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A prospective controlled study of the risk of bacteremia in emergency sclerotherapy of esophageal varices

Reported incidences of bacteremia after endoscopy with esophageal variceal sclerotherapy are conflicting. A prospective controlled study was conducted to determine the frequency of bacteremia after emergency endoscopy with esophageal variceal sclerotherapy compared with frequency after elective esophageal variceal sclerotherapy and after emergency endoscopy in patients with upper gastrointestinal bleeding from nonvariceal sources. A total of 126 endoscopies were studied in 72 patients. Groups consisted of (a) emergency endoscopy without esophageal variceal sclerotherapy, 37 sessions with 36 patients; (b) elective esophageal variceal sclerotherapy, 33 sessions with 14 patients; and (c) emergency esophageal variceal sclerotherapy, 56 sessions with 36 patients. Blood cultures were obtained before and 5 and 30 minutes after endoscopy. There was a higher frequency of preendoscopic bacteremia in emergency esophageal variceal sclerotherapy (13%) than in emergency endoscopy alone (0%) (P = 0.02). Clinically significant bacteremia in emergency esophageal variceal sclerotherapy was observed in 7 of 56 (13%) sessions, compared with 0 of 33 in elective esophageal variceal sclerotherapy (P = 0.03) and 1 of 36 (3%) in emergency endoscopy alone (P = 0.45). Of these cases, 3 (5.4%) were potentially caused by emergency esophageal variceal sclerotherapy, but not clinically significant postendoscopic bacteremia was attributable to the procedure in the other groups.

Assessment of Intestinal Permeability and Absorption in Cirrhotic Patients with Ascites Using Combined Sugar Probes

Gastrointestinal dysfunction in patients with cirrhosis may contribute to complications such as malnutrition and spontaneous bacterial peritonitis. To determine whether cirrhotic patients with ascites have altered intestinal function, we compared intestinal permeability and absorption in patients with liver disease and normal subjects. Intestinal permeability and absorption were investigated in 66 cirrhotic patients (48 with ascites, 18 without ascites) and 74 healthy control subjects. Timed recovery of 3-O-methyl-D-glucose, D-xylose, L-rhamnose, and lactulose in urine following oral administration was measured in order to assess active and passive carrier-mediated, and nonmediated, absorptive capacity, as well as intestinal large-pore/small-pore (lactulose/rhamnose) permeability. Test sugars were measured by quantitative thin-layer chromatography and results are expressed as a percentage of test dose recovered in a 5-h urine collection. Sugar excretion ratios relating to small intestinal permeability (lactulose/rhamnose) and absorption (rhamnose/3-O-methyl-D-glucose) were calculated to avoid the effects of nonmucosal factors such as renal clearance, portal hypertension, and ascites on the recovery of sugar probes in urine. Compared with normal subjects, the mean lactulose/rhamnose permeability ratio in cirrhotic patients with ascites was significantly higher (0.058 vs. 0.037, P < 0.001) but not in cirrhotic patients without ascites (0.041 vs. 0.037). Cirrhotic patients with ascites had significantly lower mean recoveries of 3-O-methyl-D-glucose (23.0 vs. 49.1%; P < 0.001), D-xylose (18.8 vs. 34.5%; P < 0.001), L-rhamnose (4.0 vs. 9.1%; P < 0.001), and lactulose (0.202 vs. 0.337%; P < 0.001) than normal subjects. However, the mean rhamnose/3-O-methyl-D-glucose ratio was the same in cirrhotic patients with ascites as normal subjects (0.189 vs. 0.189), indicating that the reduction in probe recovery was due to nonmucosal factors. Compared with normal subjects, cirrhotic patients with ascites have abnormal intestinal permeability, measured by urinary lactulose/rhamnose excretion, and normal small intestinal absorption, assessed by the urinary rhamnose/3-O-methyl-D-glucose ratio. Low urine recovery of sugar probes found in cirrhotic patients appears to be the result of nonintestinal factors affecting clearance rather than reduced intestinal absorption.

Blastocystis hominis Infection and Intestinal Injury

Blastocystis hominis is an enteric protozoan associated with clinical illness. To determine the prevalence of intestinal injury in patients with B. hominis infection, the authors prospectively evaluated 18 patients with B. hominis infection by endoscopy and a test of intestinal permeability. Seventeen patients had gastrointestinal symptoms. Colonic mucosa appeared normal by lower endoscopy in 12 of 13 patients, and was friable slightly in 1. Duodenal mucosa was normal by upper endoscopy in nine patients. Pathologic examination of mucosal biopsy specimens did not demonstrate evidence of mucosal invasion. 51Cr-edetic acid (51Cr-EDTA) was given to the 18 patients with stools positive for B. hominis and to 32 healthy control subjects. Approximately 100 uCi of 51Cr-EDTA was given orally after an overnight fast, and urine was collected for the following 24 hours. Mean 24-hour urinary excretion of 51Cr-EDTA, calculated as a percent of the administered dose, was 1.31% (0.34–2.76%) in patients with B. hominis infection and 1.99% (0.59–3.48%) in the control subjects. The intestinal permeability to 51Cr-EDTA in blastocystis-infected individuals was not increased, but was decreased significantly compared with healthy subjects (p < 0.005). Therefore, in a group of symptomatic patients with B. hominis infection, endoscopy typically did not show evidence of significant intestinal inflammation, and results of intestinal permeability testing with 51Cr-EDTA did not suggest impaired barrier function of the intestinal mucosa. The clinical literature on B. hominis infection and intestinal injury is reviewed.

Intestinal permeability to [51Cr]EDTA in infectious diarrhea

Orally administered [51Cr]EDTA was used to measure intestinal permeability in subjects with infectious diarrhea and in those without gastrointestinal complaints. [51Cr]EDTA was given to 87 subjects: 63 controls (32 normal controls, and 31 disease controls), and 24 patients with infectious diarrhea. Approximately 100 μCi of [51Cr]EDTA was given orally after an overnight fast. Urine was collected for the following 24 hr. Intestinal permeability to [51Cr]EDTA in both normal volunteers and in patients with a variety of diseases not associated with intestinal injury was low and results were in a relatively narrow range. Mean 24-hr urinary excretion of [51Cr]EDTA, calculated as a percent of the administered dose, in controls was 1.6% (0.2–3.5%). Patients with infectious diarrhea associated with invasive pathogens and/or intestinal inflammation had increased excretion of [51Cr]EDTA (mean 6.1%,P<0.0001), with elevated excretions in 75%. These results demonstrate that intestinal infections must be considered as possible causes for increased intestinal permeability as assessed by the [51Cr]EDTA test.

Frequency of recovery of Blastocystis hominis in clinical practice.

We examined the frequency of isolation of Blastocystis hominis from stools of patients seen in an indigent-care teaching hospital. Over a 2-year period, 2,744 stool specimens were examined prospectively. B. hominis was found in 262 stools (9.5% of all stool specimens and 53.5% of the positive specimens). Clinical data were obtained from 80 patients with stools positive for B. hominis. B. hominis was the only parasite isolated in 39 of 47 (83%) of the adults, compared with 17 of 33 (52%) of the children (p = 0.006). All but 2 of 52 patients without concomitant parasitic infection or bacterial pathogens in stool had gastrointestinal sysmptoms (41 abdominal pain, 26 diarrhea, and 5 vomiting), but no association was seen with fever, peripheral leukocytosis, stool occult blood, fecal leukocytes, or endoscopic or radiologic evidence of colitis. Therefore, B. hominis was frequently recovered from stools eamined in a hospital clinical parasitology laboratoty. The clinical presentations of patients in our series did not suggest that B. hominis was invasive. Most patients with B. hominis probably do not require treatment since they will either have spontaneous resolution of symptoms or will be found to have an alternative explanation for their problem.

Lower gastrointestinal bleed in a patient with typhoid fever

malignancy. The lesion was identified on the greater curvature of stomach and was locally excised with a margin of normal tissue. There was no communication with the lumen of the stomach. Histological examination revealed characteristic features of GDC (2). The cyst wall was composed of the epithelial layer, lamina propria, and inner muscle layer. The epithelial layer comprised ciliated, pseudostratified columnar epithelium and gastric foveolar epithelium without evidence of malignancy. Immunohistochemical analysis revealed CA19-9 staining–positive cells in the epithelium. The patient had an uneventful recovery and remains well 6 months after operation. GDC is extremely rare in the adult population (1), and it is often difficult to discriminate it from malignant cystic tumors. It is usually diagnosed by surgery because of unspecified symptoms and rarity (3). Our patient remained asymptomatic until adulthood although he had the large GDC. In addition to its size, the fluid analysis revealed markedly elevated concentration of CA19-9. GDC is always benign in the pediatric population (4). However, malignant transformation has been described in a few adult cases (5). Surgical removal should be considered for even an asymptomatic GDC once it is diagnosed.

Spontaneous bacterial peritonitis caused by Streptococcus bovis.

1. Poon RTP, Fan S-T, Lo C-M, et al. Hepatocellular carcinoma in the elderly: Results of surgical and nonsurgical management. Am J Gastroenterol 1999;94:2460–6. 2. Pringle JH. Notes on the arrest of hepatic hemorrhage due to trauma. Ann Surg 1908;48:541–9. 3. Bismuth H. Hepatocellular carcinoma in the elderly: Results of surgical and nonsurgical management. Am J Gastroenterol 1999;94:2336–7 (editorial).

Recurrent salmonella Arizona Infection After Treatment for Metastatic Carcinoma

Serious Salmonella arizona infection may be acquired through the ingestion of rattlesnake meat used as a folk medicine remedy. We report a patient with metastatic carcinoma and a remote history of rattlesnake meat ingestion who developed recurrent S. arizona bacteremia and reactivation of tuberculosis after receiving corticosteroid and radiation therapy. Physicians should be aware of the potential for rattlesnake-associated S. arizona infection to occur as either the presenting manifestation or as a complication in immunosuppressed patients who may take folk remedies, especially Hispanics who live along the United States-Mexico border.

New pathogens in pneumonia

It appears that many commonly recognized syndromes such as the ARDS may well be caused by agents that have only recently emerged as respiratory pathogens. HPS represents one such entity. It appears likely that the increasing pressure of antibiotic use as well as the reemergence of certain pathogens will continue to challenge the clinician. Paramount to the identification and treatment of unusual pneumonias will be the degree with which an effort is made to make an etiologic diagnosis through sputum examination, transtracheal aspirate, bronchoscopy, or lung biopsy. Although pneumococcal pneumonia is the most common community-acquired pneumonia seen by practicing physicians, in all likelihood from time to time a physician will encounter pneumonia caused by one of the unusual pathogens described in this article or else by an altogether new pathogen.

Survey of H2-antagonist usage in acute upper gastrointestinal hemorrhage.

H2-antagonists are frequently used in the management of upper gastrointestinal (UGI) hemorrhage despite their lack of proven efficacy. In order to determine the pattern of H2-antagonist usage for this indication, we retrospectively reviewed the charts of 137 patients admitted with acute UGI bleeding over a 1-year period at two teaching hospitals in West Texas. An H2-antagonist was ordered in 89% of patients (77% intravenous, 12% oral). It was administered within 2 h of admission in 25% of these patients, within 4 h in 54%, and within 8 h in 78%. An H2-antagonist was ordered among the initial six orders in 49% and among the initial 10 orders in 77% of patients. Considering orders for specific therapies, an H2-antagonist was in the initial three orders in 60% of patients and among the initial six orders in 97%. Of the patients who were prescribed an H2-antagonist and who also had upper endoscopy, the drug was ordered prior to endoscopy in 86%. This review of H2-antagonist usage in the management of acute UGI bleeding has identified a prescribing pattern of writing for these drugs early in the sequence of order writing, with the drugs being given early in the course of hospitalization.