Franz Goldstein

THE VARIED CLINICAL MANIFESTATIONS OF PULMONARY EMBOLISM

Excerpt Pulmonary embolism is a common finding at necropsy. It is nevertheless regarded in many hospitals as an unusual disorder, infrequently considered in the differential diagnosis of cardiopulm...

Acute Hemolytic Anemia Complicating Viral Hepatitis in Patients with Glucose-6-Phosphate Dehydrogenase Deficiency

Excerpt Although shortened erythrocyte survival can frequently be demonstrated, severe anemia has rarely been noted during acute viral hepatitis (1-3). In the few reported cases of hemolytic anemia...

Studies of the Mechanism of Postgastrectomy Steatorrhea.

Excerpt Previous studies by the authors and others have suggested an analogy between postgastrectomy steatorrhea and the malabsorption associated with the blind loop syndrome. In 40 postgastrectomy...

Immunosuppressant therapy of inflammatory bowel disease. Pharmacologic and clinical aspects.

The history of immunosuppressant drug use, both azathioprine (Aza) and 6-mercaptopurine (6-MP), in inflammatory bowel disease (IBD) over the past 20 years is briefly reviewed. The two drugs appear identical in their pharmacologic and biologic effects. Azathioprine is converted to 6-MP while in the body. Conflicting reports on the effectiveness of Aza have been published. The major National Cooperative Crohns Disease Study (NCCDS) has found no advantage in Aza over placebo. In contrast, 6-MP was found to be effective in a large randomized trial. The shortcomings of the NCCDS reports are discussed with possible explanations for their negative findings. Our own studies, dating from 1968, are reviewed with 38 patients having been treated for up to 18 years, always in combination with small doses of steroids. Our results with Aza are similar to those of Present and Korelitz with 6-MP; about 70% of previously intractable patients improved substantially. Both Aza and 6-MP bring about healing and closure of most fistulas. Side effects can be serious but are usually manageable and, to some extent, preventable by appropriate dosage schedules. Since Aza has been approved for another benign, presumably autoimmune disease--rheumatoid arthritis--and because of its extensive use in other autoimmune diseases, we prefer to use Aza in selected patients with Crohns disease who have failed to respond to more conventional modes of therapy. The use of immunosuppressants in ulcerative colitis is less clearly indicated.

Intralesional steroid therapy of pyoderma gangrenosum

Treatment of pyoderma gangrenosum complicating ulcerative colitis has in the past been frustrating and usually unsuccessful, frequently resulting in colectomy. Intralesional steroid therapy has been used off and on in a few patients, but the treatment is not widely known to gastroenterologists. We report two patients successfully treated for early pyoderma gangrenosum by intralesional injection of triamcinolone acetonide (Kenalog, 40 mg injection) together with conventional doses of systemic steroids. A single series of injections was sufficient to bring about healing of the lesions in both patients. The treatment permitted early discharge of patients from the hospital, and the skin lesions were completely healed within 2 months. The lesions have not recurred in follow-up examinations of 11/2 and 21/2 years, respectively. We hope that other physicians will find this approach equally effective.

Biliary tract dysfunction in giardiasis.

Although giardiasis as a cause of diarrhea and matabsorption has been increasingly recognized in the United States in the past two decades (1), an association between giardiasis and biliary tract dysfunction has not been widely appreciated. We recently encountered a patient in whom a clinical syndrome of biliary tract dysfunction was found to be associated with Giardia lamblia infection. On reviewing the literature, we encountered many pertinent references from the 1920s and 1940s, fewer since then, and mostly in foreign-language journals. The purpose of this report is to relate the experiences with our patient, together with a brief review of the pertinent literature.

Diverticulosis of the small intestine. Clinical, bacteriologic, and metabolic observations in a group of seven patients.

Seven patients with small-intestinal diverticulosis were studied by means of intestinal absorptive tests, biopsies, and bacterial cultures of small-intestinal aspirates. Aerobic bacterial cultures were obtained in all patients, while anaerobic cultures with a modified Hungate roll-tube technic were performed in 3. Three of the patients manifested steatorrhea and were studied over prolonged periods of time. The bacterial flora varied over a wide quantitative range, with highest total counts in excess of 109 colony-forming units per milliliter found in the 2 patients with the most severe malabsorption. Despite multiple diverticulosis, 1 patient without steatorrhea had no recoverable aerobic or anaerobic bacterial flora. E. coli predominated among the recovered aerobic organisms in this series, but A. aerogenes and various streptococci also were encountered repeatedly. Patients treated with antibiotics directed at the aerobic flora showed prompt improvement in absorption, and reduction in bacterial counts. Repeated short courses of antibiotics were needed to treat early bacteriologic and clinical relapses. After several such courses, all 3 patients treated maintained their clinical and metabolic improvement for periods of close observation ranging from 2 to 15 months without additional antibiotic treatment, and the clinical remissions were accompanied by gradual reductions in total bacterial counts to “borderline normal” limits. Of the 3 patients, 1 has now been followed for 5 years without relapse. It is apparent that the mere presence of diverticulosis does not lead necessarily to malabsorption. Malabsorption of fat, Vitamin B12, and other nutrients was found only in patients with excessive bacterial flora, emphasizing the crucial role bacteria play in the pathogenesis of malabsorption in diverticulosis of the small intestine.

Cholecystokinin cholecystography in the differential diagnosis of acalculous gallbladder disease

Forty-two patients with acalculous biliary tract disease were studied by means of cholecystokinin (CCK) cholecystography between 1959 and 1972. Comparing responses to CCK with normal responses in “control” subjects, several types of abnormal responses were recognized. Patients with cystic duct syndrome (CDS), previously identified, showed marked impairment of gallbladder emptying and minimal, if any, filling of bile ducts. Patients with partial obstruction at the sphincter of Oddi also showed impaired gallbladder emptying, but their common duct became prominent, dye refluxed into hepatic ducts, and no dye entered the duodenum. Sphincter spasm could be differentiated from sphincter stenosis by the response, or lack of it, to nitrates and/or anticholinergics. Marked hypercontraction of the gallbladder characterized patients with hyperplastic cholecystoses. All abnormal CCK responses were associated with reproduction of biliary tract pain. Treatment based on CCK cholecystography has been successful for a large majority of patients, with follow-up information ranging from 6 months to 11 years.

Eosinophilic gastroenteritis. Report of a case with malabsorption and protein-losing enteropathy.

The case of a 77-year-old white woman with eosinophilic gastroenteritis of long duration is presented. The occurrence of malabsorption and protein-losing enteropathy is well documented. The diagnosis was made by means of peroral jejunal biopsy, making exploratory laparotomy unnecessary. The response to corticosteroids was prompt and sustained, although incomplete and could be maintained on an alternating day schedule of steroid administration.

DIARRHEA AND STEATORRHEA DUE TO A LARGE SOLITARY DUODENAL DIVERTICULUM. REPORT OF A CASE.

SummaryMild steatorrhea, severe diarrhea, weight loss, and minimally impaired absorption of vitamin B12 were present in a 61-year-old white man with a large duodenal diverticulum. Repeated bacteriologic cultures of duodenal contents revealed excessive growth of a predominantly gram-negative flora. Temporary improvement in the diarrhea, improved fat absorption, and weight gain followed several courses of treatment with tetracy-cline. This patient represents the first known instance of malabsorption due to a single duodenal diverticulum in the absence of jejunal diverticula. Other causes of malabsorption were excluded by exhaustive tests.