Wright Jp

FAILURE OF REPEATED INJECTION SCLEROTHERAPY TO IMPROVE LONG-TERM SURVIVAL AFTER OESOPHAGEAL VARICEAL BLEEDING: A Five-year Prospective Controlled Clinical Trial

The role of sclerotherapy in long-term management after oesophageal variceal bleeding was assessed by comparing repeated sclerotherapy by means of a rigid oesophagoscope in 37 patients with control medical management in 38 patients. Varices were eradicated in 21 of the 22 patients analysed (95%) in the sclerotherapy group, but recurred in 13 of the 21 patients (average 21.5 months). Varices persisted in 13 of 14 surviving controls. The sclerotherapy patients had fewer recurrent bleeds than control patients (43 versus 73); the majority occurred before variceal eradication and were mild. However, there was no difference in survival in the two groups. The commonest cause of death was liver failure (37 patients). 32 complications occurred in 24 patients during 258 injections. Repeated sclerotherapy failed to improve survival in this trial, although varices were eradicated and recurrent variceal bleeds were prevented with adequate follow-up.

Acute bleeding varices: a five-year prospective evaluation of tamponade and sclerotherapy.

In a five-year study of massive upper gastrointestinal hemorrhage, 143 patients had esophageal variaes diagnosed on emergency endoscopic examination. Seventy-one patients had active bleeding from varices and required Sengstaken tube tamponade during at least one hospital admission. The remaining patients included 33 with varietal bleeding which had stopped and 39 who were bleeding from another source. Sixty-six of the former group of 71 patients were referred for emergency injection sclerotherapy. These 66 patients were followed prospectively to August 1980, and had 137 episodes of enduscopically proven variceal bleeding requiring Seng-staken tube control followed by injection sclerotherapy during 93 separate hospital admissions. Definitive control of hemorrhage was achieved in 95% the patients admitted to the hospital (single injection 70%; two or three injections 22%). The death rate per hospital admission was 28%. No patient died of continued variceal bleeding, and exsanguinating variceal hemorrhage no longer poses a major problem at our hospital. The cumbiued use of initial Sengstaken tube tamponade followed by injection sclerotherapy has simplified emergency treatment in the group of patients who continue to bleed actively from esophageal varices, despite initial conservative treatment

Ocular Inflammation in Crohn's Disease

During a 4-year period, the authors examined 19 patients with Crohns disease and associated ocular inflammation. Seven patients had uveitis, eight had episcleritis, and four had anterior scleritis. Large peripheral corneal infiltrates developed in two patients with scleritis. Increased bowel activity was closely related to the presence of acute episcleritis but not to uveitis or scleritis. To determine risk factors for the development of ocular inflammation, this group of 19 patients was compared with a group of 93 patients with Crohns disease in whom ocular inflammation was not present. There were no demographic differences between the groups. Patients with colitis or ileocolitis were more likely to suffer from ocular inflammation (23.9%, 17 of 71), than patients with small bowel involvement alone (2.8%, 1 of 36) (P = 0.013). Those with arthritis or arthralgia had a higher incidence of ocular inflammation (29.4%, 15 of 51), than patients without joint involvement (6.6%, 4 of 61) (P = 0.003). These results suggest that the risk of developing ocular inflammation in Crohns disease may be related to the site of bowel involvement and to the presence of arthritis.

Predictors of acute relapse of Crohn's disease. A laboratory and clinical study.

Relapses of Crohns disease appear to be almost random. If these attacks could be reliably predicted, it might be possible to abort them with early treatment. In order to identify laboratory and clinical parameters that would predict an acute relapse, patients who had been assessed clinically in the three months prior to an attack were studied. Published clinical indices as well as a variety of laboratory parameters were measured. The clinical indices and the serum C-reactive protein, orosomucoid,α1-antitrypsin, and iron were increased at the time of the attack as compared to three months earlier, while only the clinical indices, orosomucoid andα1-antitrypsin increased between three months and one month prior to the attack. There was a poor correlation of the parameters to each other. Further prospective studies are needed to determine the specificity of the suggested indices in predicting acute relapses of Crohns disease.

Olsalazine in maintenance of clinical remission in patients with ulcerative colitis

Frequent minor side effects are associated with sulfasalazine. The realization that it is the 5-aminosalicylic acid moiety that is the active component of sulfasalazine and that the side effects are probably due to the sulfapyridine has prompted the search for a similar but safer compound. Olsalazine, consisting of two molecules of 5-ASA without sulfasalazine may avoid the problems due to sulfasalazine. One hundred one patients were entered into a double-blind placebo-controlled study of the use of olsalazine 92 g daily) in preventing relapse in patients who had recently recovered from an acute attack of ulcerative colitis. Patients were treated for 12 months. Forty-nine were randomized to olsalazine (39 with limited and 10 with extensive disease) and 52 to placebo (42 with limited and 10 with extensive disease). Life-table analysis showed that the median time to relapse in patients on olsalazine was 342 days, which was significantly longer than the 100 days in the placebo group (P=0.024). The most important side effect experienced with olsalazine that necessitated withdrawal from the study was “drug-induced diarrhea” in 16% (8/49). There was a similar incidence of minor side effects reported in the two groups, and in no patients were major or dangerous side effects reported. In patients who did not develop diarrhea, olsalazine was well tolerated and successfully prevented rapid relapse in the recently ill patients entered into this study.Frequent minor side effects are associated with sulfasalazine. The realization that it is the 5-aminosalicylic acid moiety that is the active component of sulfasalazine and that the side effects are probably due to the sulfapyridine has prompted the search for a similar but safer compound. Olsalazine, consisting of two molecules of 5-ASA without sulfasalazine may avoid the problems due to sulfasalazine. One hundred one patients were entered into a double-blind placebo-controlled study of the use of olsalazine 92 g daily) in preventing relapse in patients who had recently recovered from an acute attack of ulcerative colitis. Patients were treated for 12 months. Forty-nine were randomized to olsalazine (39 with limited and 10 with extensive disease) and 52 to placebo (42 with limited and 10 with extensive disease). Life-table analysis showed that the median time to relapse in patients on olsalazine was 342 days, which was significantly longer than the 100 days in the placebo group (P=0.024). The most important side effect experienced with olsalazine that necessitated withdrawal from the study was “drug-induced diarrhea” in 16% (8/49). There was a similar incidence of minor side effects reported in the two groups, and in no patients were major or dangerous side effects reported. In patients who did not develop diarrhea, olsalazine was well tolerated and successfully prevented rapid relapse in the recently ill patients entered into this study.

Relapse rates after initial ulcer healing with sucralfate and cimetidine.

The relapse rate after successful short-term therapy with sucralfate (Sc) or cimetidine (Cm) was studied in a group of 86 patients with recently healed duodenal or gastric ulcers. The patients were endoscoped on clinical relapse or, routinely, at 6 weeks, 6 months, and 1 year. Patients whose ulcers had healed with Cm relapsed earlier than did those whose ulcers had healed with Sc (p less than 0.05 at 12 weeks), but the cumulative relapse rate by the end of 1 year was of the order of 70% in both treatment groups. The mean duration of remission in patients who developed a recurrence was significantly greater in patients treated initially with Sc than in those treated initially with Cm--7.3 and 4.6 months, respectively (p less than 0.01).

PEG-400 excretion in patients with Crohn's disease, their first-degree relatives, and healthy volunteers

An altered small bowel permeability may be implicated in the pathogenesis of Crohns disease. Intestinal permeability, using polyethylene glycol 400 (PEG 400) as the orally ingested probe, was assessed in 45 patients with Crohns disease (ilealN=14, ileocolonicN=9, colonicN=10, postresectionN=12), 20 first-degree relatives, and 31 controls. PEG 400 excretion was measured using a direct injection HPLC method, and results are expressed as percent of dose recovered in urine (median and range). No quantitative differences in the recovery of PEG-400 were found [Crohns patients 21.9% (6.1–39.9), relatives 23.7% (4.9–39.9), controls 25.0% (4.5–39.7)]. In all groups, the composition of ingested and recovered PEG-400 was similar and no selective permeability to any molecular weight species was found. Disease site did not influence probe recovery [ileal 23.8% (7.7–30.6), ileocolonic 22.6% (14.4–33.8), colonic 27.8% (9.5–33.5)]. Resected patients had significantly lower PEG-400 recovery [18.8% (8.1–39.9)] than nonresected patients [23.5% (6.1–33.8%)P<0.02]. The data suggest either that altered intestinal permeability is not a factor in Crohns disease or that PEG-400 is not a suitable probe.

Immunoproliferative small-intestinal disease: clinical features and outcome in 30 cases.

Experience with 30 patients with immunoproliferative small intestinal disease followed prospectively between 1971 and 1986 is described. All presented with malabsorption or growth retardation and had similar clinical, biochemical, and radiological features, irrespective of the presence of lymphoma or immunological abnormality. Alpha-chain disease protein was detected in 4 of the 11 patients who had a non-lymphomatous, predominantly plasmacytic infiltration of the small bowel; and in 5 of the 19 cases with diffuse intestinal lymphoma. The importance of exploratory laparotomy to include full-thickness intestinal biopsy in patients who have a benign infiltrate on peroral biopsy is demonstrated by the finding of lymphoma in operative specimens in 9 of 15 patients with mature, lymphoplasmacytic cells, and 5 of 8 patients with atypical, lymphoplasmacytic cells. The majority of patients with fully established benign disease, even those elaborating alpha-chain disease protein, appeared to have a good prognosis. No patient with immunoproliferative small intestinal disease developed immunologically demonstrated alpha-chain disease or frank lymphoma, when this was not found initially at explorative laparotomy.

Vitamin A therapy in patients with Crohn's disease

Vitamin A therapy has been claimed in isolated reports to be of benefit to patients with Crohns disease. To investigate this further, 86 patients were entered into a long-term double-blind study of vitamin A, 50,000 U twice daily, as compared with placebo. After a mean of 14.1 mo of treatment there was no significant difference between the groups as measured by a variety of activity indices (including the National Cooperative Crohns Disease Activity Index), the number of acute attacks, and the surgical rate. No toxic effects of vitamin A were observed during the study. In this study vitamin A has not been shown to be of benefit to patients with Crohns disease who are in remission.

6-Mercaptopurine-related pancreatitis in 2 patients with inflammatory bowel disease

Two patients with inflammatory bowel disease who developed acute pancreatitis within 21 days of commencing treatment with 6-mercaptopurine are presented. Both were inadvertently reexposed to the drug and developed recurrent pancreatitis within 3 hr of a single dose.Two patients with inflammatory bowel disease who developed acute pancreatitis within 21 days of commencing treatment with 6-mercaptopurine are presented. Both were inadvertently reexposed to the drug and developed recurrent pancreatitis within 3 hr of a single dose.