John B. Marshall

Aortoenteric fistulas: Recognizing a potentially catastrophic cause of gastrointestinal bleeding

Aortoenteric fistulas are a relatively rare but serious cause of massive gastrointestinal hemorrhage. Most occur as a consequence of aortic reconstructive surgery and involve the proximal graft anastomosis. The distal duodenum is the site of bleeding in about three fourths of cases. Most patients have an initial episode of bleeding followed hours to weeks later by catastrophic hemorrhage. Patients with gastrointestinal bleeding who have undergone prior aortic reconstructive surgery should be approached with a great sense of urgency and a high index of suspicion. Endoscopic and radiographic studies can be very helpful, but the absence of abnormalities does not exclude the diagnosis. Exploratory laparotomy is indicated in patients with massive bleeding or those in whom results of other diagnostic studies have been normal. Treatment of aortoenteric fistula is early surgical intervention. Complete excision of the graft is preferred over patching or closing the defect. The mortality rate is essentially 100% without prompt surgical treatment.

Bleeding esophagogastric varices. Ways to treat active episodes and prevent recurrence.

Bleeding from esophagogastric varices carries a high mortality rate. Active variceal bleeding can usually be temporarily controlled medically with a combination of intravenous vasopressin and nitroglycerin, with balloon tamponade, or with endoscopic sclerotherapy. Because of the high likelihood of recurrence, long-term treatment, such as repeated sclerotherapy, propranolol therapy, or shunt surgery, is necessary. The proper selection of such measures requires consideration of the site of variceal bleeding, local availability of specialized techniques, and patient factors. Only liver transplantation reverses the liver damage and offers hope of improved long-term survival. As success at identifying high-risk patients by endoscopic features improves, propranolol or other pharmacologic prophylaxis may become an acceptable treatment.

How to make consultations work

The consultation process exists to improve patient care in an era of medical complexities, but breakdowns in the process are common because of poor communication and inadequate physician education on the subject. The referring physician and the consultant both need to assume important responsibilities if quality patient care is to be ensured. The referring physician has to establish the reasons for and urgency of the consultation, communicate them to the consultant, and supply appropriate clinical information. The consultant has to determine the questions being asked, evaluate the patient, and communicate the findings and recommendations back to the referring physician. Whenever possible, the patient should be included in the decision-making process.

Dysphagia: Diagnostic pitfalls and how to avoid them

Oropharyngeal and esophageal dysphagia involve different phases of swallowing, have different causes, and can usually be distinguished by a thorough patient history. Initial evaluation of patients with suspected oropharyngeal dysphagia includes patient history, physical and neurologic examination, and careful videofluoroscopic study of pharyngeal dynamics. Initial evaluation of patients with suspected esophageal dysphagia includes patient history and barium swallow with esophagography. Lesions such as Schatzkis ring or peptic stricture may not be detected unless the esophagus is sufficiently distended and the patient is given a bolus challenge.

Acute gastrointestinal bleeding: A logical approach to management

Management of acute gastrointestinal bleeding follows a logical sequence of steps. The first priority is to assess the magnitude of blood loss and resuscitate the patient. The patient history and nasogastric aspiration can help localize the source of bleeding to the upper tract or lower tract. Treatment of suspected upper gastrointestinal bleeding is usually empirical and consists of histamine 2 blockers (or sucralfate [Carafate]) or antacids. Diagnosis of the specific bleeding site is based on the severity, activity, and nature of the bleeding. Endoscopic and radiographic techniques may be useful. Intravenous vasopressin (Pitressin) therapy and endoscopic sclerotherapy are important in the management of variceal hemorrhage. Therapeutic endoscopic techniques are being used more often to manage nonvariceal bleeding as well.

ACUTE POLYARTHRITIS : FIFTH DISEASE PASSED FROM CHILD TO ADULT

Preview Although erythema infectiosum occurs primarily in children, the infection may be responsible for acute arthritis or arthralgia in adults. In this article, a case of acute symmetric polyarthritis affecting one of the authors is described. His symptoms were caused by parvovirus B19 infection, which was probably acquired from one of his children who had had erythema infectiosum a short time earlier.

Chronic constipation in adults: How far should evaluation and treatment go?

In all patients who present with constipation, a history should be taken and physical examination and proctosigmoidoscopy performed. Structural evaluation of the entire colon by barium enema should be considered when constipation is of recent onset, is severe, or does not resolve with simple measures. A colonic transit study should also be considered in the latter two situations. Anorectal manometry, defecography, and electromyography are helpful in patients with diagnosed or suspected outlet delay. Treatment is most often empirical. Simple, helpful measures include education, dietary fiber supplementation, adequate fluid intake, and regular physical activity. When laxatives are necessary, they should be used sparingly. Pelvic floor retraining may be helpful in the management of patients with outlet delay. Select patients with intractable constipation may benefit from surgery, although results are variable.

Dysphagia. Pathophysiology, causes, and evaluation.

The two types of dysphagia, oropharyngeal and esophageal, involve different phases of swallowing, are accompanied by different symptom complexes, and have different etiologies. They can usually be distinguished by history, which often will also suggest the specific cause. The initial evaluation of oropharyngeal dysphagia entails a general history and physical examination, careful examination of the pharynx and hypopharynx, and barium esophagography (preferably with videotape recording). The initial evaluation for esophageal dysphagia entails barium esophagography and fiberoptic endoscopy. Esophageal manometry is indicated when a motor disorder is suspected.

Current options in gallstone management: What to do when symptoms are mild or absent

Preview Should surgery to remove gallstones be deferred until symptoms occur? When should therapy with oral bile acids, lithotripsy, or methyl tert-butyl ether be considered? How should nonspecific dyspeptic symptoms in a patient with cholelithiasis be managed? Dr Marshall discusses these and other questions and controversies.

Diagnosis of esophageal motility disorders.

Esophageal motility disorders are now known to be a heterogeneous group of conditions that commonly cause dysphagia and chest pain. Motor dysphagia is usually provoked by solids and liquids (in contrast to mechanical dysphagia, which is usually provoked by solids only). Chest pain with these disorders is nonspecific and can mimic angina pectoris. In many patients with diffuse esophageal spasm or nutcracker esophagus, pain appears to be caused by abnormal sensory function rather than contraction abnormalities. Barium esophagography and esophageal manometry are complementary studies in the evaluation of motility disorders.