A diagnostic approach to chronic diarrhea

Summary A diagnostic approach to chronic diarrhea has been outlined. This approach emphasizes the importance of the history and physical examination, not only to suggest the correct diagnosis, but to aid the physician in the proper selection of laboratory studies to substantiate his clinical impression. Read at the meeting of the American Proctologic Society, Denver, Colorado, June 10 to 13, 1968.     

参苓白术散治疗慢性腹泻效果的Meta分析

目的评价参苓白术散对慢性腹泻的治疗效果。方法计算机检索中国知网、维普、万方、Pubmed等数据库中关于参苓白术散对慢性腹泻的影响的随机对照试验(RCT),同时筛检纳入文献的参考文献。由3名研究者对文献质量进行严格评价及资料提取,对符合质量标准的RCT进行Meta分析。结果参苓白术散治疗慢性腹泻较常规西药更能有效减少大便量及大便次数,改善大便性状。结论参苓白术散治疗慢性腹泻效果优于常规西药。     

Clinical approach to diarrhea

Diarrhea is defined as reduced stool consistency, increased water content and number of evacuations per day. A wide array of causes and pathophysiological mechanisms underlie acute and chronic forms of diarrhea. This review focuses on the major clinical aspects which should aid clinicians to diagnose chronic diarrhea. Clinical history, physical examination and stool evaluation and the predominant stool characteristic, i.e., bloody, watery, and fatty diarrhea, may narrow the differential diagnosis. Although mainly involved in acute diarrhea, many different infectious agents, including bacteria, viruses and protozoa, can be identified in chronic bloody/inflammatory diarrhea by appropriate microbiological tests and colonoscopic biopsy analysis. Osmotic diarrhea can be the result of malabsorption or maldigestion, with a subsequent passage of fat in the stool leading to steatorrhea. Secretory diarrhea is due to an increase of fluid secretion in the small bowel lumen, a mechanism often identified in gastroenteropancreatic neuroendocrine tumors. The evaluation of the fecal osmotic gap may help to characterize whether a chronic diarrhea is osmotic or secretory. Fatty diarrhea (steatorrhea) occurs if fecal fat output exceeds the absorptive/digestive capacity of the intestine. Steatorrhea results from malabsorption or maldigestion states and tests should differentiate between these two conditions. Individualized diagnostic work ups tailored on pathophysiological and clinical features are expected to reduce costs for patients with chronic diarrhea.     

Surveillance of patients with chronic hepatitis C not on antiviral therapy: a practical approach

Surveillance of patients with HCV-related chronic liver disease (CHC) not on antiviral therapy is mandatory, because of the risk of worsening of the disease and progression to cirrhosis and its lethal complications. Unfortunately, data from the literature are scarce, and sometimes there are differences among experts and discrepancies between recommendations. Furthermore, the wide range of diagnostic tests and the continuous development of new diagnostic tools not rarely results in expensive, redundant and not justified surveillance programs. The identification of the optimal frequency of follow-ups constitutes another source of difficulties for the physicians. The purpose of this article is to provide practicing physicians with published criteria for performing a cost-effective and adequate surveillance program for patients with CHC not on antiviral treatment. On the basis of randomized controlled trials (RCTs), metanalysis, and international guide-lines and Consensus Conference statements we have attempted to outline a cost-effective surveillance program for HCV carriers with normal aminotransferases (ALT), for responders to previous interferon (IFN) treatment and for patients with CHC non-eligible for antiviral therapy. This surveillance strategy relies upon the judicious use of un-expensive and widely available tests.     

A practical approach to guide clinicians in the evaluation of male patients with breast masses

Breast cancer must be considered in the evaluation of breast masses in men, although various benign causes are more common, including gynecomastia and conditions of the skin and subcutaneous tissue. A patient's history may identify key features suspicious for malignancy or reassuring for benign disease. Physical examination has been documented to be as effective as mammography in distinguishing benign from malignant lesions, and both have been reported as highly accurate for the identification of malignancy. Mammography is therefore best used when the physical examination findings are indeterminate. Ultrasonography may be used as an adjunct to mammography; no evidence supports the use of magnetic resonance imaging in male breast patients. If clinical or mammographic features are suspicious or indeterminate for malignancy, tissue diagnosis is warranted and may be achieved surgically or via core-needle biopsy or fine-needle aspiration cytology. Given the lack of uniformity in the clinical recommendations for the evaluation of breast masses in men, a practical approach is proposed.     

The retrograde approach to coronary artery chronic total occlusions: a practical approach

The retrograde approach has revolutionized the treatment of chronic total occlusions. Several retrograde techniques have recently been described. In this article, we present a practical review with step-by-step instructions on the indications for retrograde interventions, equipment and retrograde channel selection, and techniques for retrograde crossing and treatment of chronic total occlusions.     

A practical approach to maternal phenylketonuria management

Summary More women with phenylketonuria are becoming pregnant and need appropriate management to avoid the effects of raised phenylalanine on the fetus: facial dysmorphism, microcephaly, growth retardation, developmental delay and congenital heart disease. Here we describe our experiences from a single centre gained over almost three decades. A series of six cases is presented to illustrate key points in management. Ideally, phenylalanine-restricted diet is started before conception in a planned fashion, but some women present pregnant and blood phenylalanine must be lowered rapidly. The aims of management are to maintain blood phenylalanine concentration in the target range (100–250 μmol/L) before and throughout the pregnancy, and to ensure adequate maternal nutrition and appropriate weight gain. Blood phenylalanine is monitored twice, three times a week, before and after conception respectively. Weight is monitored on a weekly basis and key micronutrients are monitored every 6–8 weeks in clinic. From the second trimester onwards, dietary phenylalanine intake has to be promptly increased, as phenylalanine tolerance increases rapidly. Postnatal management includes a neurological assessment of the infant at 4–8 weeks and an echocardiogram for infants conceived off diet. Subsequently, offspring are seen at 1 year, 4 years, 8 years and 14 years for neuropsychometric evaluations. Regular follow-up of the mother remains important whether on or off a phenylalanine-restricted diet. Electronic Supplementary Material Supplementary material is available for this article at Communicating editor: Deborah Marsden Competing interests: None declared References to electronic databases: PKU, OMIM 261600     

A practical approach to torsade de pointes

The term torsade de pointes refers to polymorphic ventricular tachycardia that occurs in the setting of an abnormally long QT interval. While the most common cause is treatment with QT prolonging drugs, torsade de pointes also occurs in the congenital long QT syndromes and in the setting of acquired heart block or severe electrolyte disturbance, notably hypokalemia. Among QT prolonging drugs that cause torsade de pointes, both antiarrhythmics and “noncardioactive” drugs have been recognized. The electrocardiographic features of torsade de pointes include labile QT intervals, prominent U waves, and a “pause-dependent” onset of the arrhythmia. Treatment consists of recognition of the syndrome, correction of underlying electrolyte abnormalities, and withdrawal of any offending drugs. Magnesium, isoproterenol, or cardiac pacing provides specific antiarrhythmic therapy in torsade de pointes.     

Cyclospora cayetanensis in patients with AIDS and chronic diarrhea

Cyclospora spp. is a protozoan parasite responsible for significant gastrointestinal disease in patients infected with the human immunodeficiency virus. We report the clinical features of two patients with chronic diarrhea and intestinal cyclosporosis caused by Cyclospora cayetanensis. The average value for CD4 count in these patients was lower than or equal to 100 cells/mm3. The oocysts were detected in smears from stool samples stained with modified acid-fast or safranin technique. Light microscopy revealed parasites in the enterocytes and these parasites were associated with villous atrophy. Cyclospora cayetanensis infection might be an important cause of diarrhea in patients with AIDS in Argentina.     

A practical approach to the evaluation and management of gastrointestinal symptoms in patients with systemic sclerosis

The gastrointestinal (GI) tract is the most commonly affected internal organ system in systemic sclerosis (SSc). SSc may lead to impaired function in any region of the GI tract, from the esophagus to the anorectum, which causes significant morbidity as well as mortality in patient subsets. Given the low prevalence of SSc in the community, many rheumatologists may not have a systematic framework for diagnosing or treating the GI complaints in this disease. These practice recommendations aim to summarize and consolidate the current guidelines from the fields of gastroenterology and rheumatology and establish a symptom-based framework for diagnosis and management based on available evidence in the literature. Subject areas that are in need of additional research are also identified.     

A practical approach to achieving recommended blood pressure goals in diabetic patients.

Approximately 11 million Americans have both hypertension and diabetes mellitus. This double diagnosis places such patients at high risk for renal damage, especially end-stage renal disease. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommends a blood pressure goal of less than 130/85 mm Hg to reduce or slow the onset of renal disease and cardiovascular events in patients with hypertension and diabetes mellitus. Recent data, however, now suggest that an even lower diastolic blood pressure goal (ie, <80 mm Hg) may be necessary. Studies have shown that use of angiotensin-converting enzyme inhibitors can prevent the progression of microalbuminuria to overt proteinuria, reduce proteinuria in patients with overt diabetic nephropathy, slow the deterioration of the glomerular filtration rate, delay progression to end-stage renal disease, and lower blood pressure. Thus, all diabetic patients with blood pressure greater than 130/80 mm Hg should begin angiotensin-converting enzyme inhibitor treatment and be titrated to moderate or high doses until the blood pressure goal is achieved. However, monotherapy still may not control blood pressure to the recommended target. Studies have shown that use of multiple antihypertensive agents is necessary and successful in helping patients reach their target blood pressure, and this may offer more renoprotection than one agent used singly. A case study that applies these concepts in outpatient practice is included.