Biomedical subjects
E Passaro
Publications and source records attributed to E Passaro.
Late complications of vagotomy in relation to alterations in physiology.
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Bacterial flora of the small bowel before and after bypass procedure for morbid obesity.
The contents of the proximal jejunum and distal ileum were cultured quantitatively in eight patients who were undergoing intestinal bypass procedure for obesity. Five jejunal specimens were sterile, and three contained low counts of a predominantly aerobic flora. Ileal contents yielded variable but usually higher counts than in the jejunum, and there were similar numbers of anaerobes and aerobes. In three patients in whom a bypass was established, contents of the functioning small bowel showed counts of 10(5.0)-10(7.6) colony-forming units/ml. These counts exceeded the counts in the normal terminal ileum, and the flora qualitatively resembled that of feces. Four specimens from excluded loops revealed colonization with fecal organisms, and the counts ranged between 10(6.4) and 10(9.7) colony-forming units/ml. In jejunoileal bypass both the functioning small bowel and the excluded loop become colonized with colonic flora, a phenomenon that may contribute to some of the side effects of this procedure.
Hypertrophic protein-losing gastropathy and vitiligo. Report of a second case.
A second patient with hypertrophic protein-losing gastropathy and extensive vitiligo was studied. Upper gastrointestinal radiographs and endoscopy revealed multiple polyps of the upper half of the stomach. The patient was achlorhydric to pentagastrin stimulation. Clearance of 51Cr-labeled protein by the gastrointestinal tract was about 15 times normal. A total gastrectomy was done for relief of persistent epigastric pain and correction of hypoproteinemia. Histologically the polyps consisted of hypertrophied mucosal glands with cystic dilatation deep to the glandular layer. The similarity of this patient to a patient previously seen at our hospital led us to report the possible association of hypertrophic protein-losing gastropathy with vitiligo.
Bypass enteropathy: an inflammatory process in the excluded segment with systemic complications.
Evidence is presented that many of the enteric and systemic manifestations after jejunoileal bypass can be related to an inflammatory process within the bypassed small bowel rather than to the surgically induced sequelae of a short bowel syndrome with malabsorption. Invasion of the excluded segment by fecal flora was associated with a histologically demonstrable inflammatory response of the mucosa. The disorder was of variable severity and duration and occurred in the majority of 28 bypass patients. Progression to a clinical syndrome resembling an acute abdomen occurred in about 15% of the patients. Small bowel ileus and, in some patients, obstruction of the colon were suggested by physical signs and x-ray findings. Surgical exploration in such instances demonstrated an inflammaotry process of the excluded small bowel loops with severe distention of this segment and of the colon, but not organic obstruction. Pneumatosis cystoides intestinalis was a sequal in two patients. Exudative protein loss was documented in the severe cases. Most of the systemic sequelae are comparable to those seen with inflammatory diseases of the bowel such as Crohn's disease. Fever, excessive weight and lean tissue loss, and the involvement of skin, blood vessels, joints and possibly, the liver suggest an immune response as a common factor in the pathogenesis. The clinical improvement with antibiotics such as metronidazole or with restitution of normal bowel continuity indicates that the bacterial flora in the excluded small bowel segment or its byproducts are causally related to the systemic complications. Hyperoxaluria may be primarily the sequela of steatorrhea and not of the inflammatory process.
Treatment of peptic ulcer disease in the renal transplant patient.
This study reviews previous reports of peptic ulcer disease in kidney transplant recipients and includes our own experience. Between 1968-1976, 12 transplant centers reported on gastrointestinal complications occurring in 1853 renal transplant recipients. Among these are 52 patients in whom peptic ulcers developed before trnasplantation and 72 patients in whom peptic ulcers developed after transplantation. Included are 21 patients with peptic ulcer from 115 renal transplant recipients at VA Wadsworth Hospital. Patients who were operated upon for peptic ulcer before trnasplant were compared to patients with peptic ulcer before transplant but who were not operated upon. Ulcer recurrence was significantly lower in the operated group p less than .0003. Following transplantation 59 of 68 patients with peptic ulcer disease presented with bleeding or perforation. Mortality was high: 31 deaths in 72 patients (43%). Symptoms usually occurred early, 74% in 6 months, but 19% occurred after one year. The mortality from duodenal, gastric, combined gastric and duodenal and recurrent ulcers did not differ significantly. Elective surgery is indicated for peptic ulcer when demonstrated before or after kidney transplantation.
Effect of betazole on serum group I pepsinogen levels: relationship to gastric acid output in unoperated and postoperative patients.
A significant association has previously been found between a betazole-induced decrease in serum group I pepsinogen (PG I) levels and a low peak acid output (PAO) in symptomatic patients with vagotomy and gastric resection or a drainage procedure. This study compares the effect of betazole on serum PG I levels and gastric acid output in 245 unoperated patients (115 duodenal ulcer, 25 prepyloric ulcer, 32 gastric ulcer, 73 nonulcer) and in 73 symptomatic postoperative patients (15 subtotal gastric resection, 28 vagotomy and gastric resection, 30 vagotomy and drainage). A negative serum PGI response (2-hr serum PG I level less than 92% of basal) occurred in 10 (4.1% of the unoperated patients and in 31 (42.5%) of the postoperative patients. Seven (70%) of the former and 29 (93.5%) of the latter patients had a PAO of less than 10 mEq per hr, indicating that a negative serum PG I response is associated with a low PAO in both unoperated and postoperative patients. The PAO was greater than 10 mEq per hr in 93.1% of the 277 patients with a 2-hr serum PG I level of more than 92% of basal. Additional studies revealed that neither aspiration of gastric juice nor perfusion of the stomach with acid altered the serum PG I response. This suggests that topical acid does not modulate the effect of betazole on serum PG I levels. Finally, a negative serum PG I response has been shown to be paradoxical, in that gastric pepsin levels have been found to increase over basal concurrently with the decrease in serum PG I levels.
Treatment of peptic ulcer disease- a symposium.
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Bypass enteropathy. Intestinal and systemic manifestations following small-bowel bypass.
Many manifestations following jejunoileal bypass are due to chronic inflammation of the excluded bowel rather than short bowel malabsorption. Diarrhea, abdominal distention, and gas-fluid levels were common diagnostic features of "bypass enteropathy." Exploration showed the bypassed bowel to be dilated, with serosal inflammation and pneumatosis cystoides intestinalis. The bypassed loops contained a fecal flora and the mucosa demonstrated nonspecific chronic inflammatory changes. Exudative protein losses were noted. Systemic complications of bypass enteropathy were similar to other inflammatory diseases of the bowel. Improvement following treatment with metronidazole or after dismantling of the bypass suggested that bacterial byproducts originating in the excluded bowel were causally related.
Bypass enteritis. A new complication of jejunoileal bypass for obesity.
Four patients who had jejunoileal bypass for morbid obesity had increased frequency of diarrhea, diffuse abdominal tenderness and distention, and fever to 104 degrees F. Roentgenographic studies disclosed multiple distended loops in the bypassed bowel with few air fluid levels. Two of these patients underwent operation for suspected peritonitis from abscess or obstruction. No abscess or mechanical obstruction was found. The bypassed bowel contained many subserosal gas-filled blebs. The remaining two patients were treated with antibiotics and showed prompt improvement. "Bypass enteritis" must be considered in the postoperative period in patients undergoing surgery for morbid obesity. It responds to antibiotics and appropriate electrolyte therapy. The presumed factor is overgrowth of enteric bacteria in the distal portion of the bypassed bowel. Accurate diagnosis will obviate the need for surgical exploration to exclude peritonitis.
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.
A retroperitoneal cystic leiomyosarcoma spontaneously draining into the stomach.
An unusual case of a retroperitoneal cystic leiomyosarcoma clinically resembling a pancreatic pseudocyst with subsequent spontaneous cystgastrostomy drainage is presented.
Serum gastrin concentrations in infants with short gut syndrome.
Seven babies with 100 cm or less remaining small bowel have been evaluated for evidence of gastric hyperacidity and/or hypergastrinemia. Two babies were also studied after feeding. No patient demonstrated hyperacidity or hypergastrinemia. This infant data is discussed in regards to reported contradictory data in adult studies.
Marginal ulcer: a guide to management.
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Recurrent peptic ulcer.
From 1 to 5% of patients can be expected to develop recurrent ulceration following current surgical therapy for peptic ulcer disease. The development of recurrent ulcer frequently reflects an inadequacy of the initial procedure. The nature of the inadequacy is often difficult to delineate because of alterations in anatomy and physiology and the lack of accurate diagnostic procedures. Incomplete vagotomy and inadequate gastric resection account for the vast majority of surgical deficiencies. Gastrinoma, retained gastric antrum, and hyperparathyroidism are the most frequently encountered endocrine causes. A thorough evaluation must include gastrointestinal X-rays, fiberoptic endoscopy, multiple serum calcium and gastrin determinations, and provocative testing. Medical management of recurrent ulcer fails in the vast majority of cases. Reoperation is successful in about 70% of cases and has a mortality rate of 4%. Recurrent ulcer after simple gastroenterostomy is best treated by gastric resection or vagotomy and resection. After initial adequate gastric resection, vagotomy alone usually suffices. Antrectomy and, if necessary, re-vagotomy should be done for recurrent ulcer after vagotomy and drainage. Re-vagotomy alone is usually effective therapy for recurrent ulcer after initial vagotomy and resection. Non-acid reducing operations should not be done, as they result in high mortality and high second recurrence rates.
Serum group I pepsinogen levels and their relation to gastric acid secretion in patients with and without recurrent ulcer.
Serum group I pepsinogen (PG I) levels have been determined by radioimmunoassay in 15 patients without, recurrent ulcer after vagotomy and either a gastric resection or a drainage procedure. The mean (+/-SE) levels were 151.8 +/- 16.9 ng per ml in the patients with recurrent ulcer and 79.7 +/- 9.8 ng per ml in those without recurrence (P less than 0.001). A recurrent ulcer was present in 6 of 7 patients with an elevated serum PGI (greater than 175 ng per ml) but not in any of 10 patients with a low serum PGI (less than 50 ng per ml). The correlation between serum PG I and peak acid output (PAO) was statistically significant in patients with recurrent ulcer (pi=0.815, P less than 0.001) and in those without recurrence (r= 0.540, P less than 0.025). In patients with recurrent ulcer, a serum PG I level within the normal range (50 to 175 ng per ml) was uniformly associated with a PAO of more than 10 mEq per hr. In contrast, of 10 patients without recurrent ulcer and a normal serum PG I, eight had a PAO of less than 10 mEq per hr. The reason for the discordant results in the two groups of patients is not certain.
The effect of betazole on serum group I pepsinogen levels: studies in symptomatic patients with and without recurrent ulcer after vagotomy and gastric resection or drainage.
Serum group I pepsinogen (PG I) levels have been determined before and at intervals after the administration of betazole hydrochloride (Histalog) in 50 symptomatic postoperative patients, 20 with and 30 without recurrent ulcer, after either a vagotomy and gastric resection or a drainage procedure. In patients with recurrent ulcer, mean serum PG I levels increased after betazole and reached a maximum of 116.5 +/- 2.2% (SE) of basal at 2 hr; range 98.9 to 135.7%. In contrast, mean serum PG I levels decreased in patients without recurrent ulcer and reached a nadir of 75.0 +/- 4.3% of basal at 2 hr; range 46.9 to 142.4%. All 20 patients with recurrent ulcer and 5 patients without recurrence had a 2-hr serum PG I level of more than 98% of basal, while each of the remaining 25 patients without recurrent ulcer had a 2-hr level of less than 92% of basal. A 2-hr serum PG I level of more than 98% of basal was also correlated with a vagotomy and drainage, a peak acid output of more than 11 mEq per hr, and a positive insulin test, while a level of less than 92% of basal was correlated with a vagotomy and gastric resection, a peak acid output of less than 11 mEq per hr, and a negative insulin test. In addition, basal serum PG I and serum gastrin levels were significantly higher (P less than 0.001) in patients with the former type of PG I response than in those with the latter type of response. The cause of each type of response is not certain, but the data suggest that one of the determinants may be the completeness of vagotomy.