Lung carcinoid related Cushing's syndrome: report of three cases and review of the literature

Three patients with lung carcinoid related Cushing''s syndrome (LCRCS) treated at Frenchay Hospital, Bristol between 1984 and 1994 are described. The first patient presented with hyperpigmentation 13 years after bilateral adrenalectomy. The second patient had no recurrence or metastases 14 years after removal of a typical carcinoid tumour. The last patient survived nine years after diagnosis of liver metastasis. The possibility of LCRCS should be considered in every patient proved to have Cushing''s disease and bilateral adrenal enlargement on abdominal computed tomography. Biochemical sets of investigation (for example, adrenocorticotrophic hormone (ACTH) stimulation, dexamethasone suppression, and metyrapone response) could be misleading and should not be relied upon solely. Search for an ectopic ACTH source should be called off only when ACTH has been demonstrated in the surgically removed specimen, and most importantly, when the serum ACTH concentration returns to normal after surgery. Lung carcinoid tumours are compatible with long survival, and liver metastasis could prove indolent and slowly growing.


     

Scurvy and vitamin C deficiency in Crohn's disease.

A case of scurvy presenting in a patient with Crohn''s disease is reported. A normal response to replacement therapy is seen. Vitamin C (ascorbic acid) deficiency was found in 7 out of 10 patients with clinically quiescent Crohn''s disease, 4 of whom had an adequate oral intake of vitamin C. There was no significant difference in oral intake between patients with Crohn''s disease and matched controls but there was a significant difference (P less than 0.001) in leucocyte ascorbic acid levels. It is recommended that patients with Crohn''s disease be screened for vitamin C deficiency and receive prophylactic vitamin C supplements daily.     

Cogan's syndrome: an oculo-audiovestibular disease

Typical Cogan''s syndrome is a rare disease of young adults consisting of flares of interstitial keratitis and sudden onset of Ménière-like attacks (nausea, vomiting, tinnitus, vertigo and hearing loss). Life-threatening aortic insufficiency develops in 10% of reported cases. Atypical Cogan''s syndrome (audiovestibular dysfunction with other types of inflammatory eye disease) is associated with vasculitis in 20% of cases and has a less favourable prognosis than typical Cogan''s syndrome.


     

MDCTE评分评价克罗恩病活度的临床应用

收集临床确诊并行CT小肠检查的活动期克罗恩病患者50例.回顾性分析患者的CT表现,将患者的CT所见赋予一定的分值并进行综合评分,根据活动度指数将患者分为轻度活动期、中度活动期和明显活动期,比较CT评分与患者的活动度指数之间的相关性,结果显示CT评分与患者活动度明显相关(r=0.825,P＜0.001).表明多排CT小肠成像评分可以用于临床评估克罗恩病患者的活动度..     

Small bowel infarction mimicking Crohn's ileitis

A case of superior mesenteric arterial embolic occlusion with radiological features mimicking small bowel Crohn''s disease is reported.     

Lemierre's syndrome (necrobacillosis)

Lemierre''s syndrome or postanginal septicaemia (necrobacillosis) is caused by an acute oropharyngeal infection with secondary septic thrombophlebitis of the internal jugular vein and frequent metastatic infections. Fusobacterium necrophorum is the most common pathogen isolated from the patients. The interval between the oropharyngeal infection and the onset of the septicaemia is usually short. The most common sites of septic embolisms are the lungs and joints, and other locations can be affected. A high degree of clinical suspicion is needed to diagnose the syndrome. Computed tomography of the neck with contrast is the most useful study to detect internal jugular vein thrombosis. Treatment includes intravenous antibiotic therapy and drainage of septic foci. The role of anticoagulation is controversial. Ligation or excision of the internal jugular vein may be needed in some cases.


     

Management of non-Hodgkin's lymphomas

The non-Hodgkin''s lymphomas (NHL) are a heterogenous group of disorders characterised by malignant proliferation of lymphoid cells. The cellular origin is relatively well established with subtypes corresponding to the various stages of lymphocyte differentiation. The term encompasses a hotchpotch of conditions with very different morphological appearance, behaviour and clinical outcome. NHL comprise 2.4% of all cancers, with incidence increasing with age. The commonest presentation is with progressive lymphadenopathy, though extranodal manifestations are present in a significant proportion. The clinical behaviour ranges from a benign, indolent course to rapidly progressive disease; prognosis varies from weeks to many years. Treatment is correspondingly diverse, from `watchful waiting'' to high-dose chemotherapy with bone marrow stem cell transplantation. Cure is possible in an increasing number of patients and much interest currently lies in identifying patients with high-risk disease necessitating the use of intensive treatment regimens.


     

Crohn's disease in Bangladeshis and Europeans in Britain: an epidemiological comparison in Tower Hamlets.

The incidence of Crohn''s disease in a defined Bangladeshi community was assessed in a retrospective, epidemiological study in the London Borough of Tower Hamlets from 1972 to 1989. The borough population of 164,000 includes over 28,000 Bangladeshis. Potential cases were identified from hospital pathology and medical records. There were 99 cases of Crohn''s disease during the study period, of which five were Bangladeshi. The mean standardized incidence in Bangladeshis was 1.2/10(5)/year in the 1970s and 2.3/10(5)/year in the 1980s compared with 3.8/10(5)/year and 4.1/10(5)/year in Europeans, and 4.6/10(5)/year and 5.4/10(5)/year in West Indians, respectively. None of the changes with time was statistically significant. There were no cases amongst Hindus. The relative risk to Europeans, compared to Bangladeshis, was 2.5 during the 1970s and 2.0 in the 1980s. The difference between European incidence and that of other ethnic groups was not statistically significant; however, the number of Bangladeshi cases was small (five), and diminishes the power of the study. The apparent similarity of the incidences of Crohn''s disease in Bangladeshis and Europeans contrasts with findings in other South Asians. Further investigations of the differences in incidence of Crohn''s disease in South Asians is needed.     

英夫利西单抗治疗的小肠克罗恩病患者不同肠段黏膜愈合情况分析

目的：探讨小肠受累的克罗恩病（CD）患者使用英夫利西单抗（IFX）治疗第30周回末及结肠和小肠黏膜愈合情况。方法回顾性分析了18例接受IFX治疗的小肠受累CD患者的临床资料。观察治疗前和治疗后第30周时患者实验室指标（血常规、CRP、白蛋白）、克罗恩病活动度指数、胶囊内镜Lewis评分、克罗恩病简化内镜评分及不良反应的情况。结果与治疗前相比,治疗后第30周18例小肠CD患者的内镜下克罗恩病简化内镜评分、Lewis评分、克罗恩病活动度指数评分、C反应蛋白均显著下降,体质量指数和白蛋白明显升高。临床缓解率为88.9%（16/18）,回末及结肠黏膜愈合率58.8%（10/17,1例患者治疗后未复查结肠镜）,小肠黏膜愈合率22.2%（4/18）,深度缓解率17.6%（3/17）。在IFX治疗第30周,4例小肠黏膜愈合者回末及结肠黏膜均达到愈合,而回末及大肠黏膜愈合而小肠黏膜未愈合者6例。结论 IFX可有效诱导和维持小肠CD患者的临床缓解及黏膜愈合,减轻炎性活动。小肠黏膜愈合滞后于回末及结肠的黏膜愈合。小肠CD治疗疗效评价除关注回末及结肠的黏膜愈合外,还应结合小肠黏膜愈合情况。     

探讨国内抗酿酒酵母抗体（ASCA）鉴别诊断克罗恩病的截断点（cutoff值）的相关研究

目的检测抗酿酒酵母抗体IgG、IgA在克罗恩病患者中的表达水平,探讨其鉴别诊断克罗恩病的cutoff值。方法纳入2018年10月～2019年4月期间诊断为克罗恩病的患者109例,溃疡性结肠炎30例,内镜检查无异常者25例。间接酶联免疫检测法测定患者血清中抗酿酒酵母抗体IgG、IgA表达水平,计算其cutoff值、灵敏度、特异度等指标。结果抗酿酒酵母抗体的阳性率为47.71%,抗酿酒酵母抗体IgG的cutoff值为10.5,灵敏度为71.56%,特异度为61.82%;抗酿酒酵母抗体IgA的cutoff值为0.415,灵敏度为66.06%,特异度为78.18%;两者任一阳性的灵敏度为85.32%,两者均阳性的特异度为80.00%。结论抗酿酒酵母抗体IgG、IgA在中国人群克罗恩病患者中的表达水平不高,需制定相应的cutoff值,两者联合检测可提高克罗恩病患者检出率。     

Does patient knowledge affect the colorectal cancer risk in ulcerative colitis?

Objectives: Formal efforts to improve patient education are associated with fewer disease complications in a number of conditions. The possible relationship between knowledge about ulcerative colitis and its cancer risk, and the development of colorectal cancer using a previously developed and validated instrument—the Crohn''s and colitis knowledge (CCKNOW) score—were investigated. Methods: The 24 item CCKNOW questionnaire was mailed to patients known to have developed colorectal cancer as a complication of ulcerative colitis (cases) and to colitics from the Leicestershire inflammatory bowel disease patient database who had not developed cancer (controls). Results: The mean (SD) CCKNOW scores for cases was 8.21 (3.02) and for controls was 8.27 (4.3). These scores did not differ significantly between cases and controls (difference 0.06, 95% confidence interval (CI) -1.7 to 1.5, p=0.9). There were four times as many members of the National Association of Crohn''s and Colitis (NACC) in the control group compared with the cancer group and patients who are members of NACC achieve statistically significantly higher scores than non-members (11.6 v 7.8, p=0.05, 95% CI -0.1 to 7.6). However, after adjusting for NACC membership, the CCKNOW score did not appear to be associated with having developed cancer (odds ratio 1.04, 95% CI 0.92 to 1.18, p=0.5). Conclusions: The CCKNOW scores were comparable in cases and controls. Thus, in a retrospective study, no evidence has been demonstrated of an association between patient knowledge and the risk of developing colorectal cancer in patients with ulcerative colitis. However, knowledge may have been increased in cases as a direct result of having had colorectal cancer as a complication of ulcerative colitis.     

Inflammatory bowel disease in pregnancy

Concerns about sexual health, fertility, and pregnancy are common in patients with inflammatory bowel disease (IBD). Fertility is usually normal, although may be decreased in women with active Crohn''s disease. Women with active IBD (especially Crohn''s disease) are at risk of having small and premature babies. In some patients with IBD it may be desirable to continue drug treatment during pregnancy in order to control disease activity. Early engagement in discussion of these issues is important and it should be possible for most patients with IBD to have a normal outcome of pregnancy.     

Unusual extra-intestinal manifestations in inflammatory bowel disease (IBD)

The extra-intestinal complications of inflammatory bowel disease (IBD) usually appear in patients with long standing active intestinal disease. A patient with Crohn''s colitis is described, in whom extra-intestinal symptoms, some of which were unusual, preceded the definitive diagnosis by 9 years.     

张伯礼教授治疗克罗恩病验案一例

克罗恩病是一种以慢性肠道炎症为主要表现的全身性疾病,具有难治愈,易复发的特点,目前尚缺乏根治的方法。中医具有辨证论治特色,且不良反应较小,治疗克罗恩病具有控制病情进展,改善症状的优势。张伯礼教授临证具有较丰富的临床经验,现将张教授治疗克罗恩病验案一则进行整理报告,希冀体悟张教授临床辨证思维及遣方用药经验。     

Retinal vasculitis associated with Crohn's disease.

Although systemic vasculitis can be a complication of inflammatory bowel disease at several locations (skin, eyes, brain, mesentery, and lung) the association of retinal vasculitis with Crohn''s disease is rare. We studied a 26-year-old woman with biopsy-demonstrated Crohn''s disease who developed a severe bilateral retinal arteritis and phlebitis, with acute loss of vision.     

Teaching medical undergraduates basic clinical skills in hospice—is it practical?

AIM—Basic clinical skills teaching to medical undergraduates was a new departure for the hospice stimulated by the changing philosophies and organisation of students'' training. This study was undertaken to assess the practicalities of the venture.
METHOD—Questionnaires were designed for each of the three major groups of people involved, namely the students, the patients, and the hospice nurses. Involved patients completed theirs after teaching sessions, while the students and nurses were given two different questionnaires each, one at the start and another at the end of the academic year.
RESULTS—All students completed both questionnaires. Overall they had acquired adequate skills to pass their end of year assessments and considered themselves more comfortable with difficult situations than may otherwise have been the case. The majority of patients had enjoyed the experience and found it personally educational and a change to hospice routines. The nurses'' response rates were very poor, limiting any conclusions that could be drawn.
CONCLUSION—The venture was successful, stimulating, and practical for patients and students. Its impact on the nurses remains uncertain but, by their unusual lack of opinion expression, it can be inferred tentatively that this was minimal.


     

Determinants for the course of acute sinusitis in adult general practice patients

BACKGROUND—Although the prognosis of acute sinusitis is important, little is known about it and the factors predicting its course in a general practice population.
OBJECTIVE—To determine the course of acute sinusitis and factors predicting it in adults in general practice.
METHODS—The prognostic value of demographic and clinical factors and the patient''s emotional state, for example anxious or depressed, were determined prospectively by means of multivariate analysis.
MAIN OUTCOME MEASUREMENTS—Resolution of facial pain, resumption of daily activities, and the patient''s reported improvement. Factors with a significant predictive value were used to classify the patients into three different groups: quick, moderate, and slow recovery.
RESULTS—The median time from enrolment to recovery was six (range percentile 25-75: 4-10) days in a population of 177 patients. Factors predictive of a prolonged clinical course were: female sex (hazard ratio (HR) 0.60; 95% confidence interval (CI) 0.42 to 0.83), history longer than 14 days before inclusion (HR 0.62; 95% CI 0.41 to 0.94), headache, cold, or cough as a reason for the encounter (HR 0.65; 95% CI 0.44 to 0.96), and absence of cervical adenopathy (HR 0.71; 95% CI 0.51 to 0.96). Antibiotic treatment did not influence the course of disease. The median time to recovery was three days for patients with a quick, five days for those with a moderate, and seven days for those with a slow recovery.
CONCLUSION—In general practice acute sinusitis is mostly a self limiting disease. A limited number of characteristics are predictive of a (slightly) prolonged clinical course of acute sinusitis in general practice.


     

Discriminating Potential of Extraintestinal Systemic Manifestations and Colonoscopic Features in Chinese Patients with Intestinal Beh?et's Disease and Crohn's Disease

Background:

The distinction between intestinal Behçet''s disease (BD) and Crohn''s disease (CD) is always challenging due to many overlapping clinical features. We conducted a retrospective study to reveal valuable strategies for the differential diagnosis between intestinal BD and CD in Chinese patients based on their clinical and colonoscopic features.

Methods:

Thirty-five intestinal BD patients and 106 CD patients hospitalized from January 1983 to January 2010, who had ulcerative lesions in the terminal ileum or colon under colonoscopy and no history of gastrointestinal operation except appendectomy before admission, were enrolled. Univariate and multivariate logistic regression analyses were conducted to find discriminating predictors among demographic data, clinical manifestations, and colonoscopic findings.

Results:

Based on univariate analysis, massive gastrointestinal hemorrhage, fever, and extraintestinal systemic manifestations were more common in intestinal BD patients (P = 0.022, 0.048 and 0.001, respectively), while diarrhea, intestinal obstruction, and perianal lesions were more common in CD patients (P = 0.002, 0.010, and 0.027 respectively). Based on colonoscopy, focal involvement, ileocecal valve deformity, solitary ulcers, large ulcers (ulcer size > 2 cm), and circumferential ulcers were more common in intestinal BD patients (P = 0.003, 0.003, 0.014, 0,013, and 0.003, respectively), while segmental involvement, longitudinal ulcers, a cobblestone or nodular appearance, and pseudo-polyps were more common in CD patients (P = 0.003, 0.008, 0.023, and 0.002, respectively). Based on multivariate logistic regression analysis, diarrhea, extraintestinal manifestations, ulcer distribution, size, and type, and pseudo-polyps were independent discriminating predictors between the two groups (P = 0.048, 0.008, 0.006, 0.021, 0.002, and 0.041, respectively). The discriminating algorithm composed of the above independent predictors had the highest area under the curve of 0.987 for distinguishing between the two diseases.

Conclusions:

Extraintestinal systemic manifestations and the characteristic colonoscopic features, such as ulcer distribution, size and type, helped to distinguish intestinal BD from CD.     

Prognosis and management of Crohn's disease in the over-55 age group.

The course, prognosis and management of 62 patients with Crohn''s disease aged 55 years or over at diagnosis has been reviewed. The distal ileus was the commonest site of disease in the older patient, where the characteristic presentation was acute after initially mild symptoms. Early local resection was often required, particularly where there was diagnostic doubt or suspicion of caecal malignancy. Recurrence rates were much lower in the older patient than after resection in younger patients. Medical treatment played a minor role in the management of patients with distal ileal disease, in part because stricture formation was present at diagnosis and the acute nature of symptoms at presentation led to early surgical treatment. Colonic Crohn''s disease was usually confined to the distal or left side of the colon and initially could be difficult to distinguish from diverticular disease. Extensive colonic Crohn''s disease was rare. The apparently limited disease was not necessarily associated with a good prognosis, since disease at this site sometimes progressed rapidly, necessitating urgent surgical resection. Medical treatment (corticosteriod therapy, with or without azathioprine) was usually effective initially for treatment of symptomatic colonic Crohn''s disease, but sustained remission was rare. Those patients with persistent symptoms were restored to good health with surgical treatment but at a price, in that nearly half eventually required a permanent stoma.     

Free perforation of the small bowel in Crohn's disease.

A rare case of free double ileal perforation in previously asymptomatic and undiagnosed Crohn''s disease of the terminal ileum is described. At operation, a primary resection and anastomosis of the diseased bowel was performed. The management of free perforation in Crohn''s disease is discussed, together with a review of the literature. It is suggested that the absence of steroids in a previously undiagnosed case may favour primary resection and anastomosis.