Prospective Evaluation of Quality of Life in Patients with Zollinger–Ellison Syndrome

Background  

Zollinger–Ellison syndrome (ZES) is associated with complicated ulcer disease of the upper gastrointestinal tract. While management of ZES has dramatically improved with proton pump inhibitor therapy, quality of life in medically treated patients has not been evaluated.     

Clinical Gestalt and the Diagnosis of Pulmonary Embolism: Does Experience Matter?

STUDY OBJECTIVES: We sought to determine whether the accuracy of pretest assessment of the likelihood of pulmonary embolism (PE) was related to physician experience. We compared the accuracy of the subjective pretest probability assessment made by senior physicians (postgraduate year [PGY]-4+) to that of interns (PGY-1) and residents (PGY-2 and PGY-3) working in the emergency department of a large teaching hospital. DESIGN: Prospective observational study. SETTING: Urban, academic emergency department with an annual census of 48,000 patient visits. PATIENTS: Five hundred eighty-three adults evaluated for PE in the emergency department. INTERVENTIONS: Eligible patients had at least one diagnostic test ordered to workup PE. The physician treating the patient was asked whether he or she considered PE the most-likely diagnosis or whether an alternative diagnosis was most likely. This result was compared to the ultimate diagnosis. Physician experience was categorized by the number of years of training since medical school graduation. MEASUREMENTS AND RESULTS: There was a trend toward increasing accuracy with increasing experience, demonstrated by the frequency of true-positive assessments (17% vs 20% vs 25%), true-negative assessments (89% vs 94% vs 96%), and likelihood ratio (1.49 vs 2.34 vs 3.33), respectively. CONCLUSIONS: Accurate determination of the pretest probability of PE appears to increase with clinical experience. However, the difference in accuracy between inexperienced and experienced physicians is not sufficiently large to distinguish between the two when determining whether clinical gestalt or a clinical prediction rule should be used to determine the pretest probability of PE.     

Ventricular Ectopy following Successful Cryoablation for Wolff–Parkinson–White Syndrome in the Right Posterior Septum: A Case Report

We report a case of new onset ventricular ectopy following cryothermal ablation of a right posterior septal accessory pathway. To our knowledge, this is the first report of secondary arrhythmias from cryothermal ablation of atrial arrhythmias.     

Clinical Guidelines Update on the Diagnosis and Management of Barrett’s Esophagus

Barrett’s esophagus is a condition in which metaplastic columnar epithelium replaces stratified squamous epithelium in the distal esophagus. This condition occurs due to chronic gastroesophageal reflux disease and is a risk factor for the development of esophageal adenocarcinoma. Multiple clinical guidelines have been published around the world in recent years to assist gastroenterologists in the management of these patients and have evolved as new data have become available. While some information such as surveillance technique has not drastically changed, there has been an evolution over the years in diagnostic criteria, screening and endoscopic therapy with a variety of subtle differences among the different guidelines. Herein, we highlight areas of agreement and disagreement on definitions, screening, surveillance, and treatment techniques among these guidelines for the optimal management of Barrett’s esophagus patients.     

Seasonal Variation in Metabolic Syndrome Components: How Much Do They Influence the Diagnosis of Metabolic Syndrome?

Obesity and hypertension are increasing problems worldwide, resulting in an enormous economic burden to the society. The metabolic syndrome components (ie, central obesity, dyslipidemia, hyperglycemia, and hypertension) are used to identify individuals at high risk of developing cardiovascular disease and type 2 diabetes. The cause of the syndrome is not yet clear, but insulin resistance and dyslipidemia have been proposed. Emerging evidence suggest that increased visceral adipose tissue stimulates secretion of bioactive compounds that promote inflammation, oxidative stress, and impair lipid metabolism and vascular relaxation. Interestingly, all components of the metabolic syndrome display seasonal variation, and hence may influence diagnosis. The seasonal variability in metabolic components is partly explained by changes in climate and lifestyle factors (eg, physical activity and diet). The clinical role for seasonal variations in metabolic risk factors remains to be further elucidated. However, the new findings indicate that seasonal variation should be considered in diagnosis and management decisions.     

Clinical Presentation of Inadvertent Intrathecal Vincristine Masquerading Guillain–Barre Syndrome

Vincristine, a potent chemotherapeutic agent, is highly neurotoxic. If given intrathecally by accident it is almost always fatal. We are reporting a 6 year old girl with acute lymphoblastic leukaemia in complete remission, who was given inadvertent intrathecal Vincristine instead of Methotrexate. She developed gradually progressive quadriplegia and respiratory paralysis requiring prolonged mechanical ventilation, initially mimicking Guillain–Barre Syndrome, both clinically and electro-physiologically. She also developed progressive encephalopathy. The clinical deterioration subsequently plateaued without any significant improvement and after more than 5 months, she finally expired.     

Acute Hemorrhagic Rectal Ulcer Syndrome: A New Clinical Entity? Report of 19 Cases and Review of the Literature

PURPOSE: Acute hemorrhagic rectal ulcer syndrome is characterized by sudden onset, painless, and massive hemorrhage from rectal ulcer(s) in patients with serious underlying illnesses. It is a matter of controversy whether acute hemorrhagic rectal ulcer syndrome is a distinct clinical entity. This is the first Asian report on acute hemorrhagic rectal ulcer syndrome to be made outside Japan.METHODS: From January 1989 to December 1999, 8,085 patients underwent total colonoscopy at our institution. We retrospectively analyzed the medical records and colonoscopic files. The diagnosis of acute hemorrhagic rectal ulcer syndrome was made by means of the clinical, histologic, and colonoscopic findings.RESULTS: Among the 8,085 patients, 19 patients (11 males; mean age, 71.2 ± 10.1 years) were diagnosed with acute hemorrhagic rectal ulcer syndrome, which accounted for 2.8 percent of the patients with massive lower gastrointestinal bleeding. The duration from hospitalization to the onset of massive bleeding ranged from 3 to 14 (mean, 9 ± 3.3) days. Characteristics of colonoscopic appearance were solitary or multiple rectal ulcer(s), with round, circumferential, geographical, or Dieulafoy-like lesions located within a mean of 4.7 cm ± 1.5 cm from the dentate line. Histopathologically, the lesions appeared as necrosis with denudation of covering epithelium, hemorrhage, and multiple thrombi in the vessels of the mucosa and underlying stroma, which is considered to be similar to stress-related mucosa injury. Successful hemostasis was obtained in 74 percent (14/19) of patients with direct therapeutic maneuvers. Prognosis was largely dependent on accurate diagnosis and management of the underlying disorders.CONCLUSIONS: We assert that acute hemorrhagic rectal ulcer syndrome is a rare but important entity and stress that awareness of this clinical entity should lead to a high index of suspicion resulting in early detection, diagnosis, and appropriate therapy.Presented at the meeting of the Gastroenterological Society of Taiwan, Taipei, Taiwan, March 25 to 26, 2000.     

Diagnosis and Differential Diagnosis of Crohn’s Disease of the Ileal Pouch

Approximately 20%-30% of patients with ulcerative colitis will eventually require colectomy despite recent advances in medical therapy. Ileal pouch-anal anastomosis has become the surgical treatment of choice. A subset of patients with ileal pouches can develop Crohn's disease or a Crohn's-disease-like condition of the ileal pouch after surgery. Diagnosis, differential diagnosis, and management of Crohn's disease of the ileal pouch have been challenging. A combined assessment of clinical history, endoscopy, histology, abdominal/pelvic imaging, and examination under anesthesia is often necessary for accurate diagnosis, disease classification, management, and prognosis. A multidisciplinary approach with gastroenterologists, colorectal surgeons, gastrointestinal pathologists, and radiologists is advocated.     

Diagnosis and treatment of solid-pseudopapillary tumor of the pancreas

BACKGROUND: Solid-pseudopapillary tumor (SPT) of the pancreas is a rare exocrine pancreatic tumor. Despite the increasing recognition of the tumor in recent years, its pathogenesis and apparent therapeutic algorithm remain unclear. This study was designed to define the clinical, imaging, and pathologic features and to improve the diagnosis and treatment of this rare disease. METHOD: The clinical, imaging, and pathologic findings of 9 SPT patients managed in our hospital between 2001 and 2005 were retrospectively analyzed, and related literatures were reviewed. RESULTS: In the 9 patients aged from 14 to 68 years, 8 were female and 1 male. The mean age of these patients at diagnosis was 30 years. Initially, 8 patients complained of vague abdominal pain and one patient had pancreatic mass detected incidentally by abdominal CT. The levels of blood and urine amylase and tumor markers were all within the normal range. B-US, CT and MRI demonstrated that tumors were well encapsulated and contained some degree of internal hemorrhage or cystic degeneration. The mean transverse diameter of these tumors was 5.4 cm (range, 2-10.5 cm). The tumors were located at the head (2 patients), body (2), body and tail junction (4), and tail (1) of the pancreas. Surgical procedures included pancreaticoduodenectomy, distal pancreatectomy, distal pancreatectomy with splenectomy, and enucleation. Histological examination showed solidified cystic areas and papillary protrusions. Two malignant tumors demonstrated retroperitoneal metastases and vascular invasion. Follow-up for 2.5 years on average showed that one patient died of tumor recurrence at 10 months and the rest were alive. CONCLUSIONS: SPT exhibits unique clinical and pathologic features and is readily diagnosed by its characteristic imaging and histological appearance. Surgical resection of the primary tumor and metastases is the treatment of choice.