John K. Zawacki

Fulminant hepatic failure associated with 2',3'-dideoxyinosine (ddI)

Results from recently published phase I trials (1-3) of 2′,3′-dideoxyinosine (didanosine, ddI) show promise in the treatment of patients with the acquired immunodeficiency syndrome (AIDS) and AIDS-...

Risk of early surgery for Crohn's disease: implications for early treatment strategies.

OBJECTIVES:In this study we aimed to define the rate of early surgery for Crohns disease and to identify risk factors associated with early surgery as a basis for subsequent studies of early intervention in Crohns disease.METHODS:We assembled a retrospective cohort of patients with Crohns disease diagnosed between 1991 and 1997 and followed for at least 3 yr, who were identified in 16 community and referral-based practices in New England. Chart review was performed for each patient. Details of baseline demographic and disease features were recorded. Surgical history including date of surgery, indication, and procedure were also noted. Risk factors for early surgery (defined as major surgery for Crohns disease within 3 yr of diagnosis, exclusive of major surgery at time of diagnosis) were identified by univariate analysis. Multiple logistic regression was used to identify independent risk factors.RESULTS:Of 345 eligible patients, 69 (20.1%) required surgery within 3 yr of diagnosis, excluding the 14 patients (4.1%) who had major surgery at the time of diagnosis. Overall, the interval between diagnosis and surgery was short; one half of all patients who required surgery underwent operation within 6 months of diagnosis. Risk factors identified by univariate analysis as significantly associated with early surgery included the following: smoking; disease of small bowel without colonic involvement; nausea and vomiting or abdominal pain on presentation; neutrophil count; and steroid use in the first 6 months. Disease localized to the colon only, blood in the stool, use of 5-aminosalicylate, and lymphocyte count were inversely associated with risk of early surgery. Logistic regression confirmed independent associations with smoking as a positive risk factor and involvement of colon without small bowel as a negative risk factor for early surgery.CONCLUSIONS:The rate of surgery is high in the first 3 yr after diagnosis of Crohns disease, particularly in the first 6 months. These results suggest that improved risk stratification and potent therapies with rapid onset of action are needed to modify the natural history of Crohns disease.

Chronic cough due to gastroesophageal reflux disease: efficacy of antireflux surgery.

BackgroundGastroesophageal reflux disease (GERD) can be overlooked as the cause of chronic cough (CC) when typical gastrointestinal symptoms are absent or minimal. We analyzed the outcomes of Nissen fundoplication (NF) for patients who failed medical therapy for CC attributable only to GERD (G-CC). We performed a prospective outcome evaluation of 21 consecutive patients with G-CC undergoing NF from 1997 to 2000 at a tertiary care university hospital.Materials and MethodsTwenty-one patients without prior antireflux surgeries had G-CC diagnosed by a clinical profile and 24-h pH monitoring showing a cough-reflux correlation. Respiratory symptoms alone were present in 53% of patients. NF was performed when G-CC persisted despite intensive medical therapy, including an antireflux diet. Preoperatively, all patients underwent 24-h pH monitoring, esophageal manometry, barium swallow, gastric emptying study, bronchoscopy, and upper endoscopy. NF was utilized in all cases, laparoscopically in 18. Before and after surgery, patients graded their cough severity using the Adverse Cough Outcome Survey (ACOS). Quality of life was measured using the Sickness Impact Profile (SIP).ResultsPostoperatively, 18 patients (86%) reported an improvement of their cough. G-CC considerably improved in 16/21 patients (76%), with complete resolution in 13 patients (62%). Mild to moderate improvement was found in 2 patients (10%). Patient-reported cough severity (ACOS) and quality of life (SIP) both significantly improved early (6–12 weeks) postoperatively and persisted during the long-term (1 year) follow-up. The average hospital length of stay was 1.78±0.2 (1–4) days for the laparoscopic (n=18) and 6.3±1.2 (4–8) days for the open surgery (n=3) groups.ConclusionTwenty-four-hour esophageal pH monitoring is a valuable tool for preoperative cough—reflux correlation. Antireflux surgery is effective in carefully selected patients whose refractory CC is attributable only to GERD. NF controls the severity of cough while improving the quality of life. Outcomes are further enhanced using laparoscopic procedures with shorter hospital stays.

Treatment of acute mesenteric ischemia by percutaneous transluminal angioplasty

A 79-yr-old man with previously documented atherosclerotic vascular disease presented with acute abdominal pain, signs of peritoneal irritation, and guaiac-positive stool. A mesenteric arteriogram showed high-grade stenosis of the superior mesenteric artery with a pressure gradient of 70 mmHg and complete occlusion of the inferior mesenteric artery. Percutaneous transluminal angioplasty of the superior mesenteric artery was performed with immediate reduction of the pressure gradient, increase in vessel caliber, and relief of abdominal pain. The patient went on to complete recovery and remains pain-free 6 mo after discharge from the hospital. To our knowledge, this is the first report of percutaneous transluminal angioplasty used to treat acute mesenteric ischemia.

Computed Tomographic Enterography and Enteroclysis: Pearls and Pitfalls

Computed tomographic (CT) enterography and enteroclysis improve visualization of the small bowel mucosa and wall in comparison with traditional CT and fluoroscopic studies by distending the small bowel through enteric hyperhydration with a negative contrast agent. Although CT enterography is performed with oral hyperhydration, CT enteroclysis requires the placement of an enteroclysis tube, often in patients who are unable to orally consume the amount of liquid. When tolerated, CT enterography is often preferred due to its lack of invasiveness. Magnetic resonance enterography and enteroclysis are other modalities that are still being studied and show promise in the imaging of small bowel. Unlike small bowel follow-through, conventional enteroclysis, or capsule endoscopy, extraenteric findings are best assessed on CT enterography. These include findings in the surrounding mesentery, perienteric fat, and the adjacent solid organs that may be associated with the small bowel process and include fistulas or abscesses, mural hyperenhancement, prominent vasa recta, and other inflammatory changes. CT enterography has developed into the first-line modality in the imaging of Crohns disease and is considered the most appropriate imaging modality in patients with suspected Crohns disease. It is also increasingly being used in the assessment of small bowel infections, neoplasms, adhesions, and polyps.

Accurately Diagnosing and Successfully Treating Chronic Cough Due to Gastroesophageal Reflux Disease Can Be Difficult

Accurately Diagnosing and Successfully Treating Chronic Cough Due to Gastroesophageal Reflux Disease Can Be Difficult

Pseudomembranous colitis associated with erythromycin

Excerpt Tissue culture assays and bacterial cultures indicate thatClostridium difficileis commonly responsible for the diarrheal complications of antimicrobial use. Multiple agents have been implic...

Preoperative angiography and embolization of the site of intermittent acute small bowel bleeding with a radiopaque microcoil: facilitated precise surgical excision of the source.

LOCALIZING THE SOURCE o f i n t e rmi t t en t acute b l e e d i n g o f the small bowel is a diagnost ic chal lenge. In contrast , the source for con t inuous acute small bowel b l eed ing is usually easily local ized with d i rec t visual inspec t ion o r endoscopy at surgical explora t ion . T h e source o f intermi t t en t acute gastrointest inal b l eed ing is f requen t ly associated with obscure or igins and can the re fo re be diff icult to d e t e r m i n e and localize at opera t ion . 16 O n e o f the objectives o f surgery for small bowel b l e e d i n g is to l imit the resec t ion to the smallest s e g m e n t possible to co r rec t the defect ; this is of ten difficult to do in the set t ing o f i n t e rmi t t en t acute b leeding . We have d e v e l o p e d a t e c h n i q u e to localize the source o f such int e rmi t t en t small bowel b l e e d i n g c o m b i n i n g p reope ra tive embol i za t ion o f the vessel(s) involved and in t raoperative radiography. T h e t e c h n i q u e appears to be a p romis ing add i t ion to exis t ing t echn iques used by in te rven t iona l radiologists and gene ra l surgeons w h e n faced with such a p rob l em. We r e p o r t h e r e the use o f p reopera t ive selective embol i za t ion o f r a d i o p a q u e microcoils wi thin super io r mesen te r i c artery b ranches to localize the site and source o f i n t e rmi t t en t acute b leeding. Precise local izat ion m i n i m i z e d the a m o u n t o f small bowel excised and faci l i tated the r emova l o f the appropr ia te s e g m e n t even w h e n no b l e e d i n g site o r source cou ld be d e t e r m i n e d .

Response to drs. ours and richter

trainees in defining a cause of cough in .95–99% of patients (15, 16). However, we have recently seen two patients with chronic cough and abnormal pH testing not responding to PPIs who underwent antireflux surgery, with no resolution of their cough. We believe that our patients need to thoroughly understand the limitations of our current understanding of acid-related cough. Although laparoscopic surgery is a “minimally invasive” procedure, it does require general anesthesia, deaths have occurred, and some morbidity is not uncommon. The wide availability and popularity of this procedure does not make it the “right thing to do” when “all else fails.” Possibly a trip to Worcester, Massachusetts, is a better alternative!

Intrapancreatic Choledochal Cyst: Diagnosis by peroral transduodenal cholangiography with description of a new method of surgical treatment

A patient with a choledochal cyst presenting solely with abdominal pain is described. The cyst was diagnosed by endoscopic retrograde cholangiography. The clinical, radiographic, and surgical features of this disorder are briefly reviewed and the need to consider this entity as a possible cause of obscure abdominal pain is stressed.