Mycobacterium ulcerans infection as a cause of chronic diarrhea in an AIDS patient： A case report

Chronic diarrhea is one of the most frequent gastrointestinal manifestations in acquired immunodeficiency syndrome （AIDS）. Protozoa and nontuberculous mycobacteria （NTM） are opportunistic pathogens that can easily infect these patients. Among the NTM, Mycobacterium avium complex （MAC） is the most frequently observed pathogen in HIV-infected patients. However, NTMs other than MAC have not been reported as a gastrointestinal pathogen as yet. We present a case of chronic diarrhea in an AIDS patient in whom Mycobacterium ulcerans and cryptosporidium co-infection is evidenced from colonic tissue.     

Severe chronic diarrhea and weight loss in cholesteryl ester storage disease： A case report

AIM: An inherited deficiency of human lysosomal acid lipase (LAL) results in the rare conditions of Wolman disease and cholesteryl ester storage disease (CESD). We want to present the rare case of CESD in an adult. METHODS: We report about an adult female patient with severe chronic diarrhea and weight loss as a consequence of CESD. Clinical examination revealed signs of malabsorption and slightly elevated liver enzymes. RESULTS: Histopathologic changes in the liver tissue and DNA sequence analysis confirmed the diagnosis of CESD due to homozygosity for the most common CESD mutation, a G934A splice site defect encoded by exon 8 of the lysosomal acid lipase (LIPA) gene. CONCLUSION: It is the first case in the literature with diarrhea as a putative symptom of CESD in adult patients.     

Oxymatrine therapy for chronic hepatitis B： A randomized double-blind and placebo-controlled multi-center trial

AIM: To evaluate the efficacy and safety of capsule oxymatrine in the treatment of chronic hepatitis B. METHODS: A randomised double-blind and placebo-controlled multicenter trial was conducted. Injection of oxymatrine was used as positive-control drug. A total of 216 patients with chronic hepatitis B entered the study for 24 weeks, of them 108 received capsule oxymatrine, 36 received injection of oxymatrine, and 72 received placebo. After and before the treatment, clinical symptoms, liver function, serum hepatitis B virus markers, and adverse drug reaction were observed. RESULTS: Among the 216 patients, six were dropped off, and 11 inconsistent with the standard were excluded. Therefore, the efficacy and safety of oxymatrine in patients were analysed. In the capsule treated patients, 76.47% became normal in ALT level, 38.61% and 31.91% became negative both in HBV DNA and in HBeAg. In the injection treated patients, 83.33% became normal in ALT level, 43.33% and 39.29% became negative both in HBV DNA and in HBeAg. In the placebo treated patients, 40.00% became normal in ALT level, 7.46% and 6.45% became negative both in HBV DNA and in HBeAg. The rates of complete response and partial response were 24.51% and 57.84% in the capsule treated patients, and 33.33% and 50.00% in the injection treated patients, and 2.99% and 41.79% in the placebo treated patients, respectively. There was no significance between the two groups of patients, but both were significantly higher than the placebo. The adverse drug reaction rates of the capsule, injection and placebo were 7.77%, 6.67% and 8.82%, respectively. There was no statistically significant difference among them. CONCLUSION: Oxymatrine is an effective and safe agent for the treatment of chronic hepatitis B.     

Extended-therapy duration for chronic hepatitis C, genotype 1： The long and the short of it

With pegylated interferon and ribavirin, more than half of all chronically-infected hepatitis C patients can achieve a sustained virologic response; however, patients with genotype 1 infections and those with other poor prognostic factors have relatively inferior treatment response rates. Since new therapies are still years away from approval, it is incumbent upon providers to maximize the therapeutic efficacy of today＇s treatment. The later the virus is undetectable in serum during treatment, the less likely it will be eradicated. Patients with a delayed or slow virologic response to therapy （at least a 2-1og10 decrease in baseline hepatitis C RNA yet detectable viremia at 12 wk of therapy and undetectable virus 12 wk subsequently） may, therefore, benefit from an extended therapy course beyond one of standard duration. Although higher rates of treatment discontinuation may plague this approach, 72 wk of treatment for genotype 1-infected slow-responders may improve response rates and diminish relapse rates relative to those of 48 wk. Based on data from both viral kinetic and clinical studies, therapy prolongation in slow responders may be a reasonable strategy to improve response rates in these treatment-refractory patients.     

Extreme gastric dilation caused by chronic lead poisoning： A case report

Lead is a toxic metal that affects many organ systems and functions in humans. In the majority of adults, chronic lead poisoning comes from exposures to work places and can occur in numerous work settings, such as manufacturing, lead smelting and refinement, or due to use of batteries, pigments, solder, ammunitions, paint, car radiators, cable and wires, certain cosmetics. In some countries, lead is added to petrol. We present a rare case of gastric dilation caused by long-term petrol ingestion. A 16-year-old young man was admitted to our hospital due to a 6-mo history of exhaustion, dizziness, nausea, abdominal cramps and constipation. X-ray examination revealed dilated stomach descending into the pelvis and small bowel distension. After a long clinical observation, we found that the reason for the chronic lead poisoning of the patient was due to a 3-year history of petrol ingestion. The patient spontaneously recovered and stomach returned to its normal position and size. Lead poisoning should be taken into consideration in all unexplained cases of gastric dilation.     

Antioxidant therapy in the management of acute, chronic and post-ERCP pancreatitis： A systematic review

We systematically reviewed the clinical trials which recruited antioxidants in the therapy of pancreatitis and evaluated whether antioxidants improve the outcome of patients with pancreatitis. Electronic bibliographic databases were searched for any studies which investigated the use of antioxidants in the management of acute pancreatitis （AP） or chronic pancreatitis （CP） and in the prevention of post-endoscopic retrograde cholangio-pancreatography （post-ERCP） pancreatitis （PEP） up to February 2009. Twenty-two randomized, placebo-controlled, clinical trials met our criteria and were included in the review. Except for a cocktail of antioxidants which showed improvement in outcomes in three different clinical trials, the results of the administration of other antioxidants in both AP and CP clinical trials were incongruent and heterogeneous.Furthermore, antioxidant therapy including allopurinol and N-acetylcysteine failed to prevent the onset of PEP in almost all trials. In conclusion, the present data do not support a benefit of antioxidant therapy alone or in combination with conventional therapy in the management of AP, CP or PER Further double blind, randomized, placebo-controlled clinical trials with large sample size need to be conducted.     

A new iron free treatment with oral fish cartilage polysaccharide for iron deficiency chronic anemia in inflammatory bowel diseases： A pilot study

AIM:To investigate the effect of a new oral preparation,highly concentrated in fish cartilage,in a group of inflammatory bowel diseases(IBD)patients with chronic iron deficient anemia.METHODS:In an open label pilot study,we supple-mented a group of 25 patients(11 with Crohn's disease and 14 with ulcerative colitis)in stable clinical conditions and chronic anemia with a food supplement which does not contain iron but contains a standardized fraction of fish cartilage glycosaminoglycans and a mixture of antioxidants(Captafer Medestea,Turin,Italy).Patients received 500 mg,twice a day during meals,for at least 4 mo.Patients were suggested to maintain their alimentary habit.At time 0 and after 2 and 4 mo,emocrome,sideremia and ferritin were examined.Paired data were analyzed with Student's t test.RESULTS:Three patients relapsed during the study(2 in the 3rd mo,1 in the 4th mo),two patients were lost to follow up and two patients dropped out(1 for orticaria,1 for gastric burning).Of the remaining 18 patients,levels of serum iron started to rapidly increase within the 2nd mo of treatment,P < 0.05),whereas serum ferritin and hemoglobin needed a longer period to significantly improve their serum levels(mo 4)P < 0.05.The product was safe,easy to administer and well tolerated by patients.CONCLUSION:These data suggest a potential new treatment for IBD patients with iron deficiency chronic anemia and warrant further larger controlled studies.     

Severe delayed complication after percutaneous endoscopic colostomy for chronic intestinal pseudo-obstruction： A case report and review of the literature

Percutaneous endoscopic colostomy （PEC） is increasingly proposed as an alternative to surgery to treat various disorders, including acute colonic pseudo-obstruction, chronic intestinal pseudo-obstruction and relapsing sigmoid volvulus. We report on a severe complication that occurred two months after PEC placement. A 74-year-old man with a history of chronic intestinal pseudo-obstruction evolving since 8 years was readmitted to our hospital and received PEC to provide long-standing relief. The procedure was uneventful and greatly improved the patient＇s quality of life. Two months later, the patient developed acute stercoral peritonitis. At laparotomy, the colostomy flange was embedded in the abdominal wall but no pressure necrosis was found at the level of the colonic wall. This complication was likely related to inadvertent traction of the colostomy tube. Subtotal colectomy with terminal ileostomy was performed. We review the major features of 60 cases of PEC reported to date, including indications and complications.     

Life-threatening hemobilia caused by hepatic artery pseudoaneurysm： A rare complication of chronic cholangitis

Hemobilia is one of the causes of obscure gastrointestinal haemorrhage. Most cases of hemobilia are of iatrogenic or traumatic origin. Hemobilia caused by a hepatic artery pseudoaneurysm due to ascending cholangitis is very rare and its mechanism is unclear. We report a 74-year-old woman with a history of surgery for choledocholithiasis 30 years ago, suffering from a protracted course of life-threatening gastrointestinal bleeding. A small intestines series and endoscopic retrograde cholangiopancreatography revealed a chronic cholangitis with marked contrast reflux into the biliary tree. Angiography confirmed the bleeding from a pseudoaneurysm of the middle hepatic artery. Coil embolization achieved successful hemostasis. We discussed the mechanism and reviewed the literature.     

Bile acid malabsorption in chronic diarrhea: Pathophysiology and treatment

BACKGROUND:

Bile acid malabsorption (BAM) is a common but frequently under-recognized cause of chronic diarrhea, with an estimated prevalence of 4% to 5%.

METHODS:

The published literature for the period 1965 to 2012 was examined for articles regarding the pathophysiology and treatment of BAM to provide an overview of the management of BAM in gastroenterology practice.

RESULTS:

BAM is classified as type 1 (secondary to ileal dysfunction), type 2 (idiopathic) or type 3 (secondary to gastrointestinal disorders not associated with ileal dysfunction). The estimated prevalence of BAM is >90% in patients with resected Crohn disease (CD) and 11% to 52% of unresected CD patients (type 1); 33% in diarrhea-predominant irritable bowel syndrome (type 2); and is a frequent finding postcholecystectomy or postvagotomy (type 3). Investigations include BAM fecal bile acid assay, 23-seleno-25-homo-tauro-cholic acid (SeHCAT) testing and high-performance liquid chromatography of serum 7-α-OH-4-cholesten-3-one (C4), to determine the level of bile acid synthesis. A less time-consuming and expensive alternative in practice is an empirical trial of the bile acid sequestering agent cholestyramine. An estimated 70% to 96% of chronic diarrhea patients with BAM respond to short-course cholestyramine. Adverse effects include constipation, nausea, borborygmi, flatulence, bloating and abdominal pain. Other bile acid sequestering agents, such as colestipol and colesevelam, are currently being investigated for the treatment of BAM-associated diarrhea.

CONCLUSIONS:

BAM is a common cause of chronic diarrhea presenting in gastroenterology practice. In accordance with current guidelines, an empirical trial of a bile acid sequestering agent is warranted as part of the clinical workup to rule out BAM.     

Mucinous adenocarcinoma derived from chronic perianal fistulas: report of a case and review of the literature

Chronic perianal fistulas are a common clinical condition. However, their evolution into adenocarcinoma is rare. We report the case of a 68-year-old man with perineal and perianal chronic fistulas, who developed a perineal mass that extended proximally as a pararectal tumor. Diagnosis was confirmed by magnetic resonance imaging (MRI). Histopathological sections indicated extramucosal mucinous adenocarcinoma. No intestinal lesion was seen at endoscopic examination. The patient underwent abdominal perineal excision of the rectum without neoadjuvant or adjuvant therapy, and had a good postoperative outcome.     

Ileal pouch vaginal fistulas: Incidence,etiology, and management

Some of the initial problems associated with the ileonal reservoir have been solved. In their place, other complications have been recognized. Among these, the ileal pouch vaginal fistula stands out as a recently recognized difficult management problem. This multicenter study was undertaken to gain insight into the causes for, and treatment of, pouch vaginal fistulas. Cases were gathered from 11 surgical practices, throughout North America, in which the ileoanal reservoir procedure is frequently performed. Overall, 304 females had undergone ileoanal reservoir procedures by these surgical groups. Twenty-one patients developed 22 pouch vaginal fistulas for an overall incidence of 6.9 percent. Five additional patients with pouch vaginal fistulas, whose restorative proctocolectomies were done elsewhere, were referred to these surgeons for treatment. The courses of these 26 patients form the basis of this report. This study details the risk factors which predispose to the development of a pouch vaginal fistula, as well as the various treatment options available. Read at meeting of the American Society of Colon and Rectal Surgeons, Anaheim, California, June 12 to 17 1988.     

Congenital internal mammary artery-to-pulmonary artery fistulas: A case report

Summary A case of congenital internal mammary artery-to-pulmonary artery fistulas is reported. The patient was a 7-year-old boy in whom this condition was suspected from an abnormal shadow in the left upper lung field upon chest X-ray examination and continuous murmur. A definite diagnosis was made by selective angiography of the internal mammary artery.This condition is extremely rare. Our patient is the youngest among the 16 cases which have been reported so far in the English literature. Surgical treatment may be indicated because there is a risk of rupture of the fistula, endarteritis, and congestive heart failure.     

Guidelines to diagnose and treat peri-levator high-5 anal fistulas: Supralevator,suprasphincteric, extrasphincteric,high outersphincteric,and high intrarectal fistulas

Supralevator, suprasphincteric, extrasphincteric, and high intrarectal fistulas (high fistulas in muscle layers of the rectal wall) are well-known high anal fistulas which are considered the most complex and extremely challenging fistulas to manage. Magnetic resonance imaging has brought more clarity to the pathophysiology of these fistulas. Along with these fistulas, a new type of complex fistula in high outersphincteric space, a fistula at the roof of ischiorectal fossa inside the levator ani muscle (RIFIL), has been described. The diagnosis, management, and prognosis of RIFIL fistulas is reported to be even worse than supralevator and suprasphincteric fistulas. There is a lot of confusion regarding the anatomy, diagnosis, and management of these five types of fistulas. The main reason for this is the paucity of literature about these fistulas. The common feature of all these fistulas is their complete involvement of the external anal sphincter. Therefore, fistulotomy, the simplest and most commonly performed procedure, is practically ruled out in these fistulas and a sphincter-saving procedure needs to be performed. Recent advances have provided new insights into the anatomy, radiological modalities, diagnosis, and management of these five types of high fistulas. These have been discussed and guidelines formulated for the diagnosis and treatment of these fistulas for the first time in this paper.     

Endoscopic treatment of primary aorto-enteric fistulas: A case report and review of literature

BACKGROUNDPrimary aorto-enteric fistula (PAEF) is a rare condition, traditionally treated in the acute, bleeding phase with open surgery or endovascular repair. However, these approaches have high morbidity and mortality, indicating a need for new methods. With advances in endoscopic techniques and equipment, haemoclipping of fistulas has now become feasible. Therefore, we present a systematic review of the English literature and a rare case of a PAEF successfully treated by endoscopic haemoclipping. CASE SUMMARYA 74-year-old man with an abdominal aortic aneurysm presented with symptoms of haemorrhagic shock and bloody stools. An oesophago-gastro-duodenoscopy was performed with haemoclipping of a suspected PAEF in the third part of the duodenum. Afterward, a computed tomography-angiography showed a contrast filled protrusion from the abdominal aortic aneurysm. Based on the clinical presentation and the combined endoscopic and radiographic findings, we argue that this is a case of a PAEF. CONCLUSIONEndoscopic therapy appears capable of achieving haemodynamic stabilisation in patients with bleeding PAEF, serving as a bridge to final therapy.     

覆膜支架治疗外伤性颈内动脉海绵窦瘘的临床分析

目的探讨覆膜支架对外伤性颈内动脉海绵窦瘘的血管内治疗效果。方法自2003年10月—2008年3月,采用覆膜支架治疗外伤性颈内动脉海绵窦瘘10例。结果10例外伤性颈内动脉海绵窦瘘的患者中,9例覆膜支架置入成功,其中在3例患者释放支架后,出现少许对比剂内漏,2例以更高的压力再次充胀球囊扩张后,内漏消失;另1例再扩后仍有内漏,置入第2枚覆膜支架后,内漏完全消除。10例中的另1例为患侧颈总动脉及颈内动脉过于迂曲,支架不能到位,在证实侧支循环代偿良好及球囊闭塞试验阴性后,给予可脱性球囊闭塞患侧颈内动脉。所有患者均无手术相关的并发症发生。DSA随访7例,原病变未显示,载瘘动脉通畅。结论对于外伤性颈内动脉海绵窦瘘,覆膜支架是有效的血管内治疗手段。覆膜支架的制作工艺仍有待发展和优化,使其适用于脑血管系统的不同部位应用。     

常温非体外循环下手术治疗先天性冠状动脉瘘

目的:探讨常温非体外循环下,手术治疗先天性冠状动脉瘘(congenital coronary arterial fistula,CAF)的手术方法和远期效果。方法:2001年8月至2009年8月在阜外心血管病医院行常温非体外循环下手术治疗CAF21例。全组年龄12d～60岁,平均(20.6±20.0)岁;20例为单纯的CAF,1例合并冠心病3支病变。21例中瘘口起源于右冠状动脉5例(23.8%),左冠状动脉12例(57.1%),双冠状动脉4例(19.1%);瘘口入右心房,右心室,肺动脉及左心室分别为5例(23.8%),8例(38.1%),7例(33.3%)和1例(4.8%);结果:21例均在常温非体外循环下行冠状动脉瘘结扎或褥式带垫片缝扎,其中1例同时行常温不停跳冠状动脉搭桥术,无手术死亡。术后残余瘘1例,其余术后无心肌缺血及残余瘘等并发症。19例随访0.5～5.5年,平均(2.1±1.7)年,无远期死亡。1例残余瘘,其余无心肌缺血及残余瘘等并发症。结论:常温非体外循环下手术治疗CAF安全、有效,远期效果良好。