Serum and ascitic concentration of C3, C4 and protein in cirrhotic patients with spontaneous bacterial peritonitis

BACKGROUND: Lower concentration of ascitic or serum complement (C3, C4) or protein has been reported to participate in the development of spontaneous bacterial peritonitis (SBP). In Taiwan, the etiology of hepatic cirrhosis is mainly post-hepatic and SBP is the common complication. This study aims to determine the role of protein and complements in the pathogenesis of SBP. METHODS: 119 cirrhotic patients were divided into two groups, 30 SBP and 89 non-SBP. The concentrations of ascitic and serum complement and protein were measured for comparison. RESULTS: The ascitic and serum C3, C4 and protein levels were significantly lower (P < 0.05) in patients with SBP than in non-SBP patients. No significant differences were noted in the ascites/serum ratio of C3, C4 and protein in patient with or without SBP. CONCLUSIONS: Low levels of ascitic and serum protein and complements, C3 and C4, may be prone to develop SBP in our patients mostly with post-hepatitic cirrhosis.     

Influence of bacterial overgrowth and intestinal inflammation on duration of parenteral nutrition in children with short bowel syndrome

OBJECTIVES: Massive intestinal resection results in short bowel syndrome and necessitates prolonged parenteral feeding. The purpose of this work was to assess the impact of late complications of short bowel syndrome, including intestinal bacterial overgrowth and enterocolitis, on the duration of parenteral nutrition (PN) in comparison with factors evident in the neonatal period. METHODS: Retrospective chart review. RESULTS: Of 49 children, 42 were weaned from parenteral nutrition after a treatment course of 17 +/- 14 months. In these 42, postresection small intestinal length equaled 81 +/- 65 cm; 45% had an ileocecal valve. Small intestinal length in the seven children who were PN dependent was 31 +/- 30 cm (p < 0.05); none had an ileocecal valve (p < 0.05). Bacterial overgrowth occurred in all seven PN-dependent children and in 23 of 42 children eventually weaned from PN (p < 0.05). When bacterial overgrowth was identified before weaning (n = 12), the duration pf PN was 28 +/- 17 months, but when bacterial overgrowth was first identified only after weaning (n = 11), the duration of PN was 16 +/- 13 months (p < 0.05). Small intestinal inflammation correlated with bacterial overgrowth (r = 0.69). Those children with severe enteritis identified before weaning remained on the PN regimen for 36 +/- 15 months, in comparison with 21 +/- 14 months in those with mild enteritis and 13 +/- 11 months in those without inflammation (p < 0.02). CONCLUSIONS: Although the length of small intestine remaining after resection is the best immediate predictor of final success in terminating PN in children with short bowel syndrome, PN is prolonged by bacterial overgrowth and associated enteritis in those who will ultimately be weaned.     

The ursodeoxycholic acid-p-aminobenzoic acid test in the diagnosis of small bowel bacterial overgrowth syndrome

Contaminated small bowel syndrome is frequently associated with meteorism due to excessive gas formation, and diarrhoea as a result of bacterial fermentative processes, including splitting of carbohydrates or deconjugating and dehydroxylating bile salts. In addition to gas production, bacteria capable of metabolizing bile salts have been shown to release p-aminobenzoic acid (PABA) from and Ursodeoxycholic-acid-PABA substrate. Our aim was to determine the possible complementary role of the UDCA-PABA test in the diagnosis of bacterial overgrowth. PATIENTS AND METHODS: The H2 breath and UDCA-PABA tests were performed simultaneously on 46 patients with suspected contaminated small bowel syndrome, and on 7 healthy subjects. The H2 breath test was performed by oral loading of 25 g lactose and/or 10 g lactulose. The UDCA-PABA test was carried out by determining urinary excretion of PABA after oral loading with 250 mg UDCA-PABA conjugate. The diagnosis of bacterial overgrowth was established, when either H2 breath, or UDCA-PABA test proved to be pathological. RESULTS: Based upon the pathologic values of either the H2 breath test, or the UDCA-PABA test, 25 out of 46 patients proved to have contaminated small bowel syndrome. In 10 out of 25 patients only pathologic urinary PABA excretion (12.772 +/- 1.707 vs 4.1 +/- 0.58), indicated bacterial overgrowth, and in 9 out of the same group only positive H2 breath test (early rise of > 20 ppm of H2) indicated the same, while in 6 cases both tests proved to be pathological. In 7 CSBS patients the urinary excretion of PABA significantly decreased following a 10 day Tinidazole treatment (5.48 +/- 1.286 vs 13.068 +/- 2.068). CONCLUSION: The UDCA-PABA test proved to be a valuable complementary method to detect bacterial overgrowth, when H2 production failed to reveal bacterial overgrowth.     

Role of fiberoptic bronchoscopy in conjunction with the use of double-lumen tubes for thoracic anesthesia: a prospective study

Twenty-four-hour energy expenditure (EE) and substrate oxidation (respiratory chamber), and whole-body glucose uptake and oxidation rates (euglycemic hyperinsulinemic clamp [EHC] and indirect calorimetry) were measured in 10 male patients with posthepatitis, Child B cirrhosis, and 8 healthy male controls matched for age, body size, and body composition. Twenty-four-hour EE was higher in cirrhotic patients than in controls (8,567 +/- 764 vs. 6,825 +/- 507 kJ/d; P < .001). Resting energy expenditure (REE) was also higher in cirrhotic patients than in controls (7,881 +/- 1,125 vs. 5,868 +/- 489 kJ/d; P < .01). Twenty-four-hour respiratory quotient (RQ) (trend) and fasting RQ (0.76 +/- 0.05 vs. 0.82 +/- 0.04; P < .05) were lower in cirrhotic patients than in controls, reflecting higher lipid oxidation rates in the former group. Whole-body glucose uptake was markedly reduced in cirrhotic patients when compared with controls (22.4 +/- 3.2 vs. 44.5 +/- 7.6 mmol/kg/min; P < .001). Carbohydrate oxidation rates, computed during the last 40 minutes of the clamp, were 8.5 +/- 1.1 mmol/kg/min in cirrhotic patients and 22.6 +/- 6.1 mmol/kg/min in controls (P < .001). Nonoxidative glucose disposal was 13.9 +/- 2.5 mmol/kg/min in cirrhotic patients and 22.0 +/- 5.5 mmol/kg/min in normal controls (P < .01). In conclusion, our data indicate that patients with Child B cirrhosis who still maintain a nutritional status (i.e., body composition) comparable with healthy controls are characterized by a cluster of metabolic defects that include hypermetabolism, increased lipid utilization, and insulin resistance. This suggests that the above metabolic syndrome precedes and probably leads to malnutrition in the natural history of the liver disease. In fact, in spite of the absence of a significant difference in caloric intake between cirrhotic patients and normal controls, the elevated 24-hour EE might allow for a relevant weight loss in cirrhotic patients, because, with time, the differences may be cumulative. However, whether this hypermetabolism can lead to a real weight loss remains to be evaluated in a longitudinal study.     

Small-intestinal bacterial overgrowth in patients with liver cirrhosis, diagnosed with glucose H2 or CH4 breath tests

BACKGROUND: Small-intestinal bacterial overgrowth (SIBO) has been considered a predisposing factor of spontaneous bacterial peritonitis in cirrhotic patients by bacterial translocation or hematogenous spread during spontaneous bacteremia. We investigated 45 cirrhotic patients and 28 healthy subjects to assess the prevalence of SIBO and its relationship with the severity of liver dysfunction and the presence of ascites. METHODS: Bacterial overgrowth was measured by the glucose hydrogen and methane breath test. RESULTS: SIBO was documented in 16 (35.6%) of the 45 cirrhotic patients and in 1 (3.6%) of the 28 healthy controls. The prevalence of SIBO was significantly higher in patients with Child-Pugh class B or C (50%) than in those with class A (19%) and had no relationship with the presence or absence of ascites. CONCLUSIONS: We conclude that the prevalence of SIBO in cirrhotic patients is approximately 35.6% and that it is related to the severity of liver disease. There was no difference among various causes of cirrhosis, such as viral, alcoholic, or idiopathic.     

Fibronectin in the ascitic fluid of cirrhotic patients: correlation with biochemical risk factors for the development of spontaneous bacterial peritonitis

Cirrhotic patients (23 with alcoholic cirrhosis, 5 with posthepatitic cirrhosis and 2 with cryptogenic cirrhosis) with ascites and portal hypertension were studied and divided into two groups corresponding to high or low risk to develop spontaneous bacterial peritonitis (SBP) related to the concentration of total protein in the ascitic fluid (A-TP): group I (high risk): A-TP < or = 1.5 g/dl and group II (low risk): A-TP > 1.5 g/dl. Fibronectin (FN), C3 and C4 concentrations were measured by radial immunodiffusion while total protein was measured by the biuret method. The mean values (group I vs group II) of C3 (12.59 +/- 4.72 vs 24.53 +/- 15.58 mg/dl), C4 (4.26 +/- 3.87 vs 7.26 +/- 4.14 mg/dl) and FN (50.47 +/- 12.49 vs 75.89 +/- 24.70 mg/dl) in the ascitic fluid were significantly lower (P < 0.05) in the group considered to be at high risk for SBP. No significant difference was observed in the plasma/ascites fibronectin ratio (3.91 +/- 1.21 vs 3.80 +/- 1.26) or gradient (131.46 +/- 64.01 vs 196.96 +/- 57.38) between groups. Fibronectin in ascites was significantly correlated to C3 (r = 0.76), C4 (r = 0.58), total protein (r = 0.73) and plasma FN (r = 0.58) (P < 0.05). The data suggest that the FN concentration in ascites is related to the opsonic capacity of this fluid, and that its concentration in the ascitic fluid may be a biochemical risk factor indicator for the development of spontaneous bacterial peritonitis.     

Management of ascites in the patient with portal hypertension with emphasis on spontaneous bacterial peritonitis

The reintroduction of paracentesis has modified the way in which patients with ascites are treated. Transjugular intrahepatic portosystemic shunt can be an alternative treatment for patients with refractory ascites and for those patients with hepatorenal syndrome, although more studies are needed to clarify its usefulness and safety. The use of more potent and less nephrotoxic antibiotics together with an earlier diagnosis have improved the outcome of patients with spontaneous bacterial peritonitis (SBP). Oral antibiotics can be used in patients with SBP and good clinical conditions with an efficacy similar to that obtained with intravenous antibiotics. Prophylactic antibiotics in SBP should be restricted to cirrhotic patients at high risk, including bleeding cirrhotic patients, those with a past history of SBP, and those with low protein content in ascitic fluid. This chapter describes the management of ascites in patients with portal hypertension.     

Laparoscopic cholecystectomy in cirrhotic patients

BACKGROUND/AIMS: Laparoscopic and open cholecystectomy are the safest procedures for all diseases related to stones in the gallbladder as they have a low morbidity and mortality rate. However, the safety of laparoscopic cholecystectomy in cirrhotic patients has not been investigated. The goal of this study was to evaluate the safety of laparoscopic cholecystectomy in cirrhotic patients. METHODOLOGY: A retrospective study of laparoscopic cholecystectomy in cirrhotic versus non-cirrhotic patients was performed. Between January 1991 and November 1994, 605 laparoscopic cholecystectomies for symptomatic gallbladder diseases were performed. There were 21 patients in the cirrhotic (group A) and 584 patients in the non-cirrhotic (group B). RESULTS: There was no operative mortality in either group and the postoperative complication rates were 4.8% and 5.8% in group A and B, respectively (p > 0.05). Prolonged operative time in group A was 84.47 +/- 36.01 min vs group B 62.20 +/- 25.37 min (p < 0.01). The estimated intraoperative blood loss in group A was larger than in group B (140.76 +/- 201.19 ml vs 35.02 +/- 50.11 ml, p < 0.01). The readmission rate was higher in group A (9.5%) than in group B (1.37%) (p < 0.05). The hospital stay in group A and B were 4.12 +/- 2.15 D, 3.50 +/- 1.50 D respectively (p > 0.05). The incidence of conversion and re-operation rates indicated no difference between cirrhotic and non-cirrhotic groups. CONCLUSIONS: Laparoscopic cholecystectomy can be safely performed in mild cirrhotic patients with more operative times and meticulous management of intraoperative bleeding.     

Effect of mitomycin C on aqueous humor flow, flare and intraocular pressure in eyes with glaucoma 2 years after trabeculectomy

BACKGROUND: The purpose of this study was to determine the intraocular pressure (IOP), aqueous humor flow, flare and ocular side effects in eyes with a history of hypotony after trabeculectomy with adjunctive mitomycin C (MMC). METHODS: Thirty-six eyes with primary or secondary open-angle glaucoma and IOP < or = 8 mmHg during the postoperative period were studied 745 +/- 315 days after surgery. MMC (0.2 or 0.5 mg/ml) was applied to the episclera with a cellular sponge. Flare was studied with the Kowa Laser Flare Meter 500. Aqueous humor flow was measured in the afternoon (Fluorotron Master II). IOP, visual fields and best corrected visual acuity were also examined. Twenty-two contralateral eyes without surgical intervention served as controls. RESULTS: The mean age of patients was 44.5 +/- 16.8 years. The mean IOP was significantly lower in the MMC group than in the control group: 9.6 +/- 6.4 mmHg vs 18.0 +/- 13.6 mmHg at 2 years (P < 0.001). Aqueous flow was significantly lower in subjects treated with MMC than in controls (P < 0.001). The flare values were significantly higher in the MMC-treated group, with a mean of 12.0 +/- 7.7 photon counts/ms, than in the control group, mean 7.9 +/- 4.6 photon counts/ms (P < 0.019). CONCLUSION: Our data suggest that MMC is a useful ocular hypotensive agent which seems to participate in a change in aqueous humor dynamics when applied topically as an aqueous solution.     

Comparison of the one-gram d-[14C]xylose breath test to the [14C]bile acid breath test in patients with small-intestine bacterial overgrowth

In twelve patients with culture-proven bacterial overgrowth of the small intestine, the ability of a newly-developed one-gram d-[14C]xylose breath test to detect bacterial overgrowth was compared to that of the [14C]bile acid breath test. All patients manifested excessive production of breath 14CO2 after the administration of one gram [14C]xylose, with 83% of the patients being abnormal within the first hour of testing. In contrast, during the [14C]bile acid breath test, four of the twelve patients had no period of excessive 14CO2 production (above the 95% confidence range of controls). Nutrient malabsorption (fat, cobalamin, xylose) was seen with both true-positive and false-negative bile acid breath tests. The one gram [14C]xylose breath test, utilizing a substrate with more predominant absorption in the proximal small intestine and which can be catabolized by Gram-negative aerobic bacteria, appears to have a greater degree of sensitivity and specificity than the bile acid breath test in detecting the presence of small-intestine bacterial overgrowth.     

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.     

Systemic antibiotic prophylaxis after gastrointestinal hemorrhage in cirrhotic patients with a high risk of infection

In cirrhotic patients with gastrointestinal hemorrhage, bacterial infections are frequent and play a significant role in mortality. We have previously found that patients with a Child-Pugh's class C or a rebleeding are a subgroup of cirrhotic patients with a high risk of infection. The aims of the study were (1) to validate these indicators and (2) to assess the effectiveness of a systemic antibiotic treatment in preventing bacterial infections in bleeding cirrhotics with a high risk of infection. One hundred and nineteen bleeding cirrhotic patients were divided into 3 groups. Patients with a Child-Pugh's class A-B and no rebleeding (i.e., with a low risk of infection) constituted group 1 (n = 55). Patients with a high risk of infection were randomly allocated to serve as controls (group 2, n = 34) or to receive the ciprofloxacin and a combination of amoxicillin and clavulanic acid for 3 days after hemorrhage (group 3, n = 30). This antibiotic prophylaxis was administered first intravenously and then orally when the bleeding was controlled. The study period was defined as 10 days after hemorrhage. Incidence of bacterial infections was significantly higher in patients from group 2 than in patients from group 1 (52.9% vs. 18.2%; P < .001). Moreover, infections were more severe in group 2: a sepsis syndrome or a septic shock developed in 66.7% of infected patients from this group, but in only 20% of infected patients from group 1. Incidence of bacterial infections was much lower in patients from group 3 than in those from group 2 (13.3% vs. 52.9%; P < .001). Eight patients from group 2 (23.5%) and 4 patients from group 3 (13.3%) died during the first four weeks (P-not significant). Septic shock was the cause of death in 3 patients from group 2 and in only 1 patient from group 3. The cost of antibiotic therapy, including antibiotic prophylaxis in group 3, was $208 +/- $63 per patient in group 2 and $167 +/- $42 per patient in group 3 (P < .05). We conclude that (1) patients with a Child-Pugh's class C and/or a rebleeding are a subgroup of cirrhotic patients with a high risk of infection after gastrointestinal hemorrhage and that (2) in these patients, a prophylactic treatment with systemic antibiotics is very effective in preventing bacterial infections.     

Massive lymphocytic infiltration of uterine leiomyomas associated with GnRH agonist treatment

OBJECTIVE: This study was designed to clarify how thrombopoietin (TPO) functions in and, to some extent, causes thrombocytopenia complicating liver cirrhosis and portal hypertension. METHODS: Our study population consisted of 19 cirrhotic and six noncirrhotic patients who underwent percutaneous transhepatic portography (PTP) and hepatic venography. RESULTS: The platelet counts of the cirrhotic patients were significantly lower than those of the noncirrhotic patients (8.7 +/- 4.1 vs 17.4 +/- 7 x 10(4)/microl; p < 0.01). The flow direction in the splenic vein was confirmed by PTP. Ten hepatofugal and nine hepatopetal flow directions in the splenic vein were noted among the cirrhotics. The hepatofugal group showed lower portal venous pressure (20 +/- 10 vs 32 +/- 4 cm H2O; p < 0.01) than the hepatopetal group and had a higher incidence of hepatic encephalopathy (six of 10 vs zero of nine; p < 0.01). The hepatic vein-portal difference in TPO did not differ substantially between the cirrhotics and noncirrhotics (0.12 +/- 0.04 vs 0.24 +/- 0.07 fmol/ml). Comparisons of this value among the three groups showed the TPO difference to be lowest in the hepatofugal group (hepatofugal: 0.04 +/- 0.03, hepatopetal: 0.21 +/- 0.07, noncirrhotic: 0.24 +/- 0.07; p < 0.05). CONCLUSIONS: Our findings suggest that TPO production in the cirrhotic liver is regulated by the portal blood supply to the liver. Thus, portal hemodynamics may play a critical role in the development of thrombocytopenia.     

Cost-analysis of prophylactic antibiotics in spontaneous bacterial peritonitis

BACKGROUND & AIMS: Antibiotic prophylaxis has been shown to decrease the incidence of spontaneous bacterial peritonitis (SBP) in patients with cirrhosis and ascites. The aim of this study was to test whether antibiotic prophylaxis for SBP is cost-effective and to compare the costs associated with different patient groups and treatment strategies. METHODS: A cost-effectiveness analysis was performed using a Markov chain model. The costs incurred during 1-year treatment with prophylactic antibiotics vs. no prophylaxis in patients with cirrhosis and ascites were calculated. The incidence rates of primary and recurrent SBP and the mortality rate of SBP were obtained from the literature. Total direct costs of SBP treatment were determined from the wholesale price of drugs and from disbursements by the Health Care Financing Administration. RESULTS: Norfloxacin prophylaxis resulted in savings between $2216 and $8545 per patient per year, depending on the patient group studied. Trimethoprim-sulfamethoxazole prophylaxis resulted in savings between $2934 and $9251 per patient per year. The groups that benefited most from prophylaxis were patients with an ascitic fluid total protein concentration of < or = 1 g/dL and those with a previous history of SBP. CONCLUSIONS: The use of prophylactic antibiotics to decrease the incidence of SBP is a cost-saving strategy in patients with cirrhosis and ascites.     

Epidemiology of extrapulmonary tuberculosis among persons with AIDS in the United States

We compared the antihypertensive efficacy of once-daily amlodipine (AM) versus nitrendipine (NTR) by 24-h ambulatory blood pressure monitoring (24-h ABPM) in 32 patients with mild to moderate essential hypertension (EH). After a 2-week single-blind, placebo run-in period, patients were randomized in a double-blind, parallel fashion: 14 received AM 5 mg and 18 NTR 10 mg. After 2 weeks, dose was adjusted if necessary (AM 10 mg or NTR 20 mg) and continued for another 6-week period. At the end of the placebo period and during the last week of treatment, patients underwent 24-h ABPM. Initial office BP mean values were similar in both groups (169.8 +/- 14/102.5 +/- 6 vs. 167.1 +/- 14/98.7 +/- 5 mm Hg, respectively, p = NS). A comparable decrease in office mean values of systolic BP (SBP, -22.3 +/- 13 vs. -19.1 +/- 16 mm Hg) and diastolic BP (DBP, -12.0 +/- 5 vs. -8.1 +/- 8 mm Hg) was observed. Nevertheless, 24-h ABPM mean values differed significantly between patients treated with AM or NTR with regard to 24-h SBP (120.0 +/- 10 vs. 132.5 +/- 1 mm Hg, p = 0.01). Moreover, the average decrease in 24-h SBP (-19.3 +/- 6 vs. -5.2 +/- 11 mm Hg, p = 0.0036) and 24-h DBP (-10.7 +/- 4 vs. -3.7 +/- 6 mm Hg, p = 0.0047) was higher in the AM group, with no changes in 24-h heart rate (HR). At equivalent once-daily dosage, AM was more effective than NTR in decreasing BP assessed by 24-h ABPM.     

Abnormal progression of a liquid meal through the stomach and small intestine in patients with Chagas' disease

This study describes the abnormal pattern of gastrointestinal progression of a liquid meal in patients with the digestive form of chronic Chagas' disease. This condition is known as a natural model of intramural denervation of the gut. Sixteen patients with clinical and radiographic evidence of esophageal and/or colonic involvement and 18 healthy volunteers were studied. Orocecal transit time after the ingestion of a 10% lactulose solution (180 ml) tagged with 99mtechnetium was measured by a conventional H2 breath technique. Gastric emptying and the arrival of the front of the meal to regions of interest corresponding to proximal and distal areas of the small intestine were assessed by abdominal scintigraphy. Orocecal transit time was significantly greater (P < 0.05) in Chagas' disease patients (N = 13) than in control subjects (N = 18) (mean +/- SD: 100.7 +/- 48.7 min vs 62.9 +/- 18.2 min). Half-time for gastric emptying of liquids in chagasic patients (N = 9) was significantly lower (P < 0.01) than in controls (N = 7) (9.7 +/- 2.7 min vs 26.4 +/- 3.4 min). The time of arrival of the liquid meal to the proximal small intestine was also significantly shorter (P < 0.02) in patients than in controls (5.6 +/- 3.7 vs 11.4 +/- 5.5 min), but there was no difference between the two groups concerning the time the meal first arrived to the distal small intestine (15.0 +/- 11.0 min vs 23.5 +/- 11.4 min, P > 0.05). These results indicate that patients with Chagas' disease have a combination of exceedingly rapid gastric emptying and abnormally delayed transit of liquids through the more distal segments of the small bowel.(ABSTRACT TRUNCATED AT 250 WORDS)     

Diagnosis of small intestinal bacterial overgrowth in clinical praxis: a comparison of the culture of small bowel aspirate, duodenal biopsies and gastric aspirate

BACKGROUND/AIMS: This study was undertaken to validate the usefulness of the culture of duodenal biopsy specimens and gastric aspirate compared to the culture of small bowel aspirate for diagnosing small intestinal bacterial overgrowth. We also investigated the occurrence of predisposing conditions in these patients. METHODOLOGY: Seventy five consecutive patients, admitted because of symptoms which caused us to suspect small intestinal bacterial overgrowth, were studied. For all patients, specimens for the culture of small bowel aspirate, duodenal biopsies and gastric aspirate were obtained during upper endoscopy. RESULTS: Eighteen patients showed growth of gram negative bacteria, 22 growth of gram positive bacteria and 35 showed no significant growth in cultures of small bowel aspirate. Cultures of duodenal biopsies revealed gram negative bacteria in 11 patients, gram positive bacteria in 9 and no growth in 55. Cultures of gastric aspirate revealed gram negative bacteria in 7 patients, gram positive bacteria in 12 and no growth in 51. Ten of the 18 patients with gram negative overgrowth and 13 of the 22 patients with gram positive overgrowth had a predisposing condition. In contrast, only 4 of the 35 without overgrowth had a predisposing condition. CONCLUSIONS: The culture of duodenal biopsy specimens or gastric aspirate is a less sensitive method than the culture of small bowel aspirate. Most patients with culture-proven small intestinal bacterial overgrowth had at least one predisposing condition.     

Resection of the metatarsal head for diabetic foot ulcers

Dobutamine-induced hypotension has been disregarded as a marker of more severe functional abnormalities in patients with suspected coronary artery disease. However, its functional significance in patients with myocardial infarction has not been studied. The aim of this study was to define the predictors of systolic blood pressure (SBP) response to dobutamine in patients with previous myocardial infarction. Dobutamine stress (up to 40 microg/kg per minute) echocardiography was performed in 326 patients with prior myocardial infarction referred for evaluation of myocardial ischemia. A 16-segment, four-grade score model was used to assess left ventricular function. Wall motion score index was derived by summation of wall motion score divided by 16. SBP and heart rate increased from rest to peak dobutamine stress (127 +/- 22 vs 134 +/- 27 mm Hg and 72 +/- 14 vs 122 +/- 24 bpm, p < 0.00001 in both). An increase of SBP > or = 30 mm Hg occurred in 50 patients (15%). By multivariate analysis, independent predictors of failure of SBP increase were higher peak wall motion score index (p < 0.001), higher resting SBP (p < 0.01), and medication with calcium channel blockers (p < 0.05). SBP drop > or = 20 mm Hg occurred in 54 patients (17%). Independent predictors of SBP drop were higher resting wall motion score index (p < 0.001), higher resting SBP (p < 0.0001), and older age (p < 0.05). In patients with myocardial infarction, left ventricular function and baseline systolic blood pressure are powerful predictors of SBP response to dobutamine stress testing.     

Cryosurgical treatment of professional chronic radiodermatitis

The results of open cholecystectomy ([OC] n = 7) versus laparoscopic cholecystectomy ([LC] n = 7) in cirrhotic patients were analyzed prospectively. Groups were well matched for surgical indication, presence of ascites/bleeding tendency, and Child's grade. There was no mortality. Mean operating time was significantly longer in the LC group (155 +/- 47 vs. 103 +/- 25 min, p < 0.05). Operative blood loss was significantly greater in the OC group (128 +/- 125 vs. 642 +/- 467 ml, p < 0.05). No patient in LC group required blood transfusion in contrast to three patients in OC group. Compared with 0% postoperative complications in LC group, wound infections developed in 43% of the patients in OC group (p < 0.05). Mean hospital stay in LC group was significantly less (6.7 +/- 4 vs. 17.4 +/- 7.3 days, p < 0.01). Thus, contrary to previous belief, cirrhosis per se is not a contraindication to LC. Laparoscopic cholecystectomy may be the procedure of choice whenever cholecystectomy is indicated in a cirrhotic patient because it may be associated with less bleeding and fewer incision-related complications.     

Stool bacterial aerobic overgrowth in the small intestine of children with acute diarrhoea

The aerobic flora of 2 groups of children (normal and with malnutrition) with acute diarrhoea was studied, by intubation of the upper and middle small intestine and by stool culture. All the 27 children studied presented bacterial concentrations of 10(5) germs/ml at one or both levels studied. In 9 cases enteropathogen bacteria e were isolated from stools, and in 6 of these they were also found in the small intestine. The results show the elevated incidence of overgrowth of the small intestinal aerobic flora in children with acute diarrhoea. This fact is mentioned as another etiological factor to be taken into consideration in this pathology.