Endoscopic palliation of oesophageal carcinoma with Atkinson prosthesis.

To assess the degree of palliation, the associated morbidity and mortality and to compare our results with other published series, we reviewed our use of the Atkinson prosthesis in 100 consecutive patients for the palliation of unresectable oesophageal carcinoma. The group had a mean age of 71.2 +/- 2.3 years. All prostheses were placed by the pulsion method. Intubation was successful in 91%. Improvement in swallowing was seen in 82.1%. Major early procedure-related morbidity was high at 23% with 11 perforations (11%). Procedure-related mortality was 12%. Those aged 70 years or more had a 34.5% risk of morbidity and 15.5% risk of dying from the procedure. Late procedure-related complications requiring further endoscopic procedures occurred in 27%. Our 7 day mortality was 14.7% (14 patients) and 31 patients (32.6%) had died within 30 days, usually from the disease itself. Those surviving the procedure (> 7 days) had a mean survival of 105 (range 9-735) days. We obtained acceptable palliation but with a significant morbidity and mortality. Endoscopic intubation remains a useful palliative treatment for patients with unresectable carcinoma of the oesophagus and cardia.

Upper gastrointestinal endoscopy in patients with human immunodeficiency virus infection: is it worthwhile?

AIM: To determine the diagnostic accuracy of upper gastrointestinal endoscopy in a selected group of patients with HIV infection, who had severe symptoms unresponsive to empirical treatment. METHOD: We reviewed all patients with HIV infection, who had undergone upper gastrointestinal endoscopy at Auckland Hospital. Specific diagnoses were based on the endoscopic appearances and on the histological and microbiological examination of endoscopic biopsies taken from the oesophagus, stomach and duodenum. RESULTS: A definitive diagnosis was reached in 16 of the 21 patients endoscoped, of whom 13 had a good clinical response to treatment. The median survival was three months. The most common diagnosis was oesophageal candidiasis seen in six patients, all of whom responded to treatment with a median survival of six months. Invasive cytomegalovirus gastrointestinal disease was seen in three patients, none of whom had positive blood cultures for cytomegalovirus. All responded to intravenous ganciclovir. Three patients with severe diarrhoea had opportunistic infection of the small bowel. All three had advanced AIDS with a median survival of less than one month. CONCLUSION: Upper gastrointestinal endoscopy has a high diagnostic yield in patients with HIV infection with oesophageal symptoms which fail to respond to antifungal therapy, or with severe weight loss and diarrhoea and it should be considered in these patients because excellent palliation may be possible.

Long-term follow-up of dilatation treatment of oesophageal strictures.

A review of the endoscopy records of 100 consecutive patients with oesophageal strictures was undertaken to determine the effectiveness of endoscopic dilatation therapy. The follow-up period from presentation ranged from 6 to 72 (mean 39 months) and the symptom-free period after the last dilatation ranged from 3 to 66 months (mean 29 months). Three hundred and fifty procedures were performed with no perforations and minimal morbidity. Eighty-one patients who had been followed for at least 12 months since their last dilatation were free of significant dysphagia. Of these 81 patients, 77% became symptom-free within 1 year, and 88% within 2 years. Only 35 patients required more than three dilatations; 30 patients required one dilatation and 35 required two to three dilatations. Age, sex, the presence of Barrett's oesophagus, or the oesophageal lumen diameter at presentation was not significantly correlated with outcome.

Antral vascular ectasia: the watermelon stomach.

Antral vascular ectasia (watermelon stomach) is an uncommon localised vascular abnormality which may cause occult gastrointestinal blood loss and iron deficiency anaemia. The endoscopic appearances are characteristic with well demarcated, often raised or nodular bright red streaks radiating from the pylorus back along the antrum. Endoscopic biopsies can be taken without risk of haemorrhage and may help distinguish this condition from gastritis. The aetiology remains obscure, but there is an association with achlorhydria, hypergastrinaemia, and cirrhosis of the liver. Four patients are described; two had antrectomy with long term control of their anaemia, and two were treated conservatively. The lesion may be diagnosed more frequently with more widespread recognition of the condition.

Duodenal perforation in primary systemic amyloidosis.

Spontaneous duodenal perforation in two patients with primary systemic amyloidosis associated with multiple myeloma is described. Bowel perforation is a rare and often fatal complication of amyloidosis, and duodenal perforation has not been previously described. Both patients survived the bowel perforation with conservative management. Bowel perforation should be suspected in patients with amyloidosis presenting with acute abdominal pain, and active non-surgical management can be associated with prolonged survival.

Neuropathy in multiple symmetric lipomatosis. Madelung's disease.

With increasing age, peripheral neuropathy becomes more common in multiple symmetric lipomatosis (MSL) and the principal cause of severe disability. High alcohol consumption is frequently associated and the peripheral neuropathy of MSL is often attributed to alcoholism. In this study, sural nerve biopsies from MSL patients revealed an absence of acute axonal degeneration, a significant shift to the left of myelinated fibre diameter distributions, reduced indices of axonal and nerve fibre circularity, and an increase in myelin periodicity. This pathology supports the view that the neuropathy of MSL is not alcohol-induced but that a chronic distal axonopathy is an integral part of the MSL syndrome. Biochemical observations suggest a defect in catecholamine-stimulated lipolysis in MSL at a membrane level, possibly in the amount or function of Gs membrane protein or in the catalytic unit of adenylate cyclase. Evidence is presented that the frequent association of MSL with alcoholism is on the basis of an additional ethanol-induced membrane lesion involving beta-adrenergic receptors.

Clostridium septicum infection in neutropenic enterocolitis.

A 36-year-old woman developed neutropenia following chemotherapy for inoperable carcinoma of the cervix. She suffered acute abdominal pain, nausea, vomiting, and peritonitis of rapid onset. The right hemicolon and 15 cm of terminal ileum were resected at laparotomy and this showed marked edema of the cecum and ileo-cecal valve associated with superficial ulceration of the valve. There was necrosis of submucosal tissues and the muscle wall which contained a large number of Gram-positive bacilli. These showed positive membrane immunofluorescence with specific anti-Clostridium septicum antisera. We identify a case of enterocolitis due to Clostridium septicum infection. This is associated with neutropenia and is often fatal due to the rapid course of and failure to recognize the infection.

Neurofibromatosis associated with somatostatinoma: a report of two patients.

Two patients with neurofibromatosis and somatostatinoma are described, one patient in addition having a parathyroid adenoma diagnosed post mortem. The other patient had a partial somatostatinoma syndrome with diabetes, abdominal pain and cholelithiasis. The tumour was diagnosed preoperatively and metabolic studies demonstrated mild diabetes mellitus apparently due to suppression of insulin secretion by somatostatin, since oral glucose tolerance returned to normal post-operatively despite hemipancreatectomy. The tumour also secreted gastrin. There are now 18 reported cases of neurofibromatosis and duodenal carcinoid tumours which makes a genuine association between these two conditions very likely. With the present two cases, seven of the carcinoid tumours in this group have been positively identified as somatostatinomas. The histological finding of psammoma bodies is important in the diagnosis of duodenal somatostatinomas.

A familial syndrome of cardiac myxomas, myxoid neurofibromata, cutaneous pigmented lesions, and endocrine abnormalities.

A family syndrome of cardiac myxomas, myxoid neurofibromata, cutaneous pigmented lesions, and endocrine abnormalities is described. Three cases from a family of four are presented. All had cutaneous pigmented lesions. The mother had left and right atrial myxomata, her daughter a left ventricular myxoma, subcutaneous myxoid neurofibromata, and mammary fibroadenosis, and her son has no evidence of cardiac myxoma. Elevated circulating levels of insulin-like growth factors in the one family member tested raises the possibility of abnormal stimulation of somatic growth and may be linked to development of soft tissue neoplasms in these patients.

Streptococcus bovis bacteraemia requires rigorous exclusion of colonic neoplasia and endocarditis.

Twelve patients presented to the hospitals of the Auckland Hospital Board with bacteraemia caused by Streptococcus bovis in the years 1979-84. Ten had endocarditis, affecting homograft valves in two cases and the tricuspid valve in one case. Of nine patients who underwent investigation of the large bowel, only one did not have a colorectal tumour. Three had colonic adenocarcinoma and three had colorectal villous adenoma. Two, including a patient with acute hepatic failure from alcoholic cirrhosis, had colonic adenomata. Colonoscopy provided a tissue diagnosis of colorectal neoplasia despite negative radiological studies in three patients. Bacteraemia due to S. bovis should prompt rigorous investigation to exclude both endocarditis and tumours of the large bowel.

Amoebic liver abscess: an Auckland experience.

Globally, liver abscess caused by Entamoeba histolytica is a common condition. In New Zealand, however, it occurs infrequently. Eight cases were diagnosed in Auckland between 1972 and 1982, each patient having travelled through an endemic area within two years of presentation. Management often was not ideal, with both delays in diagnosis and inappropriate treatment. There is a need for increased awareness of possible amoebic abscesses in those who have been in endemic areas because with prompt use of effective treatment complications can be avoided.

Six years of experience using patient instructors to teach interviewing skills.

In 1974 a competency-based program was developed at the University of Arizona College of Medicine that used patient instructors (PIs) to evaluate interviewing skills objectively. PIs are nonphysicians who are taught to function in the multiple roles of patient, teacher, and evaluator. For each specialty area, objective evaluation instruments have been developed to measure the student's interviewing technique (interview process) and the amount of relevant historical information obtained from the patient (interview content). Data from the six most recent classes of second-year medical students demonstrate that: (a) there is a positive correlation between process and content scores; (b) students learn from their interviews with PIs; and (c) there is a positive relationship between the scores students obtain on their first interview with each of two different PIs in two different specialty areas. It is concluded that the PI program provides an effective way to teach interviewing skills to medical students.

The composition and dissolution of phytobezoars.

The plant fiber content (cellulose, hemicellulose, lignin, and tannins) in phytobezoars was determined. Phytobezoars were found to have a high concentration of polymerized tannins composed mainly of leucoanthocyanins and catechins. Unripe fruit was found to have a high concentration of the tannin monomers. It is concluded that the formation of phytobezoars is due to the polymerization of these tannin monomers. On the ingestion of unripe fruit, the hydrochloric acid of the stomach initiates the polymerization, resulting in a tannin-cellulose-hemicellulose-protein complex. This complex disintegrated in a crude preparation of cellulase. Cellulase is a simple and effective method of treating human gastric phytobezoars.

Liver biopsy--an outpatient procedure.

Experience with 67 liver biopsies performed on outpatients has been retrospectively analysed. One serious complication was encountered but would not have been detected earlier even had the patient been retained in hospital for 48 hours. The results suggest that liver biopsy can be performed on many outpatients with safety.

Per endoscopic sphincterotomy: a minimum trauma technique for the removal of retained common bile duct stones.

Drainage of the biliary tree and removal of retained common bile duct stones can be achieved by performing a sphincterotomy of the ampulla of Vater using a diathermy sphincterotome directed through a fibre-optic endoscope. The procedure was successfully performed on two patients considered unfit for abdominal surgery. It is a useful method in selected patients to release stones retained in the common bile duct after cholecystectomy.