Case report--melanoma of the anorectum.

Melanomas of the gastrointestinal tract are rare tumours, the anorectum being the most common site. Anorectal melanomas can pose difficult diagnostic and therapeutic problems. Awareness on the part of both the clinician and histopathologist that melanomas can rarely occur in the anorectum is an important pre-requisite to its diagnosis as specific histopathological staining may be required. Therapeutically, surgery remains the primary option. Prognosis is however poor as metastatic disease is commonly established at presentation. When the tumour is sited in the rectum, the cells of origin is controversial. A case of disseminated anorectal melanoma is described.

Hepatic granulomas--an experience over the last 8 years.

Twenty cases of hepatic granulomas seen in the Department of Medicine over the period of 8 years from 1981-1988 were reviewed. Prolonged fever and jaundice were the commoner presentations. While the aetiology was varied, patients with tuberculosis and idiopathic causes formed the major groups. There were also 2 rare causes, one due to cytomegalovirus infection and the other a result of allopurinol hypersensitivity. The idiopathic group of cases fared well but those with tuberculosis did badly and 2 out of 6 died. The absence of pulmonary involvement and the high incidence of jaundice and liver dysfunction in the patients with tuberculosis were the other striking features.

Primary sclerosing cholangitis--a report of 2 cases.

Primary Sclerosing Cholangitis (PSC) is a rare cholestatic condition seen locally. Its etiology is unknown and it is commonly associated with ulcerative colitis, another rare condition seen locally. In this report, 2 patients with PSC, both Indian males, had ulcerative colitis and in one PSC was diagnosed some 15 years later. An interesting feature common to both patients was that of intra-hepatic ductal involvement. Percutaneous transhepatic cholangiogram (PTC) and Endoscopic Retrograde Cholangio-Pancreatogram (ERCP) showed characteristic stricturing and beading of the intra-hepatic ducts.

Systemic amyloidosis with severe amyloid heart disease--a case report.

Cardiac Amyloidosis was first observed by Vichow in 1957. Since then many more cases have been documented, but there has been no case report of mortality from severe cardiac involvement in the local literature. We describe one such case seen in the Singapore General Hospital and review briefly the clinico-pathological data on this uncommon entity.

Early gastric cancer in Singapore.

A study was carried out on 41 cases of early gastric cancer over a five year period (1983-1987) based on resected stomach specimens. Males (29) outnumbered females (12) by 2.4:1. Mean age was 63 years (Range 30-80 years), and there was an overwhelming Chinese preponderance (40, 97.6%). The indications for endoscopy were: dyspepsia (24, 58.5%), gastro-intestinal bleeding (14, 34.1%) and follow up of megaloblastic anaemia (3, 7.4%). The diagnosis of malignancy was unsuspected at endoscopy in 38 patients and the commonest finding was a chronic ulcer (35, 85.4%). Most of the lesions were located in the body (24, 58.5%) and along the lesser curvature (36, 87.8%). Depressed lesions (Type III and combined IIc + III) were the commonest macroscopic lesions. Intestinal type carcinoma was the commonest microscopic type (34, 82.9%). Submucosal infiltration was present in 19 (47.3%) and lymph node metastases in 4 (9.8%). There was only one death from carcinoma of the stomach (mortality 2.4%).

Ulcerative colitis in Singapore: a clinical study of sixty-one patients.

Sixty-one consecutive cases of ulcerative colitis from the Department of Medicine, Singapore General Hospital, over a 16-year period (1971 to 1986) were reviewed. Mean duration of follow-up was 35.9 months (range 2 months to 16 years). Fifty-one (83.6%) cases were diagnosed in the last 8 years. Sex ratio was almost equal (males 30, females 31) and mean age was 38.2 years. All racial groups were affected but a predilection among Indians (21.3%) was observed. At presentation, the disease was mild in 36 (59.0%), moderate in 14 (22.9%) and severe in 11 (18.1%) patients. Fifty-two (85.2%) patients had symptoms of at least one month's duration before presentation. The 3 commonest symptoms were haematochezia (95.1%), diarrhoea (95.1%) and mucoid stools (83.6%). Extraintestinal manifestations of disease such as backache (8.2%), peripheral arthritis (6.5%), iritis (6.5%) and liver disease (1.6%) were uncommon. Severe intestinal complications include toxic megacolon (1.6%), colonic perforation (1.6%) and massive gastrointestinal haemorrhage (1.6%). Haematological and biochemical indices at presentation generally reflected the activity and severity of disease. The disease was limited to the rectum and sigmoid colon in 12 (19.7%) patients, extended up to the splenic flexure in 16 (26.2%), up to the hepatic flexure in another 16 (26.2%) and involved the whole colon in 17 (27.9%). Pseudopolyposis was present in 13 (21.3%) patients. Of 49 patients: (a) 18 (36.7%) had remission and were relapse free subsequently (b) 14 (28.6%) had infrequent relapses (less than 3 x/year) (c) 3 (6.1%) had frequent relapses (greater than 3 x/year) (d) 10 (20.4%) had chronically active disease (e) 4 (8.2%) had a short fulminant course terminating in death.(ABSTRACT TRUNCATED AT 250 WORDS)

Ischaemic colitis in systemic lupus erythematosus--report of a case and review of the literature.

We report a case of perforation of the colon from systemic lupus erythematosus (SLE) presenting initially with diarrhoea and later with acute abdominal symptoms. She was found to have widespread arteriolitis involving the colon resulting in necrosis, ulceration and perforation with peritonitis and ultimately, death from septicaemia. Although intra-abdominal symptoms are not uncommon in cases of SLE, actual involvement of the gastrointestinal tract of a degree severe enough to warrant surgical intervention is a relatively uncommon phenomenon.

Crohn's disease--a diagnostic rarity in Singapore.

Nine cases of Crohn's disease from the Department of Medicine, Singapore General Hospital were collected over a duration of 9 years (1978-1986). Male (5): Female (4) ratio was nearly equal. Predominantly young people (mean age 30.5 year, range 12-59 year) from all races in Singapore were affected. Presentation could be acute (1), subacute (2), or chronic (6). The commonest symptoms were abdominal pain (8) diarrhoea (6) and weight loss (6). Three patients had a palpable right iliac fossa mass, 3 had definite malabsorption from ileal disease and 1 had perianal involvement leading to an anal stricture. The only extraintestinal manifestations of disease were clubbing and sacroiliatis. Haematological (haemoglobin, total white count, erythrocyte sedimentation rate) and biochemical (albumin) parameters generally reflected the degree of activity and chronicity of disease prior to presentation. The diagnosis and assessment of disease sites were based on a combination of radiological, endoscopic, operative and histological criteria. Ileal disease (4) per se was commonest followed by ileocolic disease (3) and colonic disease (2). Medical treatment consisted of sulphasalazine +/- steroids in all patients. Azathioprine and metronidazole were used for steroid sparing and perianal disease respectively. Laparotomy was performed in 2 patients. Six patients were well with infrequent (less than or equal to 2 times/year) or no relapses during follow up. Of the remaining three, 2 had either chronically active disease or frequent relapses (greater than 2 times/year) and one severe recurrent disease despite repeated gut resection.

The varied manifestations of abdominal tuberculosis.

Eight cases of abdominal tuberculosis from the Department of Medicine, Singapore General Hospital are reported to illustrate the varied clinical manifestations of the disease. Presentation ranged from asymptomatic hepatomegaly to acute abdomen (intestinal obstruction/perforation). Chronic non-specific symptomatology (fever, weight loss, abdominal pain, diarrhoea, jaundice) was commonest. There were three patients with hepatic tuberculosis, two with tuberculous mesenteric lymphadenitis and three with intestinal tuberculosis, two of whom had concomitant tuberculous peritonitis. Only three patients had coexisting pulmonary tuberculosis. The diagnosis was unsuspected at presentation in four patients. Initial provisional diagnoses included typhoid, abdominal lymphoma, hepatic malignancy, chronic hepatitis and iatrogenic gut perforation. All patients responded totally to conventional antituberculous therapy.

Liver disease in asymptomatic hepatitis B surface antigen carriers.

Fifty-five Chinese healthy asymptomatic Hepatitis Bs Antigen carriers, 49 males and 6 females, were studied over a six year period, 1978 to 1984. Seventeen patients (30.9%) had normal transaminases, and 38 patients (69.1%) had fluctuating levels of transaminases throughout the period of study. 83.6% of patients were below 40 years, and mean age was 29.5 years (range 18 to 49 years). Twenty three patients (41.8%) had liver biopsy, and a spectrum of chronic liver diseases was seen, with Chronic Lobular Hepatitis (CLH) and Chronic Persistent Hepatitis (CPH) being the commonest. Six patients (26.1%) had normal histology, seven patients (30.4%) had CLH, seven patients (30.4%) had CPH, two patients (8.7%) had Chronic Active Hepatitis (CAH), and one patient (4.4%) with Active Cirrhosis (AC). An attempt to correlate the severity of histological changes with the levels of transaminases at the time of biopsy failed to show any definite correlation. However, three patients with transaminases of more than four times normal had severe liver diseases (2 CAH and 1 AC).

Liver abscess--a clinical study.

Forty consecutive cases of liver abscess from the Department of Medicine III, Singapore General Hospital, from 1978 to July 1983 were reviewed. Nineteen (47.5%) were amoebic, 15 (37.5%) pyogenic and 6 (15%) of unknown aetiology. Of the first 20 cases from 1978 to 1980, amoebic abscesses (60%) predominated. An increased incidence of pyogenic abscess constituting 50% was seen in the next 20 cases. Though all racial groups were affected, a predilection among Indians was seen. Males outnumbered females (4:1), and peak incidence occurred in the 40 to 70 age group (62.5%). Fifty percent presented early (less than one week of symptoms) to hospital. Common physical signs were fever (97.5%) and hepatomegaly (92.5%). Investigations showed leucocytosis in excess of 10,000 WBCs/cmm (87.5%), an ESR of 80 mm/hr (80%) and an elevated alkaline phosphatase of at least twice normal (73.6%). Single abscesses (72.5%) located in the right lobe were more likely to be amoebic. Where abscesses were multiple, they were more likely to be pyogenic (63.6%). Two-thirds of the pyogenic abscesses were due to either Klebsiella species or E. coli. Medical treatment consisted of broad spectrum antibiotics, usually in combination with metronidazole. Aspiration or drainage (open or closed) was employed when indicated. These were carried out more often for pyogenic than amoebic abscesses. Amoebic abscesses responded faster to treatment compared to pyogenic abscesses. Mortality in the first 20 cases prior to 1981 was 30%, being mainly confined to pyogenic abscesses. However, after 1981, there has been no mortality in the ensuing 20 cases.

Liver disease in blood donors with raised transaminases.

1000 consecutive blood donors had their liver functions studied. 110 donors (11%) were found to have raised ALT of more than twice normal levels. 29 donors had liver biopsies done. Histologically 23 had fatty change, 5 had chronic persistent hepatitis and 1 had liver cirrhosis. Fourteen out of the 23 donors with fatty change also had hypercholesterolemia and hypertriglyceridemia. Viral serology of the 110 donors showed that 3 donors were HBsAg positive, 5 donors were Anti-HAV (IgM) positive and 20 donors were Anti-HBc (IgM) positive. Majority of donors with raised ALT had fatty liver on biopsy with only 6 donors having significant findings of chronic persistent hepatitis and cirrhosis. Serologically, most of the donors (74.5%) with raised ALT had no markers of Hepatitis A, Hepatitis B, CMV or EBV. An interesting finding is the high incidence (18%) of positive, Anti HBc (IgM) in donors with raised ALT.

Liver biopsies from psoriatics treated with methotrexate.

To study the effects of Methotrexate (MTX) on the liver, light microscopic examination of liver biopsies from 18 consecutive patients with moderate to severe psoriasis receiving MTX seen between 1981-1985, were carried out. All patients received MTX (mean dosage of 1808 gm, mean duration of 88 months) prior to biopsy. There were 12 males, 6 females, with mean age of 55.1 yrs (range 39-77 yrs). All patients were HBsAg negative, non diabetic, and with no significant drug history or alcohol intake. Twenty liver biopsies were examined. Attempts to correlate severity of histological changes to dosage and duration of MTX therapy; and to the levels of raised SGPT at biopsy, failed to show any definite relationship. A variety of histological changes were seen in liver biopsies of MTX treated psoriatics, with 2 patients showing progression of histological changes following repeat biopsy.

Ultrasonography in the diagnosis of cholestatic jaundice.

Fifty consecutive patients (32 males and 18 females) with cholestatic jaundice were examined by grey-scale ultrasound from June 1981 to June 1983. All patients were studied without access to case notes. All patients had a diagnosis established by subsequent liver biopsy, clinical course, surgery or autopsy. Using the presence or absence of a dilated biliary system as the criterion, intrahepatic or extrahepatic cholestasis was correctly differentiated in 48 of the 50 patients, giving an overall accuracy of 96%. All 16 patients with intrahepatic cholestasis were correctly identified. Two of the 34 patients with extrahepatic cholestasis, each of whom had biliary stones, were misdiagnosed as intrahepatic cholestasis. In the 34 patients with extra-hepatic cholestasis, site of obstruction was defined in 55.9%, and specific aetiology diagnosed in 44.1%. Ultrasound proves to be an accurate method for the evaluation of cholestatic jaundice, and would have a definite value as a screening test before proceeding to invasive studies.

Hepatocellular carcinoma--a clinical study.

Hepatocellular carcinoma afflicts mainly Chinese Singaporeans 75/77 (97.4%), of which 71/77 (92.2%) of the patients are males. It is rare below the 3rd decade of life (1.3%), with the peak incidence occurring in the 5th to 7th decade of life (68.5%). Common presenting features are hepatomegaly (85.7%), jaundice (63.6%), and right hypochondrial pain (51.9%). Liver function tests were abnormal in 98.7%. Alpha-foetoprotein were positive in 61/77 (79.2%) of patients. Hepatitis B surface Antigen were positive in 43.75 (57.3%) of patients. Radiology and ultrasound studies demonstrated that 70.1% had lesions involving both lobes at diagnosis. Only 4/77 (5.1%) had surgical resections of the tumour. 50/65 (76.9%) died within six months of diagnosis, 11/65 (16.9%) survived for one year, 1/65 (1.5%) for 1 1/2 years, 1.65 (1.5%) for 2 years and 2/65 (3.0%) for more than 2 1/2 years; the longest survivor is still alive, at 4 1/2 years after diagnosis.

Assessment of fat malabsorption.

For the assessment of fat malabsorption, the standard method of measuring faecal fat excretion using a 5 day stool collection has been compared with the alternative methods: stool microscopy, a lipid tolerance test and a continuous marker technique for the estimation of fat content on a single stool sample. The lipid test, using an emulsion of arachis oil (Prosparol), was less reliable than had been expected with a sensitivity of 33% and a specificity of 45.4%. Stool microscopy using Oil Red O to stain fat globules had a sensitivity of 72.2% and a specificity of 95.4%. Fat estimation of a single stool sample using copper (1) thiocyanate showed a high correlation with that determined on a 5 day stool collection (p less than 0.001). It is concluded that lipid tolerance tests have little place in the estimation of fat absorption. In laboratories where faecal fats are not measured, microscopic examination of stool for fat globules provides a specific and relatively sensitive method for detecting steatorrhoea. The use of a continuous marker provides a method for assessing the degree of steatorrhoea on a single stool sample without the disadvantages of the conventional method of faecal fat analysis.