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The development of tuberculosis-related bowel obstruction or pseudo-obstruction during anti-tuberculosis therapy is rarely reported in immunocompetent patients. A 44-year-old male, who had neither HIV infection nor diabetes, was hospitalized because of pulmonary tuberculosis in November 2006. Three months after starting anti-tuberculosis therapy, he was admitted for suspected mechanical bowel obstruction. An emergency exploratory laparotomy showed distended bowel loops, and multiple skip lesions from the terminal ileum to the ascending colon. PCR analyses showed Mycobacterium tuberculosis. The therapy regimen was unchanged after the operation; the patient gradually improved over the course of a month and was discharged without further symptoms thereafter.
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PMID:Gastrointestinal tract pseudo-obstruction or obstruction due to Mycobacterium tuberculosis breakthrough. 1909 79

The treacherous and deceptive nature of pheochromocytoma makes it crucial to detect and treat it promptly; otherwise it will almost certainly be fatal from cardiovascular complications or metastases. Hypertension occurring in patients with pheochromocytomas is sustained in about 50% and paroxysmal in the remainder; however, many patients remain normotensive. Hypertension attacks may be precipitated by physical activity, postural changes, anxiety, certain foods or wine, some drugs, operative procedures, etc. Cardinal manifestations are paroxysmal hypertension, headache, palpitations +/- tachycardia, inappropriate sweating; anxiety, tremulousness, pallor (rarely flushing), chest and abdominal pains; nausea and vomiting often occur. Hypercatecholaminemia manifestations are more common and pronounced when paroxysmal hypertension occurs, but persons with familial pheochromocytoma may be asymptomatic. Protean manifestations of pheochromocytoma may simulate many conditions, some of which may have elevated plasma and urine catecholamines and their metabolites. Baro-reflex failure, postural tachycardia syndrome, sleep apnea, carcinoid, renal failure, and pseudopheochromocytoma may be diagnostic challenges. The history, physical examination, biochemical testing (after eliminating interfering drugs, when possible) for plasma and urinary metanephrines can usually establish or exclude presence of pheochromocytomas. Occasionally a clonidine suppression test is needed to differentiate neurogenic from pheochromocytic hypertension. Manifestations suggesting hypercatecholaminemia without hypertension are highly atypical of pheochromocytoma. Pheochromocytoma may present as panic attacks, pre-eclampsia, cardiomyopathy, infection with fever and leucocytosis, diabetes, migraine, shock, Cushing's syndrome, multiple organ failure with lactic acidosis, neurological manifestations, transitory electrocardiogram abnormalities, constipation, intestinal obstruction, visual impairment, convulsions, etc. The key to diagnosis is always to think of pheochromocytoma in the differential diagnosis of hypertension.
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PMID:The protean manifestations of pheochromocytoma. 1924 99

Lung transplantation has become a viable option for those cystic fibrosis (CF) patients with end-stage lung disease. Despite the challenges that the CF patients present, the survival seen after lung transplantation is more favorable than seen in patients with chronic obstructive pulmonary disease and pulmonary fibrosis. Although the CF patients with severe respiratory disease usually are infected with organisms that display in vitro resistance to the commonly used antibiotics, these patients usually have successful outcomes with transplantation. The other challenges include the presence of nontuberculous mycobacteria, the significant incidence of liver involvement, the development of an ileus or the development of the distal intestinal obstruction syndrome, and the presence of gastroesophageal reflux. Most of the patients have metabolic bone disease, even preoperatively, that warrants treatment, especially with the significant loss of bone density seen in the first year after transplant, thought to be related, in part, to the high dose of corticosteroids. Diabetes mellitus and its consequences are not uncommon. The malabsorption of fat seen in the pancreatic-insufficient patients complicates the absorption kinetics of the anti-rejection drugs. In May 2005 the United Network of Organ Sharing instituted a lung-allocation score to better distribute the donated lungs to those patients who would achieve the most benefit. This score uses several variables to balance the likelihood of the patients living one year with a transplant versus one year without a transplant. With this change in the allocation of organs, the median waiting times have significantly decreased, the mortality on the waiting list has decreased, and the number of CF patients transplanted has not changed. With substantial experience, more programs are now transplanting patients who require constant mechanical ventilation or patients who have undergone previous pleural procedures, especially in the treatment of a pneumothorax. The limiting factor now in lung transplantation is the number of organs available. Efforts to increase the donor pool, such as alveolar recruitment strategies to improve gas exchange, have been effective in allowing more patients to be transplanted. Lung transplantation is now an accepted form of therapy in those patients who are developing progressive respiratory failure.
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PMID:Lung transplantation in cystic fibrosis. 1946 64

The adrenalin index as used in this paper means the amount of adrenalin in milligrams per gram of gland. As in our hands the chemical colorimetric method has proved more accurate, these values rather than the physiological values will be given in the final analysis. The two adrenal glands in the same individual as a rule contain about the same amount of adrenalin per gram, but variations of 10 to 20 per cent. are not unusual. Normal dogs show an index which may vary from 1.2 to 1.8 milligrams. The dogs were killed by short ether anesthesia and bleeding from the carotid. Normal human beings, dying from trauma, rupture of aneurysm, etc., show an index of 0.35 to 0.50 of a milligram, when autopsy takes place a few hours after death. Deterioration of uncut glands or of a gland hash kept on ice in the dark is not rapid and rarely exceeds 10 per cent. in twenty-four hours. Acute intoxication in dogs shows a low adrenalin index, especially the intoxication associated with intestinal obstruction and the closed intestinal loop. Intravenous injection of the poison found in closed duodenal loops sufficient to cause fatal shock causes a great drop in the adrenalin index, at times to one fourth normal or even lower. After recovery from a sublethal toxic dose the adrenalin index may rise rapidly to a point considerably above normal. The same may hold for recovery after chloroform poisoning. Anesthesia by chloroform or ether causes a drop in the adrenalin index depending upon the length of anesthesia and probably in part on the depth of anesthesia. Liver poisons (chloroform, phosphorus, hydrazine) cause a drop in the adrenal index to a low level, perhaps one half normal in acute cases. Pancreas extirpation with prolonged glycosuria and death produces a great drop in the adrenalin index (cat). There is evidence that this may hold in some cases of human diabetes. In man disease of one adrenal (tuberculosis) may be associated with an adrenalin index of double the normal value in the intact adrenal. Pernicious anemia is the only disease so far found to present an abnormally high adrenalin index, and the single case shows an index at least twice normal. This is of interest especially in relation to the views recently put forward to indicate that the spleen and adrenal may be concerned in the lipoid metabolism which is thought to be profoundly disturbed in this disease. Secondary anemia due to repeated hemorrhage or the intoxication of cancer or tuberculosis causes a fall in the adrenalin index. Cachexia due to neoplasm or tuberculosis may cause a marked fall in the adrenalin index, perhaps to less than one half of normal. Acute infections (typhoid fever), septicemia, peritonitis, and similar conditions may be associated with a normal adrenalin index or one somewhat below normal. Diseases of the kidneys, heart, or blood vessels associated with elevated blood pressure show no constant variation in the adrenalin index, which may be normal or slightly subnormal.
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PMID:THE ADRENALIN INDEX OF THE SUPRARENAL GLANDS IN HEALTH AND DISEASE. 1986 91

The volvulus of the small bowel is a surgical emergency, causing small bowel obstruction. We performed a retrospective study of all the patients diagnosed and treated with small bowel volvulus between 1977 and 2007 at our institution. One hundred twenty-nine patients were analyzed. Thirty-nine patients presented primary volvulus and 90 secondary ones. The most frequent symptom was sudden abdominal pain. CT scan was the best diagnostic method with an accuracy of 83 per cent. Necrotic small bowel loops appeared in 46.5 per cent of the patients. Eighteen patients had postoperative complications (14%). Mortality rate was 9.3 per cent. A higher mortality is observed among patients with previous abdominal surgeries and cardiopathies. Necrotic loops are associated with higher mortality and incidence of surgical complications; patients with diabetes are associated with a higher incidence of necrotic loops. Cardiopathies are associated with more frequent medical and surgical complications. Recurrence rate was 3.9 per cent associated with simple devolvulation. Primary volvulus are more frequent among males and patients with diabetes. Jejunal location is associated with primary volvulus and these correlate with a higher incidence of necrotic loops. Primary volvulus presents a higher incidence of surgical complications. A bowel obstruction with sudden abdominal pain must be suspicious of small bowel volvulus. The main aim is to achieve an early diagnosis to prevent a necrotic small bowel. CT scan is the imaging test with the best diagnostic accuracy. Primary volvulus, the presence of necrotic loops, and patients with cardiopathies, diabetes mellitus, and with previous abdominal surgery are associated with a worse outcome.
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PMID:Volvulus of the small bowel in adults. 1999 8

Anaerobic bacteria remain an important cause of bloodstream infections and account for 1-17% of positive blood cultures. This review summarizes the epidemiology, microbiology, predisposing conditions, and treatment of anaerobic bacteremia (AB) in newborns, children, adults and in patients undergoing dental procedures. The majority of AB are due to Gram-negative bacilli, mostly Bacteroides fragilis group. The other species causing AB include Peptostreptococcus, Clostridium spp., and Fusobacterium spp. Many of these infections are polymicrobial. AB in newborns is associated with prolonged labor, premature rupture of membranes, maternal amnionitis, prematurity, fetal distress, and respiratory difficulty. The predisposing conditions in children include: chronic debilitating disorders such as malignant neoplasm, hematologic abnormalities, immunodeficiencies, chronic renal insufficiency, or decubitus ulcers and carried a poor prognosis. Predisposing factors to AB in adults include malignant neoplasms, hematologic disorders, transplantation of organs, recent gastrointestinal or obstetric gynecologic surgery, intestinal obstruction, diabetes mellitus, post-splenectomy, use of cytotoxic agents or corticosteroids, and an undrained abscess. Early recognition and appropriate treatment of these infections are of great clinical importance.
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PMID:The role of anaerobic bacteria in bacteremia. 2002 84

Encapsulating peritoneal sclerosis is a complication of peritoneal dialysis characterized by persistent, intermittent, or recurrent adhesive bowel obstruction. Here we examined the incidence, predictors, and outcomes of encapsulating peritoneal sclerosis (peritoneal fibrosis) by multivariate logistic regression in incident peritoneal dialysis patients in Australia and New Zealand. Matched case-control analysis compared the survival of patients with controls equivalent for age, gender, diabetes, and time on peritoneal dialysis. Of 7618 patients measured over a 13-year period, encapsulating peritoneal sclerosis was diagnosed in 33, giving an incidence rate of 1.8/1000 patient-years. The respective cumulative incidences of peritoneal sclerosis at 3, 5, and 8 years were 0.3, 0.8, and 3.9%. This condition was independently predicted by younger age and the duration of peritoneal dialysis, but not the rate of peritonitis. Twenty-six patients were diagnosed while still on peritoneal dialysis. Median survival following diagnosis was 4 years and not statistically different from that of 132 matched controls. Of the 18 patients who died, only 7 were attributed directly to peritoneal sclerosis. Our study shows that encapsulating peritoneal sclerosis is a rare condition, predicted by younger age and the duration of peritoneal dialysis. The risk of death is relatively low and not appreciably different from that of competing risks for mortality in matched dialysis control patients.
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PMID:Encapsulating peritoneal sclerosis: incidence, predictors, and outcomes. 2037 81

Human intestinal microbiota create a complex polymicrobial ecology. This is characterised by its high population density, wide diversity and complexity of interaction. Any dysbalance of this complex intestinal microbiome, both qualitative and quantitative, might have serious health consequence for a macro-organism, including small intestinal bacterial overgrowth syndrome (SIBO). SIBO is defined as an increase in the number and/or alteration in the type of bacteria in the upper gastrointestinal tract. There are several endogenous defence mechanisms for preventing bacterial overgrowth: gastric acid secretion, intestinal motility, intact ileo-caecal valve, immunoglobulins within intestinal secretion and bacteriostatic properties of pancreatic and biliary secretion. Aetiology of SIBO is usually complex, associated with disorders of protective antibacterial mechanisms (e.g. achlorhydria, pancreatic exocrine insufficiency, immunodeficiency syndromes), anatomical abnormalities (e.g. small intestinal obstruction, diverticula, fistulae, surgical blind loop, previous ileo-caecal resections) and/or motility disorders (e.g. scleroderma, autonomic neuropathy in diabetes mellitus, post-radiation enteropathy, small intestinal pseudo-obstruction). In some patients more than one factor may be involved. Symptoms related to SIBO are bloating, diarrhoea, malabsorption, weight loss and malnutrition. The gold standard for diagnosing SIBO is still microbial investigation of jejunal aspirates. Non-invasive hydrogen and methane breath tests are most commonly used for the diagnosis of SIBO using glucose or lactulose. Therapy for SIBO must be complex, addressing all causes, symptoms and complications, and fully individualised. It should include treatment of the underlying disease, nutritional support and cyclical gastro-intestinal selective antibiotics. Prognosis is usually serious, determined mostly by the underlying disease that led to SIBO.
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PMID:Small intestinal bacterial overgrowth syndrome. 2057

We compared patients with small bowel obstruction (SBO) admitted through the emergency department to the surgical service (SS) with those admitted to the medical service (MS) with respect to outcomes and healthcare cost. We conducted a retrospective analysis of our SBO database comparing 482 patients admitted to SS and 153 patients admitted to MS at a single institution over a 5-year period (January 2003 to December 2007). Study outcomes included length of hospital stay (LOS), time to surgery (TTS), hospital charges, incidence of bowel resection, and mortality. Both groups were comparable for age, gender, and race. The SS group had a shorter LOS (6.1 vs. 7.5 days; P = 0.01), less hospital charges ($29,549 vs. $35,789; P = 0.06), shorter TTS (log rank comparison; P = 0.006), and less mortality (eight [1.66%] vs. six [3.92]; P = 0.11). The SS group had more bowel resections (13.1 vs. 5.2%; P = 0.007). Coronary artery disease (CAD), acute renal failure (ARF), admission to SS, and female gender were significant predictors of bowel resection. CAD and ARF were significant predictors of mortality. Two hundred forty-four patients required operative intervention (surgery operative subgroup [SOS] 210 [43.6%], medicine operative subgroup [MOS] 34 [22.2%]). SOS and MOS were comparable for gender and race. SOS had shorter LOS (9.1 vs. 12.3 days; P = 0.02), less hospital charges ($46,258 vs. $62,778, P = 0.05), and less mortality (eight [3.81%] vs. four [11.76%]; P = 0.07). Bowel resection was comparable (SOS 30% vs. MOS 23%; P = 0.44). CAD and congestive heart failure (CHF) were significant predictors of bowel resection, whereas CAD was the only significant predictor of mortality in this subgroup. We recommend that patients with SBO be admitted to SS because this might translate to shorter LOS, earlier operative intervention, and reduced healthcare use direct cost. Bowel resection and death are more likely to occur in patients with comorbidities like CHF, CAD, diabetes mellitus, and ARF.
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PMID:Small bowel obstruction: outcome and cost implications of admitting service. 2069 71

Encapsulating peritoneal sclerosis (EPS) is a serious and often fatal complication of long-term PD with severe malnutrition and poor prognosis. It causes progressive obstruction and encapsulation of the bowel. This retrospective study reviews our experience and that reviewed in the literature concerning EPS. It refers to a total of 1966 patients treated with chronic PD between 1974 and 2008. Twenty one of them (1.1%) developed EPS, with the incidence increasing with the duration of PD. Mean age of our patients with EPS was 43, ranging from 18 to 71 years, 8 were men and 13 women with a mean body mass index (BMI) of 21.6 kg/m(2). Only one patient had Type II diabetes, 15 patients had glomerular disease, and six of these 15 had an autoimmune disease such as Wegener's granulomatosis and SLE. Thirteen patients developed EPS while on PD, 7 within 2 years after transfer to HD, and only one after renal transplantation. However, 7 patients had a previous renal transplant before returning to PD and subsequently developing EPS. Interestingly, we did not observe more episodes of EPS after transplantation. In the patients who developed EPS, the peritonitis rate over the period of observation was 1/15.6 pt-months and was due to Staphylococcus aureus, coagulase-negative staphylococcus, Pseudomonas and fungi. A history of peritonitis was not a prerequisite for developing EPS, since one patient had no episodes of peritonitis and 4 had just one previous episode. Fifteen patients presented with peritonitis within 4 months before the diagnosis of EPS with particularly virulent micro-organisms such as S. aureus, Candida, Pseudomonas, Corynebacterium, and Peptostreptococcus. Eleven patients were treated with hypertonic dextrose solutions (4.25 g/dl of dextrose) and seven with icodextrin, indirectly suggesting problems with ultrafiltration. Nine of 21 patients were on beta-blockers. The diagnosis of EPS was made either surgically or radiologically with signs of small bowel obstruction in combination with severe malnutrition. Eleven of our patients (52%) had evidence of small bowel obstruction and 14 patients required total parenteral nutrition (TPN). Tamoxifen (10-20 mg daily) was started in 6 patients, 4 of whom are alive and 2 deceased 3 and 5 years after EPS was diagnosed. Of the 12 patients who were not given tamoxifen, 2 are alive and 10 died. No side effects of tamoxifen were reported. Only 7 of our patients (33%) died during the first year after the diagnosis of EPS. Currently, 4 patients are on HD and 3 have had a renal transplant. Six patients of the fourteen who underwent surgery (42.8%) died within the first 6 months after operation and five died after an average of 6.6 years, mostly due to cardiovascular causes, three are still alive. As EPS becomes more prevalent with longer duration of PD, large multicenter prospective studies are needed to establish its incidence and identify risk factors, therapeutic approach, and prognosis.
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PMID:Encapsulating peritoneal sclerosis: a single-center experience and review of the literature. 2092 72


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