Clinical presentation of enteric fever: its changing pattern in Kuwait

The clinical experience with enteric fever (1985-89) at a general hospital in Kuwait is presented. There were 90 cases of typhoid and 10 cases of paratyphoid fever, with a mortality rate of 2%. Typhoid complications of bowel perforation, haemorrhage or septic shock were present in 5% and abortion in 2%. Neurological or psychiatric manifestations were a feature in 15%. Most infections were imported (78%). Despite rapid economic development, enteric fever may still be acquired locally but less frequently with time. This contributed to initial diagnostic uncertainty in 18% of cases, and especially in children. Another changing pattern emerged with the recent finding of five drug-resistant Salmonella typhi isolates, two in 1988 and three in 1989. Efforts are clearly needed to diagnose enteric fever more rapidly and to utilize new antibiotics for drug-resistant cases.     

Perforated peptic ulcer--the changing scene.

There is a changing scene with perforated peptic ulcer. The older age of presentation, the increased association with non-steroidal anti-inflammatory drugs, associated increased debility, and resulting higher mortality in the elderly, are causing a rethink in management protocols. Whereas years ago most discussion was on whether urgent definitive surgery was the most effective therapy, nowadays there is a tendency to less invasive measures. A 'deliberative' approach, wherein not all patients require surgery, is detailed, and there may be an increasing role for laparoscopic perforation-sealing techniques in the remainder. Anti-secretory and anti-helicobacter drugs have an important role in post-operative care following lesser procedures than definitive surgery.     

Clinical aspects of hemochromatosis

The term hemochromatosis is commonly used as synonymous with HFE-associated genetic iron overload but several rarer causes of an identical clinicopathological syndrome have been described in recent years. The most common symptoms are lethargy and arthralgia, and the major complications of end-stage disease are cirrhosis, diabetes, and cardiac and endocrine manifestations. However, with the development of cascade screening for family members of affected probands as well as screening for common diseases at health checks, hemochromatosis is being detected at increasingly early stages, often when there are only biochemical abnormalities. The available evidence from screening studies strongly suggests that approximately 75% of C282Y homozygous subjects have biochemical expression. Hepatic iron overload is present in approximately 56% and 34% of men and women, respectively, advanced hepatic fibrosis in 18.7% and 5.4%, respectively, and cirrhosis in 5.8% and 1.9%, respectively. In subjects with severe expression of the disease, additional modifying genetic mutations have been described including those in hepcidin and hemojuvelin. Treatment is by regular phlebotomy which, if instituted before the development of cirrhosis, results in normal life expectancy.     

Bile duct cysts: A changing spectrum of presentation

Since the report of our early experience in 1984, the clinical management of 33 patients (23 adults, 10 children) with bile duct cysts has been reviewed. The mean age was 28 years, and female preponderance was observed. Complicated clinical presentations (namely, cholangitis) and coexistent hepato-biliary-pancreatic diseases (present in 45% of the patients) were encountered more frequently in adult patients and those who had had previous cyst enteric drainage operations. Pancreatitis occurred in 27% and cyst-associated malignancy in 9%, with 2 patients alive 29 and 125 months, respectively, postoperatively after curative resection. Cyst type included type I, 58%; type II, 3%; and type VIA, 33%. Anomalous biliary-pancreatic junction (as a long common channel in 18 patients) was observed in 19 patients in whom the anatomy was documented. Eighteen patients (group I) underwent primary extrahepatic cyst excision, and 15 patients (group II) with previous cyst-related operations (35 previous surgical procedures) underwent secondary cyst excision. Mortality was nil, but postoperative morbidity was significantly higher in group II. During a mean follow-up of 51 months, satisfactory results were observed in 94% of the patients. In conclusion, primary complete cyst excision of extrahepatic component is recommended as the treatment of choice, achieving satisfactory clinical results in the majority of patients. The clinical spectrum of the disease has changed in our experience because of the routine use of early cyst excision in patients with bile duct cysts.     

Is proliferative colonic disease presentation changing?

AIM: To compare the site, age and gender of cases of colorectal cancer (CRC) and polyps in a single referral center in Rome, Italy, during two periods.METHODS: CRC data were collected from surgery/pathology registers, and polyp data from colonoscopy reports. Patients who met the criteria for familial adenomatous polyposis, hereditary non-polyposis colorectal cancer syndrome or inflammatory bowel disease were excluded from the study. Overlap of patients between the two groups (cancers and polyps) was carefully avoided. The χ² statistical test and a regression analysis were performed.RESULTS: Data from a total of 768 patients (352 and 416 patients, respectively, in periods A and B) who underwent surgery for cancer were collected. During the same time periods, a total of 1693 polyps were analyzed from 978 patients with complete colonoscopies (428 polyps from 273 patients during period A and 1265 polyps from 705 patients during period B). A proximal shift in cancer occurred during the latter years for both sexes, but particularly in males. Proximal cancer increased > 3-fold in period B compared to period A in males [odds ratio (OR) 3.31, 95%CI: 2.00-5.47; P < 0.0001). A similar proximal shift was observed for polyps, particularly in males (OR 1.87, 95%CI: 1.23-2.87; P < 0.0038), but also in females (OR 1.62, 95%CI: 0.96-2.73; P < 0.07).CONCLUSION: The prevalence of proximal proliferative colonic lesions seems to have increased over the last decade, particularly in males.