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Biomedical subjects

M S Cappell

Publications and source records attributed to M S Cappell.

At least 55 records · Page 3Linked to original sources
PubMed1994

Obstructive jaundice due to retroperitoneal fibrosis involving the head of the pancreas.

A 51-year-old man with no history of liver disease had acute severe jaundice, with a serum level of total bilirubin of 27.4 mg/dl and an alkaline phosphatase level of 731 IU/L due to distal common bile duct compression from peripancreatic head fibrosis associated with retroperitoneal fibrous. Other obstructive phenomena in this patient included bilateral hydronephrosis from ureteral fibrosis encasement and testicular swelling from fibrous encasement of vessels draining the scrotum. Autopsy demonstrated massive retroperitoneal fibrosis, with angulation and compression of the distal common bile duct by fibrosis covering the head of the pancreas. The intrahepatic biliary tree was dilated because of the distal choledochal obstruction, but the proximal common bile duct was not dilated due to mural fibrosis.

Cholestasis↗
PubMed1994

A multicenter, case-controlled study of the clinical presentation and etiology of ascites and of the safety and clinical efficacy of diagnostic abdominal paracentesis in HIV seropositive patients.

OBJECTIVE: To analyze the clinical presentation and etiology of ascites in HIV seropositive patients compared with the general population and to analyze the safety and clinical efficacy of abdominal paracentesis in HIV patients. METHODS: We did a multiyear study of 24 HIV seropositive and 60 control patients with ascites undergoing diagnostic abdominal paracentesis at two university hospitals. RESULTS: HIV seropositive patients presented with similar clinical findings as other patients with ascites, except HIV patients had a significantly higher incidence of pyrexia and a lower serum albumin level and leukocyte count. The two groups had similar mean ascitic fluid values of lactate dehydrogenase, total protein, glucose, and erythrocyte count. HIV patients had a trend of a higher rate of infected ascites than controls (29% vs 12%; odds ratio = 3.12; odds ratio confidence interval = 0.80-12.3; p < 0.06; chi 2). HIV and control patients with culture-proven bacterial peritonitis had similar ascitic fluid leukocyte and absolute neutrophil counts. In eight (33%) of the HIV patients, major new diagnoses were made from ascitic fluid analysis, including spontaneous bacterial peritonitis in four, tuberculous ascites in two, fungal peritonitis in one, and lymphoma in one (control rate = 30%; not significantly different; chi 2). The HIV patients did not experience any complications from paracentesis, whereas the controls experienced one minor complication of prolonged drainage of ascitic fluid from the paracentesis site (not significantly different rates; Fisher's exact test). Six (25%) of the HIV patients had ascites caused by AIDS-defining illnesses of lymphoma, peritoneal tuberculosis, or disseminated candidiasis. CONCLUSIONS: Abdominal paracentesis is a safe and effective clinical diagnostic tool in HIV patients. In addition to standard tests, ascitic fluid should be sent for mycobacterial and mycological histological stains and cultures in HIV patients. AIDS-unrelated causes are the most common cause of ascites in HIV patients, with only about 1/4 of cases due to AIDS-related diseases.

Adult↗
PubMed1994

Esophageal necrosis and perforation associated with the anticardiolipin antibody syndrome.

The anticardiolipin antibody syndrome has been previously associated with seven cases of gastrointestinal ischemia involving the duodenum, jejunoileum, or colon. In prior cases patients presented with gastrointestinal bleeding, abdominal pain, or an acute abdomen without gastrointestinal perforation. A patient with prior pulmonary emboli, right leg thrombophlebitis, and right popliteal artery thrombosis associated with anticardiolipin antibodies developed fatal esophageal ischemia. Postmortem examination revealed esophageal necrosis and perforation due to esophageal vascular thrombosis, as well as ischemic colitis and numerous other thromboembolic phenomena. This case report extends the gastrointestinal manifestations of the anticardiolipin antibody syndrome by describing esophageal involvement and by reporting the first case of alimentary tract perforation.

Antibodies, Anticardiolipin↗
PubMed1994

Predominantly gastrointestinal symptoms and signs in 11 consecutive AIDS patients with gastrointestinal lymphoma: a multicenter, multiyear study including 763 HIV-seropositive patients.

OBJECTIVES: Gastrointestinal lymphoma is a distinct subgroup of lymphoma in HIV-seronegative patients. This study analyzes whether gastrointestinal lymphoma similarly forms a distinct clinical subgroup in HIV-seropositive patients. METHODS: Case control study of medical records of 763 human immunodeficiency virus-seropositive patients admitted to three university hospitals from 1986 through 1992, including 22 with non-Hodgkin's lymphoma. Eleven patients (50%) had gastrointestinal lymphoma, and 11 controls had extraintestinal lymphoma. RESULTS: The clinical presentation in patients with gastrointestinal lymphoma was dominated by gastrointestinal symptoms and signs and gastrointestinal complications. Common symptoms and signs included: change in bowel habits, gross or occult blood per rectum, involuntary weight loss, abdominal pain, abdominal tenderness, peripheral lymphadenopathy, cachexia, and hepatosplenomegaly. Significant gastrointestinal complications during the presenting admission included gastrointestinal bleeding in five, intestinal obstruction in one, and dysphagia from an esophageal stricture in one. Subsequent complications included a walled-off perforating gastric ulcer in one and obstructive jaundice in one. In contrast, the control patients with extraintestinal lymphoma had significantly fewer gastrointestinal symptoms and gastrointestinal complications (p < 0.001 and p < 0.01, respectively, Fisher's exact test). Upper gastrointestinal series or barium enema identified lymphomatous gastrointestinal lesions in all seven patients undergoing these tests. The pathologic diagnosis was made from endoscopic biopsies in six of six patients undergoing panendoscopy, and two of three patients undergoing lower endoscopy. Tumor sites included stomach in six, colon in three, ileum in two, esophagus in two, and duodenum in one. Eight patients had extraintestinal lesions at diagnosis, including four with extraabdominal extranodal lesions. The outcome of gastrointestinal lymphoma was poor with all therapies (mean combined survival = 3.6 +/- 2.2 months), and was not significantly different from that for the controls (mean survival = 4.1 +/- 2.7 months, Student's t test). CONCLUSIONS: This study suggests that gastrointestinal lymphoma in AIDS shares the poor prognosis and aggressive features of extraintestinal lymphoma in AIDS, but has unique localizing features at presentation of predominantly gastrointestinal symptoms and signs, and frequent gastrointestinal complications.

Adult↗
PubMed1993

Splenic infarction associated with anticardiolipin antibodies in a patient with acquired immunodeficiency syndrome.

Although patients with AIDS frequently develop high titers of anticardiolipin antibodies, the clinical significance of this laboratory abnormality in AIDS patients is unknown. A 33-year-old female with AIDS, a prior small cerebrovascular accident, thrombocytopenia, and a coagulopathy suddenly developed left upper quadrant pain and tenderness due to splenic infarction associated with a high titer of anticardiolipin antibodies. Possible clinical manifestations of anticardiolipin antibodies in this patient include recurrent thromboembolism, coagulopathy, and thrombocytopenia. This case report suggests that anticardiolipin antibodies are associated with splenic infarction and that anticardiolipin antibodies associated with AIDS may sometimes be clinically significant.

Acquired Immunodeficiency Syndrome↗
PubMed1993

Massive hemobilia and acalculous cholecystitis due to benign gallbladder polyp.

A 37-year-old male with metachromatic leukodystrophy, a congenital cerebroside storage disease strongly associated with benign gallbladder polyps, presented with hemobilia and acalculous cholecystitis due to a long, slender, benign gallbladder polyp. This case report extends the clinical spectrum of gallbladder polyps and demonstrates a novel cause of hemobilia. The unusually long, slender polyp shape may have promoted hemorrhage due to the potential for torsion around a slender stalk. The mechanism of cholecystitis may have been cystic duct obstruction from blood clots or possibly from prolapse by the long, slender polyp into the cystic duct.

Adult↗
PubMed1993

Pancreatic disease in AIDS--a review.

Patients with the acquired immunodeficiency syndrome (AIDS) can develop pancreatic disease from causes unrelated to AIDS as well as AIDS-specific lesions. AIDS-specific causes include opportunistic infection, AIDS-associated neoplasia, and medications used to treat complications of AIDS. Reported pancreatic opportunistic pathogens include Mycobacterium tuberculosis, Mycobacterium avium intracellulare, Cryptococcus neoformans, Candida, Aspergillus, Toxoplasma gondii, Pneumocystis carinii, cytomegalovirus, herpes simplex, cryptosporidium, and microsporidium. Although cytomegaloviral pancreatic infection can occur without clinically evident pancreatic disease, cytomegalovirus can cause pancreatitis. Other opportunistic infections that can cause pancreatitis include Toxoplasma gondii, Cryptococcus neoformans, and Candida. Mycobacterial infection can produce a pancreatic abscess. Hepatobiliary or pancreatic duct infection by cytomegalovirus, cryptosporidium, and microsporidium causes irregular ductular narrowing and dilatation. This cholangiographic abnormality resembles the pattern found in idiopathic sclerosing cholangitis. Reported AIDS-associated pancreatic neoplasms include Kaposi's sarcoma and lymphoma. Pancreatic involvement is usually part of widely disseminated tumor and rarely produces clinical symptoms. Pentamidine, trimethoprim-sulfamethoxazole, and 2', 3'dideoxyinosine are medications commonly used in AIDS patients which can cause pancreatitis. Pentamidine also causes hypoglycemia or hyperglycemia.

AIDS-Related Opportunistic Infections↗
PubMed1993

Colonic toxicity of administered medications and chemicals.

Although medication-induced colonotoxicity is uncommon, it is important that it be recognized, because the initial therapy for this condition is medication discontinuation. This review categorizes the association between the listed medications and colonotoxicity as "well-established" or "probable," according to the following criteria: number of clinical studies by independent clinical investigators, total number of reported cases, plausibility of an association based on experimental and pharmacologic studies, and validity of an association in each reported case. Medications associated with colonic ischemia include cocaine, ergotamine, estrogen, amphetamines, digitalis, methysergide, and vasopressin. Medications associated with colonic pseudoobstruction include narcotics, phenothiazines, vincristine, atropine or other anticholinergics, ganglionic blocking agents, and tricyclic antidepressants. Medications promoting infectious or necrotizing enterocolitis include numerous antibiotics associated with pseudomembranous colitis, deferoxamine associated with Yersinia enterocolitis, chemotherapy associated with neutropenic colitis, and hyperosmolar medications or formulas in infants. Medications associated with an allergic, inflammatory, or cytotoxic colitis include gold compounds, nonsteroidal antiinflammatory drugs, alpha-methyldopa, flucytosine, methotrexate, salicylates, and sulfasalazine. Potassium chloride, administered in slow-release wax matrices, can cause intestinal ulcers. Chronic cathartic use leads to colonic hypomotility and abdominal distention. Methysergide can cause a colonic stricture due to retroperitoneal fibrosis. Intrarectally administered compounds that have produced a toxic colitis include powerful acids, bases, and other corrosives. Enemas using hypertonic radiographic contrast agents have been associated with colitis in patients with colonic obstruction.

Colonic Diseases↗
PubMed1993

A multicenter, multiyear study of the safety and clinical utility of esophagogastroduodenoscopy in 20 consecutive pregnant females with follow-up of fetal outcome.

OBJECTIVES: To analyze the risks versus benefits of panendoscopy to the pregnant female and fetus. METHODS: Retrospective study of 20 consecutive pregnant patients admitted to three university teaching hospitals during 7 1/2 yr who underwent panendoscopy. RESULTS: Indications for panendoscopy included hematemesis in eight, vomiting and abdominal pain in five, vomiting in four, abdominal pain in two, and melena without hematemesis in one. Six patients were in the first trimester of pregnancy, eight were in the second trimester, and six were in the third trimester. Fourteen patients (70%) had a lesion diagnosed by panendoscopy, including esophagitis in seven, duodenal ulcer in two, gastritis in three, and Mallory-Weiss tear in two. In particular, all nine patients (100%) with gastrointestinal bleeding had a lesion identified by esophagogastroduodenoscopy. No significant endoscopic complications occurred. Panendoscopy did not induce labor in any patient. Fetal outcome was ascertained in 19 (95%) of the pregnancies. Seventeen infants were delivered at full term. Two were delivered at 33 and 35 weeks of gestation. No infant had a congenital malformation noted in the neonatal nursery. The mean infant Apgar scores were 8.2 +/- 1.3 (SD) at 1 min, and 9.1 +/- 0.3 (SD) at 5 min. CONCLUSIONS: In this study of 20 pregnancies, panendoscopy did not induce labor or result in congenital malformations. Panendoscopy is not absolutely contraindicated during pregnancy. Panendoscopy appears to be beneficial in medically stable pregnant patients with significant gastrointestinal bleeding. Panendoscopy should be performed with monitoring by electrocardiography and pulse oximetry after stabilization of vital signs, which may require transfusion of blood products and supplemental oxygen administration.

Endoscopy, Digestive System↗
PubMed1993

A multicenter case-controlled study of percutaneous endoscopic gastrostomy in HIV-seropositive patients.

OBJECTIVES: Malnutrition is an important cause of morbidity and mortality in AIDS patients. Percutaneous endoscopic gastrostomy (PEG) is a safe and effective method of providing nutrition in HIV-seronegative patients who are unable to swallow food, but have an otherwise functional alimentary tract. This study analyzes the risks and benefits of PEG in HIV-seropositive patients. METHODS: The risks of PEG were analyzed in 14 consecutive HIV-seropositive patients admitted to two university hospitals, and were compared with the risks in a sex- and age-matched control group of 21 patients. Thirteen HIV patients had AIDS. RESULTS: PEG indications included mechanical esophageal obstruction in six, wasting in six, and central nervous system disorders in two. The mean weight of the HIV patients increased by 7.4% +/- 3.0% (SE) 3-8 wk after PEG. Despite advanced HIV infection, serum biochemical parameters of nutritional status remained stable at 3-8 wk after PEG. Nine HIV patients suffered 10 complications during a mean follow-up of 111 +/- 147 (SD) days. The HIV patients had six (43%) minor complications, whereas the controls had four (19%) minor complications (not significantly different, Fisher's exact test). Minor complications in the HIV patients included transient tenderness and erythema at the PEG site in four, transient pyrexia without a source in one, and transient ileus in one. The HIV patients had four (29%) significant complications, compared to none in the controls (p < 0.02, Fisher's exact test). Significant complications in the HIV-seropositive patients included stomal cellulitis treated with intravenous antibiotics in three, and gastric bleeding requiring transfusion of one unit of packed erythrocytes in one. None of these complications were severe; all complications rapidly resolved with therapy. The high rate of wound infection following PEG in AIDS patients, like the previously reported high rate of postoperative wound infection in AIDS patients, is attributable to immunosuppression. During the study period, four HIV patients underwent surgical gastrostomy, with one complication of severe gastrointestinal bleeding. CONCLUSIONS: This work suggests that PEG is a useful and relatively safe method of providing long-term nutritional support in selected AIDS patients with a functional gastrointestinal tract.

Acquired Immunodeficiency Syndrome↗
PubMed1993

Fulminant acute colitis following a self-administered hydrofluoric acid enema.

A 33-yr-old white male presented with bloody diarrhea, leukocytosis, and left lower quadrant direct and rebound tenderness after a self-administered concentrated hydrofluoric acid enema while intoxicated from intranasal cocaine administration. Intraoperative flexible sigmoidoscopy and a gastrografin enema revealed severe mucosal ulceration and edema in the rectum and sigmoid colon. Laparotomy revealed an ulcerated, necrotic, and purulent sigmoid colon and intraperitoneal pus. The patient underwent a limited sigmoid resection and a Hartman procedure. Five months later, the patient presented with a rectal stricture which was resected. This case demonstrates that a hydrofluoric acid enema can cause fulminant acute colitis and chronic colonic strictures.

Acute Disease↗
PubMed1993

Chyloperitoneum associated with chronic severe sarcoidosis.

A 51-year-old black female with sarcoidosis diagnosed 20 yr earlier developed massive chyloperitoneum and chylothorax. Autopsy demonstrated fibrotic and enlarged thoracic and mesenteric lymph nodes. Sarcoidosis can produce chyloperitoneum by producing intrathoracic nodal fibrosis and lymphatic obstruction.

Chronic Disease↗
PubMed1993

The safety and clinical utility of esophagogastroduodenoscopy for acute gastrointestinal bleeding after myocardial infarction: a six-year study of 42 endoscopies in 34 consecutive patients at two university teaching hospitals.

The risks versus benefits of panendoscopy performed soon after myocardial infarction were studied. At Robert Wood Johnson University Hospital from January 1986 through December 1991 and at Princeton Medical Center from January 1990 through December 1991, 82 patients developed overt gastrointestinal bleeding (1.2% of all myocardial infarctions) and 14 patients developed occult gastrointestinal bleeding (0.2% of all myocardial infarctions) within 3 weeks after myocardial infarction. Thirty-four of the patients underwent 42 panendoscopies within 3 weeks of myocardial infarction. Indications for the initial endoscopy included hematemesis in 25, melena without hematemesis in four, red blood per rectum in three, and occult blood in the stool in two. The initial panendoscopy, on average, was performed 6.2 +/- 7.5 (SD) days after myocardial infarction. The 34 initial panendoscopies provided the diagnosis in 27 (79%), and clinically helpful information in four (12%). Common diagnoses were duodenal ulcer in 11, hemorrhagic gastritis in four, and hemorrhagic esophagitis in three. Three complications were due to the initial endoscopy, including fatal ventricular tachycardia, near respiratory arrest, and hypotension. These complications occurred in three (37.5%) of eight patients who were significantly unstable before endoscopy. No (0%) complications occurred in the 26 relatively clinically stable patients undergoing the initial endoscopy. This difference in complication rate was statistically significant (p < 0.01, Fisher's exact test). We conclude that recent myocardial infarction is not an absolute contraindication to panendoscopy. In this retrospective study, the benefits exceeded the risks of panendoscopy in medically stable patients with significant gastrointestinal bleeding. Panendoscopy should be performed with monitoring by electrocardiography and pulse oximetry after stabilization of vital signs, which may require transfusion of blood products, supplemental oxygen administration, endotracheal intubation, and mechanically assisted ventilation. Panendoscopy in highly unstable patients had a high complication rate in this study.

Aged↗
PubMed1993

Clostridium difficile infection is a treatable cause of diarrhea in patients with advanced human immunodeficiency virus infection: a study of seven consecutive patients admitted from 1986 to 1992 to a university teaching hospital.

Of 427 human immunodeficiency virus-seropositive patients admitted to the Robert Wood Johnson University Hospital from January 1986 through August 1992, seven had Clostridium difficile enteric infection documented by the presence of cytotoxin B in the stool, without other enteric infection. All seven patients had AIDS, and all had recently received antibiotics. These patients had a severe clinical presentation of C. difficile infection. All patients had profound watery diarrhea, with a mean of 20 +/- 14 (SD) bowel movements per day. Four had fever > 38.5 degrees C, and another had hypothermia. Three patients had borderline hypotension, and another was orthostatic. The mean pulse was 119 +/- 26 (SD) beats/min. Five patients had abdominal pain and tenderness. Two had occult blood in the stool. Four had metabolic derangements such as hyponatremia, hypokalemia, or prerenal azotemia. Three of four patients undergoing abdominal roentgenography had radiographic findings consistent with severe colitis of colonic dilation, mural thumbprinting, or mural thickening. Sigmoidoscopic findings ranged from diffuse erythema to prominent pseudomembranes. During a mean interval of 14.3 +/- 6.2 (SD) days before institution of specific antibiotic therapy, the diarrhea spontaneously resolved in only one of the seven patients. In the others, the diarrhea resolved on average 7.3 +/- 4.0 (SD) days after instituting antibiotic therapy. During a mean follow-up of 4.4 +/- 6.3 (SD) months, only two patients redeveloped diarrhea. Both patients had recurrent C. difficile colitis; the symptoms again rapidly resolved after repeat antibiotic therapy. We conclude that in patients with AIDS C. difficile may present as a severe enteric infection with profound diarrhea due to immunosuppression, that the diarrhea may be prolonged and not remit spontaneously, and that the diarrhea usually rapidly resolves with specific antibiotic therapy.

AIDS-Related Opportunistic Infections↗
PubMed1992

Spatial clustering of simultaneous nonhereditary gastrointestinal angiodysplasia. Small but significant correlation between nonhereditary colonic and upper gastrointestinal angiodysplasia.

Simultaneous nonhereditary colonic and upper gastrointestinal angiodysplasia were spatially clustered in an endoscopic study of 46 consecutive patients. For example, clustering of colonic angiodysplasia was demonstrated using a nonparametric test of clustering (Kruskal-Wallis statistic with 29 degrees of freedom = 76.2, P less than 0.0005), and a parametric test of clustering (F test statistic with 29 and 101 degrees of freedom = 6.91, P less than 0.0005). In accord with spatial clustering, only two of 13 patients (15%) with colonic angiodysplasia who underwent panendoscopy had upper gastrointestinal angiodysplasia. Two of nine patients (22%) with upper gastrointestinal angiodysplasia who underwent colonoscopy had colonic angiodysplasia. These findings suggest that local factors may be important in the pathogenesis of simultaneous nonhereditary angiodysplasia. Possible local factors include intermittent venous obstruction, increased intraluminal pressure, intermittent abnormal arterial flow, and local vascular degeneration. Due to the approximately 20% correlation between upper and lower nonhereditary gastrointestinal angiodysplasia, the upper and lower tract should be examined by endoscopy prior to elective local resection for bleeding from gastrointestinal angiodysplasia.

Aged↗