Mid-esophageal traction diverticulum: rare cause of massive upper gastrointestinal bleeding.

Traction diverticula of the mid-esophagus are usually incidental findings on barium swallow or upper endoscopy. They are thought to arise secondary to adjacent inflammation in the mediastinum, usually from granulomatous infection such as histoplasmosis. They are usually asymptomatic. Rarely, erosion or extension of the inflammatory process into the adjacent lung or bronchial arteries can result in clinical symptoms such as pneumonia or gastrointestinal bleeding. Diagnosis is often delayed due to the rarity of clinical symptoms. We present a case of massive upper gastrointestinal bleeding due to a mid-esophageal diverticulum.

Alpha-1-antitrypsin deficiency: rare cause of adult cirrhosis--a case report.

Alpha-1-antitrypsin is a glycoprotein which inactivates proteolytic enzymes, especially neutrophil elastase. Infants deficient in this enzyme commonly develop neonatal hepatitis. In adults, the deficiency typically results in emphysema. Only rarely will an adult manifest liver disease. We present a case of adult liver cirrhosis due to Alpha-1-antitrypsin deficiency in a 63-year-old man. Manifestations of alpha-1-antitrypsin deficiency and liver disease are discussed.

The importance of fluoroscopic guidance for Maloney dilation.

One hundred and forty-five patients were evaluated for the importance of fluoroscopic monitoring during Maloney esophageal dilation. In 35 patients (24%), fluoroscopy altered the dilation technique. Dilation of peptic strictures (27 of 75, 36%) was much more likely to be affected by fluoroscopy than Schatzki's rings (eight of 70, 11%, p < 0.05). Patients whose stricture was altered by fluoroscopy also had larger size hiatal hernias (6.5 vs. 4.3 cm, p < 0.05). Patients with Schatzki's ring with a hiatal hernia size of less than or equal to 4.0 cm did not benefit from fluoroscopy. In 26 of 35 cases, successful redirection of the dilator and passage under fluoroscopy was accomplished. In nine patients, Maloney dilation was impossible, and use of Savary wire-guided dilators was needed. We had no morbidity and mortality. We advise the use of fluoroscopy for Maloney dilation for peptic strictures and for large hiatal hernias.

Primary biliary cirrhosis: current diagnosis and treatment.

Primary biliary cirrhosis is a progressive noninflammatory destruction of the interlobular bile ducts within the liver, leading to cholestasis and eventual cirrhosis. Ninety percent of affected patients are women. Most patients are initially without symptoms or have mild symptoms such as fatigue or pruritus. A minority of patients have the classical triad of jaundice, pruritus, and xanthelasmas. Almost all patients will have positive anti-mitochondrial antibody test results and an elevation of the serum alkaline phosphatase level. Primary biliary cirrhosis is thought to be an autoimmune disorder with additional liver injury being mediated by the subsequent cholestasis and accumulation of toxic bile acids. New treatment modalities include colchicine, ursodeoxycholic acid, and methotrexate. All patients, including those with only minor symptoms, have increased mortality compared with age-matched controls, thereby emphasizing the need for early diagnosis.

Esophageal stricture: results of dilation of 300 patients.

Three hundred patients underwent 1,177 esophageal dilations over a nine-year period. There were 164 men and 136 women. Mean age was 63 years. Etiology of stricture was peptic (160), Schatzki's ring (124), cancer (8), post-surgical (3), post-radiation (2), caustic ingestion (1), and esophageal web (2). Dilators used were Maloney red-rubber mercury weighted (78.1%), Savary wire-guided (15.2%), Eder-Puestow (6.3%) and Balloon (0.4%). Fluoroscopy was used in 98% of cases. One hundred and two of the 111 patients with peptic strictures observed for longer than six months had successful dilation. Forty-five of these patients (40.5%) required 54 redilations to maintain relief of dysphagia. Nine patients were refractory to dilation, two needing serial dilation and seven surgery. All Schatzki's rings were treated successfully. Ten of 82 patients followed for greater than six months needed redilation (12%). Morbidity was 0.2% with two complications occurring, an esophageal perforation and one case of hematemesis. There was no mortality.

Esophageal dilation. Six-year experience in a small community hospital.

The results of this review indicate esophageal strictures can be effectively and safely managed by dilation in the community hospital setting.

Classical heatstroke: clinical and laboratory assessment.

We reviewed the clinical and laboratory characteristics of 34 patients who had classical heatstroke during the Kansas City heat wave of 1980. The patients were elderly, predominantly black, and of low socioeconomic class. Overall mortality was 18%, with 9% of patients exhibiting severe residual neurologic deficit; 73% had full recovery. Patients with coma, temperature greater than or equal to 108 F (42.2 C), severe hypotension, coagulopathy, and need for respiratory assistance were at highest risk of death. Associated disease was common (67%), with hypertension (32%), diabetes (21%), and alcoholism (21%) being most frequent. Medications known to predispose to heatstroke were used by 56% of patients. Hematologic abnormalities were nonspecific, and clinical evidence of renal or hepatic failure was rare. Hyponatremia, hypokalemia, hypocalcemia, hypomagnesemia, hypophosphatemia, and elevated levels of creatine phosphokinase and glucose were frequent but did not correlate with outcome. The predominant arterial blood gas abnormality was metabolic acidosis or a combined metabolic acidosis and respiratory alkalosis.

Risk factors for cholecystectomy: analysis of 935 patients.

We evaluated 935 patients for risk factors of cholecystectomy. Factors assessed included reason for cholecystectomy, preoperative laboratory values, sex, age, weight, presence of associated disease, and pathologic findings. Evaluation revealed an overall significant complication rate of 10.50% and a mortality of 1.07%. Risk factors were age over 60 years, hypertension, atherosclerotic cardiovascular disease with prior heart failure, and acute cholecystitis. Incidental cholecystectomy was associated with an increased risk due to concomitant associated disease. Patients with obesity and uncomplicated diabetes had the same risk as the general population.

Prevalence of gallstones in obese Caucasian American women.

Although the association between gallstones and obesity is well known, no attempt has been made to quantitate the increased risk for gallstone formation associated with moderate obesity commonly seen in clinical practice. To determine the prevalence of both asymptomatic and symptomatic gallstones, screening oral cholecystograms were combined with prior documented history in 249 consecutive obese Caucasian women aged 20-59 yr who were seeking treatment for obesity in an out-patient clinic. To ascertain the relative risk of moderate obesity for gallstone formation, the results were compared with a control group of 60 consecutive women who were undergoing screening health examinations in the same clinic. Both groups were without gastrointestinal symptoms. Gallstone prevalence averaged 31 percent among obese women compared to 10 percent in the control group. Sixty percent of gallstones in the combined 20-29 yr age group were asymptomatic. However, among all patients with gallstone disease 59 percent had symptomatic disease evidence by prior cholecystectomy. Moderate obesity imposes at least a three-fold risk of gallstone disease in Caucasian women.

Factitial bleeding: successful management with psychotherapy.

A young female nurse presented with unusual upper and lower-gastrointestinal bleeding, shown to be factitial. Following detection, she was successfully confronted and treated with psychotherapy. A plan for successful management of the Munchausen syndrome is discussed.