Martin Jourdan

Colocutaneous fistula as late complication of total hip replacement in rheumatoid arthritis.

Late complications affecting various intrapeivic structures may occur following total hip replacement in association with medial displacement of bone cement into the pelvis. We describe here what we believe to be the first report of a colocutaneous fistula occurring as a result of this problem, and discuss the possible causes.

Disseminated aspergillosis and bleeding colonic ulcers in renal transplant patient.

Case report The patient, a 37-year-old Nigerian woman, was treated for glomerulonephritis with regular haemodialysis from 1975 until December 1978 when she received a cadaver renal transplant. Despite a number of severe rejection episodes, which led to a modified regimen of immunosuppression that included high-dose parenteral steroids, good function was maintained. An episode of ureteric obstruction complicated by Salmonella typhimurium septicaemia was successfully treated in December 1981. In January 1983 she was admitted semicomatose with pneumonia and septicaemia due to Salmonella typhimurium. Ultrasound showed no ureteric obstruction and oliguria responded to fluid replacement, but her chest proved resistant to intensive treatment, including broad-spectrum antibiotics, and ventilation was required. Twelve days after admission she passed 400 ml of fresh blood per rectum. Upper gastrointestinal endoscopy and a labelled red cell localization study (pertechnate) failed to locate the source. Clotting studies were within normal limits but platelets were low at 170 x 109/l. A further red cell study after repeated bleeding suggested activity in the sigmoid colon (Figure 1). At laparotomy a single shallow bleeding ulcer was resected from the sigmoid colon and a double-barrelled colostomy constructed. Three days later the source of fresh bleeding from the colostomy was localized to the right colon and right hemicolectomy was performed, the caecum and terminal ileum containing several shallow haemorrhagic ulcers (Figure 2). No further intestinal bleeding occurred, but intraperitoneal haemorrhage led to a third laparotomy at which no specific bleeding point could be identified. The patient died within 12 hours of this operation, 23 days after admission.

Colonoscopy: a survey of its value in a teaching hospital surgical unit.

A survey has been undertaken of the diagnostic, therapeutic and economic value of colonoscopy in a teaching hospital surgical unit. Provided it is undertaken in conjunction with a good clinical history and double contrast barium enema, colonoscopy provides a high yield of information bearing upon the patients subsequent management. Therapeutic polypectomy was undertaken in 21% of examinations. Its value in acute colonic disease is discussed, and the importance of training colonoscopists for the future is emphasized.

Fibre-Optic Endoscopy In Clinical Practice

Mans curiosity has led him to seek methods of investigating the inner workings of the human body, but it is only recently that it has become possible to properly visualise the inner cavities of the human frame. Physiologists such as William Beaumont have occasionally had the opportunity to see the function of the gastrointestinal tract, in this case the gastric fistula of Alexis St Martin who was injured following an accidental firearm explosion. Rigid instruments, down which lights are shone, can be used to visualise the respiratory passages, the gullet, the rectum, and the bladder, and in the past artists were employed to record what was seen. Such instruments are still in use, although light from a powerful source is now conducted down the instrument using a fibreoptic bundle. The first semi-flexible instrument which could be inserted into the stomach and used to visualise its walls was developed by Schindler and Wolf in Germany in 1932. The optics consisted of a series of convex-lenses, transmitting an image back to the eye, but again the view obtained was limited and since its optics were side viewing, the gullet could not be viewed. The advent of fibre-optics revolutionised the situation, and the first fibrescope conducting the image up a fibreoptic bundle was a side-viewing instrument, developed by Hirschowitz, Curtiss, Peters and Pollard by 1958, and used for viewing the stomach. Since those pioneering days, the development of fibrescopes for viewing every potential cavity in the human body has proceeded in leaps and bounds.