Repeated clinical and laboratory examinations in patients with an equivocal diagnosis of appendicitis.

In-hospital observation with repeated clinical examinations is commonly used in patients with an equivocal diagnosis of appendicitis. It is not known if repeated measurements of temperature and laboratory examinations have any diagnostic importance in this situation. The importance of repeated measurements of the body temperature, white blood cell (WBC) and differential cell counts, C-reactive protein concentration (CRP) and of the surgeon's repeated assessments was prospectively analyzed in 420 patients with an equivocal diagnosis of appendicitis at admission who were reexamined after a median of 6 hours of observation. The final diagnosis was appendicitis in 137 patients. After observation the inflammatory response was increasing among patients with appendicitis and decreasing among patients without appendicitis. The variables discriminating power for appendicitis consequently increased, from an area under the receiver operating characteristic (ROC) curve of 0.56 to 0.77 at admission, to 0.75 to 0.85 after observation. The ROC area of the surgeons' clinical assessment increased from 0.69 to 0.89. The WBC and differential cell counts were the best discriminators at the repeat examination. The change in the variables between the observations had weak discriminating power and had no additional importance in addition to the actual level at the repeat examination. To conclude, the diagnostic information of the temperature and laboratory examinations increased after observation. Repeated controls of the body temperature and laboratory examinations are therefore useful in the management of patients with equivocal signs of appendicitis, but the result of the examinations must be integrated with the clinical assessment.

Intraabdominal infections and gut origin sepsis.

Intraabdominal postoperative or posttraumatic infections remain a major threat to life in spite of generation after generation of increasingly effective antimicrobial drugs indicating the importance of immunological host defense failure following major trauma or surgical complications. The spectrum of infectious postoperative or posttraumatic complications can, in part, be explained by pathogenic factors inherent to the methodology of modern surgical intensive care and techniques. This report presents a survey of the historical background as well as current concepts of the multiple systems organ failure syndrome as related to postoperative or posttraumatic intraabdominal infectious complications. The pathophysiology of nosocomial infectious complications in the intensive care unit setting is analyzed. The concept of "gut origin sepsis" is presented and possible preventive and therapeutic actions discussed. A judicious use of antimicrobial drugs on strict indications is emphasized as is the importance of increased knowledge of the interactions between the gut flora, antibiotics, and absence of enteral nutrition.

The spleen is not a major synthetic site of alternative pathway components.

The serum concentrations of the complement proteins C1q, C1s, C4, C3, factor D, factor B, properdin, C1 inactivator, factor I and factor H were determined in 7 patients before and after splenectomy. The concentrations of C1q, factor D and properdin were moderately decreased 1-2 days after surgery, while the other components were virtually unchanged. During the course of 4 weeks the values either returned to normal, or were slightly increased. In general, the findings could be ascribed to the inflammatory plasma protein response and were similar in cholecystectomized patients. The results provided no evidence of significant complement protein synthesis in the human spleen.

Increased gut permeability to fluorescein isothiocyanate-dextran after total parenteral nutrition in the rat.

Sepsis with subsequent multiple organ failure is the commonest complication seen in the surgical intensive care unit today. A gut mucosal barrier dysfunction is assuming an increasingly important role as one possible explanation for the initiation of the septic process. It is known that the gut bacteria and endotoxins can, in the presence of a seemingly intact epithelium, translocate to extraintestinal sites, but the exact mechanism behind this process is not understood. In the present study we have approached this problem by testing the gut permeability to two macromolecules, bovine serum albumin (BSA) and fluorescein isothiocyanate (FITC)-dextran, after 7 days of enteral or parenteral nutrition in the rat. The plasma values of FITC-dextran after 4 h of marker feeding showed a significant increase in gut permeability after parenteral but not after enteral nutrition as compared with the controls. The plasma values of BSA, however, did not show any significant change in any of the groups. Thus, parenteral nutrition, with the changes occurring in the gut mucosa, may be one of the etiologic co-factors behind a gut mucosal barrier dysfunction, eventually leading to absorption of noxious agents into the systemic circulation with subsequent multiple organ failure.

Nonoperative treatment of blunt trauma to liver and spleen.

Nonoperative management of 20 cases of liver injury in 1969-1984 and 13 of splenic injury in 1977-1984, all due to blunt abdominal trauma, is retrospectively reviewed. The total of blunt hepatic injuries treated in the same period was 63 and that of blunt splenic injuries 52. There were no major differences in etiology, age, sex distribution or need for blood transfusion between the liver and splenic trauma cases. After initial resuscitation and diagnostic work-up with angiography, computed tomography, ultrasonography and/or scintiscan, circulatorily stable patients were selected for nonoperative treatment. These patients showed evidence of mild trauma with few associated major injuries, few complications and no mortality. Following initial bedrest and observation, they were gradually mobilized and could leave the hospital after about 2 weeks.

The effect of serial intravenous immunoglobulin infusion on type-specific anti-pneumococcal antibodies in children.

The effect of a series of five immunoglobulin G infusions--at 3-4 week interval--on serum IgG antibody concentrations against some pneumococcal types commonly associated with acute otitis media (AOM) was studied in 11 children, 1-4 years old, suffering from recurrent AOM. Increase of specific IgG antibody concentrations was observed when the initial concentrations were low. However, once higher antibody concentrations had been achieved as a result of the treatment, subsequent infusions resulted in a decrease of the antibodies. In two children with initially high specific antibody concentrations, antibodies successively decreased in response to repeated immunoglobulin infusions.

Prophylactic effect of human immunoglobulin against pneumococcal post-splenectomy sepsis in the rat.

Failure to clear the blood of pneumococci after splenectomy may be corrected by active immunization, but some patients show poor antibody response to pneumococcal vaccination. Long-term antibiotic prophylaxis against post-splenectomy sepsis carries the risk of development of bacterial resistance and low patient compliance. In the present study, using a rat model for post-splenectomy sepsis, human immunoglobulin was given 24 h before challenging the animals with 10(3) Streptococcus pneumoniae. Immunoglobulin at a dosage of 300 mg/kg body weight was protective. Reducing the immunoglobulin dose to 75 mg/kg did not alter the mortality rate but significantly prolonged the survival time. The results indicate that the new immunoglobulin preparations for intravenous use might provide an effective means of reducing the risk of post-splenectomy sepsis, even in the most susceptible patients.

Treatment of pneumococcal postsplenectomy sepsis in the rat with human gamma-globulin.

A rat model was used to evaluate the possible effect on experimental postsplenectomy sepsis of a human gamma-globulin preparation for intravenous use (Sandoglobulin). Sixty splenectomized male Sprague-Dawley rats were given 3 X 10(3) Streptococcus pneumoniae type 1 intravenously. Twelve of the animals received no treatment and all died, in contrast to 12 sham-operated controls which all survived the challenge. The remaining splenectomized rats were divided into four groups, each consisting of 12 animals. One group was given 120 mg human gamma-globulin twice intraperitoneally (0.3 g/kg body wt), at 18 and 42 hr, after challenge; 10 of the 12 survived, in contrast to none of the 12 in the second group receiving 120 mg human albumin instead of gamma-globulin (P = 0.00003). When the injections were delayed to 24 and 48 hr, 9/12 gamma-globulin-treated animals still survived, in contrast to 0/12 in the albumin group. These findings point to new possibilities for treatment and perhaps prevention of overwhelming postsplenectomy sepsis by administration of high doses of gamma-globulins.

Effect of gamma globulin infusion on type-specific pneumococcal antibody levels in splenectomized adults.

Using an ELISA technique, changes in specific antibody levels against pneumococcal serotypes 1, 4, 7F, 14, 18C and 23F were studied in 8 adults healthy at the time of investigation but splenectomized previously because of hematological disease following infusion of 200 mg/kg body weight of a commercially available immunoglobulin preparation for intravenous use (Sandoglobulin). Among the 4 patients with initially low serum levels of antipneumococcal antibodies, significantly raised antibody levels were demonstrated against type 14 for 8 weeks. On the other hand, the infusion did not lead to increased antibody levels in 3 patients with high preinfusion values for antipneumococcal antibodies. In contrast, a significantly lower antibody value for type 7F was recorded 3 weeks after infusion. Efficacy of immunoglobulin prophylaxis is, therefore, probably doubtful in certain splenectomized patients, and if contemplated should be preceded by analysis of antibody levels against common pathogens.

Comparison of antibody levels and protective efficacy against pneumococci in two immunoglobulin preparations for intravenous use.

Passive immunization with modern intravenous immunoglobulin preparations might be used prophylactically in individuals at extreme risk of contracting postsplenectomy sepsis or therapeutically in established infections. Since pneumococci are the predominant causative organisms, we determined antibodies against 14 pneumococcal serotypes in two commercially available immunoglobulin preparations (two batches of each) using enzyme-linked immunosorbent assay. The four batches were remarkably similar in antibody content. Low levels against some clinically important serotypes, i.e. types 3, 8 and 18C were recorded. The protective effect of one batch of each preparation against type 1 pneumococci was documented in splenectomized rats.

Synergism between gammaglobulin prophylaxis and penicillin treatment in experimental post-splenectomy sepsis in the rat.

In spite of long-term antibiotic prophylaxis and pneumococcal vaccination, there still exists a proportion of highly susceptible splenectomized or functionally hyposplenic patients at risk of contracting fatal overwhelming infections. We have studied the effect of gammaglobulin prophylaxis in experimental sepsis among splenectomized rats. Administration of 37.5 mg human gammaglobulin/kg body weight 24 h before challenge with 10(3) pneumococci resulted in the survival of 19 of 24 rats, in contrast to 1 of 24 controls. A dose of 19 mg/kg body weight was not protective (7 of 23 survived). However, treatment with penicillin 18 h after challenge in the gammaglobulin-pretreated group of animals saved 21 of 24 animals, although penicillin without gammaglobulin prophylaxis showed no effect. These data indicate that even relatively low circulating concentrations of specific antibody after gammaglobulin prophylaxis might nonetheless be adequate to render septic disease easier to treat.

Administration route and splenectomy effects on resistance to pneumococci in rats.

Normal and splenectomized rats were challenged with Streptococcus pneumoniae type 1 via different administration routes. In experiment I, previously splenectomized or sham-operated rats received 4 X 10(3) colony-forming units (CFU) of pneumococci via (i) a peripheral vein, (ii) subcutaneously, or (iii) intraperitoneally. The results indicated an increased susceptibility of the splenectomized animal to pneumococci administered via all three routes. However, subcutaneously administered pneumococci gave a lower mortality than pneumococci given intravenously or intraperitoneally. In experiment II 40 splenectomized rats received 4 X 10(3) CFU of pneumococci via (i) peripheral, (ii) portal, or (iii) caval veins or the aorta. No differences in mortality were found. In experiment III, non-operated animals received 4 X 10(5) CFU of pneumococci either intravenously or intraperitoneally, resulting in mortality rates of 0/20 and 17/20, respectively. After 2 weeks the rats surviving intravenous challenge received 4 X 10(5) CFU of pneumococci intraperitoneally; all survived. The data indicate the the spleen and the subcutis have a greater capacity to protect against pneumococci in the absence of specific antibody than the peritoneum or the circulation outside the spleen.

Gastro-duodenal ulceration in abdominal angina.

Two cases of verified abdominal angina are presented. Multiple, atypical ulcerations in the postbulbar duodenum were diagnosed endoscopically in both cases. Atypical gastric ulcers were also present in one case. The suggestion is made that such ulceration may not be uncommon in intestinal ischaemia. Such findings at endoscopy should arouse the suspicion of abdominal angina, especially when preceding diagnostic procedures, including biopsies, have failed to demonstrate other clear-cut gastrointestinal disease.