Advanced minimal residual ovarian carcinoma: abdominopelvic irradiation following combination chemotherapy

Seventeen patients with advanced ovarian carcinoma who had minimal residual intraabdominal disease after six months of combination chemotherapy were treated with abdominopelvic irradiation. All 17 patients had residual intraabdominal tumor nodules with a cross-sectional diameter of less than 2 cm. Eleven had only microscopic residual disease at the time of irradiation. Fourteen have relapsed at a median of eight months after the completion of radiotherapy. All but two had intraabdominal recurrences. Myelosuppression was common and severe, causing marked delays or discontinuation of radiotherapy in ten of 17 patients. Patients receiving the entire planned dose of radiotherapy had longer disease-free survival (14 months median) than did patients receiving only partial doses (seven months median). However, six of seven patients receiving full dose irradiation have relapsed. Abdominopelvic irradiation in the schedule employed here is poorly tolerated and is not an effective salvage treatment in patients with limited or microscopic residual tumor following initial combination chemotherapy.     

Acute diarrhea during pelvic irradiation: is small-bowel volume effect different in gynecologic patients with prior abdomen operation or not?

OBJECTIVE: To evaluate volume effect of small bowel for diarrhea during pelvic irradiation in gynecologic patients with or without prior abdomen operation. METHODS: From January 1996 through December 2003, 759 patients undergoing 4-field pelvic irradiation for cervical or uterine cancer were analyzed. Whole pelvic (WP), modified whole pelvic (MWP), or lower pelvic (LP) irradiation were delivered initially. According to contrast medium within small bowel in simulation films, we categorized the small-bowel volume of full dose related to WP fields as small-volume and large-volume groups. We recorded the severity of diarrhea until 39.6 Gy/22 fractions of pelvic irradiation. The actuarial rates of overall and moderate to severe diarrhea were compared among different groups. RESULTS: Significantly more large-volume distribution (85%) was noted in patients >60 years without prior operation (P < 0.001). Large-volume distribution was 53%, 65%, and 82% in post-operative patients with no diarrhea, mild diarrhea, and moderate to severe diarrhea (P = 0.002), respectively. The corresponding rate was 79%, 77%, and 80% in patients without prior abdomen operation (P = 0.869). In multivariate analysis, prior operation with LP fields (P = 0.005) and prior operation with small volume (P = 0.031) were significantly protective factors for overall diarrhea. The latter was also a protective factor for moderate to severe diarrhea (P = 0.026). Prior operation could diminish overall diarrhea in patients without simultaneous large-field (WP or MWP) and large-volume. Large volume was a significant factor of overall (P = 0.014) and moderate to severe (P = 0.004) diarrhea in large-field patients with operation. The volume effect did not exist in those patients without operation. CONCLUSION: Age and operation can change small-bowel distribution. Prior operation may attenuate diarrhea if irradiated volume of small bowel is small. There is a volume effect in post-operative rather than non-operative patients receiving large-field irradiation. More practical dose-volume evaluation of small bowel may be applied for volume effect in gynecologic patients without prior operation.     

Salvage radiotherapy for carcinoma of the ovary following chemotherapy

Following single-agent or combination chemotherapy, 9 patients with epithelial carcinoma of the ovary had elective second-look laparotomy. Macroscopic intraperitoneal disease was resected in 4 patients. Therefore, after the laparotomy, all 9 patients had only biopsy-proven, microscopic residual disease, and they received whole abdominopelvic irradiation. Hematological tolerance was satisfactory, with only 2 patients developing asymptomatic thrombocytopenia. Mild gastrointestinal reactions, while frequent during radiotherapy, did not interrupt treatment in any patient. After follow-up from 12 to 34 months (median 16 months) [corrected], 2 patients died of cancer, 2 were alive with cancer, 3 were alive without clinical recurrence, and 2 were alive without biopsy-proven recurrence. Bowel complication occurred in 4 patients: 2 developed intestinal obstruction due to recurrent tumor, 1 developed subacute bowel obstruction which spontaneously resolved, and 1 patient required bowel resection because of a radiation complication. This study indicated that after single- or multiple-drug chemotherapy, most patients could complete the course of whole abdominopelvic irradiation. Gastrointestinal complications could be secondary to radiation damage or to recurrent tumor. While whole abdominopelvic irradiation was not an effective second-line treatment, some long-term survivors could still be expected.     

Intracervical versus intravaginal PGE2 for induction of labor at term in patients with an unfavorable cervix

In a randomized double-blind study we evaluated the effects on cervical ripening and labor induction of 0.5 mg PGE2 in gel given intracervically and 2.0 mg PGE2 given as a vaginal suppository. All patients were at term with unfavorable cervical scores. The indications for induction were toxemia, diabetes mellitus, Rh-immunization, or intrauterine growth retardation. Significantly better results for both cervical priming and labor induction were obtained after intracervical PGE2-gel application than after treatment with placebo or vaginal suppositories. Eleven out of 19 patients (58%) were delivered within 24 h after intracervical PGE2-gel compared to two out of 19 patients given placebo (p less than 0.01). In patients not delivered 24 h after the start of treatment, the mean cervical score had changed from 3.7 to 6.0 (p less than 0.05) after PGE2-gel application compared to a change from 3.9 to 4.3 after placebo treatment (n.s.). The outcome after treatment with PGE2 suppositories did not differ significantly from that with placebo treatment. In a subsequent study 25 patients were given 0.5 mg PGE2-gel intracervically. The results were consistent with those obtained in patients receiving PGE2-gel intracervically in the double-blind study. Few side effects were noted. No patient complained of gastro-intestinal discomfort but increased myometrial activity was observed in two patients; one after placebo and the other after active intracervical PGE2-gel treatment. The hyperactivity was readily countered with the beta 2-agonist, terbutaline. All infants were born in good condition with Apgar scores of 7 or more within 5 min. At pediatric examinations at 1 week and at 6 months of age all children seemed healthy.     

Comparative study of conservative and surgical management for symptomatic moderate and severe hydronephrosis in pregnancy: a prospective randomized study

BACKGROUND: To analyze the role of different measures in the treatment of acute moderate or severe symptomatic hydronephrosis in pregnancy. METHODS: Of the 18,130 women delivering at our institution between January 2000 and December 2004, 93 patients were admitted due to symptomatic hydronephrosis. Among these, 50 patients were diagnosed with moderate or severe hydronephrosis, and were randomly treated with conservative measures (25 patients) or double pigtail stent insertion (25 patients). Renal sonography, urinalysis, serum creatinine levels, white blood cell counts, and urine culture were done in all patients at first visit. The clinical and perinatal outcomes of the two groups were compared. RESULTS: The incidence of symptomatic hydronephrosis in pregnancy was 0.5% in our institution (93/18,130). The majority of the moderate or severe hydronephrosis (88%) cases were diagnosed after the first trimester. There were no statistically significant differences in the fetal body weight, Apgar score, preterm labor, and hospitalization day between the two groups. Among those receiving conservative treatment, five patients (5/25, 20%) failed to respond and were subsequently treated by double pigtail stent insertion successfully, compared with the surgical group, in which all patients were successfully relieved by double pigtail stent (p=0.018). Four patients receiving double pigtail stent insertion complained of stent discomfort and flank pain after the procedure (16%). CONCLUSION: Double pigtail stent insertion is effective for the treatment of moderate or severe symptomatic hydronephrosis in pregnancy, and showed a lower failure rate than the conservative treatment. However, due to the complications and discomfort with surgical treatment, conservative treatment should still be the first choice.     

Extended field irradiation for cervical cancer based on surgical staging

Surgical staging was done in 355 patients with carcinoma of the cervix. Periaortic node biopsies, peritoneal cytology, and/or biopsy were obtained to determine the need of extended field irradiation. Forty-one patients received extended field irradiation. On review, 38 of these patients were shown to have cancer in the periaortic nodes or peritoneal cavity. Of these patients, 5 have survived longer than 5 years, 3 with metastatic cancer in the periaortic nodes and 2 in the peritoneal cavity. Irradiation to extended fields was 4500 rad or less for the first 17 patients. Since then 5100 rad has been delivered at the rate of 850 rad per week. The incidence of bowel complications was not excessive, utilizing a suture technique to exclude small bowel from the pelvis. Control of the cancer occurred in one patient with massive metastatic periaortic disease. A safe and effective dosage level for radiation therapy has been established with the described limited surgical exploration.     

Extended field irradiation for invasive carcinoma of the cervix

Fourteen patients with primary carcinoma of the cervix and 1 patient with recurrent carcinoma received extended field irradiation because of lymphangiographic evidence of para-aortic nodal metastases. After a minimum follow-up of 24 months, 6 of 15 patients survived with no evidence of disease and 1 survived with disease. Five patients developed major bowel complications and 1 patient died from small bowel perforation probably caused by the radiation treatment. The morbidity of extended field irradiation was high when the radiation dose was more than 4500 rads in 5 weeks to the para-aortic lymph nodes.     

Radical surgery compared with intracavitary cesium followed by radical surgery in cervical carcinoma stage IB. Analysis of patients less than or equal to 45 years of age with small tumors with regard to treatment results and ovarian preservation in the primary surgery group

Forty-nine patients aged less than or equal to 45 years, with cervical carcinoma stage IB (less than or equal to 3 cm) were treated with either primary radical surgery (n = 26), or intracavitary irradiation followed by radical surgery (n = 23). With primary surgery, ovarian function had been preserved in 15 of the 25 patients, who were alive and well. Seven of the primary surgery patients were irradiated postoperatively and 2 others with a central recurrence were cured by irradiation. One other patient, who was not irradiated postoperatively, had an intestinal metastasis and died of the disease. If any of the adverse prognostic factors (as reported in the literature) had been considered as an indication for postoperative irradiation, 17 patients instead of 7 would have been irradiated after primary radical surgery. In the comparable group of 23 patients treated by intracavitary irradiation and radical surgery (and in 4 cases postoperative irradiation as well) there was no recurrence. There was no significant statistical difference between the treatment results in the cesium + surgery group and those who underwent primary radical surgery. Young patients with early cervical carcinoma without prognostic indicators for postoperative irradiation can benefit from primary radical surgery, because their ovarian function can be preserved.     

A prospective, randomized, national trial for treatment of ovarian cancer: the role of chemotherapy and external irradiation

A prospective, randomized, national trial for comparing the effects of cytotoxic agents and radiotherapy on survival in primary epithelial ovarian cancer stages I-IV was carried out in 363 patients. After laparotomy, the patients were staged according to disease spread and randomized into treatment groups within each stage. The single or combined cytotoxic agents used were: cyclophosphamide (C) and vincristine (V); 5-fluorouracil (F) and dactinomycin (D) and V; treosulfan (T); and CF. In stages I, II and III there was one treatment group receiving external irradiation; in stage IV only different cytostatics were used. It was found that, in stage I, surgery alone was superior to surgery +CV or surgery + irradiation. In stage II disease, no differences in survival between treatment groups receiving pelvic irradiation or FDV, and in stage III between whole abdomen + pelvic irradiation or CV or FDV were found. In stage IV, FDV, T and CF were of similar, poor efficacy. The authors conclude that in stage I pelvic irradiation or combined chemotherapy do not improve survival. In advanced disease, chemotherapy may be better tolerated and thus preferable to whole abdomen irradiation; the combination of more modern cancer drugs with the ones used in this study is probably likely to improve the treatment results.     

Whole-abdomen radiation as a second-line therapy for epithelial ovarian cancer

Whole-abdomen irradiation was delivered to 11 patients with persistent epithelial ovarian cancer after chemotherapy. Ten of the eleven patients have recurred and subsequently died of disease. The median time to recurrence was 5.5 months. All 10 recurrences were within the irradiated field. All 6 patients with microscopic disease at second-look laparotomy recurred. Four of the five patients with minimal residual disease (less than or equal to 5 mm) at second-look laparotomy recurred. One patient is alive with no evidence of recurrence at 14 months. Four patients developed small bowel obstruction, three of which were associated with recurrence. During therapy, 4 patients developed significant enteritis and 5 patients developed significant bone marrow suppression. All 11 patients completed radiation therapy, although in 4 there were interruptions of 1 to 3 weeks. Whole-abdomen irradiation does not appear to be an effective second-line regimen for epithelial ovarian cancer, even in the presence of microscopic or minimal residual disease.     

10-Gy single-fraction pelvic irradiation for palliation and life prolongation in patients with cancer of the cervix and corpus uteri.

OBJECTIVE: The goal of this study was to evaluate the effects of single fractions of 10 Gy pelvic irradiation for palliation and life prolongation in patients with cancer of the uterine cervix or corpus. METHODS: A retrospective analysis was performed on 37 cervical cancer and 27 corpus cancer patients treated in the period 1988-1998. All patients had a life expectancy of less than 1 year. Due to stage of disease, age (median 82 years), or comorbidity they were considered unapt for surgery or conventional radiotherapy. Eleven patients with recurrence within irradiated field or early progression received one, 51 patients received two, and 2 patients received three fractions with a 4-week interval. RESULTS: Vaginal bleeding stopped in 90% and malodorous discharge in 39% of the patients. Among 46 patients with advanced disease treated for palliation, 10 (22%) showed complete tumor responses. Median time to progression was 6 months, and median survival, 9 months. Eighteen patients with early-stage disease and serious comorbidity were treated with life prolongation and symptom prevention as intention, and showed seven complete responses. Median survival was 13 months, and half the deaths were caused by intercurrent disease. Median hospital stay was 5 days and rehabilitation was easy. Fifty-six percent of the patients experienced no acute side effects and 33% had minor gastrointestinal problems. Three patients (6%) had serious late bowel complications, one with a fatal outcome, the symptoms appearing 9-10 months posttreatment. CONCLUSION: The 10-Gy single-fraction pelvic radiation regimen is an effective means of symptom palliation and is well tolerated. Tumor responses are obtained. The risk of late bowel complications is a concern for patients with a life expectancy greater than 9 months.     

Secondary cytoreductive surgery in epithelial ovarian cancer: nonresponders to first-line therapy

Thirty-three patients with progressive or stable epithelial ovarian cancer who underwent secondary tumor-reductive surgery at the University of Texas M. D. Anderson Cancer Center were retrospectively studied. All patients had primary cytoreductive surgery followed by chemotherapy. Lack of response to chemotherapy was clinically documented preoperatively. The tumors of 55% of the patients were secondarily cytoreduced to a greatest diameter of less than 2 cm. Sixty-six percent of the patients required bowel resection. Operative morbidity occurred in 24% of patients, mostly in those with bowel resection. Overall, median survival after secondary surgery was 9.4 months. For patients with residual tumor less than 1 cm, median survival after secondary surgery was 19.5 months, compared with 8.3 months for patients with residual tumor of 1 cm or more (P less than 0.004). Patients with an interval between primary cytoreductive effort and secondary surgery of less than 12 months survived a median of 7.3 months, compared with an 18.3-month median survival for patients with an interval of 12 months or more (P less than 0.004). The present study provided no evidence that secondary surgery is of significant benefit in most patients who have progressive disease during chemotherapeutic treatment of epithelial ovarian cancer.     

Incidence of fecal incontinence after coloproctostomy below five centimeters in the rectum

Anastomosis of the descending colon to the rectum below 5 cm can result in fecal incontinence. We have reviewed 90 patients who underwent radical resection of the rectosigmoid colon with very low anastomosis that healed; 88 patients resumed defecation per anus. Indications for the resections were recurrent squamous cell carcinoma after total pelvic irradiation, adenocarcinoma of the endometrium with invasion of the mesentery of the rectosigmoid colon, endometriosis with low rectal involvement, and serous carcinoma of the ovary with invasion of the rectosigmoid mesentery and irradiation stenosis of the rectum. The rectum was transected at the level of the levator ani or below resulting in less than 5 cm of rectum above the anus. All patients had reanastomosis, coloproctostomy, with the end-to-end anastomosis stapler. All coloproctostomies were protected by proximal diverting colostomy if one of three conditions existed: (a) total pelvic irradiation; (b) significant diverticulitis or other inflammatory bowel disease; and (c) inadequate or unprepared bowel at the time of surgery. The proximal diverting colostomies were closed 8-16 weeks postoperatively after demonstrable healing of the anastomosis. Of the 90 patients, 88 eventually resumed defecation per anus after coloprotostomies and 5 (5%) required replacement of the colostomy for fecal incontinence. Eighty-three patients (92%) had successful reanastomosis, closure of the proximal colostomy, and defecation per rectum without fecal incontinence.     

Clinical manifestations of acute rejection in renal allograft recipients receiving cyclosporin-A therapy.

Cyclosporin-A-treated renal allograft recipients have demonstrated an improved graft survival rate, when compared to that of patients treated with conventional azathioprine and steroid therapy. Cyclosporin-A has been used for immunosuppressive therapy after renal transplantation at the National Taiwan University Hospital since November 1985. Since then, the one-year graft survival rate has been 78%, and the patient survival rate is 91%. At our service, acute rejection is confirmed mainly by an increase in the serum creatinine level of 0.5 mg% per day and a subsequent return of kidney function to normal after pulse steroid therapy. Twenty patients receiving cyclosporin-A and suffering from acute rejection episodes were chosen for comparison with 18 patients receiving conventional azathioprine and steroid therapy. Compared to conventional therapy, the classical systemic manifestations of rejection, such as malaise, lethargy, apathy, general weakness, vague discomfort, increase in body weight, swelling of graft with tenderness, were all more mild and less frequent in the cyclosporin-A-treated group. Episodes of rejection appeared earlier and the duration of rejection was shorter than in those of the conventional group. The urinary sodium concentration and the ratio of urine urea nitrogen to blood urea nitrogen were reliable references during the acute rejection episode in the conventional group, but it cannot be used as indices in the cyclosporine group. These findings can help us understand the changes which occurred in acute rejection in patients who receive renal transplantation during the cyclosporine era.     

Capsule endoscopy for gastrointestinal bleeding with an obscure etiology.

BACKGROUND AND PURPOSE: Capsule endoscopy (CE) is a new diagnostic modality that is being utilized with increasing frequency for examination of lesions suspected to be of small bowel origin. The most common indication for CE is obscure gastrointestinal bleeding. This study investigated the safety and diagnostic value of CE in patients with obscure gastrointestinal bleeding. METHODS: From February 1 to October 30, 2003, 35 patients with obscure gastrointestinal bleeding among 43 consecutive patients with suspected small bowel pathology were enrolled. The mean age of the patients was 50.5 years (range, 24-81 years). A negative panendoscopy and colonoscopic study were required for study eligibility. An M2A video capsule endoscope was swallowed by each patient after an overnight fast if plain abdominal radiograph done 1 day prior to the procedure was negative for obstruction. Bowel preparation using a mixed solution containing magnesium carbonate, citric acid anhydrous and potassium bicarbonate, and bisacodyl was performed only in selected patients. RESULTS: Abnormal findings were noted in 31 of 35 patients (89%), 20 (57.2%) of whom had gastrointestinal pathology explaining their symptoms. Only 12 (34%) of the 20 patients had lesions solely in the small bowel. Angiodysplasia was the most common source of bleeding (37%), followed by Crohn's disease (14%). Other findings included Osler-Weber-Rendu's disease, gastrointestinal stromal tumor, vascular ectasia and small bowel diverticulum. Three capsules became lodged and did not provide images during subsequent transit through the colon, but serial abdominal plain radiographs done every 3 days after capsule ingestion showed passage of the capsules had occurred by 1 week. No discomfort or side effects were noted up to 2 months after ingestion. CONCLUSION: CE is a safe, painless and effective method for diagnosing obscure gastrointestinal bleeding. A final diagnosis was reached in more than one half of the patients and positively affected treatment. The capsule produced clear and recognizable images of lesions even without bowel preparation. If done early, CE can aid in directing proper management in patients with suspected small bowel pathology.     

Significance of para-aortic node irradiation in the treatment of cervical cancer

In 1980, we introduced para-aortic node irradiation as a part of our treatment of cervical cancer. Eighty-six patients with cervical cancer were selected for such treatment, based on histologic or radiologic criteria for lymph node involvement. We delivered 45 Gy to the para-aortic nodes in 5 weeks. Comparison studies on the prognosis and on the incidence of side effects with and without para-aortic node irradiation were carried out on a total of 783 patients who had invasive cervical cancer and were treated from 1975 to 1984. For patients in stages Ib and II who met, or before 1980 would have met, our criteria there was no significant difference in survival for those in stage Ib, but in stage II the para-aortic node irradiation group did significantly better (P less than 0.01). For the entire series of patients, for all stages from Ib to IV, the prognosis for the group treated after the introduction of para-aortic node irradiation was superior, with a statistically significant difference from the prognosis for patients treated before the introduction of this mode (Ib, P less than 0.05; II, P less than 0.01; III, P less than 0.01; IV, P less than 0.05). None of the patients had severe complications after para-aortic node irradiation. We conclude that, by irradiating the para-aortic nodes, we can improve the prognosis of cervical cancer patients who may have para-aortic node involvement, a situation which formerly was considered hopeless.     

Long-term effects of hyperthermia combined with chemotherapy and irradiation for the treatment of patients with carcinoma of the esophagus

Hyperthermia combined with irradiation and chemotherapy was prescribed for patients with resectable or unresectable squamous cell carcinoma of the esophagus. The long term results were compared between two groups of patients; one group was treated with chemotherapy, radiotherapy and hyperthermia (HCR), and the other was treated with chemotherapy and radiotherapy, but not hyperthermia (CR). The five year survival rates of patients with resectable carcinoma, given preoperative HCR or CR, were 43.2 and 14.7 per cent, respectively; the difference was statistically significant (p less than 0.05). The two year survival rates of those with unresectable carcinoma and receiving HCR or CR were 15.5 and 1.2 per cent, respectively. In particular, for the patients classified as TNM Stages I and II, a significantly longer survival period was obtained with HCR. As severe side effects in patients given hyperthermia were nil, this treatment deserves serious consideration when treating patients with a malignant lesion of the esophagus.     

Adjuvant radiotherapy in stage I-II epithelial ovarian cancer

OBJECTIVE: The purpose of this study was to assess the efficacy and side-effects of abdominopelvic irradiation applied as adjuvant postoperative therapy in early stage ovarian carcinomas. METHODS: From 1 January 1988 to 31 December 1993, 113 patients with FIGO stage IA-IIC epithelial ovarian carcinoma were treated with postoperative radiotherapy. Whole abdominal irradiation or lower abdominopelvic irradiation was used. The dose of specification was 20 Gy to the upper part of the abdominal cavity and 40 Gy to the lower part of the abdomen and the pelvic region. RESULTS: Primary cure was achieved in 110 patients (97%). During the period of follow-up, 33 cases of tumor recurrences (30%) were recorded. Abdominopelvic metastases were most frequent (18%). The overall 5-year survival rate for the complete series was 69% and the cancer-specific survival rate was 72%. Tumor grade was an independent and significant prognostic factor (Cox multivariate analysis; p = 0.007). Early radiation reactions of any type were noted in 93% of the cases and, in 11%, discontinuation of radiotherapy was necessary. Late radiation reactions were noted in 58% of the cases and the most common side-effect was diarrhea, but in most cases these reactions were of limited clinical significance. The incidence of severe bowel toxicity was 10% and, in two patients ( 1.8%), surgery was necessary due to late radiation reactions. CONCLUSIONS: Adjuvant abdominopelvic radiotherapy is one option among others (e.g. various types of chemotherapy or no further treatment) in primary treatment of early stage ovarian carcinoma. The optimal adjuvant therapy for this group of patients is not known today and further prospective and randomized studies are needed.     

Abdominal Bloating: An Under-recognized Endometriosis Symptom

ObjectiveTo explore the association between the symptom of abdominal bloating and the diagnosis of endometriosis.MethodsTwenty-six patients with endometriosis diagnosed by laparoscopy and 25 women without endometriosis were recruited to a case-control study. Subjects completed detailed questionnaires regarding perception of abdominal bloating, bloating-related symptoms, and effect on lifestyle. Abdominal girth was measured three times daily for one whole menstrual cycle, as were ratings of perceived abdominal bloating severity and discomfort. Experiences of abdominal and gastrointestinal symptoms were compared.ResultsA significantly larger proportion of women with endometriosis than control subjects experienced abdominal bloating (96% vs. 64%). In women with abdominal bloating, the following were more common in those who had endometriosis: associated severe discomfort (30% vs. 0%), wearing loose clothes during bloating (87% vs. 38%), and simultaneous hand swelling (30% vs. 6%). The experiences of cyclically related diarrhea and constipation were more frequent with endometriosis. While there were significant changes in bloating and discomfort ratings across the menstrual cycle, there was a trend towards a difference between the control subjects and unmedicated endometriosis groups only in how the pattern of bloating severity fluctuated across the cycle. Lower abdominal girth measurements changed significantly across menstrual cycle phases. Control and unmedicated endometriosis groups differed significantly in girth changes across the menstrual cycle, controls experiencing much less variation. Compared with the unmedicated endometriosis group, women receiving hormonal treatment had higher bloating severity ratings and discomfort scores, but there was no objective difference in abdominal girth.ConclusionPainful abdominal bloating appears to be common in women with endometriosis and causes considerable symptomatic distress.     

Antibiotics in infections of the biliary tract

The combination of a penicillin and an aminoglycoside has been recommended as the initial treatment of choice for patients with infections of the biliary tract. However, elderly, septic, patients with jaundice have a high incidence of renal problems. For this reason, amingolycoside treatment of these patients must be reevaluated as newer less nephrotoxic agents become available. We, therefore, performed a prospective, randomized trial of ampicillin plus tobramycin, cefoperazone and piperacillin in patients with biliary tract infections. During a 20 month period, 106 patients with acute cholecystitis (53) or cholangitis (53), or both, received one of these antibiotic regimens for a minimum of five days. In patients with acute cholecystitis, ampicillin plus tobramycin, cefoperazone and piperacillin had clinical cure rates of 85, 95 and 95 per cent, respectively. In patients with cholangitis, however, cure rates for the three regimens were 85, 56 (p less than 0.05 versus ampicillin plus tobramycin) and 60 per cent (not significant versus ampicillin plus tobramycin), respectively. Moreover, 13 per cent of the patients receiving cefoperazone had an increased prothrombin time and three of 39 patients receiving this antibiotic had clinical problems with bleeding. Nephrotoxicity was greatest in patients with cholangitis receiving ampicillin plus tobramycin, 10 per cent, as compared with 3 per cent in those who did not receive an aminoglycoside. This difference, however, was not statistically significant. It was concluded that piperacillin should be considered for antibiotic management of patients with acute cholecystitis and that further studies are necessary in patients with cholangitis to determine whether or not newer agents should replace penicillin and aminoglycoside combinations.