Gastroenterology
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In a patient with cirrhosis and bleeding esophageal varices who had previously undergone a partial gastric resection, the gastric balloon of a Sengstaken-Blakemore tube was inadvertently placed into the efferent jejunal limb of the gastrojejunostomy. Inflation of the balloon to the standard volume of 150 ml resulted in rupture of the jejunum. Precautions in the use of the Sengstaken-Blakemore tube that might prevent this complication are described.
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Comparative Study
Effects of somatostatin on hepatic and systemic hemodynamics in patients with cirrhosis of the liver: comparison with vasopressin.
The effects of somatostatin on hepatic and systemic hemodynamics were investigated in 17 patients with chronic liver disease and severe portal hypertension during the hemodynamic assessment before elective portal-systemic shunt surgery. The injection of somatostatin (1.0 microgram/kg) caused a decrease of the wedged hepatic venous pressure, from 19.5 +/- SE 1.3 mmHg to 14.0 +/- 1.0 mmHg (p < 0.001). ⋯ In marked contrast to the selective action of somatostatin on splanchnic hemodynamics, vasopressin infusion (0.3 U/min) in 6 patients caused not only significant falls in the wedged hepatic venous pressure and estimated hepatic blood flow (-28.6% and -31.8%, respectively), but also significant changes in the systemic circulation, including a reduction of the cardiac output (-19.7%, p < 0.01) and heart rate (-12.6%, p < 0.01) and an increase of the arterial pressure (+18.8%, p < 0.01) and peripheral resistance (+46.8%, p < 0.01). These results show that somatostatin effectively reduces hepatic blood flow and portal pressure in patients with cirrhosis and severe portal hypertension, without altering the systemic circulation.
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This study examines the effect of increasing duration of intestinal ischemia on the mucosal integrity and the release of the enzyme diamine oxidase from the small intestine. Acute ischemia was produced by the occlusion of the superior mesenteric artery, and the subsequent changes in DNA and 125I-albumin content in the lumen were taken as indices of intestinal lesions. Diamine oxidase activity was measured in the intestinal lumen, mucosa, lymph, and serum. ⋯ Increases in the diamine oxidase activity were also observed in the intestinal lymph and serum, reaching levels that were 2.6 and 3.6 times that of the control respectively after 60 min of ischemia. These findings suggest that intestinal ischemia reduces the diamine oxidase content in the intestinal mucosa by desquamation of the surface epithelial cells and by releasing the enzyme into the intestinal interstitial fluid, from which at least a portion is transported to the blood via the lymphatics. The early release of diamine oxidase seems to occur before the mucosal barrier is broken.
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Randomized Controlled Trial Comparative Study Clinical Trial
Double-blind cross-over study comparing loperamide, codeine and diphenoxylate in the treatment of chronic diarrhea.
As no adequate comparison of these widely used drugs has been made, we have performed a double-blind cross-over trial in 30 individuals with chronic diarrhea. Each underwent three randomized treatment periods of 4 wk duration. Patients were instructed to increase the daily dose gradually until control was achieved or side effects became intolerable. ⋯ Side effects, particularly central nervous effects, were greatest with diphenoxylate and least with loperamide. Approximately equal numbers discontinued each preparation; poor control and central-nervous-system side effects were the usual reasons for stopping diphenoxylate and codeine, and abdominal pain and constipation for stopping loperamide. We conclude that both loperamide and codeine phosphate are superior to diphenoxylate in the symptomatic treatment of chronic diarrhea.
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Comparative Study
Portal hypertension, size of esophageal varices, and risk of gastrointestinal bleeding in alcoholic cirrhosis.
We studied the relationship between the degree of portal hypertension measured by the gradient between wedged and free hepatic venous pressures, the size of esophageal varices, and the risk of gastrointestinal bleeding in a series of 100 unselected patients with alcoholic cirrhosis. The degree of portal hypertension was not different in patients with no visible, in those with small-sized, and in those with large-sized, esophageal varices. ⋯ The risk of gastrointestinal bleeding, whether due to ruptured varices or acute gastric erosions, was significantly higher in patients with large-sized, than in those with no visible or small-sized, esophageal varices. It is concluded that, in patients with alcoholic cirrhosis, (a) the degree of portal hypertension has no predictive value for the risk of gastrointestinal bleeding and (b) large-sized esophageal varices are associated with a high risk of occurrence or recurrence of gastrointestinal bleeding and could be taken into account for a better selection of patients for portacaval shunt.