Biomedical subjects
Publications and source records attributed to R E Kottler.
Fatty infiltration of the liver can be identified by means of and may have a spectacular appearance on computed tomography (CT). Fifteen cases are described and the clinical associations are discussed. CT may be useful as a primary technique for the diagnosis of a fatty liver when performance of a biopsy is contraindicated.
Previously documented and new patients with ulcerative colitis seen between 1975 and 1980 in the Gastro-intestinal Clinic of Groote Schuur Hospital were studied to establish the local incidence and clinical features of this disease. There were 220 patients and the mean follow-up was 7,7 +/- 0,4 years. Sixty per cent of patients were White, 37% Coloured and 3% Black. The incidence for the Coloured and White population was calculated to be 1,3 and 2,4/100 000 per year during 1970-1974 and 1,6 and 2,1/100 000 per year during 1975-1980, respectively. In Jews the rates were 8,5 and 10,4/100 000 per year for the two periods. Insufficient data are available to calculate an incidence for the Black population. The disease was limited to less than 15 cm above the anus in 14% of patients, to the rectosigmoid colon in 45%, and to the rest of the colon in 40%. Although the severity of symptoms was related to the extent of disease, 22% of patients with extensive colitis had mild symptoms, while 15% with disease limited to the rectum had severe symptoms. The clinical features were similar in the White and Coloured population groups. A total colectomy was performed on 20% of patients with extensive colitis; in 2% the disease was complicated by colonic carcinoma.
Patients with Crohn's disease seen in the Gastro-intestinal Clinic of Groote Schuur Hospital between 1975 and 1980 were studied to establish the incidence and clinical features of this disease. There were 117 patients and the mean (+/- SEM) follow-up was 6,1 +/- 0,5 years. Of these patients 72% were White, 37% Coloured and 1% Black. The incidence for the Coloured and White population groups was calculated to be 0,4 and 0,9/100 000 per year during 1970-1974 and 1,3 and 1,2/100 000 per year during 1975-1980 respectively. In Jews the rates were 5,0 and 7,2/100 000 per year for the two periods. Insufficient data are available to calculate an incidence for the Black population. The disease involved the ileum in 39%, the colon in 17% and both areas in 44% of patients. At presentation 18% of patients had mild, 37% moderate, and 45% severe disease. The severity of symptoms was not related to the extent of the disease. A peri-anal fistula was present in 24% of patients. There was no difference in clinical features between the different population groups. Surgical resection had been performed in 50% of patients and 29% of these had had two or more resections. The surgical rate in the ileitis group was 63%, in the ileocolitis group 49% and in those with colitis 20%.
Patients with inflammatory bowel disease and serum alkaline phosphatase persistently raised to more than twice the normal level were investigated to assess the frequency of primary sclerosing cholangitis (PSC) in the Gastro-intestinal Clinic from 1975 to 1981. Twelve patients had a persistently raised alkaline phosphatase level of hepatic origin, 9 out of 250 with ulcerative colitis and 3 out of 164 with Crohn's disease. PSC was demonstrated in 8(3%) of the patients with ulcerative colitis, and carcinoma of the pancreas in the remaining 1. Three of the patients with PSC also had gallstones. The colitis antedated the biliary symptoms and signs in all but 1 patient. There was no correlation between the duration, extent and activity of the colitis and the development and outcome of the liver involvement. Investigations in the 3 patients with Crohn's disease revealed the presence of PSC in 2 (1,2%) and chronic active hepatitis in the 3rd. Of the 2 with PSC, one had cholelithiasis and has had recurrent episodes of cholangitis. The other has had only mild symptoms.
A case of cholecystitis in an intrahepatic gallbladder with concurrent choledocholithiasis is reported. The patient initially presented with pyrexia of unknown origin and subsequently with suppurative cholangitis; the diagnosis was resolved pre-operatively using contemporary techniques of gallbladder delineation. Simple drainage of the gallbladder with choledocholithotomy proved effective.
A case of tuberculosis of the distal colon is described. The presenting features and the sites of the lesions are unusual even in a country where gastrointestinal tuberculosis is common. Attention is drawn to the diagnostic difficulty encountered, as the lesion is often clinically and radiologically indistinguishable from amoebiasis, carcinoma or Crohn's disease.
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Benign or malignant gastric ulcers may influence the contour of the lesser curve. A normally acute incisura angularis (angulus) may become blunted or obliterated by an ulcer because of oedema, fibrosis or infiltration. At a later stage the fibrosis resulting from a chronic ulcer may cause scarring and lesser curve shortening, with displacement of the pylorus towards the fundus. Marked deformities may arise, causing gastric stasis. The radiological demonstration of an abnormal angulus of a shortened lesser curve may occasionally provide the first clue to the presence of a gastric ulcer or other lesion.
Total parenteral nutrition (TPN) carried out by the patient at home is a new concept in the treatment of intestinal failure. We describe a patient with Crohn's disease who has extensive involvement of the small intestine with resultant severe malabsorption, and who was therefore treated with 'home' TPN for 4 months. During this treatment there were no serious complications. The disabling symptoms present before hyperalimentation was commenced disappeared, and overall clinical improvement has been maintained for a further 6 months after TPN therapy. This case illustrates the feasibility of safe TPN at home in selected patients who have access to specialized hyperalimentation units.
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The insertion of oesphagogastric tubes in the palliative treatment of carcinomatous obstruction of the oesophagus is well established. Complications of this procedure are not uncommon whether the tubes are inserted via a gastrotomy or endoscopically. As the aim of insertion is to palliate the patient's condition the prompt recognition of complications is essential. The two most commonly used tubes are described and the complications associated with their use illustrated and discussed. The important role of the radiologist in the initial assessment of the oesophagus (prior to tube insertion) and in the prompt diagnosis of post-insertion complication is stressed.
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Two cases of intramural rupture of the oesophagus are described. In both cases the diagnosis was made endoscopically and confirmed radiologically. Both patients were successfully managed conservatively but were later found to have disordered oesophageal motility. The clinical presentation of severe retrosternal chest pain followed by haematemesis and then dysphagia is stressed, and the diagnostic features on barium swallow examination and endoscopy are described. It is suggested that the diagnosis should be made on clinical presentation and barium swallow, and that the possible hazards of endoscopy in the acute stage should be avoided.
We studied the pancreatic function, alcohol history, and ERCP findings in 26 patients with painless and 34 patients with painful alcohol-induced calcific pancreatitis (AICP). About 50% of patients in both the painless and painful groups continued to take alcohol, the incidence of duct stricture or obstruction was of the order of 62% in both groups, and the proportion of patients with duct stricture or obstruction and continued alcohol intake was comparable. In all instances the patients in the painless category had significantly greater pancreatic insufficiency, or more impaired function, than patients with pain. This applied to those patients who continued to take alcohol, to those with an obstruction or stricture on ERCP, and to the subgroup with both duct narrowing and continued alcohol intake. We conclude that grossly impaired pancreatic function confers a degree of freedom from painful attacks in AICP in those patients who continue to drink even in the presence of duct obstruction or stricture on ERCP; and that patients with AICP become free of pancreatic pain once gross pancreatic insufficiency supervenes.
Twenty-six cases of greater curve gastric ulcers are presented, of which all but one were benign. There appears to have been an increased occurrence of benign greater curve gastric ulcers in our institution. By using a double contrast barium examination diagnostic accuracy was high, although endoscopy and biopsy are required for confirmation. Greater curve gastric ulcers were commonest in elderly patients with concomitant disease and a high intake or oral drugs, particularly analgesics, potassium chloride supplements and steroids. The constant location of the ulceration in the most dependent part of the stomach suggests a causal relationship with drug ingestion in these patients. The term "sump-ulcer" is suggested. A relatively high incidence of perforation and gastrocolic fistulae was found. It would appear that gastrocolic fistulae from benign peptic ulcer disease, previously thought to be excessively rare, are becoming more commonly recognized.
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Some of the recent trends in the detection of breast lesions, in particular carcinoma, are reviewed. The value, indications, accuracy and limitations of mammography are outlined. Malignant calcifications and their localisation for surgery, specimen radiography, cysts of the breast, duct discharge and the problem of juvenile breast lumps are discussed. The possible hazards from radiation should not be deterrent in any examination with a specific clinical problem. The position may have to be reviewed if extensive use is made of mannography in screening well women.