptying, small bowel transit and colonic filling in patients with motility disorders, with particular attention to the patterns of colonic filling. Gastrointestinal transit was assessed using a previously validated radiolabeled mixed meal. Fourteen patients with clinical and manometric features of chronic intestinal pseudoobstruction & classified as intestinal neuropathy and 6 as intestinal myopathy, were studied. The results were compared with those from 10 healthy controls studied similarly. Gastric emptying and small bowel transit of solids were significantly slower in both groups of patients than in healthy controls (P less than 0.05). In health, the ileocolonic transit of solid chyme was characterized by intermittent bolus transfers. The mean size of boluses transferred to the colon (expressed as a percentage of ingested radiolabel) was significantly less (P less than 0.05) in patients with intestinal myopathy (10% +/- 4% (SEM)] than in healthy controls (25% +/- 4%) or in patients with intestinal neuropathy (25% +/- 4%). The intervals between bolus transfer of solids (plateaus in the colonic filling curve) were longer (P less than 0.05) in myopathies (212 +/- 89 minutes) than in health (45 +/- 7 minutes) or neuropathies (53 +/- 11 minutes). Thus, gastric emptying and small bowel transit were delayed in small bowel neuropathies and myopathies. Bolus filling of the colon was less frequent and less effective in patients with myopathic intestinal pseudoobstruction, whereas bolus transfer was preserved in patients with neuropathic intestinal pseudoobstruction.

Hepatic hydrothorax: report of two cases.

This paper describes two patients with liver cirrhosis presenting with right sided hydrothorax. The diagnosis of hepatic hydrothorax was confirmed by a radionuclide study using an intraperitoneal injection of radioactive 99mTc-tin-colloid, demonstrating the one-way transdiaphragmatic flow of fluid from the peritoneal to pleural cavities. Pleural taps, salt restriction and diuretics resulted in volume depletion and impaired renal function in the first patient. Medical therapy and a single thoracocentesis were successful in the other patient.

[Non-invasive methods in the study of hemodynamics of Klippel-Trenaunay syndrome]. / Méthodes non-invasives dans la mise au point de l'hémodynamique du syndrome de Klippel-Trenaunay.

In 10 patients with Klippel-Trenaunay syndrome, we have examined 13 extremities presenting characteristic lesions, using a mercury-gauged plethysmography. All cases had previously underwent arteriography and phlebography. The venous volume increased markedly in 12 of these 13 extremities, as well as the arterial flow in 6 extremities. The elevated skin blood flow was demonstrated in 4 of the 5 hemangiomas by Laser-Doppler velocity measurements.

Human gastric emptying and colonic filling of solids characterized by a new method.

Our first aim was to compare 111In-labeled Amberlite IR-12OP resin pellets and 131I-labeled fiber in the assessment of gastric and small bowel transit and colonic filling in healthy humans. Both radiolabels were highly stable for 3 h in an in vitro stomach model and remained predominantly bound to solid phase of stools collected over 5 days [90.5 +/- 2.1 (SE)% for 131I and 87.4 +/- 1.4% for 111In). The lag phase of gastric emptying was shorter for 111In-pellets (30 +/- 11 min compared with 58 +/- 12 min for 131I-fiber, P less than 0.05). However, the slope of the postlag phase of gastric emptying and the half time of small bowel transit were not significantly different for 111In-pellets and 131I-fiber. Filling of the colon was characterized by bolus movements of the radiolabel (10-80% range, 26% mean) followed by plateaus (periods of no movement of isotope into colon lasting 15-120 min, range; 51 min, mean). Half of the bolus movements occurred within 1 h of the intake of a second meal. Thus 111In-labeled Amberlite pellets provide an excellent marker for the study of gastric and small bowel transit and colonic filling in humans. The ileum acts as a reservoir and transfers boluses of variable sizes into the colon, often soon after the intake of a subsequent meal.

Chronic intestinal pseudo-obstruction: diagnosis and treatment.

Chronic intestinal pseudo-obstruction is a rare syndrome characterized by recurrent episodes of small bowel obstruction without evidence of a structural obstructing lesion. The two pathophysiologic types of this motility disorder are myopathic and neuropathic. The latter may affect extrinsic or intrinsic neural control of gut motility. Diagnosis is based on (1) recognition of the clinical syndrome and exclusion of mechanical obstruction by endoscopy, radiologic studies, or laparotomy and (2) manometric studies of the stomach and small bowel. Full-thickness biopsy specimens for histologic analysis may not be essential for the diagnosis in the future. The goals of treatment are the restoration of normal gut peristalsis and the correction of nutritional deficiencies. Prokinetic medications, surgical excision in cases of localized disease, and parenteral nutrition are frequently necessary. Management is difficult because of the lack of efficacious medications, extension of the disease to other regions, and complications of central parenteral nutrition. Prokinetic agents, venting enterostomies for relief of symptoms, and enteral supplementation are being evaluated in this intractable and serious condition.

A case of diversion rectitis.

We report a case of diversion rectocolitis, an inflammatory process that frequently develops in the distal blind colorectum, after surgical diversion of the fecal stream. Since the endoscopic and histologic findings closely resemble those of inflammatory bowel disease, the differential diagnosis can be difficult. However, the inflammation permanently resolves after surgical reanastomosis. Because diversion colitis can also be treated effectively by local application of short-chain fatty acids, it has been postulated that a local nutritional deficiency, resulting from the absence of these acids, triggers the inflammation.

Prehospital thrombolytic treatment of acute myocardial infarction with anisoylated plasminogen streptokinase activator complex.

In cooperation with a group of general practitioners (GP), we investigated the possible risk and benefit of prehospital initiation of thrombolytic therapy in acute myocardial infarction (AMI) with anisoylated plasminogen streptokinase activator complex (APSAC) at the patient's home. During a 14-month period, 58 patients with suspected AMI were evaluated by their GP using a protocol with strict inclusion and exclusion criteria. The GP alerted a special mobile intervention team which administered APSAC at home in 13 of the 19 patients. Coronary reperfusion was achieved in ten of these 13 patients. Apart from short and easily treated episodes of bradycardia and/or hypotension after the injection of the thrombolytic drug in four of 13 patients, no major adverse events were noted in the early treatment period. The estimated time gain by treating the patient at home instead of starting the treatment in the coronary care unit was 46 +/- 14 min. Therefore, at-home initiation of thrombolytic treatment seems feasible, fast, and safe.