Richard R. Babb

Acute acalculous cholecystitis. A review.

Acute acalculous cholecystitis is an uncommon but very serious illness, that, if undiagnosed, may lead to gallbladder perforation and death. The condition has numerous causes that result in bile stasis and ischemia leading to inflammation and infection in the gallbladder wall. The bedside diagnosis may be difficult, especially in critically ill patients. Current imaging techniques including ultrasonography, computer tomography, and radionuclide cholescintigraphy are very helpful. Depending on the clinical situation, the gallbladder should either be drained by a surgical or percutaneous cholecystostomy under local anesthesia or removed.

Colonic varices: a rare, but important cause of gastrointestinal hemorrhage.

The diagnosis of colonic varices, a rare cause of gastrointestinal hemorrhage, may be exceedingly difficult. If this entity is not considered, a rectal or colonic biopsy may lead to brisk and dangerous bleeding, as in our patient on two separate occasions. Once the diagnosis is made, appropriate surgery will prevent future bleeding episodes.

Gastric volvulus and obstruction in paraesophageal hiatus hernia

Patients with a paraesophageal hiatus hernia are usually asymptomatic. If gastric volvulus and obstruction of the herniated stomach should occur, however, symptoms rapidly ensue and surgery is mandatory for patient survival. We have presented 4 such cases which illustrate the clinical spectrum of this complication and the necessity for rapid diagnosis and definitive surgery.

The use of metronidazole (Flagyl) in Crohn's disease.

The efficacy of metronidazole in the treatment of Crohns disease remains unproven. It has not been superior to a placebo in three small studies. Uncontrolled reports suggest it may be of benefit in selected patients who have not responded to previous medical or surgical therapy. Metronidazole therapy can lead to complete healing of perineal fistulas. Persistent concerns over side-effects, carcinogenicity, and bacterial resistance suggest that drug should be prescribed with caution for long-term use.

Cirrhosis in an adult with emphysema and alpha1-antitrypsin deficiency

The association of pulmonary emphysema with a deficiency of alpha~-antitrypsin in serum was first reported 10 years ago (1) and has since been amply confirmed (2-5). In children, a deficiency of alpha~-antitrypsin may be accompanied by cirrhosis (6, 7). More recently some adults with this inherited protein deficiency and emphysema have been shown to have intracellular globular material in liver tissue (8-10). Some have had clinical evidence of liver disease and others have not. We are reporting the case of an elderly male with a) marked deficiency of serum alpha~-antitrypsin, b) basilar pulmonary emphysema with no history of cigarette smoking, c) hepatic intracellular globular material, and d) clinical and pathologic evidence of cirrhosis.

Sexual dysfunction after abdominoperineal reseaction

Sexual dysfunction after abdominoperineal surgery for cancer or colitis is not uncommon. The possibility of this distressing complication is a frequent patient question prior to operation, and it must be carefully and intelligently discussed. In our experience, there is considerable confusion among physicians relative to postoperative impotence, and this paper has therefore been written to give background information on this subject.

Auscultation of the abdomen with reference to vascular sounds.

This is a brief review of the diagnostic rewards associated with careful abdominal auscultation for vascular sounds. The causes of a well localized arterial bruit or venous hum are listed and briefly described. These include cancer, collateral veins secondary to portal hypertension and cirrhosis, and enlarged, tortuous, stenotic or dilated vessels. Abdominal murmurs may also be heard in 15 to 20% of normal subjects.

Mondor's disease in a patient with ulcerative colitis

R ~CENTLV, a young male was seen suffering from an exacerbation of chronic ulcerative colitis complicated by the development of acute thro,mbophlebitis of the thoracoepigastric vein (Mondor s disease). Such a case illustrates not only a vascular rarity but also emphasizes the increased incidence of acute venous thrombosis in patients with this inflammatory large bowel disorder. CASE R E P O R T

The role of surgery in acute pancreatitis

Due to the lack of randomized controlled studies comparing medical with surgical therapy, the role of surgery in acute pancreatitis is not clear. This is especially true in critically ill patients who are rapidly deteriorating with hemorrhagic or necrotizing pancreatitis. Surgical intervention may be of benefit in those patients who do not have a clearcut diagnosis of pancreatitis and may have a surgically correctable disorder, who have biliary or pancreatic duct disease, or who have developed a complication such as abscesses or a pseudocyst. The mortality rate of performing a laparotomy on patients with acute pancreatitis is not prohibitive.

Cholangiocarcinoma in a patient previously given thorotrast

SummaryThe long-term effects of thorotrast administration include local granulomas, blood cell abnormalities, and cancer. To date, more than 100 cases of liver cancer have been reported in patients previously given this radioactive contrast material, with a latency period of approximately 22 years. We report such a case; the patient not only had a thorotrast-induced cholangiocarcinoma, but also showed striking morphologic changes in the red blood cells secondary to splenic dysfunction.