ISSN:0192-0790    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Endoscopic variceal sclerotherapy (EVS) is highly effective in arresting active esophageal variceal bleeding. Subsequent repeated EVS sessions significantly reduce recurrence of bleeding; long-term survival is reported as prolonged or unaltered. In contrast, EVS for preventing first variceal bleeding (prophylactic sclerotherapy) is not recommended, even for high-risk patients, because it enhances mortality by significantly increasing the risk of bleeding in the treated group compared with controls. The risk of variceal rebleeding is maximum within 6 weeks of index bleeding; most patients who survive 6 weeks of variceal bleeding (with or without sclerotherapy) behave like patients who have never bled from varices. Thus, EVS continued beyond 6 weeks, to obliterate the veins completely, is akin to prophylactic sclerotherapy. Significant complications of EVS—its cost, discomfort to patient, and loss of doctor and patient time—should be weighed against doubtful benefit of continuing prolonged EVS beyond 6 weeks, just to completely obliterate esophageal veins. The possibility of better long-term survival with sclerotherapy limited to 6 weeks cannot be excluded, because prophylactic sclerotherapy shortens long-term survival.

ISSN:0192-0790    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Constipation is not a sign but a symptom, which is not measurable scientifically. It has emotional components and must be dealt with in a holistic manner. The scientific approach aims only at the physiological derangement and serves to place the complaint in a more objective perspective. An algorithm can be constructed to select treatment including surgery, but there is no gold standard at present because the natural history of the symptoms is unknown. Most physicians confuse normality with epidemiology, neglecting in the process the evolution of mankind in terms of behavior. Constipation now means less than five stools per week, while it used to mean three. Thus, all complaints should be addressed. As for surgery, it should be performed in few, high select patients with no dysfunction other than that in the colon and in conjuction with a fully normal thorough psychological evaluation.

ISSN:0192-0790    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Sixty patients who presented with erosive/ulcerative refractory reflux esophagitis were randomized to receive a 4− to 8-week treatment with omeprazole 20 mg daily, or ranitidine 150 mg twice daily. Patients not healed after treatment were given the same drugs at doubled doses for a second period of equal duration. Patients still unhealed after this received open treatment with omeprazole 20 mg twice daily for a third period of 4 to 8 weeks. Endoscopic assessment and clinical and laboratory evaluation were performed every 4 weeks until there was complete esophageal mucosal repair. After 4 weeks, complete healing was observed in 50% of patients on omeprazole 20 mg daily, compared with 20.7% on ranitidine 150 mg twice per day (p < 0.01). After 8 weeks, the figures were 79.3% versus 34.5% (p < 0.5). With doubled doses after 4 weeks, complete healing was achieved in 96.6% of patients on omeprazole 40 mg daily, compared with 64.2% on ranitidine 300 mg twice per day (p < 0.05). The eight still “refractory” patients (one omeprazole, seven ranitidine) healed completely with 8 more weeks of omeprazole 20 mg twice daily. Patients treated with omeprazole experienced faster relief of heartburn, which disappeared in 60% of patients after 4 weeks, as compared to 21% of patients treated with ranitidine (p < 0.006). Apart from the mode of treatment, the only factor that proved to be related to healing at multivariate analysis was the pretreatment severity of gastroesophageal reflux, as measured by esophageal pH monitoring. Our study confirms that omeprazole, even at a low dosage, is the choice for refractory reflux esophagitis.

ISSN:0192-0790    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Of 213 patients with proctitis of all etiologies seen between 1977 and 1987, we studied an original cohort of 96 patients with idiopathic ulcerative proctitis (mean follow-up of 62 months). The diagnosis was made according to strict inclusion criteria, and all cases with any initial feature suggestive of Crohn's disease were excluded. Follow-up showed that 13 patients (13.6%) eventually progressed to Crohn's disease, usually within the first 3 years of the initial diagnosis of idiopathic ulcerative proctitis. Their clinical, endoscopic and histological features at initial presentation were indistinguishable from those in whom the diagnosis remained that of idiopathic ulcerative proctis. In nine of 13 of these patients (70.0%), the clinical course was characterized by a more protracted course and a poorer response to standard treatment. Such features were not found in those in whom the diagnosis of idiopathic ulcerative proctitis was maintained. Clinicians should be aware that Crohn's disease may present intially as apparent idiopathic ulcerative proctitis.

ISSN:0192-0790    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Crohn's disease is a rare cause of gastrocolic and duodenocolic fistulas. Only 83 examples (27 gastric, 52 duodenal, four both) have been described. Weight loss, abdominal pain, and diarrhea are common features but fail to distinguish a fistula from active inflammatory bowel disease. Fecal vomiting is pathognomic but is present in one third of gastrocolic and only 2% of duodenocolic fistulas. Diagnosis is most readily made by contrast radiography, with barium enema being more sensitive than barium meal. Although several gastrocolic fistulas have been successfully treated with long-term 6-mercaptopurine, surgery is the mainstay of therapy. An isolated duodenocolic fistula should not be regarded as the primary indication for operation because most are asymptomatic. Ileocolonic resection with simple gastric or duodenal repair is safe and effective in most cases. An ileocolonic anastomosis should be positioned away from the stomach or duodenum or protected with omentum to prevent recurrent fistulization. A number of fistulas appear to have arisen from gastric or duodenal Crohn's, but the vast majority originate from diseased colon.

ISSN:0192-0790    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

We evaluated 224 consecutive patients referred for severe constipation prospectively by strict criteria to determine their candidacy for subtotal colectomy. Eighteen patients had insufficient symptoms to warrant evaluation. Two hundred six patients had anorectal manometry and defecography, and 182 had colonic transit measurement. Forty-nine patients had normal or minimally abnormal studies. One-hundred twenty-nine patients had abnormalities such as outlet obstruction, mild colonic inertia, diffuse gut dysfunction, or combinations of factors not favoring subtotal colectomy. Twenty-eight patients had colonic inertia without outlet obstruction and with disabling symptoms; 19 of these patients underwent subtotal colectomy. Follow-up 12 months was available in 14 patients from this group. Of these patients, 12 (86%) were clinically improved. Preoperative evaluation accurately predicted postoperative fecal incontinence and likely reduced postoperative constipation. Small-bowel obstruction occurred postoperatively in 4 patients (29%), and remains a major risk of subtotal colectomy even in carefully selected candidates.

ISSN:0192-0790    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

We established an open-access, flexible, fiberoptic sigmoidoscopy service in an outpatient clinic in Kiriat-Shmona, Northern Israel. Twenty-eight general physicians in the city and in 41 surrounding rural residences (population 40,000) were encouraged to refer patients for sigmoidoscopy. In the first operative year, flexible sigmoidoscopy was performed on 255 patients (age range 10–90 years, mean 54). The male to female ratio was 123:132; women were slightly older than men (mean age 55.9 years vs. 51.1). Rectal bleeding and change in bowel habits were the most common indications. The sidmoidoscope was passed to the splenic flexure in 156 patients (61%). In five patients (2%) the instrument could not be inserted beyond the rectosigmoid junction. Excluding hemorrhoids and anal lesions, abnormalities were detected in 69 patients (27%). In 29 patients (11.4%) a cancer or polyp was found. Analysis of referral indications showed an increased positive predictive value for neoplastic lesions in patients referred for anemia (22.2%), weight loss (20.0%), abdominal pain (17.8%), and positive fecal occult blood test (15.4%). There were only two patients with polyp or cancer of 55 (3.6%) < 40 years of age, in contrast to 27 of 200 (13.5%) > 40 (p < 0.05). Sixty-six patients underwent further investigation, and 26 had positive results: colonic lesions were confirmed in 20 patients, sigmoid colon cancer was found on barium enema in one, and lesions outside the colon were detected in seven. Such open-access, flexible sigmoidoscopy gave higher yield for colorectal polyps or cancers than open-access or hospital-initiation barium enema. Direct referral for flexible sigmoidoscopy (a) may reduce delay in diagnosing colorectal pathology, (b) should offer increased diagnostic accuracy for mucosal disease, (c) provide opportunity for tissue diagnosis, and (d) may reduce the number of patients requiring multiple procedures. Diagnostic yield may be improved when specific referral symptoms are identified.

ISSN:0192-0790    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Two patients, after ABO-incompatible liver transplant, developed a picture of chronic cholestasis that was associated with unique ductular appearances within the donor graft on retrograde cholangiography. We believe that the appearance of progressive ductular ectasia within liver grafts indicates a specific immunologically mediated injury to ductular epithelium, probably because of ductular epithelial expression of ABH antigens.

ISSN:0192-0790    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Three residents of New Jersey suddenly developed vomiting, abdominal pain, and watery diarrhea 12 h after ingesting five to 13 hand-pickedAmanita phalloides–type mushrooms. The group was led by an amateur mycologist who had been eating hand-picked mushrooms without complications for 20 years. The patients developed mild to severe acute hepatic injury, with a peak serum aspartate aminotransferase level ranging from 133 to 826 Karmen U/L, and a peak serum alanine amino-transferase level ranging from 163 to 1176 Karmen U/L. One of the patients developed a transient severe coagulopathy, but no one developed renal failure or hepatic coma, and all rapidly improved. These three cases demonstrate that mycetismus can occur in the heavily urbanized northeastern United States, that consuming handpicked mushrooms even under the guidance of an experienced amateur may be dangerous, and thatAmanita phalloidesingestion produces a biphasic illness with early gastrointestinal symptoms and subsequent hepatic injury.

ISSN:0192-0790    

出版商:OVID    

年代:1992

数据来源: OVID