Kimball I. Maull

Fibrinolysis in multisystem trauma patients

Changes in the fibrinolytic system may lead to coagulation disorders in acute trauma patients. This study examined fibrin degradation by measuring D-dimer crosslinked fibrin degradation products (indicates hypercoagulability), plasminogen activators (fibrinolysis), and antithrombin III in 42 adult trauma patients and correlated these data with injury severity, types of injury, complications, and clinical tests of coagulation. Hypercoagulability and suppression of fibrinolysis were seen in most patients and were not correlated with severity of injury. These changes appeared most severe in patients with nervous system injury. Several patients with less severe injuries but evidence of hypercoagulability developed clinical evidence of pathologic thrombosis. Latex agglutination of D-dimer provides a rapid test of fibrinolysis that may be clinically useful in the management of trauma patients who cannot be easily studied for thrombosis.

Liquid caustic ingestions: An in vitro study of the effects of buffer, neutralization, and dilution

Changes in pH and temperature of solutions of common commercial liquid caustics were determined in vitro following the addition of neutralizing agent, buffer, and diluent. Neutralization of strong base was complete following the addition of less than twice the volume of weak acid with only a minimal release of heat. Buffer added to a strong acid caused an immediate temperature elevation without changing the pH; a gradual rise in pH followed. Large volumes of diluent caused little change in temperature or pH of either strong base or strong acid. We conclude that dilution as a first-aid measure is ineffective, whereas buffer is ineffective and possibly harmful. Neutralization is effective in reversing pH change, but in vivo studies are needed to confirm the relative roles of pH extremes and heat in the genesis of tissue injury.

Endometriosis of the abdominal wall

Endometriosis of the abdominal wall typically occurs as a painful mass in a lower abdominal incision from previous cesarean section or hysterectomy. Most patients are young and in their active reproductive years. The histologic diagnosis requires a combination of either endometrial-like glands, endometrial stroma, or hemosiderin pigment. The diagnosis must be considered in any woman with an abdominal wall mass and a history of transabdominal gynecologic surgery. Wide excision offers the best chance to prevent recurrence.

Bile reflux gastritis

Bile reflux gastritis is a disabling postgastrectomy condition characterized by abdominal pain, bilious vomiting, and weight loss. The syndrome appears to be caused by free enterogastric reflux of bile and other proximal small bowel constituents. Endoscopic confirmation of bile reflux and documentation of gastritis support the diagnosis but are not specific for it. Results of medical therapy with chelating agents or drugs that promote gastric motility have been disappointing. Diet and antacids frequently aggravate symptoms. The only effective treatment is surgical diversion of bile away from the gastric mucosa. During a recent seven-year period, 15 patients had diversionary operation for bile reflux gastritis diagnosed by history and endoscopic findings. Before operation, medical management had failed to yield improvement in any case. After operation, all patients showed improvement, and pain was relieved in 85%. Based on our experience, we conclude that (1) current medical therapy may alter but not cure symptoms of bile reflux gastritis; (2) Roux-en-Y diversion is the treatment of choice in patients with persistent symptoms; and (3) delayed gastric emptying is a common complication after the Roux-en-Y procedure, but in our series, the incidence was reduced by using the Tanner 19 modification. New cytoprotective agents that may offer an alternative to operation are currently being studied.

Serum amylase isoenzyme alterations in acute abdominal conditions

To determine the accuracy of the serum amylase in identifying a pancreatic source, amylase isoenzymes were determined prospectively in 65 patients initially evaluated with a complaint of abdominal pain and associated hyperamylasemia. Isoenzyme patterns were demonstrated by an electrophoretic technique, and the results were correlated with clinical diagnoses. Patients were divided into two diagnostic groups. Group I consisted of 42 patients with clinical findings suggesting pancreatitis. P-type isoenzymes were normal or elevated in 31 of these patients (74%), and s-type isoenzymes were normal or elevated in 11 (26%). Group 2 consisted of 23 patients with abdominal pain attributed to causes other than pancreatitis. Four patients (17%) had elevation of p-type isoenzymes, and 19 patients (83%) had predominantly s-type patterns. We conclude that amylase isoenzymes cannot determine unequivocally the cause of hyperamylasemia, but they can enhance the diagnostic specificity of the serum amylase. Elevated serum amylase with a predominant p-type pattern suggests pancreatic disease; elevation of s-type isoenzymes suggests but is not conclusive for, diagnoses other than pancreatitis. Hyperamylasemia with a normal isoenzyme pattern occurred in a few patients in both groups, and it was nondiagnostic.