Anil Minocha

Role of Appendectomy and Tonsillectomy in Pathogenesis of Ulcerative Colitis

We wished to determine the effect ofappendectomy and tonsillectomy on the subsequent riskfor development of ulcerative colitis (UC). We conducteda case-control study at the University of OklahomaHospital and VA Medical Center gastroenterology clinics,as well as at the offices of private physicians.Subjects being followed for UC formed the study group.Patients being followed at Internal Medicine Associates of the University of Oklahoma clinics formedthe controls. We recorded the patients name, age, sex,race, history of smoking, and history of appendectomy ortonsillectomy. The study group consisted of 193 patients, and there were 394 controls. Theprevalence of appendectomy was lower (17.8% vs 5.2%)among patients with UC (P < 0.01). The prevalence oftonsillectomy was similar in the two groups (20.6% vs 18.1%; P = NS). We conclude thatappendectomy is associated with a decreased risk forsubsequent development of ulcerative colitis.

Excitatory and inhibitory responses mediated by GABAA and GABAB receptors in guinea pig distal colon

The actions of gamma-aminobutyric acid (GABA) and the receptor selective agonists, muscimol (GABAA) and baclofen (GABAB), on motor activity of the longitudinal muscle-myenteric plexus of guinea-pig distal colon were studied in vitro. Preparations exhibited spontaneous contractions that were blocked by scopolamine (1 microM) or tetrodotoxin (1 microM). GABA (3-100 microM) inhibited these contractions; the EC50 was 8 microM. GABA-induced relaxations were not blocked by picrotoxin (30 microM). The GABAA receptor antagonist, bicuculline (3-30 microM), increased the amplitude of spontaneous contractions; this response was not blocked by tetrodotoxin. Baclofen (3-100 microM; EC50 = 14 microM) mimicked the GABA-induced relaxation. Baclofen-induced relaxations were not blocked by the GABAB antagonist, phaclofen (30-100 microM). Muscimol (10-100 microM) induced a contraction followed by a relaxation; both responses faded in the presence of muscimol. The muscimol EC50s for contraction and relaxation were 12.5 and 11 microM, respectively. The muscimol contraction was blocked by tetrodotoxin, scopolamine and picrotoxin and was reduced by hexamethonium (30 microM). Muscimol relaxations were blocked by tetrodotoxin, picrotoxin and apamin (0.1 microM). Muscimol responses were not altered after preincubation of the tissues with cortisol (10 pM-1 microM). These data indicate that GABA can act at presynaptic GABAB receptors to inhibit acetylcholine release from enteric neurons and reduce spontaneous contractions. There are also GABAA receptors on excitatory and inhibitory neurons and agonist action at these receptors results in contraction and relaxation.

Is a history of tonsillectomy associated with a decreased risk of Helicobacter pylori infection

To determine the relation between a history of tonsillectomy and the prevalence of colonization by Helicobacter pylori (HP), we conducted an observational, cohort study at the University of Oklahoma Hospital over a 13-month period. Subjects under-going upper endoscopic evaluation and antral biopsies for HP at the University of Oklahoma Hospital formed the database. The indication of the endoscopy and biopsies was determined by the endoscopist. The antral biopsy specimens were tested for HP using a rapid urease test. We recorded the patients name, age, gender, race, history of smoking, and history of appendectomy or tonsillectomy. One hundred nine subjects constituted our database. There was no difference in age, gender, or smoking between the HP+ (n = 37) and HP- (n = 72) groups. The ability to pay for healthcare through a third-payor party also was similar. The prevalence of prior tonsillectomy was 30.6% in HP- group versus 5.4% in HP+ group (p < 0.01). In contrast, the prevalence of prior appendectomy was 21.6% in HP+ group versus 23.6% in HP- group (p = not significant). Multiple regression was carried out to account for confounding variables. The model showed that only white race and tonsillectomy were significantly related to the presence of HP colonization. Both appendectomy and health insurance, which were the surrogate markers for access to healthcare and socioeconomic status, were insignificant. We conclude that a history of tonsillectomy is associated with decreased prevalence of HP colonization.

Reliability and reproducibility of breath hydrogen and methane in male diabetic subjects

We studied the variability and reliability ofbreath hydrogen and methane as well as the alterationsin intestinal gas profile in response to lactuloseingestion in 13 asymptomatic male patients with diabetes mellitus (DM). Seventeen healthy subjectsserved as controls. The prevalence of methane producerswas 33% in DM and 45% among control subjects (P NS). Theprevalence of nonhydrogen producers was 7.7% and 5.9%, respectively. The coefficient forinterday variation of H was 72.6 ± 9.8% in DM and49.7 ± 9.8% in controls (P < 0.05). 2Similarly, the coefficient for interday variation ofCH4 was 94.3 ± 18.8 and 69.4 ±16.8% respectively (P = NS). The reproducibility ofbasal H2 and CH4 among diabeticsas assessed by r1 (measure of reliability)was poorer among diabetics when breath analysis wasperformed on different days (P < 0.001). There was no significantdifference between diabetics and controls with respectto basal or peak or area under the curve forH2 and CH4 in response tolactulose. We conclude that there is poor reproducibility of fasting breath gas levelsamong asymptomatic male subjects with diabetes. Inaddition, DM is not associated with alterations inhydrogen- or methane-producing potential.

Sengstaken-Blakemore Tube for Control of Massive Bleeding from Gastric Varices in Hiatal Hernia

Surgicalemorrhage from varices in a hiatal hernia sac was controlled by a Sengstaken-Blakemore tube. There is little data available regarding the safety and effectiveness of balloon tamponade in patients with hiatal hernia. Therefore we review the available literature and discuss balloon tamponade in patients with a hiatal hernia.

Conscious Sedation Pearls and Perils

Conscious sedation is de ® ned as a a minimally depressed leve l of consciousne ss that retains the patient’ s ability to maintain the airway independently and continuously and to respond appropriate ly to physical stimulation and verbal commando (1). The American Society of Anesthesiologists task force on sedation and analge sia by nonane sthesiologists decided that the term a sedation and analge siao is a more accurate ly descriptive term than conscious sedation, although the latter term is more commonly used (2). Deep sedation implie s that the patient is unable to respond purpose fully to verbal command and may be uncoope rative ; protective re exes may be lost and vital signs may be labile . In case of deep sedation, pain is eliminate d centrally. Amnesia is always present during deep sedation requiring prolonged recovery. In this article , we will review the pharmacologic al principle s of conscious sedation and therapeutic recommendations. We recognize that this subject lends itse lf to controversy. There may be a disparity between the results of some studies and the personal experiences of the reader. The review is primarily based on gastrointe stinal endoscopy, although the pharmacological principle s would apply to conscious sedation in any discipline .

Pneumomediastinum as a complication of upper gastrointestinal endoscopy.

Secondary or complex pneumomediastinum following esophagoscopy is due to an esophageal perforation. Primary or simple pneumomediastinum may be caused by maneuvers such as coughing, gagging, swallowing, choking, and valsalva. These maneuvers are common during upper gastrointestinal endoscopy. Esophageal perforation is a potentially life threatening event, while simple pneumomediastinum is usually a benign self-limited disorder. Although the presentation may be similar, different morbidities compel prompt evaluation for distinction between these two entities and appropriate management. We present a case of pneumomediastinum that developed immediately following upper gastrointestinal endoscopy. Implications of diagnosis, management, and prognosis are discussed.

Omeprazole therapy does not affect pharmacokinetics of orally administered ethanol in healthy male subjects

The purpose of this study was to study the effect of high-dose omeprazole therapy (20 mg twice daily) on kinetics of moderate amounts of orally administered ethanol. Eight healthy men participated in the study. After an overnight fast, they drank 0.5 g/kg body weight ethanol over 20 min. Blood samples were drawn before and then every 20 min after ethanol ingestion for the next 3 h. Subjects then ingested omeprazole 20 mg twice daily for 6 days. On the seventh day, the same dose of oral ethanol was administered as before and blood samples drawn. Blood ethanol concentrations were determined. We fit a one-compartment model with first-order absorption and zero order elimination to the blood ethanol data with PCNONLIN (SCI Software, Lexington, KY, U.S.A.) separately for each subject before as well as after omeprazole therapy. Area under the curve was calculated using the trapezoidal rule. There were no differences in the peak concentration, time to peak concentration, area under the curve, or elimination rate constant for ethanol before and after omeprazole treatment. Omeprazole treatment (20 mg twice daily) does not affect the pharmacokinetics of orally ingested ethanol in healthy male subjects. Our results do not rule out a possible effect on psychomotor function as a result of a pharmacodynamic interaction.

Acute Sulfasalazine Overdose

Sulfasalazine (salicylazosulfapyridine, Azulfidine) has been widely used over the last half century for inflammatory bowel diseases, but overdose has not been reported. A 23 year-old male ingested 25 g of sulfasalazine in a suicide attempt. He underwent prompt treatment and survived with no ill-effects.

Racial differences in general health, suicidal thoughts, physical and sexual abuse in African-Americans and Caucasians with irritable bowel syndrome

Objectives: Knowledge of the contribution of race to irritable bowel syndrome (IBS) -associated morbidity helps not only with health care policy decisions but also may provide important clues to the pathophysiologic interactions involved. Methods: We conducted a survey at 9 different sites in our metro area. Subjects filled a questionnaire which included Rome II criteria for IBS. Subjects were asked about demographic and clinical characteristics. Subjects with a prior history of chronic inflammatory bowel disease and gastrointestinal cancer were excluded. Results: Nine hundred and ninety subjects (670 African-Americans and 320 Caucasians) were included in the final analysis. IBS patients had more food allergies and were more likely perceived to have poor health as well as physical limitations. A reduced logistic regression model demonstrated that travel abroad, upper respiratory infections, tonsillectomy, and loss of appetite were independently associated with race in the IBS patients. There were no racial differences in physical or sexual abuse, loss of interest in life, or suicidal thoughts. Conclusions: Substantial similarities as well as differences in IBS patients of the two races support the concept that, while there is an important role for a biological component to the pathogenesis of IBS, it by itself may not be an exclusive determinant.