Treatment of achalasia with the Witzel pneumatic dilator.
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Adult↗
Biomedical subjects
T T Nostrant
Publications and source records attributed to T T Nostrant.
Supraventricular tachycardia induced by swallowing: a case report and review of the literature.
A 64-year-old man who complained of palpitations brought on by swallowing was found to have short runs of paroxysmal supraventricular tachycardia (SVT) induced by swallowing. Electrophysiology studies suggested that the SVT was an automatic atrial tachycardia. An esophageal manometric study demonstrated that the tachycardia was coincident with relaxation of the upper esophageal spincter and preceded peristaltic activity in the esophageal body. Atropine and bethanechol did not affect the swallow-induced tachycardia. The patient's symptoms were controlled by verapamil and quinidine. After five months, these medications were discontinued, with no recurrence of symptoms. Based on analysis of ten prior cases and the present case, it appears that swallow-induced SVT generally occurs in men between the ages of 45-75 years who have no evidence of structural heart disease or an esophageal disorder. The SVT is usually either a nonsustained automatic atrial tachycardia or atrial fibrillation. The mechanism is conjectural, but the most likely possibility is a vagally-mediated neural reflex, probably involving a neurotransmitter other than acetylcholine.
Deglutition↗
Maintenance therapy for prevention of recurrent peptic ulcers.
Peptic ulcer disease is a chronic, relapsing disease. Successful healing of duodenal and gastric ulcers with antacids, cimetidine, ranitidine, famotidine, or sucralfate is frequently followed by ulcer recurrence. The need for long-term, low-dose maintenance therapy is based on disease severity, ulcer history, complications, therapeutic intervention, response to treatment, and potential risk factors. Comparison of ulcer maintenance trials requires consideration of important factors such as frequency of endoscopy, duration of follow-up period, and the method used to calculate ulcer recurrence rates. Clinical trials indicate that chronic treatment with low-dose cimetidine, ranitidine, famotidine, and probably sucralfate decreases the frequency of duodenal ulcer recurrence and that ranitidine may be superior to cimetidine. Preliminary studies indicate that higher doses of these same medications may be required to prevent gastric ulcer recurrence. Long-term maintenance therapy with these agents must be continuous in order to prevent relapses, but treatment should be limited to one year because of unknown consequences beyond this period.
Anti-Ulcer Agents↗
Propranolol for the treatment of the alcoholic hangover.
Hangover following consumption of alcohol includes many disagreeable signs and symptoms that are suggestive of sympathetic overactivity. We performed a randomized, double-blind, crossover controlled study to assess the effect of beta blockade in preventing the symptoms of hangover. Ten subjects were randomized to receive 160 mg of a long-acting preparation of propranolol or a placebo and then participated in a controlled drinking situation. Patients were then evaluated for symptoms and signs of hangover. The results showed that although beta blockade was achieved, there was no clinically important reduction in symptoms of hangover. We conclude that propranolol does not prevent the symptoms of hangover.
Adult↗
Treatment of Wilson's disease with zinc: III. Prevention of reaccumulation of hepatic copper.
Twelve patients with Wilson's disease, most of whom had received intensive treatment with penicillamine, were given zinc therapy as their sole medication for copper control. Serial liver biopsies were performed during a 12- to 20-month follow-up period to determine whether hepatic copper reaccumulates during zinc therapy. Mean baseline liver copper concentration was 255 micrograms/gm dry weight, whereas the mean value after therapy was 239 micrograms. No patient demonstrated hepatic reaccumulation of copper during zinc therapy. Copper balance, 24-hour urinary copper excretion, and nonceruloplasmin plasma copper concentration all indicated good copper control during zinc therapy. Hepatic zinc concentration increased twofold to threefold over baseline values but no toxicity was seen. Hepatic zinc concentrations appeared to reach a plateau after 12 to 18 months of zinc therapy. We conclude that oral zinc as the sole maintenance therapy in patients with Wilson's disease prevents hepatic reaccumulation of copper.
Copper↗
Gastric xanthomatosis and cholestasis. A causal relationship.
We report two cases of gastric xanthomatosis which developed in patients with marked cholestasis. In both cases, one with acute and one with chronic cholestasis, the gastric xanthomas disappeared with resolution of the cholestasis. A review of the literature is also provided.
Adult↗
Bethanechol increases the diagnostic yield in patients with esophageal chest pain.
The diagnostic yield of routine esophageal manometrics in evaluating noncardiac chest pain is low. To determine if bethanechol stimulation would increase the diagnostic yield, we examined 87 patients with chest pain but no gastroesophageal reflux, 47 patients with gastroesophageal reflux but no chest pain, and 20 normal subjects. All subjects underwent standard esophageal manometrics before and after two doses of 50 micrograms/kg body wt bethanechol administered subcutaneously 15 min apart. Mean amplitude and duration of contractions and percentage of abnormal contractions were measured in the distal 7 cm of the esophageal body. Pathologic manometric parameters were defined as mean +/- 2 SD of values obtained in normal patients. Patients with chest pain had pathological responses for amplitude of contraction, duration of contraction, and percentage of abnormal contractions of 31%, 14%, and 22%, respectively, in the basal period. This increased to 43%, 66%, and 40%, respectively, after the first dose of bethanechol and to 53%, 85%, and 82% after the second dose of bethanechol. Chest pain was reproduced with new manometric abnormalities in 46% of patients after the first dose of bethanechol and in 77% after the second dose. Our conclusions are that: sequential bethanechol administration significantly increases the diagnostic yield of standard esophageal manometrics in the evaluation of noncardiac chest pain and duration of contraction after pharmacologic provocation with bethanechol is the best parameter to segregate patients with chest pain from normal subjects and gastroesophageal reflux patients.
Adult↗
Propranolol for the treatment of the alcoholic hangover.
Hangover following consumption of alcohol includes many disagreeable signs and symptoms that are suggestive of sympathetic overactivity. We performed a randomized, double-blind, crossover controlled study to assess the effect of beta blockade in preventing the symptoms of hangover. Ten subjects were randomized to receive 160 mg of a long-acting preparation of propranolol or a placebo and then participated in a controlled drinking situation. Patients were then evaluated for symptoms and signs of hangover. The results showed that although beta blockade was achieved, there was no clinically important reduction in symptoms of hangover. We conclude that propranolol does not prevent the symptoms of hangover.
Adult↗
Cytomegalovirus cholangitis in a homosexual man with acquired immune deficiency syndrome.
A 29-year old white homosexual man with acquired immune deficiency syndrome presented initially with right upper quadrant pain and progressive cholestasis. Diffuse mucosal irregularities were seen at endoscopic retrograde cholangiography. Histopathological examination of the gallbladder and wedge liver biopsy showed evidence of cytomegalovirus infection. A repeat endoscopic retrograde cholangiography for persistent symptoms of right upper quadrant pain and cholestasis showed progressive mucosal irregularities of the intra- and extrahepatic bile ducts consistent with progressive cholangitis. Subsequently the patient developed evidence of disseminated infection and died. Postmortem examination revealed histologic features of cytomegalovirus infection in lungs, pancreas, small bowel, adrenal glands, and liver. Immunohistochemical staining of liver confirmed the presence of cytomegalovirus infection of the biliary duct system.
Acquired Immunodeficiency Syndrome↗
Gastroduodenal artery aneurysm presenting as chronic gastrointestinal blood loss.
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Aneurysm↗
Leucocytoclastic vasculitis (hypersensitivity angiitis) of the small bowel presenting with severe gastrointestinal hemorrhage.
A case of leucocytoclastic vasculitis involving the entire small bowel is reported. A high index of suspicion and recognition of the early palpable purpuric skin lesions in patients with acute abdominal pain and gastrointestinal hemorrhage might avert unnecessary surgical exploration in some patients.
Accidents↗
Esophagitis caused by nonsteroidal anti-inflammatory medication: case reports and review of the literature on pill-induced esophageal injury.
We report six cases of pill-induced esophageal injury, two of which were caused by the nonsteroidal anti-inflammatory medications ibuprofen and piroxicam, which have not been implicated previously in pill-induced injury.
Adult↗
Herpetic esophagitis: a diagnostic challenge in immunocompromised patients.
Viral esophageal infection is common in immunocompromised patients. Twelve patients with esophagitis secondary to herpes viruses are described. Odynophagia, dysphagia, and gastrointestinal bleeding were the most common symptoms. Multiple infections particularly with candida were present in three of the 12 cases (25%). Typical "volcano ulcers" at endoscopy and discrete diffusely scattered shallow ulcers seen on double contrast esophagram are highly suggestive of herpetic esophagitis. Single contrast esophagram plays no specific role in the diagnosis of herpetic esophagitis. An analysis of clinical, endoscopic, radiological, and pathological features is presented.
Adolescent↗
Giant hamartoma of the colon: Peutz-Jeghers type.
We have seen a young man with multiple large-bowel polyps and a single immense colonic polyp of the Peutz-Jeghers type. It was completely removed primarily to control hemorrhage and to exclude focal adenomatous or carcinomatous change. We review the spectrum of colonic hamartomas.
Adult↗
Gastroduodenal ulcerations in patients receiving selective hepatic artery infusion chemotherapy.
Ninety-three patients with liver metastases underwent selective hepatic arterial infusion of chemotherapeutic agents through a surgically implanted hepatic artery catheter and pump. Fourteen patients who developed upper gastrointestinal symptoms at some time during the course of treatment were found to have gastroduodenal disease endoscopically. The severity of symptoms did not necessarily correlate with severity of endoscopic findings. There was no temporal relation between 5-fluoro-2'-deoxuridine infusion and symptoms; however, with mitomycin C, symptoms worsened in five of eight patients within 2 wk of the initial injection. Patients who received mitomycin C had more severe endoscopic findings and two of the 14 patients required partial or total gastrectomy. When biodegradable starch microspheres were coadministered with mitomycin C this was not associated with a higher incidence of gastroduodenal disease. The early experience with therapy using this system has been associated with a significant incidence of upper gastrointestinal symptoms. The presence of gastrointestinal symptoms in such patients should alert one to potentially serious disease.
Adult↗
Bleeding lipomas of the upper gastrointestinal tract. A diagnostic challenge.
Submucosal lipoma of the upper gastrointestinal tract is a rare benign tumor. However, it may present as both a diagnostic problem and as a life threatening lesion due to exsanguinating hemorrhage. The authors report four patients with significant upper gastrointestinal bleeding due to ulcerating lipomas. In two patients the lesions were gastric and in two patients the lesions were duodenal in origin. In no instance could the diagnosis of lipoma be accurately established short of operative intervention because of unusual morphologic features. Surgical extirpation was necessary to stop the bleeding and establish the histologic diagnosis of the tumor.
Adult↗
Patient selection and survival after peritoneovenous shunting for nonmalignant ascites.
Patient selection and survival after peritoneovenous shunting for nonmalignant ascites was assessed in 30 patients undergoing 44 peritoneovenous shunting procedures over a 5-year period. Indications for peritoneovenous shunting included refractory ascites alone, refractory ascites complicated by hepatorenal syndrome, and nonrefractory but recurrent ascites. Fifty-six percent of shunting procedures were complicated by shunt malfunction and an additional 13% ended in shunt removal or ligation. Serious perioperative morbidity occurred in 47% of patients. Mean duration of shunt function was significantly less (p less than 0.05) in the patients with hepatorenal syndrome (15 +/- 5 days) compared to the patients with refractory ascites alone (45 +/- 13 days), or the patients with nonrefractory ascites (64 +/- 34 days). Mean survival was 265 +/- 87 days. Survival of patients with nonrefractory ascites (767 +/- 214 days) was significantly longer (p less than 0.05) than that seen in patients with hepatorenal syndrome (28 +/- 5 days) or in patients with refractory ascites alone (256 +/- 148 days). Combined inhospital mortality was 30%. It was significantly greater (p less than 0.05) in patients with hepatorenal syndrome (70%) than in patients with refractory ascites alone (14%) or in patients with nonrefractory ascites (0%). We conclude that patient selection significantly influences survival after peritoneovenous shunting and may account for the varying results reported by other groups.
Adult↗
Non-obstructive colonic dilation: radiologic findings in 50 patients following colonoscopic treatment.
Fifty patients with acute onset of colonic dilatation without mechanical obstruction were evaluated before and after colonoscopic decompression. Colonic dilatation, as demonstrated radiographically, was segmental or consistent with mechanical obstruction in 33 (66%). Signs of impending cecal perforation were seen in five (10%) and these patients had colonoscopic decompression, tube cecostomy, or both. Following colonic decompression, cecal diameter may remain unchanged for two to four days, despite decreased abdominal girth and even shortening of the colon radiographically. Improvement in pain, distention, tenderness, fever and leukocytosis may precede radiographic improvement. The radiologist must recognize this entity, look for signs of impending perforation and signs of bowel shortening, with or without decompression after treatment. Barium studies of the colon should be avoided since they can hamper the endoscopic diagnosis and treatment of colonic dilatation.
Adult↗