Systemic lupus erythematosus with a protein-losing enteropathy

Anasarca with pronounced hypoalbuminemia developed in a young woman 15 months after the onset of a mild, arthralgic type of systemic lupus erythematosus (SLE) without evidence of active nephritis. Investigation indicated a gastrointestinal rather than a renal site for protein loss. A full clinical remission was achieved with low-dose corticosteroid therapy.     

Detection and quantification of protein-losing enteropathy with indium-111 transferrin

BACKGROUND: Acid fast cell wall deficient forms (CWDF) of bacteria have been grown from blood, bronchial washings, and ocular anterior chamber fluid from patients with sarcoidosis. A monoclonal antibody raised against Mycobacterium tuberculosis whole cell antigen (H37RV) was used to characterise further CWDF grown from the blood of patients with sarcoidosis. METHODS: Blood from 20 patients with active sarcoidosis and from 20 controls was cultured using methods favourable for the growth of CWDF. Isolates were further characterised by indirect fluorescent antibody analysis using a monoclonal antibody highly reactive with M tuberculosis. RESULTS: CWDF were grown from the blood of 19 of 20 subjects with sarcoidosis. All isolates stained positively with the monoclonal antibody and with a modified Kinyoun stain. No organisms were grown from the blood of controls. CONCLUSIONS: These data demonstrate that CWDF can be grown from the blood of nearly all patients with active sarcoidosis. The results confirm that the organisms are mycobacterial in origin and are similar, if not identical, to M tuberculosis. Their role in the pathogenesis of sarcoidosis is unknown.     

Gastroesophageal reflux and airway disease

Gastroesophageal reflux may cause a variety of airway diseases such as asthma, aspiration pneumonia, chronic bronchitis, posterior laryngitis, and ulceration or polyp formation on the vocal cords. Among these asthma seems most common and important clinically. Reflux not only may trigger and aggravate an episode of airway obstruction but also may contribute to nocturnal symptoms. Both clinical and experimental observations suggest that the pathogenetic mechanism may be a vagal reflux following stimulation of lower esophageal receptors and/or microaspiration of gastric acid into the trachea. Diagnosis is usually based on clinical history of asthma and symptoms of gastroesophageal reflux, but in some cases, diagnostic tests such as 24-hour esophageal pH monitoring may be necessary. General measures to avoid reflux and an H2-receptor antagonist together with supportive gastric medications may be the standard treatment. If symptoms persist, proton pump inhibitor may be helpful. Antireflux surgery may provide long-term improvements. Although surgical treatment is indicated only in patients with intractable esophagitis at present, it may be used more commonly through a laparoscopic approach in the near future.     

Gastroesophageal reflux disease--extraesophageal manifestations

Gastroesophageal reflux is often associated with symptoms of the respiratory tract. Chronic cough of unknown origin, laryngeal complaints and even non allergic asthma, resistant to steroid therapy, are suspicious of being reflux related. These extraesophageal manifestations can occur without typical reflux complaints, such as heartburn, and even without evident esophagitis. Therefore, prolonged pH-monitoring is essential to confirm the diagnosis. In some cases it will be adequate to start a therapeutic trial with proton pump inhibitors (PPI) to prove the causal connection between reflux and symptoms. The treatment of the extraesophageal manifestations of gastroesophageal reflux disease is identical with the management of reflux esophagitis. PPI are the treatment of choice. Sometimes higher doses of PPI are required. Fundoplication may be appropriate for selected patients.     

Gastroesophageal reflux in children

BACKGROUND: Gastroesophageal reflux is common in small children. It is important to recognise that its natural history and management differ from reflux in adults. OBJECTIVE: This article will summarise the clinical presentation, pathophysiology, appropriate investigations and therapy of reflux in small children. DISCUSSION: A small amount of regurgitation is common in infancy, and is only pathological if it results in harm. In children, reflux-induced injury can result from either acid exposure, nutrient loss or respiratory complications. Recognised presentations include heartburn, oesophagitis, infant irritability, dysphagia, haematemesis, stricture, growth failure, aspiration, apnoea and pneumonia. Excessive crying and irritable behaviour in infancy can be due to a variety of causes, but there is a fashionable tendency to assume that gastroesophageal reflux is a major factor. Regurgitation can be a symptom of other conditions such as infection or metabolic disturbance. It is important to carefully evaluate any infant with distressed behaviour to exclude a significant medical cause. Prolonged oesophageal pH monitoring is a very useful means of linking episodes of reflux with putative symptoms. The severity of gastroesophageal reflux tends to improve with age in infants and this should be considered when advising appropriate therapy, especially fundoplication.     

Gastroesophageal reflux disease and respiratory disease

The patients treated for oesophageal atresia present a correlation between the clinical sintomatology after recanalization characterized by disfagia, dispnea, recurrent cough, chronic pneumopaties and oesophageal anomalies. Where morphological alterations accounting for the presence of gastro-oesophageal reflux (GOR) were not evident, possible functional alterations of the motility were considered. The incidence of GOR was considerably high and, expression of a congenital alteration of the lower oesophageal sphincter and of oesophageal peristalsis, becomes even more severe due to further stretching of the gastro-esophageal junction. The authors underline that the early demonstration of histological changes, even before recanalization, and the motility disorders of the oesophagus have to be well studied, while the LES is normalized, in order to prevent and treat the possible appearance of the well-known complications of GOR.     

Gastroesophageal reflux in infants and children

Gastrooesophageal reflux is a common clinical condition in infancy and childhood. Evaluation and treatment are indicated if it is associated with complications such as failure to thrive, oesophagitis or pulmonary symptoms. Depending on the clinical symptoms, investigations may include pH-monitoring, upper gastrointestinal series and endoscopy. Gastrooesophageal reflux may be treated by parental reassurance, dietary advice, positional treatment, prokinetic agents and acid secretion inhibitors. Surgery is rarely indicated.     

Gastroesophageal reflux in infants and children

The modulatory effects of 1DMe (d-Tyr-Leu-(NMe)Phe-Gln-Pro-Gln-Arg-Phe-NH2), an agonist of Neuropeptide FF (NPFF) receptors, on opioid antinociceptive activity have been compared in naive and tolerant mice in the tail-flick and the hot-plate tests. In naive mice, 1DMe alone had no effect on pain threshold but decreased dose-dependently (3-22 nmol) the analgesic activity of morphine in both tests. In tolerant mice, injections of 60-fold lower doses of 1DMe (0.05-0.5 nmol) reverse morphine-induced analgesia in the tail-flick test but this anti-opioid effect was no longer observed with the highest doses of 1DMe tested (3-22 nmol). In the hot-plate test, the anti-opioid action of 1DMe was not detected, whatever doses tested. Neither the NPFF-like immunoreactivity content of spinal cord and of olfactory bulbs, nor the density of NPFF receptors in olfactory bulbs, were altered. These results indicate that a chronic morphine treatment modifies the pharmacological properties of NPFF but the type of pain test is crucial in determining NPFF effects.     

Gastroesophageal reflux disease in patients with columnar-lined esophagus

Columnar-lined esophagus or Barrett's esophagus is closely associated with gastroesophageal reflux disease. Animal and human studies have shown not only acid but duodenogastroesophageal reflux acting in synergy with acid causes the most esophageal injury. Patients with Barrett's esophagus manifest typical and atypical symptoms of reflux. Ten percent to 25%, however, have clinically silent reflux. Early diagnosis is essential for this disease as it is a risk factor for the development of adenocarcinoma of the esophagus.     

Surgical treatment of Cronkhite-Canada syndrome associated with protein-losing enteropathy: report of a case

PURPOSE: The case of a patient with Cronkhite-Canada syndrome, who developed a protein-losing enteropathy, is reported. METHODS: After localization of the protein-losing region, a right colectomy was performed. RESULTS: Hypoproteinemia and ectodermal changes improved postoperatively. CONCLUSIONS: Surgery is an effective treatment for protein-losing enteropathy in Cronkhite-Canada syndrome. Ectodermal changes improve after correcting malnutrition.     

Gastroesophageal reflux in the preterm infant

Gastroesophageal reflux is a problem familiar to most pediatricians. The focus of this article is to provide a synopsis of the current state of knowledge regarding gastroesophageal reflux in the premature population, as well as to provide the practitioner with a rational basis upon which to diagnose and treat gastroesophageal reflux in this population.