Indomethacin-induced colonic ulceration and bleeding

OBJECTIVE: To report a case of nonsteroidal antiinflammatory drug (NSAID)-induced lower gastrointestinal (GI) bleeding. CASE SUMMARY: A patient in whom short-term ingestion of indomethacin was associated with colonic ulceration and significant gastrointestinal bleeding is described. DISCUSSION: The bleeding ulceration of the ascending colon, associated in our patient with short-term indomethacin intake, confirms previous reports of the drug's deleterious effect on the lower GI tract. The incidence of NSAID injury of the small intestinal colon may be higher than that previously reported. CONCLUSIONS: A prospective study of NSAID users could assess the magnitude of lower GI lesions, concomitant with upper GI evaluation, and help determine limitations in the use of this drug class.     

New technique for endoscopic treatment of bleeding gastric ulcer

In two patients with bleeding gastric ulcer hemorrhage could be stopped by submucous infiltration around the lesion without any complication. This simple method using a selfconstructed needle seems to guarantee good results especially in bleeding little arteries. Infiltration was performed with a 1.5% solution of Aethoxysklerol (Kreussler, Wiesbaden-Biebrich) using 3-5 ml totally for treatment.     

Complications in the endoscopic polypectomy of colonic adenomas

Endoscopic polypectomy is associated with a small but definite risk of bleeding and perforation. Patients with large adenomas are thus usually hospitalized for endoscopic resection. In order to evaluate whether these procedures can be performed in the setting of one day surgery, we retrospectively analyzed the complications and results of polypectomy done in the period from 1.1.1990 through 31.12.1994. Of 1399 colorectal adenomas respected in 680 patients, 385 (28%) were larger than 1 cm. Altogether we observed only 3 (0.2%) clinically significant complications: bleeding was seen in 2 patients, of whom only one required transfusion of one unit. One patient required surgery because of perforation after removal of a sessile cecal adenoma with uneventful outcome. These results show that endoscopic resection of colorectal adenomas is safe even if the polyps are large.     

Are endoscopic measurements of colonic polyps reliable?

Many clinical studies of colorectal adenomatous polyps rely on endoscopic estimation of polyp size. To examine the reliability of such measurements, we conducted a study using artificial polyps in an endoscopy teaching model. Eight experienced endoscopists estimated the size of 13 polyps in two separate sessions 2 wk apart. Endoscopic estimates of polyp size tended to be significantly lower than the true polyp size for all polyps and all endoscopists at both sessions. We also found a statistically significant difference in the magnitude of the underestimation between the first and second session (p < 0.0001). At the first session, polyps tended to be estimated at 64% of their true size, and at the second session, the estimates tended to be at 77% of the actual polyp size. We estimate the magnitude of the variation in polyp measurements due to individual polyps, endoscopist, and examination session, and discuss the impact these sources of variation have in planning of clinical trials.     

Gastric duplication-colonic fistula with colonic ulceration and bleeding

An 11-month-old girl had massive rectal bleeding. A midabdominal mass was palpated. Ultrasound scan showed a large cystic mass with diffusely echogenic contents; Tc-99M radionuclide scan confirmed a duplication. Exploratory surgery and pathology examination showed a gastric duplication with formation of a fistula into the transverse colon with a colonic ulcer and hemorrhage. This combination of findings is presented as a rare cause of lower gastrointestinal hemorrhage in infancy.     

Laparoscopic oversewing of a bleeding Mallory-Weiss tear under endoscopic guidance

Continuous bleeding from a Mallory-Weiss tear required laparoscopic surgery to halt the bleeding. The oversewing of the laceration at the esophagogastric junction was readily performed under video control with endoscopic guidance and the bleeding ceased. To stop bleeding from such a tear, we prefer to use this modern approach.     

Role of endoscopic injection therapy in the treatment of bleeding peptic ulcer

Transforming growth factor beta (TGF beta) was examined regarding its regulation of the mitogen EGF. A431 human epidermoid carcinoma cells were treated with TGF beta and epidermal growth factor (EGF) (10 ng/ml each) to determine if TGF beta modulates EGF-induced Ca2+ signaling and c-Fos oncoprotein levels. Changes in [Ca2+]i were determined by digital imaging analysis or photon counting. In HBSS + Ca2+ (1.37 mM), EGF treatment resulted in a transient increase in [Ca2+]i from 75 to 150 nM, which lasted approximately 3.5 min and re-equilibrated to 90 nM. In nominally Ca(2+)-free (2-5 muM) HBSS, EGF caused a [Ca2+]i elevation that peaked at 140 nM and returned to baseline. TGF beta in HBSS + Ca2+ did not elicit a [Ca2+]i increase, although affinity labeling revealed types I, II, and III TGF beta receptors. TGF beta added simultaneously with EGF in HBSS + Ca2+ caused a gradual rise in [Ca2+]i from 50 to 100 nM over 16 min. Pretreatment with TGF beta (3 h; 10 ng/ml) abolished the EGF-induced [Ca2+]i elevation. EGF or TGF beta treatments increased c-Fos immunoreactivity by around 1 h. In summary, EGF elevated [Ca2+]i in the presence or absence of [Ca2+]e, resulting in high [Ca2+]n, associated with tyrosine and threonine phosphorylation, and increased c-Fos oncoprotein immunoreactivity. TGF beta did not increase [Ca2+]i but did increase c-Fos; TGF beta + EGF added simultaneously altered the EGF-induced [Ca2+]i elevation, and TGF beta pretreatment eliminated EGF-induced [Ca2+]i elevation. This suggests that TGF beta can regulate EGF in A431 cells and that increased c-Fos may not be mediated by Ca2+.     

Is endoscopic injection hemostasis of bleeding gastrointestinal ulcers obsolete in 1995?

Bleeding non-neoplastic lesions of the upper gastrointestinal tract, not due to portal hypertension, are a frequent cause of emergency admission. In the present paper we report our retrospective experience in hemostatic injection treatment of these lesions. From May 1990 to May 1994, 164 patients were admitted to our institution for a bleeding gastrointestinal lesion. In 124 cases an ulcer classified according Forrest's criteria was detected. Four patients underwent immediate surgery. The second group of 86 patients (FIIa/FIIb/FIII) were treated conservatively. The third group of 34 patients (FIa/FIb/FIIa) underwent perilesional injection of adrenaline 1:10,000 and polidocanol 1% saline solution during endoscopic examination; 29% (25 pts) of the second group re-bled during the first 72 h vs 8.8% (3 pts) of the third group. The postoperative morbidity in the rebleeding patients was higher in the second group: 38.4% vs 0%. The importance of immediate, inexpensive, and simple hemostatic treatment extended to Forrest IIa lesions is emphasized.     

Vesico-sigmoidal fistulas of diverticular origin

OBJECTIVE: To evaluate the course and outcome of expectantly managed twin pregnancies with single fetal death in the second half of gestation. DESIGN: Case-controlled study of 29 consecutive pregnancies from 1973 to 1993, with sonographic evidence of a twin at 20 weeks gestation with antenatal demise later in pregnancy, matched for maternal parity with 58 twin pregnancies without fetal death and delivered in the same year as the index case. Outcome measures included the incidence of complications of pregnancy, gestational age and mode of delivery, placentation, and perinatal outcome. SETTING: University Hospital Rotterdam. RESULTS: The frequency and severity of pregnancy-induced hypertensive disorders was significantly higher in the study group than in controls. We found no differences between the study group and controls with regard to median gestational age at delivery (33 weeks versus 34 weeks) and median birthweight of liveborn infants (1880 g versus 2160 g). No consumptive coagulopathy was apparent in our 29 patients. The main cause of neonatal death was prematurity; multicystic encephalomalacia was not observed. CONCLUSIONS: Our results support expectant management in twin pregnancies complicated by single fetal death.     

Case report: successful obliteration of a bleeding duodenal varix using endoscopic ligation

BACKGROUND: To determine the concentration of cytokines having an immunomodulating effect in the first trimester in women who subsequently developed preeclampsia. METHODS: The serum concentrations of IL-10, TNFalpha, IL-6 and IL-2R were determined in ten women who later developed severe preeclampsia and in ten healthy controls. The groups were compared with the Mann-Whitney U test. RESULTS: The IL-2R concentration was significantly higher in the women who later developed preeclampsia than in normal patients (p = 0.028). No significant differences were detected between the groups with respect to the other evaluated cytokines. CONCLUSION: Elevated IL-2R concentrations in maternal serum as early as in the first trimester may be a sign of immunological maladaptation and might be associated with a disturbance of trophoblastic invasion.     

Colonic chicken skin mucosa: an endoscopic and histological abnormality adjacent to colonic neoplasms

AIMS: We examined the effects of growth hormone administration on the sympathetic nervous system in patients with idiopathic dilated cardiomyopathy. BACKGROUND: Growth factor therapy is emerging as a new potential option in the treatment of heart failure. Although growth hormone provides functional benefit in the short term, it is unknown whether it affects the sympathetic nervous system, which plays a role in the progression of heart failure. METHODS: Seven patients with idiopathic cardiomyopathy received 3 months treatment with recombinant human growth hormone (0.15-0.20 IU.kg-1.week-1). Standard medical therapy was unchanged. Myocardial norepinephrine release, both at rest and during submaximal physical exercise, plasma aldosterone, and plasma volume were measured before and after growth hormone treatment. Myocardial norepinephrine release was assessed from arterial and coronary venous plasma concentrations of unlabelled and tritiated norepinephrine and coronary plasma flow (thermodilution). RESULTS: Growth hormone induced a significant fall in myocardial norepinephrine release in response to physical exercise (from 180 +/- 64 to 99 +/- 34 ng.min-1; P < 0.05). Basally, plasma aldosterone was 189 +/- 28 and 311 +/- 48 pg.ml-1 in the supine and upright position, respectively, and fell to 106 +/- 16 (P < 0.01) and 182 +/- 29 pg.ml-1 (P < 0.05) after growth hormone therapy. Growth hormone increased plasma volume from 3115 +/- 493 ml to 3876 +/- 336 ml (P < 0.05), whereas serum sodium and potassium concentrations were unaffected. CONCLUSIONS: The data demonstrate that growth hormone administration to patients with idiopathic cardiomyopathy reduces myocardial sympathetic drive and circulating aldosterone levels. This neurohormonal deactivation may be relevant to the potential, long-term use of growth hormone in the treatment of patients with heart failure.     

Sequential changes of esophageal motility after endoscopic injection sclerotherapy or variceal ligation for esophageal variceal bleeding: a scintigraphic study

OBJECTIVE: Endoscopic injection sclerotherapy and variceal ligation are two popular endoscopic methods used to treat esophageal variceal hemorrhage. These two methods have not been compared with regard to esophageal dysfunction after treatment. This is a prospective investigation of esophageal dysmotility after endoscopic injection sclerotherapy and variceal ligation. METHODS: Sequential changes of esophageal motility after endoscopic injection sclerotherapy (n = 25) and variceal ligation (n = 25) were investigated in 50 cirrhotic patients with recent variceal bleeding. Another 22 cirrhotics without esophageal varices were included as controls. Radionuclide esophageal transit tests were performed before initial endoscopic treatment, and 1 and 3 months after variceal eradication. RESULTS: The baseline esophageal transit time was longer in both the sclerotherapy (n = 25, 7.8 +/- 1.4 s) and ligation groups (n = 25, 8.2 +/- 1.8 s) than in controls (n = 22, 6.7 +/- 0.7 s, p < 0.005). The transit time was longer in patients with large varices than in those with small varices (8.3 +/- 1.7 vs. 7.2 +/- 0.7 s, p < 0.05). In the sclerotherapy group, the transit time was prolonged 1 month after variceal eradication, compared with its pretreatment state (n = 20, 7.6 +/- 1.5 vs. 10.0 +/- 2.2 s, p < 0.0001) but was shortened at 3 months compared with 1 month after variceal eradication (n = 12, 10.7 +/- 1.5 vs. 8.6 +/- 2.2 s, p < 0.05). Multiple regression analysis showed that the number of treatment sessions required to eradicate varices was the only significant factor associated with prolonged transit time (p < 0.05). In the ligation group, the transit time changed little at 1 month or 3 months after variceal eradication. CONCLUSIONS: Impairment of esophageal motility can be significant with endoscopic injection sclerotherapy but is reversible. However, endoscopic variceal ligation exerts no significant impact on esophageal motility.     

Evaluation of yeast functional assay to detect p53 gene mutation in minute endoscopic samples of colonic mucosal neoplasia

Male and female C57BL/6 (B6) and DBA/2 (D2) mice were subjected to either acute or 5 days of repeated restraint in ventilated, 50 ml centrifuge tubes. Control animals were not disturbed. The acute restraint animals were killed immediately following 15, 30 or 60 min of restraint and blood collected for corticosterone (CORT) analysis. The results of the acute restraint procedure revealed a strain difference in time to peak CORT in plasma with D2 animals showing an earlier peak. The males of both strains evinced similar maximum response and similar to B6 females; however, the D2 females showed a 2-fold greater CORT response than did the B6 females. Repeated restraint consisted of 5 days of 12 h in the tubes. At the end of 5 days, the animals were weighted and adrenalectomized in preparation for determination of brain corticosteroid receptors. Upon sacrifice, brains, thymus, adrenals and blood were harvested, the last for corticosteroid binding globulin (CBG). Five days of repeated restraint produced body weight loss in both strains, with B6s less affected than D2s. Repeated restraint reduced the mass of the adrenals in the B6s only. Restraint also reduced the mass of the thymus in both strains and sexes, but to a greater extent in the B6s. Plasma CBG densities were also sensitive to restraint, but only in females, showing a restraint-related decrease. Repeated restraint had no effect on hippocampal glucocorticoid or mineralocorticoid receptors; however for the latter, we observed significant strain and sex effects with D2 having higher Bmax than B6 and females having higher Bmax than males. In the pituitary, glucocorticoid receptors (GR) were reduced by repeated restraint in males, but increased in females, especially in the B6. These findings lend preliminary evidence for involvement of sex and genetics as sources of individual differences in bioadaptation to stress.     

Sigmoidovesicocutaneous fistula complicating diverticular disease of the colon

A sixty-six year old diabetic male had a draining sinus tract from the lateral portion of a fourteen year old left herniorrhaphy scar. The diagnosis of sigmoidovesicocutaneous fistula was confirmed by a sinogram and the patient was treated in one stage with left hemicolectomy and resection of the fistula site from the dome of the bladder. To our knowledge this is the first report of a sigmoidovesicocutaneous fistula.