Haim Paran

Treatment of acute colonic pseudo-obstruction with neostigmine

BACKGROUNDnColonic pseudo-obstruction is a poorly understood syndrome, described by Ogilvie, and characterized by signs of large-bowel obstruction, without a mechanical cause. An imbalance in the autonomic nerve supply to the colon has been suggested as the pathophysiology. Recently, promising results with pharmacologic manipulation with neostigmine have been described.nnnSTUDY DESIGNnA prospective study was undertaken with 11 consecutive patients with clinical and radiologic signs of colonic pseudo-obstruction, in one general hospital, over a 1-year period. Patients were treated primarily with 2.5 mg of neostigmine in 100 mL of saline for 1 hour, under cardiac monitoring. Results were assessed by the clinical and radiologic responses.nnnRESULTSnRapid and effective spontaneous decompression of the colon was achieved in 8 patients after a single dose of neostigmine, within a mean of 90 minutes from the beginning of treatment. In another two patients decompression occurred only after a second dose was administered 3 hours after the first dose. In one patient, no changes were observed and colonoscopic decompression was performed. No significant bradycardia was observed in any of the patients.nnnCONCLUSIONSnNeostigmine is a simple, safe, and effective therapy for treatment of colonic pseudo-obstruction.

Octreotide for treatment of postoperative alimentary tract fistulas.

Eighteen patients with postoperative fistulas of the gastrointestinal tract were treated with the somatostatin analog octreotide between November 1989 and November 1992. Fourteen patients had enterocutaneous fistulas: seven from the duodenum and seven from the ileum. Another three patients had pancreatic fistulas, and one patient had a biliary fistula. Within 24 hours of octreotide treatment, a mean reduction of 52% in the intestinal fistulas output, 40% in the pancreatic fistulas, and 30% in the biliary fistula was noted. In the intestinal fistulas group the closure rate was 72% after a mean of 11 days. Early closure (mean 6 days) was achieved in all three pancreatic fistulas. In the patient with the biliary fistula a 30% reduction was observed twice following the administration of octreotide, and an increase occurred when it was withheld. The reduction rate of the secretions in high-output intestinal fistulas (>500 ml/day) was higher than in the low-output fistulas (63±8% versus 39±4%, p<0.05). Fistula output and the initial response to octreotide treatment had no value in predicting spontaneous healing. In conclusion, octreotide is a valuable tool for the conservative treatment of fistulas of the digestive tract. It is especially valuable for management of high-output enteric fistulas and pancreatic fistulas.RésuméDix-huit patients ayant une fistule postopératoire du tube digestif ont été traités par un analogue de la somatostatine, loctréotide, entre Novembre 1989 et Novembre 1992. Quatorze patients avaient une fistule entérocutanée sept intéressant le duodénum, les sept autres, lintestin grêle. Trois autres patients avait une fistule pancréatique et enfin, un patient avait une fistule biliaire. En moins de 24 heures après ladministration de loctréotide, des réductions moyennes de 52% du débit de la fistule intestinale, de 40% de la fistule pancréatique, et de 30% de la fistule biliaire ont été enregistrées. On a noté que 72% des fistules intestinales se sont fermés après une moyenne de 11 jours. Une fermeture précoce (moyenne = 6 jours) a été obtenue chez les trois patients ayant une fistule pancréatique. Chez le patient ayant une fistule biliaire, une réduction de 30% a été observée chaque fois que loctréotide a été administrée et le débit a ensuite augmenté chaque fois que loctréotide a été retiré. La réduction des sécrétions des fistules à grand débit (>500 ml/j) était plus importante que pour les fistules à bas débit (<500 ml/j) (63±8% vs 39±4%, p<0.05). Le débit de la fistule et la réponse initiale à loctréotide navaient aucune valeur prédictive de la guérison spontanée. En conclusion, lanalogue de la somatostatine, loctréotide, est utile dans le traitement conservateur des fistules du tube digestif. Elle semble trouver une indication particulière dans le traitement des fistules intestinales et pancréatiques.ResumenDieciocho pacientes con fistulas postoperatorias del tracto gastrointestinal fueron tratados con el análogo de la somatostatina, el octreótido, entre noviembre de 1989 y noviembre de 1992. Catorce pacientes presentaban fistula enterocutáneas: 7 duodenales y 7 del íleo. Otros 3 pacientes padecían fistulas pancreáticas y 1 presentaba fistula biliar. En las primeras 24 horas de iniciado el tratamiento con octreótido, se registró una reducción promedio de 52% en el drenaje de las fistulas intestinales, de 40% en el de las fistulas pancreáticas y de 30% en el de las fistulas biliares. En el grupo de las fistulas intestinales la tasa de cierre fue 72% luego de un promedio de 11 días. Se logró un cierre temprano (promedio 6 días) en los 3 pacientes con fistulas pancreáticas. En el paciente con fistula biliar se observó reducción de 30% en dos ocasiones luego de la administración del octreótido, en tanto que se observaba incremento cuando el agente no fue administrado. La reducción en el volumen de secreción de las fístulas de alto gasto (>500 ml/d) fue mayor que en las de bajo gasto (63±8% versus 39±4%, p<0.05). Ni el drenaje de la fistula ni la respuesta inicial al tratamiento con octreótido demostraron tener significado en cuanto al cierre espontáneo. En conclusión, el octreótido, análogo de la somatostatina, es un elemento valioso en el tratamiento conservador de las fistulas del tracto digestivo. Es especialmente valioso en el manejo de las fistulas entéricas de alto gasto y de las fistulas pancreáticas.

Prolonged Blood Storage Does Not Effect Survival in an Animal Model of Hemorrhagic Shock.

Background: Red blood cell (RBC) transfusion in hemorrhagic shock is life saving. However, several clinical trials have shown that blood transfusion in the critically ill patient might be associated with adverse outcomes. Furthermore, an association between prolonged blood storage and adverse effects of RBC transfusion has been postulated. The aim of this study is to examine the effect of blood storage time on resuscitation outcome, in an animal model of hemorrhagic shock. Methods: 20 Wistar rats were phlebotomized in order to induce reversible hemorrhagic shock. Half of them were resuscitated with blood stored for a short period of time (4 days), and the other ones were resuscitated with blood stored for a prolonged time (14 days). Blood samples for hemoglobin, pH, lactate, bicarbonate and creatinine were drawn prior to the induction of shock and 24 h after resuscitation. Five days after resuscitation the animals were sacrificed, and liver, lung and kidney histology was examined. Results: At 24 h after bleeding, the hemoglobin levels decreased by 3.2 and 1.7 g/dl, the pH decreased by 0.008 and 0.001, while the lactate levels increased by 1.6 and 2.7 mg/dl in the fresh and old blood resuscitation groups, respectively, with no significant difference between the groups. A trend toward more severe renal damage occurred in the old compared to the fresh blood resuscitation group (p = 0.089). Conclusion: The results of the present study show that in this animal model of hemorrhagic shock the duration of storage of RBCs used for transfusion did not affect the outcome of resuscitation.