The significance of urine phosphate measurements in the early diagnosis of intestinal infarction.

This study has confirmed previous experiments which indicated that inorganic phosphate concentrations rise in body fluids after intestinal infarction. The phosphate clearance ratio is elevated in dogs after occlusion of the superior mesenteric artery, but is not as sensitive as indicator of the presence of a necrotic intestine as the serum or peritoneal fluid phosphate levels. The rise and fall of phosphate levels occur within the first 24 hours after infarction, similar to amylase levels in acute pancreatitis. The renal failure observed in dogs after ligation of the superior mesenteric vein is likely on the basis of hypovolemia and does not seem to result from hyperphosphatemia. Intestinal infarction should be suspected with laboratory evidence of hemo-concentration, marked leukocytosis, an inappropriate metabolic acidosis and elevated serum and peritoneal fluid phosphate levels. In dogs with normal renal function, an elevated urinary phosphate clearance ratio of greater than 0.20, as measured on a spot sample of urine and serum, is also highly suggestive of the presence of this condition, but its absence, by no means, excludes the diagnosis. With these simple laboratory tests, possibly an earlier diagnosis can be made, and timely operation can be an entirely intestine-saving procedure.     

Changes in serum phosphate levels associated with intestinal infarction and necrosis.

Masive intestinal necrosis due to any cause is associated with a chemical complex that may be helpful in the early diagnosis of these conditions. This consists of elevated serum phosphate level, metabolic acidosis with significant base deficit, elevated white blood count, and elevated hemoglobin and hematocrit values. This chemical complex associated with clinical signs and symptoms, may indicate the need for laparotomy. In this way, the time period between vascular occlusion and operation could be shortened and possible lead to more gratifying results than the present day extremely high morbidity and mortality rates which are associated with massive intestinal necrosis.     

Effect of antibiotic and fluid resuscitation upon survival time in experimental intestinal ischemia

Acute massive intestinal ischemia is an abdominal catastrophe. Prompt diagnosis and restoration of blood flow is essential; otherwise, massive intestinal resection occurs, leading to death or, in the survivors, intestinal cripples. In this study, the time of warm reversible ischemia in the canine intestine was explored. After this time was established, fluids and antibiotics were administered to note change in survival times. Massive intestinal ischemia (superior mesenteric artery was clamped) was tolerated without death for five hours (20 dogs in each group). With six hours of ischemia, a 10 per cent mortality rate occurred; with seven hours of ischemia, a 90 per cent mortality rate occurred. These dogs had a maintenance of 75 milliliters of fluid administered per hour. Using this group of dogs as the control (that is, the group with seven hour clamping time of the superior mesenteric artery with maintenance intravenously administered replacement), fluids were given to dogs in the experimental group to keep the pulmonary artery wedge pressure at a normal value (average of 300 milliliters per hour). This group of dogs had an increased survival rate of 40 per cent (ten dogs). Antibiotics were given to the dogs in the experimental group both before and after clamping, increasing the over-all survival rate to more than 80 per cent (46 dogs). Aggressive fluid replacement and antibiotic coverage may lengthen the so-called golden period in which intestinal ischemia may be reversed by revascularization.     

Prevention of intestinal infarction resulting from mesenteric arterial occlusive disease

We studied 25 patients with acute intestinal ischemia resulting from arteriosclerotic mesenteric occlusion requiring surgical exploration. Their symptoms were inconspicuous but diagnostically significant. Progressive loss of body weight and symptoms mimicking peptic ulcer disease or cholecystitis were consistent findings. Delay and oversight in the clinical diagnosis resulted in an 80 per cent mortality. We stressed that awareness of possible mesenteric arteriosclerosis in patients with ill-defined gastrointestinal symptoms and weight loss is critical to diagnosis, and early aortography done in the lateral position will define superior mesenteric arterial lesions. Early surgical corrective measures can then be instituted to remedy this critical and often fatal condition.     

Primary hyperparathyroidism in patients with renal stones

There has been an observed decline in the incidence of renal stones in patients with primary hyperparathyroidism. Some believe that this is related to earlier surgical intervention. Two studies from the 1950s examined the reverse questions to determine the prevalence of primary hyperparathyroidism in patients with renal stones. This report examined 1,500 consecutive patients treated by lithotripsy seen at the Georgetown University Medical Center and found, using the historical criterion for diagnosis of hyperparathyroidism (a serum calcium level of 10.5 milligrams per deciliter or greater) that the prevalence had decreased significantly from 8.0 per cent to our level of 3.02 per cent. Neither age nor sex contributed significantly to this decrease, and there were significantly more calcium stones than in the previous studies. Using an elevated calcium level with an elevated chloride to phosphate ratio as criteria for a diagnosis of probable primary hyperparathyroidism, a true prevalence of 1.65 per cent (+/- 0.6 per cent) was found. We believe that there has been a significant decrease in the frequency of primary hyperparathyroidism in the general population of patients with renal stones.     

Bilateral luteomas of pregnancy in a patient with diabetes

A patient with diabetes and luteomas of the ovaries demonstrated a significant and progressive rise in the serum levels of androstenedione and testosterone during pregnancy. The levels of these hormones were also elevated in cord blood and ovarian fluid. The increased insulin requirement to maintain euglycemia was observed at an earlier date in this pregnancy than in her previous pregnancy.     

CA125 in peritoneal fluid of ovarian cancer patients.

The presence of CA125 was assessed in peritoneal fluid from 70 patients with ovarian cancer and 32 control patients. The follow-up period ranged from 39 to 89 months (median, 56 months). The cutoff for normal peritoneal fluid CA125 levels was determined to be 250 U/ml. A positive correlation between the serum and peritoneal fluid CA125 levels was observed (P less than 0.001). Peritoneal fluid levels were higher than serum levels in all patients. Patients with evidence of active ovarian cancer showed higher peritoneal fluid CA125 levels than the control patients (P less than 0.001). Peritoneal fluid CA125 levels correlated inversely with survival (P = 0.004). The peritoneal fluid CA125 levels were higher in patients with bulky tumor than in those with small (less than 1 cm) tumors (P less than 0.001). Eight out of twenty-six patients with active cancer and available peritoneal cytology had a negative peritoneal cytology. Three of these patients showed elevated peritoneal fluid levels. Three patients out of twenty-four showed elevated peritoneal fluid CA125 levels at second-look laparotomy. These 3 patients had negative biopsies at second-look surgery, but relapsed during the observation period. At second-look laparotomy an elevated peritoneal fluid CA125 level may imply a bad prognosis, but a normal level does not exclude the presence of disease.     

Interference in the measurement of CA-125 in peritoneal fluid

CA-125 has been found to be mildly elevated in the serum of patients with advanced stages of endometriosis, but not with minimal endometriosis. Peritoneal fluid levels were measured in conjunction with serum levels in 12 consecutive patients with endometriosis and 12 consecutive normal controls. Apparent peritoneal fluid values were found to be 10-fold higher than serum levels, with no difference between the study groups (130 versus 106 U/ml, respectively). However, when peritoneal fluid was diluted to validate the assay system in peritoneal fluid, no sample of peritoneal fluid showed decreased binding with serial dilutions of 1:2, 1:5, and 1:10. At a dilution of 1:100, there was some decreased binding, but the level was 17-fold higher than expected. The source of this interference is unknown.     

Constitutive or induced elevated levels of L-carnitine correlate with the cytokine and cellular profile of endometriosis

During the past decade, accumulated evidence indicates an association between endometriosis and an alteration of humoral and cell-mediated immunity. While the role of L-carnitine in the regulation of energy metabolism is well established, it is only recently that L-carnitine has been recognized to modify the immune response in mice after in vitro or in vivo treatment. The present study has examined whether administration of L-carnitine to young female mice alters the percentage of immune cells in peritoneal exudates and the uterus as well as the levels of IFN-gamma, TNF-alpha, IL-2, IL-4, IL-6, VEGF, GM-CSF and IGF-I in blood serum, peritoneal fluid and supernatants of uterine cultured cells as tested by immunofluorescence or ELISA techniques, respectively, leading to a pathological disorder resembling human endometriosis. The results showed that, except from infertility, L-carnitine treatment resulted in a significant increase of macrophages and to a lesser degree an increase of T-cells, while elevated levels of IFN-gamma and TNF-alpha were detected in both serum and peritoneal fluid compared to controls. Although levels of L-carnitine measured in mouse serum samples using a radioisotopic method showed an increase as compared to controls, levels of acyl-L-carnitine measured in the murine peritoneal fluid samples showed a decrease similar to that measured in peritoneal fluid samples from patients with endometriosis in stage IV of the disease. These results indicate that L-carnitine administration to female mice alters the cellular and growth factor profile in the uterus and peritoneum towards a phenotypical pathology similar to that of clinical endometriosis.     

血清及腹腔液CA125测定对子宫腺肌病的诊断价值

目的探讨血清及腹腔液CA125测定对子宫腺肌病的诊断价值.方法采用免疫化学发光法测定28例子宫腺肌病和25例子宫肌瘤患者血清及腹腔液(110稀释)CA125水平.结果子宫腺肌病患者血清CA125水平高于子宫肌瘤患者,差异有显著性(P＜0.01).两组间腹腔液CA125水平差异无显著性(P=0.18).腹腔液CA125水平明显高于血清CA125水平(P＜0.01),但二者无明显相关性(P＞0.50).腺肌病患者血清CA125水平受子宫大小、大体病理类型、使用性激素等因素影响.结论如用于子宫腺肌病的辅助诊断,血清CA125测定较腹腔液CA125测定敏感.腹腔液中CA125的主要来源可能为腹膜上皮细胞.     

Serum CA 125 levels in patients with a provisional diagnosis of pelvic inflammatory disease. Clinical and theoretical implications

In 50 patients with a provisional diagnosis of pelvic inflammatory disease (PID), CA 125 concentrations in serum were measured before laparoscopy and during hospitalization, using an enzyme immunoassay. The findings at laparoscopy were graded on the basis of the extent of inflammatory peritoneal involvement (grades 0-3; normal observations having a score of 0). On admission, 66% of the patients had serum CA 125 concentrations in excess of the cut-off value of 16 U/ml (range: 20-1300 U/ml). The serum CA 125 concentration before laparoscopy correlated with the extent of inflammatory peritoneal involvement (eta = 0.74). The predictive value of an elevated serum CA 125 level to indicate the presence of salpingitis (grades 1-3) was 97%. However, the predictive value of a normal CA 125 level indicating normal observations at laparoscopy (grade 0) was only 47%. During treatment and follow-up, the serum CA 125 concentration returned gradually to normal levels. It was concluded that the finding of an elevated serum CA 125 level confirms the diagnosis of peritoneal involvement in patients with a clinical diagnosis of PID.     

Peritoneal tuberculosis with pelvic abdominal mass, ascites and elevated CA 125 mimicking advanced ovarian carcinoma: A series of 10 cases

Abstract. Bilgin T, Karabay A, Dolar E, Develioğlu OH. Peritoneal tuberculosis with pelvic abdominal mass, ascites, and elevated CA 125 mimicking advanced ovarian carcinoma.
Ten patients with peritoneal tuberculosis who were operated on for suspected advanced ovarian cancer during a 5-year period were analyzed. These 10 cases constituted 1.4% of the 728 new gynecologic cancer cases diagnosed and treated at our department during the same time period. Data were obtained from patients' files and pathology reports. The mean age of cases was 40.6 ± 6.1 (median 37; range 18–72). Ascites was present together with ill-defined nodularities or thickening in the Douglas pouch and/or in the adnexal areas on pelvic examination in all patients but three, who presented with well-demarcated adnexal masses of about 5 cm in diameter. All patients had elevated serum CA 125 levels with a median of 331 U/ml, (40–560 U/ml). Ultrasound and abdominopelvic CT examinations revealed omental and mesenteric thickening in addition to ascites in all patients, cystic ovarian masses or ovarian enlargement in five, and peritoneal implants in two. Abdominal paracentesis performed in the six cases in whom the findings were felt to be most inconclusive for the diagnosis of ovarian cancer revealed clear exudative fluid with benign cells. Mycobacteria could not be demonstrated on direct preparations. Tuberculosis was diagnosed at laparotomy in all. Patients received antituberculous therapy and serum CA 125 levels returned to normal within 2 months after the beginning of treatment. This case series demonstrates a high rate of misdiagnosis between advanced ovarian cancer and peritoneal tuberculosis. Whereas abdominal paracentesis is useless in ruling out peritoneal tuberculosis, and serum CA 125 levels are not helpful in the differential diagnosis, the latter marker may be useful in the follow-up of patients.     

In vivo noninvasive observation of acute mesenteric ischemia in rats

Acute intestinal ischemia remains a catastrophic event even with the advent of modern diagnostic and vascular surgical techniques. An early noninvasive test would be valuable since early operation yields better survival rates. We have used an in vivo rat model to study acute intestinal ischemia after occlusion of the superior mesenteric artery (SMA). 31Phosphorus magnetic resonance spectroscopy (MRS), a noninvasive nondestructive technique, can detect the phosphorus metabolites most likely to be altered in ischemia: adenosine triphosphate, phosphocreatine (PCr), inorganic phosphate (Pi) and phosphomonoesters and phosphodiesters. Furthermore, intracellular pH can be estimated from the pH dependent position of the Pi spectral line relative to PCr. A tourniquet was loosely placed around the SMA in five Wistar rats through a transabdominal approach to the retroperitoneum. The abdomen was immediately closed. A 20 millimeter MRS surface coil was placed on the abdomen and 31Phosphorus spectra were accumulated. The SMA was then occluded and additional 31Phosphorus spectra were taken for the next 75 minutes. Significant (p less than 10(-4) changes in the position and magnitude of the spectra lines occurred within 20 minutes; the Pi position indicates severe intracellular acidosis and rapidly increases to three times its original magnitude. The PCr line decreases in magnitude. In a similar experiment, occlusion of the superior mesenteric vein (SMV) produced equivalent results. Occlusion of vessels other than the SMA or SMV not accompanied by transmural ischemia resulted in spectra unaltered from control. These findings support the application of phosphorus MRS to clinical studies.     

Peritoneal tuberculosis simulating advanced ovarian carcinoma: a case report

Disseminated peritoneal tuberculosis accounts for 1-3% of tuberculosis disease, represented by high frequency of lung defects in endemic countries. The authors report one case in a 43-year-old woman, the initial interpretation of which, based on pleural and peritoneal exudate, showed suspected latero-uterine mass and significant elevated serum CA 125 level, mimicking disseminated ovarian carcinoma. Only after exploring laparotomy with biopsy was disseminated peritoneal tuberculosis identified, thus correcting the diagnosis. Symptomatology, X-ray defect, and cynetic of serum CA 125 level were left in totality after 3 months of antituberculosis multidrugs. This is a diagnostic trap, which presents a new interest for such pathology as tuberculosis, which is on the increase again in the West.     

Skeletal dysplasias with osteopenia in the newborn: the value of alkaline phosphatase.

Alkaline phosphatase is a commonly measured enzyme in clinical practice. Normal, excessively elevated and depressed serum or plasma levels have clinical value in the approach to the differential diagnosis of skeletal dysplasias associated with osteopenia in the newborn period. Two cases are described to illustrate this contention. In the first case we describe a neonate with congenital hypophosphatasia and markedly depressed levels of plasma alkaline phosphate, and in the second case we report a patient with a fracture of the femur, congenital rickets and an elevated alkaline phosphate level. In skeletal dysplasias with osteopenia, the nature of the abnormality in alkaline phosphate values, in association with that of calcium and phosphate, is an invaluable diagnostic aid in differential diagnosis.     

Skeletal dysplasias with osteopenia in the newborn: The value of alkaline phosphatase

Alkaline phosphatase is a commonly measured enzyme in clinical practice. Normal, excessively elevated and depressed serum or plasma levels have clinical value in the approach to the differential diagnosis of skeletal dysplasias associated with osteopenia in the newborn period. Two cases are described to illustrate this contention. In the first case we describe a neonate with congenital hypophosphatasia and markedly depressed levels of plasma alkaline phosphate, and in the second case we report a patient with a fracture of the femur, congenital rickets and an elevated alkaline phosphate level. In skeletal dysplasias with osteopenia, the nature of the abnormality in alkaline phosphate values, in association with that of calcium and phosphate, is an invaluable diagnostic aid in differential diagnosis.     

Lymphocyte activity in the presence of peritoneal fluid from fertile women and infertile women with and without endometriosis

Peritoneal fluid from women with endometriosis, unexplained infertility, and fertile controls were compared to one another and to normal human serum for effects on lymphocyte proliferation in vitro. Peritoneal fluid samples were also assayed for both interleukin-1 and interleukin-2. All peritoneal fluid samples significantly enhanced lymphocyte proliferation in both mitogen-stimulated and unstimulated cultures compared with serum controls. Mitogen-induced leukocyte proliferation was higher in the presence of peritoneal fluid from women with endometriosis compared with other samples. Five out of 23 samples from endometriosis patients contained elevated levels of interleukin-1 and three out of 23 contained elevated levels of interleukin-2. Six out of eight peritoneal fluid samples from unexplained infertility patients also had elevated levels of interleukin-2; samples from fertile women did not contain elevated levels of either cytokine. Our data indicate that peritoneal fluid from women with endometriosis and unexplained infertility support the activation and proliferation of lymphocytes. Leukocyte products may locally affect the progression of disease and fertility.     

The evaluation of IL-12 levels in peritoneal fluid and serum of women with endometriosis

We studied levels of IL-12 in peritoneal fluid and serum in patients with minimal, advanced and recurrent endometriosis compared to women without endometriotic lesions in pelvis minor. The aim of the study was to determine whether level of IL-12 detected in peritoneal fluid or serum changes with grading of severity of endometriosis. To assess IL-12 levels immunosorbent ELISA was used. There were no statistically significant differences in IL-12 levels in peritoneal fluid nor in serum in any of studied groups. There was higher concentration (without statistical significance) of IL-12 in peritoneal fluid of healthy women compared to women with endometriosis.     

Peritoneal tuberculosis with elevated serum CA 125 levels: A case report

Laparotomy in a 62-year-old woman with elevated serum CA 125 antigen levels with the provisional diagnosis of ovarian carcinoma revealed peritoneal tuberculosis. After treatment with the bacteriocidal chemotherapeutic agents, the antigen level returned to the normal, and she has been well for 24 months postoperatively.     

The significance of clostridial isolates in intra-abdominal sepsis

In order to evaluate the significance of clostridial species in intra-abdominal infections, the bacteriology records of three hospitals were reviewed during a period of five years. Included in this report were 41 patients from whom clostridial species were recovered from specimens of free peritoneal fluid, abscess cavities or bile. Seven patients died for a mortality rate of 17.1 per cent. Most patients had polymicrobial infections of which clostridial organisms were one of the several anaerobes isolated. Clostridium perfringens was the single most frequently noted species, identified in 23 of the patients, but it was not associated with a different mortality rate than was observed for the other clostridial species. Clostridial bacteremia was uncommon and demonstrated in only one patient. The mean age of the patients was 56.4 years; 56.2 for males and 56.8 for females. Neither age nor sex of the patient influenced the likelihood of survival. The source of the clostridial isolates--bile, abscess cavity or free peritoneal fluid--had no effect upon the outcome. Several underlying conditions were responsible for the intraperitoneal clostridial organisms identified in this series. Only mesenteric infarction proved significantly predictive of a fatal result. Antibiotic coverage specifically directed against clostridia did not influence survival.