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This is the first published report in Israel of ischemic colitis in a woman using the contraceptive pill; 20 such cases have been reported in other parts of the world. The patient was a 46 year old married woman with 3 children; she had been in good health except for obesity and chronic hypertension. Her medications included an oral contraceptive for a period of 3 years, and methyldopa for treatment of her hypertension. She presented with abdominal pain and diarrhea of 5 weeks duration. She underwent surgical reanastamosis of the bowel and was doing well at follow-up 1 year after surgery. The presence of ischemic colitis was definitively diagnosed by histological examination; the differential diagnosis included cancer, ulcerative colitis, Crohn's disease, and infectious disease. The authors note that although there is possible association between taking oral contraceptives and the appearance of ischemic colitis, there is not yet any statistical evidence for such a relationship. Similar cases have been reported among young women who were not using oral contraceptives.
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PMID:[Ischemic colitis in a woman on contraceptive pills]. 84 35

The influence of several diseases and conditions upon the prevalence of pulmonary embolism in autopsies performed over the July 1, 1964 to June 30, 1974 period at the University of Michigan Medical Center (Ann Arbor, Michigan) were analyzed. The prevalence of pulmonary was 12.3% in the 4600 necropsies in this sample. Patients with pulmonary fat emboli or tumor emboli and patients thought to have thrombosis of the pulmonary artery were not designated as having pulmonary thromboembolism. The patients were categorized with regard to heart disease on the basis of both clinical and necropsy findings. The major factors contributing to an increase in risk of development of pulmonary embolism include heart disease, certain types of cancer, obesity, acute paraplegia and accidental and operative trauma. Other risk factors which could not be assessed in this study include a prior history of venous thromboembolism, pregnancy and the puerperium, use of oral contraceptives, ulcerative colitis and Crohn's disease. Age plays a major role in the prevalence of pulmonary embolism. A portion of the effect of age is related to the age distribution of other diseases contributing to an increased risk, yet advanced age alone may have an independent influence. The risk factors defined should be used in a selective program designed to increase the rate of detection of deep venous thrombosis before pulmonary embolism occurs. Alternatively, patients at increased risk should be treated with prophylactic low dosage heparin during hospitalization.
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PMID:Risk factors in pulmonary embolism. 95 58

The epidemiological patterns for pancreatic and biliary cancers reveal more differences than similarities. Pancreatic carcinoma is common in western countries, although 2 Polynesian groups (New Zealand Maoris and native Hawaiians) have the highest rates internationally. In the United States the disease is rising in frequency, predominating in males and in blacks. The rates are elevated in urban areas, but geographic analysis uncovered no clustering of contiguous counties except in southern Louisiana. The origin of pancreatic cancer is obsure, but a twofold increased risk has been documented for cigarette smokers and diabetic patients. Alcohol, occupational agents, and dietary fat have been suspected, but not proven to be risk factors. Except for the rare hereditary form of pancreatitis, there are few clues to genetic predisposition. In contrast, the reported incidence of biliary tract cancer is highest in Latin American populations and American Indians. The tumor predominates in females around the world, except for Chinese and Japanese who show a male excess. In the United States the rates are higher in whites than blacks, and clusters of high-risk counties have been found in the north central region, the southwest, and Appalachia. The distribution of biliary tumors parallels that of cholesterol gallstones, the major risk factor for biliary cancer. Insights into biliary carcinogenesis depend upon clarification of lithogenic influences, such as pregnancy, obesity, and hyperlipoproteinemia, exogenous estrogens, familial tendencies, and ethnic-geographic factors that may reflect dietary habits. Noncalculous risk factors for biliary cancer include ulcerative colitis, clonorchiasis, Gardner's syndrome, and probably certain industrial exposures. Within the biliary tract, tumors of the gallbladder and bile duct show epidemiological distinctions. In contrast to gallbladder cancer, bile duct neoplasms predominate in males; they are less often associated with stones and more often with other risk factors. In some respects, bile duct and pancreatic tumors are alike. The male predominance of both tumors, an association between cholecystectomy and pancreatic cancer, and other considerations have prompted the notion that the same biliary carcinogens may affect the bile duct, ampulla of Vater, or, by reflux, the pancreatic duct. Various epidemiological and interdisciplinary approaches are needed to further clarify the origins of biliary tract and pancreatic cancers, but nutritional studies hold special promise in laying the groundwork for prevention of these tumors.
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PMID:Cancers of the pancreas and biliary tract: epidemiological considerations. 110 53

During the past ten years, 145 patients (130 with ulcerative colitis and 15 with polyposis) have undergone colectomy and endorectal ileal pull-through operations at the UCLA Medical Center. The mean age of the patients at operation was 22.4 years (a range of seven to 56 years). All of the patients had a two stage operation with temporary ileostomy. Five had an S-shaped reservoir (SR), one patient had a J-shaped reservoir (JR), 12 patients had no reservoir (NR), 97 had a lateral reservoir with the reservoir constructed at the second operation (LR-2) and 30 had a lateral reservoir constructed at the first operation (LR-1). The most common complications were reservoir inflammation, obstruction of the reservoir outlet, stricture of the ileoanal anastomosis, superficial wound infection and sinus tracts extending upward between the rectal muscle cuff and the pull-through segment of ileum. Forty-four patients underwent reoperation for one or more of the complications. Reoperation was performed upon 60 per cent of the patients with SR, 36 per cent with LR-2, 10 per cent with LR-1 and 17 per cent with NR. Of the reoperations, 33 were performed upon the first 50 patients. Only 11 of the last 95 patients required a corrective operation. Of the last 95 patients, 97.5 per cent are currently functioning well. Important features of the operative technique include using a short rectal muscle cuff (5 centimeters or less), constructing a short reservoir (less than 15 centimeters) and having a short reservoir spout (less than 2 centimeters). Although a reservoir reduces fecal urgency and frequency in most instances, patients with obesity, anorectal muscle spasm, severe rectal disease and thick mesentery may be best treated with no reservoir. In our experience, the LR-1 procedure is technically easy to construct, has a low incidence of complications and is the preferred technique.
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PMID:Update on clinical experience with different surgical techniques of the endorectal pull-through operation for colitis and polyposis. 366 Jan 95

A case of acute intestinal vascular necrosis in a 19-year-old user of oral contraceptives (OCs) is described, and hypotheses explaining the digestive complications of synthetic estrogens are reviewed. The patient had originally presented with a violent gastric pain that subsequently spread to the entire abdomen. An abrupt worsening of her condition involved cardiovascular collapse associated with a peritoneal syndrome, vomiting and dehydration, and hyperleukocytosis. Emergency opening of the peritoneum was followed by evacuation of a large quantity of fetid gas and alimentary debris, and observation of a completely necrosed stomach. A careful lavage of the entire intestinal cavity led to temporary improvement, but it became clear during an attempt at gastrectomy that further treatment would be unavailing and the patient died shortly thereafter. Estrogens were believed to be responsible for the digestive necrosis because it occurred in a young woman who had used an estrogen-rich OC for 3 years and who smoked; a hapatic biopsy confirmed the diagnosis. No traces of other risk factors such as hypertension, hyperlipidemia, diabetes, neoplasia, or obesity were observed. Recent publications indicate that OCs are responsible for a certain number of digestive problems, which may include acceleration of intestinal transit, severe diarrhea, rectorrhagia, ischemic or ulcerative colitis, intestinal infarct which is usually localized, and hepatocellular problems ranging from moderate hepatic insufficiency to malignant tumor and Budd-Chiari syndrome. OCs do not modify hemodynamic regimes, but they may cause elevation of fibrinogen and thrombin, diminution of antithrombin III acitivty, increased platelet adhesivity, and decreased fibrinolysis leading to hypercoagulability. These modifications in hemostasis occur in all OC users and are not statistically correlated with occurence of thrombotic accidents. OCs are probably responsible for parietal vascular lesions; experimental injection of synthetic estrogens is associated with both arterial and venous lesions. The most characteristic anomaly is at the level of the intima, with proliferation of smooth muscle cells and increased conjunctive tissue fibers associated with proliferation of the media or the endothelium. The absence of lipid deposits, the simultaneous appearance of arterial and venous lesions, and other evidence argues against and atheromatous origin of parietal lesions. A significant correlation has been found between high levels of anti-synthetic ethinyl estradiol antibodies and the presence of vascular lesions. It is hypothesized that these circulating immune complexes penetrate the vascular walls of OC users and produce lesions, which may depend on factors such as smoking.
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PMID:[Digestive complications of oral contraceptives: a case of extensive digestive necrosis in a young woman]. 647 54

The possible involvement of nerves containing vasoactive intestinal polypeptide in Crohn's disease was investigated by immunocytochemistry and radioimmunoassay of specimens from 17 patients with well-defined clinical and histologic features of the disease. The characteristic pattern of slender fibers, evenly distributed across the gut wall, was seen in specimens taken from controls, which consisted of (a) specimens from uninvolved areas of gut from carcinoma resection (n = 17) and (b) jejunoileal specimens obtained during bypass operation for obesity (n = 8) as well as in four of the six specimens from patients with ulcerative colitis. In contrast, this characteristic pattern was lost in all 17 patients with Crohn's disease, the pattern being replaced by thickened and more intensely immunostained fibers. These changes were consistently found in the mucosa and submucosa, and in 13 of the Crohn's disease cases, the abnormal pattern was totally transmural, involving both the myenteric and submucous plexus as well as the muscle layers. There was a > 200% increase in VIP content, as determined by radioimmunoassay, in Crohn's disease (294 +/- 29 pmol/g wet wt, mean +/- SEM) in comparison with (a) ulcerative colitis (93 +/- 5 pmol/g [P < 0.001]), and (b) controls consisting of carcinoma resection (108 +/- 39) and bypassed gut from obese patients (86 +/- 27 [P < 0.001]). At least part of the previously documented autonomic nerve changes in Crohn's disease are, thus, due to an increase in vasoactive intestinal polypeptide innervation.
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PMID:Abnormalities of vasoactive intestinal polypeptide-containing nerves in Crohn's disease. 741 8

A 15-year retrospective review was undertaken to evaluate the operative outcomes of patients with indeterminate colitis who were referred for rectal-sparing operations. Review of 95 consecutive patients operated for ulcerative colitis (UC) or indeterminate colitis (IC) revealed characteristics of IC in 13 patients. In the group as a whole, there were 45 females and 50 males; the average age was 33. A total of 64 patients had ileoanal pull-through (IAA). Analysis revealed that four of these patients had IC revealed by findings before operation in three patients and following the first stage of operation in one patient. Three of these four patients have subsequently required permanent ileostomy. Six patients who underwent IAA have subsequently demonstrated signs and symptoms of Crohn's disease (CD). All six have subsequently required ileostomy. Overall 10 patients with CD underwent IAA, and nine have required permanent ileostomy. Fourteen patients had ileorectal anastomosis (IRA) for UC or IC. IRA was performed for patients with IC in nine cases, and five patients with UC elected this operative option. Indications for IRA in patients with UC included obesity, 2; mental retardation, 1; advanced age, 1; and patient preference, 1. Of the patients with IC who underwent IRA, two have subsequently shown signs and symptoms of Crohn's disease. Overall, 14 of 14 patients who had IRA still have functioning IRA. None has required ileostomy. The poor results in patients with UC or IC subsequently shown to have CD have caused us to change our operative approach in patients with any question in the diagnosis of UC.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Ileoproctostomy is preferred over ileoanal pull-through in patients with indeterminate colitis. 779 39

Total proctocolectomy and ileal pouch-anal anastomosis (IPAA) is the best option in the surgical treatment of ulcerative colitis, and for some patients with familial polyposis. Contraindications to the procedure include old age, obesity, weak sphincters, perianal sepsis and previous enterectomy. In this study the results of IPAA in five patients with one or more of these contraindications are presented and ways of dealing with them are discussed. All patients had a favourable outcome showing that such contraindications are relative, and IPAA may be attempted as long as patients are fully informed and understand the risks to which they are subject.
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PMID:The ileal pouch-anal anastomosis in challenging patients: stretching the limits. 785 20

Restorative proctocolectomy is now the procedure of choice for patients suffering from ulcerative colitis (UC) and familial adenomatous polyposis coli (FAP). The majority of patients with UC require surgery for failure or development of side effects of medical therapy. Other indications include dysplasia, carcinoma and complications from either medical therapy or the disease, such as massive bleeding or perforation. In the adolescent patient, resection may be necessary owing to growth retardation. In patients with FAP the 100% risk of developing colorectal carcinoma can be avoided only by proctocolectomy. Crohn's colitis and carcinoma of the lower rectum represent absolute contraindications. A relative contraindication exists in indeterminate colitis, patients with poor sphincter function, mesenteric desmoids, obesity and an age above 65 years.
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PMID:[Indications for restorative proctocolectomy in systemic colorectal diseases (ulcerative colitis and familial adenomatous polyposis coli)]. 993 61

This is a review of some of the most important growing points in the specialties of gastroenterology and hepatology. It does not aim to be completely comprehensive but to pick out major areas of importance to examination candidates and doctors without special experience in the field. Topics covered include: upper gastrointestinal haemorrhage; Barrett's oesophagus; carcinoma of the oesophagus; achalasia; Helicobacter pylori; duodenal ulcer prevention; coeliac disease; dermatitis herpetiformis; Crohn's disease; small bowel overgrowth; ulcerative colitis; carcinoma of the large bowel; obesity; endoscope sterilisation; gall stones; liver transplantation; autoimmune liver disease; viral hepatitis; metabolic liver diseases; and pancreatic insufficiency.
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PMID:Advances in gastroenterology and hepatology. 1082 44


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